EuroTimes Vol 25 Issue 3 March 2020

SPECIAL FOCUS CORNEA

March 2020 | Vol 25 Issue 3

The Window to the World

CATARACT & REFRACTIVE | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY | OCULAR

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Ria Pollock Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor.

Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

CORNEA

04 Cataract surgery in eyes with diseased corneas

08 Collaborative research is a moral imperative

21 Reduced laser energy

improves outcomes in SMILE procedures

22 Toric IOL prediction

accuracy depends on the tool used

23 Bilateral same-day cataract surgery linked with lower endophthalmitis rate

09 Successful cataract surgery in 24 Pseudophakic eyes with opaque cornea

10 Corneal topography is a must in cases of vernal keratoconjunctivitis

11 ECCTR aims to provide

insight in transplantation practice patterns

13 Limbal cell

transplantation success continues to improve

15 Femto-LASIK is safe and

effective for patients who have undergone PK

measurement adds no benefit

25 Light-adjustable IOL is

‘game-changing’ technology

RETINA 26 Newer techniques lead to

better outcomes in myopic macular holes

28 Amsterdam Debates

prompt lively discussion

29 Wide-field OCT leads

to greater clarification in pathologic myopia

CATARACT & REFRACTIVE

30 3D microscopy offers

16 An ESCRS panel reviews

31 Ophthalmologica

results from longer followup of refractive procedures

17 Optical modelling used to

advantages over traditional analogue setup highlights

www.eurotimes.org

GLAUCOMA 32 New compounds could

advance glaucoma therapy beyond prevention

33 Balancing MIGS and

medications may improve outcomes

PAEDIATRIC OPHTHALMOLOGY 34 Rapid intervention key in ocular surface disease

35 IOL implantation provides

good results in patients less than six months

OCULAR 36 Across the world on the

Orbis Flying Eye Hospital

REGULARS

38 Travel 39 Society news 42 ESCRS News 43 Random thoughts 44 Practice management 45 Books 46 Calendar

characterise the aetiology of negative dysphotopsia

18 Intraoperative OCT can

improve prediction of the IOL position

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between February and December 2019 was 47,863

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19 JCRS highlights 20 AI may lead to higher levels of refractive accuracy in cataract surgery

EUROTIMES | MARCH 2020

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EDITORIAL A WORD FROM JESPER HJORTDAL MD, PhD

GUEST EDITORIAL

A beautiful structure EuCornea will hold its 11th Annual Congress in Amsterdam, the Netherlands

Jesper Hjortdal

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

A

s my colleague Dr Soosan Jacob states in this issue of EuroTimes: “The cornea is the window to the world. It’s a beautiful structure that is also the window to the patient’s eye. It gives a crystal clear, unimpeded, magnified view of the internal structures while acting as the roof to a stable chamber, allowing uneventful surgery.”

We are privileged to be cornea specialists and to be members of EuCornea, which will hold its 11th Annual Congress in Amsterdam, the Netherlands, from 2-3 October 2020.

As Dr Jacob also points out the cornea is a very important part of the eye for cataract and refractive surgeons, and we look forward to sharing information with our colleagues in the ESCRS in Amsterdam.

Our programme is still in development but we look forward to discussing exciting developments in areas including Genetic Diagnosis & Therapy, Suturing & Gluing of Corneal Lesions, DALK and DMEK. In this issue of EuroTimes, we also look The aim of the at the progress made in project is to build a developing the European common assessment Cornea and Cell methodology and Transplantation Registry.

ECCTR, whose partners establish an EU include EuCornea, is a web-based registry European Consortium and network for that aims to build an EU web-based registry in the academics, health field of cornea. The aim professionals and of the project is to build authorities 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.

ECCTR, established in 2016, is now up and running successfully, with data on 12,922 transplants from 12 countries already submitted for analysis.

I would also urge corneal specialists to read and subscribe to the EuCornea journal JEuCornea, which promotes the study and learning of the science and practice of all matters related to the health and management of diseases of the cornea, ocular surface, tears and associated tissues of the eye.

I look forward to seeing you in Amsterdam and would encourage you to visit our website www.eucornea.org for information on our Annual Congress and all of the society’s activities.

Jesper Hjortdal MD, PhD, Aarhus University Hospital, Denmark, is President of EuCornea EUROTIMES | MARCH 2020

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SPECIAL FOCUS: CORNEA

Cataract surgery in eyes with diseased corneas Damaged corneas can interrupt what should be an uneventful surgery. Soosan Jacob MD reports

EUROTIMES | MARCH 2020

T

he cornea is the window to the world. It’s a beautiful structure that is also the cataract surgeon’s window to the patient’s eye. It gives a crystal clear, unimpeded, magnified view of the internal structures while acting as the roof to a stable chamber, allowing uneventful surgery. However, we do sometimes come across cataracts in eyes that have some defect in the cornea. In this article, I take a look at some of the problems faced and how we can manage them.

Fuchs’ Endothelial Corneal Disease (FECD) One common situation we sometimes face is the development of cataract in patients with FECD. The questions here of course are – first, whether cataract surgery could worsen the already compromised endothelium and second, if it is better to remove the cataract early when it is soft and requires less phaco energy. If visual loss is not present and the patient is asymptomatic, I generally prefer to advise only observation, sometimes also adding medical management in the form of Rho kinase inhibitors for endothelial regeneration, hypertonic saline to deturgesce the cornea and anti-glaucoma medications to decrease endothelial stress.

If vision starts to decrease or the patient becomes symptomatic, I like to proceed based on grade of FECD, cataract density and estimated contribution to visual loss from each. With minimal endothelial changes and a soft cataract, phacoemulsification can usually be done uneventfully using the least possible phaco energy. I prefer torsional ultrasound and use Arshinoff’s soft shell technique using dispersive and cohesive viscoelastic. I try to debulk the nucleus within the bag before bringing fragments out for iris plane emulsification.

Soft cataracts can be removed easily using high vacuum with very low energy.

Dispersive OVD should be intermittently replenished for endothelial coating and wound burns should be avoided. I prefer an extracapsular cataract extraction or manual small-incision cataract surgery under dispersive viscoelastic cover for dense cataracts that would require excessive phaco energy.

Hydrophobic IOL is preferred as

SPECIAL FOCUS: CORNEA hydrophilic IOLs can opacify if air/gas tamponade is required during a possible future endothelial keratoplasty (EK).

Preoperative counselling regarding possible slower postoperative recovery as well as possible need for an EK is important even with soft cataracts.

With decompensated FECD, I combine phacoemulsification with in-the-bag IOL placement and an EK irrespective of the grade of cataract.

Though Descemet’s stripping automated EK (DSAEK) and Descemet’s Membrane EK (DMEK) may be performed, my personal preference is pre-Descemet’s EK (PDEK), utilising three techniques that I have described to increase success and repeatability – endoilluminator-assisted PDEK, air pump-assisted PDEK and host Descemetic scaffolding.

I prefer to remove a non-cataractous crystalline lens too as the risk of cataract developing secondary to air tamponade, prolonged steroid usage, inflammation, natural ageing etc. is high and can result in the need for surgery, which can in turn cause loss of precious graft endothelial cells.

Cataract surgery can, however, be challenging in FECD due to poor visibility. Removing the oedematous epithelium can help. Increased stromal oedema whenever the irrigation probe enters the anterior chamber together with any pre-existing haze or minimal stromal scarring decreases visibility in advanced cases. A good quality microscope, capsular staining with trypan blue and use of an endoilluminator as an external oblique light source can help. For a successful EK, it is better to emulsify the cataract working closer to the endothelium than to the posterior capsule to avoid a posterior capsular rent.

Patients with advanced cornea guttata, irido-corneal-endothelial (ICE) syndrome, severe toxic anterior segment syndrome (TASS) and other causes of endothelial dysfunction such as prolonged inflammation or trauma may also be handled using above described principles. Some of these conditions may have peripheral anterior synechiae and glaucoma which may need to be addressed simultaneously. The air pump-assisted PDEK technique allows synechiolysis under air tamponade and prevents bleeding from the iris, hyphema and a fibrinous atmosphere. It helps achieve effective intraoperative graft attachment

I prefer to remove a non-cataractous crystalline lens too as the risk of cataract developing secondary to air tamponade, prolonged steroid usage, inflammation, natural ageing etc.

and therefore gives a greater chance of success even when combined glaucoma surgery is planned.

Scarred cornea Patients with cataract and stromal and endothelial scarring may require cataract extraction combined with penetrating keratoplasty. This allows better intraoperative visibility, prompt visual rehabilitation after surgery and avoids later cataract extraction and graft endothelial loss. Major disadvantages are inability to accurately estimate IOL power because of unpredictable postoperative keratometry and suture-induced postoperative astigmatism.

Though not very accurate, with experience, it is possible to keep the predicted mean postoperative keratometry within an acceptable range to avoid very large refractive errors. I have found the Maloney intraoperative keratometer very useful to keep suture-related astigmatism to acceptable levels. I also utilise postoperative suture adjustment in the form of selective suture removal or suture replacement for astigmatism that decreases visual acuity.

Cataract extraction may be done opensky when view is poor. If view permits, closed-chamber phacoemulsification followed by a penetrating keratoplasty can decrease open sky time and allow a rhexis and in-the-bag IOL placement. Phaco incisions should be scleral or limbal and short. Postoperative refractive correction in the form of spectacles or rigid contact lenses may be given.

Postponing cataract extraction to after the keratoplasty allows correction of large refractive errors, but results in endothelial loss at the time of cataract surgery and also requires waiting until complete suture removal resulting in delayed visual rehabilitation.

Corneal dystrophies and superficial scarring In case of stromal scarring (not involving Descemet’s-endothelial complex) contributing to a significant decrease in vision, phototherapeutic keratectomy or superficial/deep anterior lamellar keratoplasty (ALK) may be indicated for treatment. I perform this first and defer cataract surgery until after complete suture removal and stabilisation of the refractive error, since endothelial loss is not a major factor.

If, however, the cataract is very dense, depending on extent, level and density of opacity, combined surgery may be done either using techniques that enhance visualisation through scarred corneas or by dissecting the anterior stromal scar by an ALK to a level that allows better visualisation, performing cataract extraction and then proceeding for deeper stromal dissection. If the scar is off the visual axis, or in case of very faint scarring, I perform only cataract surgery.

EUROTIMES | MARCH 2020

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SPECIAL FOCUS: CORNEA

Irregular cornea Another situation that occasionally presents is cataract in irregular corneas. This could be secondary to a variety of conditions such as keratoconus, pellucid marginal degeneration, post-LASIK ectasia, radial keratotomy, post-trauma, post-surgery such as after LASIK, keratoplasty, Intacs, cross-linking etc.

In these corneas, when the cataract is soft, I like to do a rigid gas permeable contact lens trial and retinal acuity meter to estimate potential best-corrected visual acuity. Corneal topography is important and multiple measurements should be taken to ensure repeatability. Corneal HOA analysis and pupillometry are also important.

The major problem here is IOL power calculation. In the case of LASIK, IOL power is underestimated post-myopic LASIK and overestimated post-hyperopic LASIK. Post-myopic LASIK, total corneal power measured by ray tracing can be used for better IOL power prediction.

Wang-Koch-Hill ASCRS online calculator; Barrett True K No History; No History Shammas-PL; Haigis-L and other methods are useful. Aramberri Double K method corrects effective lens position in SRK/T, Holladay-1 and Hoffer-Q formulas. Hoffer-Savini LASIK IOL power tool allows simultaneous calculation of various formulas to obtain possible K values. Agreement between various K values should be checked while erring toward selecting lower K values.

Another option is to use intraoperative aberrometry. Finally, in case different formulas give different IOL powers, it is better to err toward postoperative myopia, which is easier to correct than hyperopia. Since despite all attempts, it may be difficult to accurately assess anterior and posterior corneal power and astigmatism, postoperative refractive surprises may occur and should be discussed preoperatively with the patient.

Negative spherical aberration IOLs benefit patients with previous myopic LASIK. Hyperopic LASIK induces negative spherical aberration and they benefit with traditional spherical IOLs. For keratoconus and ectasias, I like to regularise the cornea as much as possible preoperatively by using a technique that I have described – Corneal Allogenic Intrastromal Ring Segments (CAIRS). This utilises thin segments of de-epithelialised and de-endothelialised donor corneal stroma that is implanted into mid-peripheral intra-stromal channels similar to synthetic intra-stromal corneal ring segments. This helps to flatten and regularise the cornea, centralise the cone, decrease refractive error and improve uncorrected and bestcorrected visual acuity while avoiding synthetic-related complications. Once refractive stability is achieved, cataract surgery may be performed using toric IOLs for residual refractive error. Techniques based on pin-hole optics such as IC-8™ IOL EUROTIMES | MARCH 2020

Courtesy of Soosan Jacob MD

6

A: Nucleus emulsification, cortex aspiration and in-the-bag IOL placement performed in an eye with Fuchs’ Endothelial Corneal dystrophy; B: Pre-Descemet’s Endothelial Keratoplasty (PDEK) graft injected into anterior chamber and graft orientation determined using endoilluminator assisted PDEK technique; C: Graft centred and edge folds removed using air pump-assisted PDEK technique.

Host Descemetic scaffolding seen at inferior 6 o’clock position; D: Well-placed PDEK graft seen with 80% air fill

(AcuFocus) or XtraFocus Pinhole implant (Morcher) as well as pin-hole pupilloplasty that can customise the pupil to lie over the visual axis may be used for very high degrees of irregular corneas such as after keratoplasty or radial keratotomy. CAIRS segments may also be tried as a green lasso suture post radial keratotomy.

Infections A past history of HSV keratitis generally doesn’t indicate anti-viral prophylaxis before and after cataract surgery; however, in rare cases, steroids and surgical trauma may cause reactivation. Postoperatively, topical NSAIDS may be used instead of steroids to decrease this risk. For active corneal ulcers, if performing a therapeutic keratoplasty, the crystalline lens should be retained as a barrier to pathogen entry into the posterior segment.

Ocular surface disease Dry eye is an important cause for errors in IOL power calculation and can be a source of dissatisfaction, especially with premium IOLs. Prior to biometry, it must be treated with topical lubricants and if required, topical steroids and cyclosporine. I also like to treat blepharitis and Meibomian gland disease prior to surgery to prevent epithelial toxicity intra- and postoperatively. Cataract surgery by itself can further exacerbate dry eye. Surface-friendly drops should be used and kept to a minimum together with plenty of lubricants.

More severe forms of dry eye such as Sjogren’s syndrome, rheumatoid arthritis,

ocular cicatricial pemphigoid (OCP), Stevens-Johnsons syndrome, peripheral ulcerative keratitis (PUK) etc. may develop complications ranging from punctate epithelial keratopathy, filamentary keratitis, peripheral ulcerative keratitis, necrotising scleritis, reactivation of disease, corneal melt etc. Preoperatively, systemic and topical disease should be brought under control and perioperative systemic immunosuppression may be required.

Surgery should be planned via small clear corneal incisions in OCP and scleral tunnel incisions in PUK. Patients with extremely severe disease such as following chemical burns or with severe limbal stem cell deficiency may, depending on their surface and on the degree of corneal neovascularisation, require Type 1 or Type 2 Boston or LVP keratoprosthesis (KPro). These are combined with cataract surgery if the crystalline lens is still present.

A Type 1 KPro is also required following multiple corneal graft rejections and as mentioned earlier, needs the crystalline lens to be removed. Either an aphakic or pseudophakic Boston KPro may be used depending on IOL status.

Thus, with adequate, judicious planning, preoperative counselling and proper care, many difficult cases with cataract and corneal disease can be given satisfactory outcomes.

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.

11th EuCornea Congress

AMSTERDAM 2 – 3 October 2020 RAI Amsterdam, The Netherlands

Abstract Submission Deadline: 15 March 2020 Hotel Bookings Open www.eucornea.org

SPECIAL FOCUS: CORNEA

Inspiring Medal Lecture Collaborative research is a moral imperative.

Priscilla Lynch reports

C

arrying out high-quality clinical research is “a moral imperative” and its importance in advancing medicine, and thus improving outcomes for patients, cannot be overstated, delegates attending the 10th EuCornea Congress Medal Lecture in Paris, France, were told.

The esteemed lecture was presented by a long-time supporter of EuCornea, Sadeer Hannush MD, USA, on the topic of “Clinical Corneal Research: Why It Is Important to Get Involved”.

The lecture drew on Dr Hannush’s three-decade posttraining experience in the areas of cornea and external disease, maintaining a private practice while being actively involved in significant academic research.

Answering why one should become involved in research, Dr Hannush commented: “An average ophthalmologist may touch the lives of 40,000 people during the course of a career. If we change practice patterns, on the other hand, we can touch the lives of millions.”

Dr Hannush acknowledged that doing research doesn’t come easy; “you have to learn the trade of it”, and outlined a number of practical tips for becoming involved in high-quality studies.

The first steps involve “not being content with the ‘what and how’, and having a drive to answer why”.

Good-quality research “should ask a simple, high-impact question” and should aim to be practice-confirming or practicechanging, he said.

Dr Hannush’s personal journey through clinical corneal research has seen him involved with such important studies as ‘Prospective Evaluation of Radial Keratotomy’, ‘The Collaborative Corneal Transplantation Studies’, ‘Herpetic Eye Disease Studies’, ‘Cornea Donor Study (CDS)’, ‘Corneal Preservation Time Study (CPTS)’ and ‘Long-term Survival of Permanent Keratoprosthesis’. Each of these studies asked a simple, high-impact question that could be answered with a well-defined answer, he noted.

The common factor in all of them was collaboration, something that is essential for robust and sound clinical research, and key to having the right expertise for each part of the research project, he stressed. “You have to work with others – very few of us can do it on our own... we can all collaborate to do this. We don’t all have to do every element of the research.

“Some of us are better at certain things than others. Maybe you are an expert at reading images – you can make your contribution there. Or maybe you are a good writer and can participate in that manner. There is a lot more to collecting and reporting data than simply making the observation or doing the surgery. So, if you are receptive to the idea of collaboration with others, even at a very young age, especially at a very young age, then I would encourage you to keep your eyes and ears open and be receptive to, indeed welcoming of, the approaches of colleagues, especially seniors in the field, when you are tapped to participate in a study.”

Speaking about the findings of his own high-impact work over the years, Dr Hannush noted how research can confirm something that clinicians suspect from practice, or it can throw up surprises.

EUROTIMES | MARCH 2020

Courtesy of Sadeer Hannush, MD

8

Penetrating keratoplasty with running suture

For example, Dr Hannush quoted research he collaborated on that showed that corneal transplant patients with higher levels of education have more successful grafts for keratoconus than patients with less education. “You may think you didn’t need a study to figure that out; it’s obvious. These are patients that are going to follow instructions, learn about complications, turn up for their post-op visits and take their topical medications. All of that is true, but unless you evaluate it with a rigorous scientific method and the help of a statistician, you don’t know this to be true. Sometimes you are surprised, as we were with the CDS and CPTS studies.”

He explained how the CDS and CPTS studies showed that older cornea donor age (even at 70 years old) does not result in poorer quality outcomes, and neither does longer preservation time (eight-to-11 days), “This has increased the number of donor tissue available for transplantation significantly”.

Prior to these studies it was believed that cornea donors should ideally be under the age of 65, and corneal tissue preserved in cold storage should ideally be transplanted if the duration of preservation was under a week. This knowledge is practicechanging. “How many ophthalmologists are surprised by these findings? I was! We learned a lot from collaboration in these studies,” Dr Hannush said.

Dr Hannush acknowledged that change is hard, but that clinicians must be open to believing and accepting key new study findings and incorporating them into their clinical practices, when the results prove a certain approach has the best outcomes. “This is very important in clinical trials – to believe the results of a well constructed and executed trial/study that you and your colleagues contribute to.”

Concluding his EuCornea Medal Lecture, Dr Hannush said: “Treating patients changes the lives of the few you treat.

Changing practice patterns amongst colleagues affects the lives of many. Collaborative clinical research is the only way to make this possible. It is our responsibility and a moral imperative!”

SPECIAL FOCUS: CORNEA

Rigorous techniques Shedding light on cataract surgery in opaque corneas.

Dermot McGrath reports

P

erforming cataract surgery in the presence of an opaque cornea can be successfully achieved with a combination of rigorous surgical techniques and by respecting certain guidelines, according to Björn Bachmann MD, FEBO. Speaking at the joint ESCRS/EuCornea Symposium on cataract surgery in eyes with diseased corneas at the 37th Congress of the ESCRS, Dr Bachmann said that key steps in a successful procedure included localisation of the key incision site, good control of the red reflex, optimal illumination using a variety of light sources and the application of appropriate staining to enhance visualisation.

“The main incision should be placed opposite the clean work zone, and we can try to improve the red reflex by using coaxial instead of full-field illumination and by enlarging the pupil. It is also advisable to avoid contact of dye with diseased endothelium when staining the anterior capsule,” he said.

Dr Bachmann, consultant at the Department of Ophthalmology, University of Cologne, Germany, noted that there are certain situations where it is advisable to perform cataract surgery in the presence of an opaque cornea before or without corneal surgery.

“This would include cases of mild or peripheral corneal opacification or in patients where there is a high risk of corneal graft failure after penetrating keratoplasty.

If there is a history of good visual acuity before cataract formation it might not be necessary to perform corneal surgery before, or in eyes with low expectations in visual acuity such as amblyopia or

The intensity of the red reflex is influenced by the diameter of the pupil, so try to make it as large as possible by dilating it either pharmaceutically or surgically Björn Bachmann MD, FEBO

Intracameral light sources can also be helpful when placed in the anterior chamber, allowing visualisation of the ocular structures by reflection. This usually works best when placed directly adjacent to the structures that the surgeon wants to visualise, he explained.

Intravitreal light sources are ideally used in combination procedures and produce reduced stray light, little reflection and high contrast, he added.

“The downside is that there is a risk of the light source tearing the posterior lens capsule so it needs to be maintained a safe distance from the posterior capsule.

LET THERE BE LIGHT It also delivers reduced 3D It is important to understand perception,” he said. the different sources of light For patients with corneal available in the operating endothelial disease, removal field in order to maximise visualisation, said Dr Bachmann. Björn Bachmann MD, FEBO of the oedematous corneal epithelium rapidly improves “The operating microscope visualisation and usually works best in delivers front light which visualises the combined procedures, said Dr Bachmann. ocular structures by reflection. It also “This can result in wound healing problems creates stray light from incident rays, if the epithelium is diseased and we proceed which are increased in opaque corneas. with cataract surgery without endothelium The red reflex visualises ocular structures transplantation. An alternative approach is by shading and gives much better contrast to apply glycerine eye drops, which clears the to these ocular structures and causes oedema quickly and should give enough time minimal stray light,” he said. to perform the cataract surgery,” he said.

The red reflex can be improved by

post retinal detachment,” he said.

Combination surgery is also possible for a large percentage of patients, noted Dr Bachmann.

“We usually perform a combined procedure with the cataract removal coming before the Descemet membrane endothelial keratoplasty (DMEK) within the same surgery. When we looked at the data for our clinic in Cologne it amounted to 931 combined procedures (triple DMEKs) or 37% out of the 2,531 DMEK cases, which represents a high proportion,” he said.

influencing the pupil diameter and using appropriate illumination techniques, said Dr Bachmann.

“The intensity of the red reflex is influenced by the diameter of the pupil, so try to make it as large as possible by dilating it either pharmaceutically or surgically.

We can experiment with different lighting techniques including full-field, coaxial and intracameral or even intravitreal illumination to obtain the best visualisation possible. The intensity of the light is also important in order to minimise stray light while still obtaining the best possible red reflex during the surgery,” he said.

Although full-field illumination is most commonly used in cataract surgery, it tends to increase stray light and reflection and results in a reduced red reflex. By contrast, employing a coaxial light source can greatly increase the red reflex and ensure good visualisation during capsulorhexis creation, said Dr Bachmann.

“It gives a sharper contrast in the area of opacification and also behind the cornea,” he said.

A TIME TO DYE Although some concerns have been raised about potential toxicity to the cornea from using trypan blue to stain the anterior capsule, a recent study from Nagashima et al. suggests that the limited exposure time means that it is probably safe to continue to use such dyes, said Dr Bachmann.

“This was a prospective randomised trial study of both brilliant blue and trypan blue in 150 cataract patients, which found no statistically significant difference between the two dyes in terms of endothelial cell loss over the follow-up period,” he said.

He stressed, however, that contact between staining dyes and diseased endothelium is best avoided as it leads to increased corneal opacification.

“Techniques to avoid contact of dyes with corneal endothelium include filling the anterior chamber with an air bubble or viscoelastic material, he concluded.

Björn Bachmann: bjoern.bachmann@uk-koeln.de EUROTIMES | MARCH 2020

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SPECIAL FOCUS: CORNEA

VKC and corneal topography Disease, which mainly affects children under the age of 10, is prone to complications. Priscilla Lynch reports

C

orneal topography should be performed in all cases of vernal keratoconjunctivitis (VKC) due to the high risk of corneal complications with this condition, the dedicated session on ocular surface diseases in paediatric patients during the 10th EuCornea Congress in Paris, France, was told.

VKC, a severe form of ocular allergy that causes itching, photophobia, burning and tearing, mainly occurs in children, particularly under the age of 10 years, explained Sihem Lazreg MD, Algeria. It is an IgE- and T-cell mediated disease in which eosinophil, lymphocyte and structural cell activation are involved. The incidence of VKC is higher in males by a ratio of three to one.

VKC usually appears from early spring until autumn, but is more prevalent and perennial in countries with warmer climates, she noted.

There are three forms – tarsal VKC, limbal and mixed forms. Tarsal forms are the most common, with a giant papillae in the tarsal side of the Sihem Lazreg MD conjunctiva. Most cases present with an irregular astigmatism, and some with keratoconus, probably due to eye rubbing, Dr Lazreg told the meeting.

Corneal involvement in VKC is very frequent and can be very severe, compromising visual function, hence the need for corneal topography, she stressed.

Dr Lazreg presented the findings of a large retrospective study from her own clinic, involving 867 cases of VKC over an 11-year period (2008-2019). Nearly two-thirds (62%) of the cohort had an allergic history (rhinitis 51%, asthma 21%, etc) with corneal involvement in 57% of cases, ie, vernal plaques, punctate keratitis, stem cell deficiency, corneal opacities and keratoconus.

Steroids are very effective for VKC, Dr Lazreg noted, adding that as ciclosporin is not available in Algeria she uses triamcinolone (supratarsal injection), while tacrolimus ointment is also effective in non-responders. Following treatment, 73% of her cases had significantly improved signs and symptoms, while 21% had satisfactory results but frequent relapses, 5% had dependence on corticosteroids, while 1% had non-responding severe forms.

Dr Lazreg also drew attention to the severe iatrogenic complications that can occur when patients self-medicate with steroids for VKC, highlighting a number of cases of steroid-related glaucoma, some very severe with loss of vision, and cataracts, which occurred in Algeria. Concluding, Dr Lazreg stressed that the psychological impact of VKC must also be addressed as well as allergen avoidance for the best outcomes in these young patients.

...Corneal involvement in VKC is very frequent and can be very severe, compromising visual function, hence the need for corneal topography

Sihem Lazreg: slazbkt@gmail.com EUROTIMES | MARCH 2020

SPECIAL FOCUS: CORNEA

ECCTR update ECCTR aims to provide insight in corneal transplantation practice patterns and real-life experiences. Colin Kerr reports

I

n October 2019, almost 60 people from 16 EU countries attended the final European Cornea and Cell Transplantation Registry (ECCTR) project conference in Brussels, Belgium.

ECCTR, established in 2016 is now up and running successfully, with data on 12,922 transplants from 12 countries already submitted for analysis. The registry contains information on the recipient, donor and eye bank processing, transplant procedure and two-year follow-up including graft survival and failure and patient-reported outcome measures (PROMs).

The median age of patients undergoing corneal transplantation is 70 years. The predominant diagnosis for transplantation is Fuchs’ dystrophy, followed by graft failure, pseudophakic corneal oedema and keratoconus.

The project is co-funded by the European Society of Cataract and Refractive Surgeons (ESCRS) and by the EU under the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA).

Professor Rudy MMA Nuijts MD, PhD, Maastricht University Eye Clinic, Maastricht, the Netherlands, said the ESCRS actively supports three major registers: The European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO); The European Cornea and Cell Transplantation Registry (ECCTR); and The European Registry for Childhood Cataract Surgery (EuReCCa).

Prof Nuijts said modern technology has improved the application of lamellar transplantation technique.

“Registries provide insight in corneal transplantation practice patterns and reallife experiences. I hope that today inspires

new ideas, new partnerships, influences new policies and discussion around the ways we can cooperate further,” he said.

Professor Mats Lundström PhD, MD, professor emeritus at Lund University, Sweden, said ECCTR aimed to build a common outcome assessment methodology for corneal transplantation; clinical outcome measures and patientreported outcome measures; establish an EU web-based registry and network for academics, health professionals and authorities; and assess and verify activity data and the safety, quality and efficacy of corneal transplants.

“We can build on our results,” said Prof Lundström, “by harmonising existing partner registers, creating and facilitating a European network of practitioners and by strengthening cooperation between EU Member States and Competent Health Authorities.”

Professor Jesper Hjortdal MD, PhD, Aarhus University Hospital, Denmark, said the first meeting of the European Eye Bank Association (EEBA) took place in Aarhus, Denmark in 1989.

“Founded with the simple objective of sharing information regarding eye-banking, the Association is today the leading pannational association in Europe dedicated to the advancement of eye-banking and an authoritative reference point for eye banks wishing to work according to quality standards,” he said.

“The ECCTR is a globally new and unique platform for further collaboration between eye banks and corneal surgeons to learn and improve the quality of corneal transplant procedures – all to the benefit of future patients,” he said.

Mor Dickman MD, PhD, Maastricht University Eye Clinic, said quality improvement registries like ECCTR offered treasure troves of invaluable data.

“Regulatory agencies and other

ECCTR Partners •

European Society of Cataract and RefractiveSurgeons (ESCRS)

•

Swedish Corneal Transplant Registry (RC Syd)

•

European Society of Cornea and Ocular Surface Disease Specialists (EuCornea)

•

NHS Blood and Transplant (NHSBT)

•

UK Transplant Registry

•

Fondazione Banca degli Occhi del Veneto (FBOV) & European Eye Bank Association (EEBA)

•

Nederlandse Transplantatie Stichting (NTS)

•

Blekinge Läns Landsting (LTBlekinge)

•

Dutch Transplant Foundation

•

Universiteit Maastricht (MU)

stakeholders increasingly rely on data collected through registries to support their decision-making,” he said. “Data from registries forms the cornerstone of post-marketing surveillance of medicines, medical devices and advanced therapy medicinal products. Health technology assessment is also increasingly in need of real-world data. Inclusion of costs and resource use can inform health-policy decisions, for example in case of conditional reimbursement models.”

Dr Dickman said that from a global perspective, more than 185,000 CT procedures are performed each year, making corneal grafts one of the most common transplant procedures.

“However, 12.7 million people are awaiting a corneal graft, and only one cornea is available for 70 needed,” he said.

“Regenerative therapies offer the promise of even better outcomes for our patients, and lower demand for donor tissue.”

Dr Dickman also gave an interesting insight into what the registry might look like in five years’ time, taking into account the increasing influence of artificial intelligence in ophthalmology.

“The registry of 2025 could look dramatically different from the registry of today,” he said.

“Digital health includes a wide variety of technologies such as health IT, personalised health (e.g. genomics) mobile sensor readouts (e.g. Google Glass) or mHealth and patientgenerated data (e.g. PROMs).

“Artificial intelligence and machine learning algorithms can unlock this knowledge to improve allocation of scarce resources, reveal patient phenotypes, reduce repeat interventions, prioritise patients and stratify outcomes,” Prof Dickman concluded.

Francisco C Figueiredo MD, PhD, FRCOphth, Professor of Ophthalmology at Newcastle University, UK, spoke about Developments in Limbal Stem Cell Transplantation, another area of interest for the ECCTR. Stating that there were 240 estimated new cases of limbal stem cell deficiency (LSCD) per year in the UK, in otherwise healthy eyes, he said that it is essential to develop alternative therapies.

However, studies have shown that autologous limbal stem cell transplantation can successfully restore the integrity of the ocular surface of eyes with total unilateral LSCD and consequently restore sight. In bilateral cases autologous oral mucosa stem cell transplantation has also shown good outcomes.

EUROTIMES | MARCH 2020

11

BOSTON | 14-15, 2020 Immediately preceding the ASCRS ASOA Annual Meeting

World Cornea Congress VIII, Featuring: Symposia

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Spotlight Sessions • Fuchs’ Dystrophy

• Refractive Surgery • Eye Banking • Complex Keratoplasty/ Anterior Segment Reconstruction

• Corneal Regenerative Medicine • DOG: Successful DMEK Surgery • SICSSO & SITRAC: Cornea Ectasia • K-Pro Society Updates • Corneal Infections • Kera-net Live

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SPECIAL FOCUS: CORNEA

13

LIMBAL CELL transplants Success of limbal cell transplantation continuing to improve.

Priscilla Lynch reports

EUROTIMES | MARCH 2020

Courtesy of Harminder Dua, CBE, MD, PhD

T

he success of limbal cell transplantation for treating non-healing corneal ulcers continues to improve due to advances in the stem cell supports for this procedure, according to Harminder Dua, CBE, MD PhD, University of Nottingham, Queen’s Medical Centre, Nottingham, UK. Addressing the potential of corneallimbic keratoplasty during a dedicated session on non-healing corneal ulcers at the 10th EuCornea Congress in Paris, France, Prof Dua noted that “limbal cell deficiency is a very important cause of non-healing corneal ulcers”, with transplantation regularly indicated to restore normal corneal epithelium in these cases.

The source of cells and tissue for treating non-healing ulcers includes the limbus, but also the conjunctiva, Buccal mucosa and mesenchymal cells, he explained.

Looking at limbal cell transplantation techniques, he said the main objective is to cover the ulcer with cells from the source tissue, with two main approaches used: in-vivo expansion and ex-vivo expansion. “Both require a good substrate for cells to grow on, from where you transfer them to where you Figure Legend: Amnion-assisted conjunctival epithelial re-direction in limbal stem cell transplantation. A. Vacuum-dried amnion (Omingen), fluorescen stained and B. without fluorescein stain is shown covering the limbal explants at 12 and 6 o’clock positions. The want them to be… and these substrates amnion is tucked under the peritomised conjunctiva along the circumference. This forces conjunctival epithelium to grow on the amnion, can be natural basement membranes, leaving the limbal explant derived epithelium to cover the cornea without conjunctivalisation as seen in C. with fluorescein stain and D. natural proteins and synthetic without fluorescein stain, after removal of the amnion on week 3 polymers,” Prof Dua said, going on to discuss the benefits of each option.

Outlining the use of amniotic membrane as a support structure for stem cells in transplantation, the latest approach involves improve the ability of the cells to grow and attach better to the modified human amnion that has been gamma-radiated and substrate” during transplantation. decellularised with sodium dodecyl sulfate or low heat vacuum “These are things that are being worked on and it is likely dried amniotic membrane without spongy layer (Omnigen) that we will eventually have synthetic polymers; there is a lot of which are efficient substates for the ex-vivo expansion of work going on with this, and these are very biocompatible,” and limbal stem cells, and have certain advantages but also some could have many customised benefits, he noted. limitations such as limited flexibility and early dissolution, In summary, Prof Dua said that natural (same site, he said. orthotopic) in-vivo substrates support stem cells best. Natural Looking at the use of biopolymers, Prof Dua said fibrin sheet (non-same site, heterotopic) substrates also support stem cells technology “is the most well-tested biopolymer and is used well, amnion being the most popular. While biopolymers have as the substrate in the only licenced stem cell product in the several advantages, synthetic polymers are likely to be the world so far (Holoclar)”, while with gelatin sheets, “it has been future, he concluded. shown you can increase the roughness, stiffness and integrin 1 expression, metabolic activity and ABCG2 expression, and Harminder Dua: profdua@gmail.com

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Femto-LASIK alongside PK Femto-LASIK safe and effective for ametropia correction post PK. Dermot McGrath reports

F

emto-LASIK is a safe and effective means of reducing postoperative refractive error in patients who have previously undergone penetrating keratoplasty procedures, according to Luca Terracciano MD. “Despite a clear corneal graft, the presence of high refractive defects can often lead to an unsatisfactory visual outcome after keratoplasty procedures. Non-surgical options such as spectacles and contact lenses may not be able to effectively correct a very high defect,” he said Dr Terracciano’s study included 10 eyes of 10 patients who underwent keratoconus full-thickness keratoplasty.

The WaveLight Refractive Suite (Alcon), incorporating the Wavelight EX500 excimer laser and the Wavelight FS200 femtosecond laser, was used to create a 130μm lamellar flap with a superior hinge. The flap diameter average was 0.2mm smaller than graft-host junction and was centred inside the donor button. After flap creation, it was lifted and excimer laser ablation for refractive correction was performed.

At 12 months’ postoperative evaluation, all patients showed a significant improvement in their uncorrected visual acuity as well as in the cylindrical ametropia and best-corrected visual acuity. No statistically significant difference was observed for postoperative spherical ametropia.

“We found this procedure to be safe and free of complications. Creating the flap with the femtosecond laser and performing excimer laser ablation within the corneal graft limits without involving the graft-host junction minimises the risk of rejection and allows good results in correction of aberrations,” he told delegates attending the 37th Congress of the ESCRS in Paris.

Dr Terracciano, Department of Translational Surgery and Medicine at the University of Florence, Italy, said that despite the overall viability of the approach, the correction of high ametropia after corneal transplantation is affected by technical and anatomical limits that do not always allow satisfactory results to be achieved.

“The procedure works better with a small amount of ametropia: in other cases, attention must be taken in defining the refractive results you may achieve and a different approach should be considered when only corneallaser therapy is not the best option – you can think about combined corneal/intraocular surgery trying to regularise the cornea before cataract surgery; toric or piggyback IOLs are another possible alternative, as is a combined corneal procedure such as astigmatic keratotomy/relaxing incisions and femto-LASIK” he said.

Summing up, Dr Terracciano said that correcting the preoperative manifest refractive error with femto-LASIK led to a significant improvement in uncorrected visual acuity without surgical complications and confirms the effectiveness and safety of femto-LASIK treatment for post PK residual refractive errors particularly in patients with low spherical and cylindrical defects as previously suggested in literature.

The reduction of astigmatism may allow improved contact lens or spectacle fitting in order to achieve best-corrected binocular visual acuity.

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.

Join

the ECCTR Registry

Track

your Surgical Results

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

Luca Terracciano: terracciano.oculista@gmail.com EUROTIMES | MARCH 2020

15

16

CATARACT & REFRACTIVE

Long-term outcomes ESCRS panel reviews what has been learned with longer follow-up of refractive procedures. Howard Larkin reports

W

hat happens to our refractive surgery patients in the long term? A panel of leading ESCRS ophthalmic surgeons addressed this question at a special session of the American Academy of Ophthalmology annual conference in San Francisco, drawing on primary research and extensive literature searches.

SUBTRACTIVE CORNEAL SURGERIES Surface ablation, including PRK and trans-PRK, lamellar procedures, including LASIK and femtolaser, and lenticule extraction procedures, including SMILE®, are safe and produce comparable visual outcomes with good predictability for periods up to 18 years, said Thomas Kohnen MD, PhD, FEBO, of Goethe University, Frankfurt, Germany.

While serious complications are rare, all subtractive procedures change the cornea’s shape and refractive power by removing tissue through ablation or lenticule removal, effectively thinning it. Because of this, treatment guidelines recommend limiting the power of corrections. For example, the German commission for refractive surgery (KRC) guidelines revised for 2019 call for generally applying myopic corrections up to -6.0Dfor PRK, and -8.0D for LASIK and SMILE, limiting corrections to no more than another -2.0D in any case, Prof Kohnen noted.

Short-term corneal haze is still an issue with surface ablation, though it generally clears with time. Haze risk increases with deeper ablations, poor corneal surface quality, hyperopic and high astigmatism corrections, repeat treatments, UV exposure and age, Prof Kohnen said. Longterm issues with PRK and LASIK include myopic regression, with LASIK more stable after six years. SMILE refractive results are stable out to five years. Challenges include predicting and preventing ectasia, and accurately calculating IOL power for subsequent cataract surgery.

PHAKIC IOLS With angle-supported PIOLs no longer on the market, Rudy MMA Nuijts MD, PhD, of Maastricht University Eye Clinic, the Netherlands, focused on iris-fixated and implantable collamer lenses (ICLs).

Iris-fixated lenses are available in myopic EUROTIMES | MARCH 2020

corrections up to -23.5D for nonfoldable, and -14.5D for foldable, while ICLs range from +10.0 to -18.0D, making them useful for higher corrections.

However, in prospective studies both angle-supported and ICL PIOLs increase endothelial cell loss by two-to-three times physiological rates overall, though rates vary widely and loss may accelerate significantly after 10 years. In addition, all phakic IOLs promote increased axial length, and ICLs promote anterior subcapsular cataract formation, resulting in an overall mean decline in uncorrected distance visual acuity of 1.5 Snellen lines due to myopisation and cataract at 10 years. In addition, 10-year explant rates vary up to 12% for iris-fixated PIOLs and 18% for ICLs, though explant rates for irisfixated lenses may increase significantly after 10 years.

Explantation risk is increased by shallow anterior chamber depth, preoperative endothelial cell density and hyperopic corrections for iris-fixated PIOL risk, and long-term insufficient vaulting leading to cataract formation with ICLs, Dr Nuijts noted. He recommended regular follow-up checking endothelial cell loss extending past 10 years, and counselling patients that PIOLS may be a temporary solution.

TORIC IOLS Long-term toric IOL success depends on rotational stability, said Oliver Findl MD, of Hanusch Hospital, Vienna, Austria. Rotation mostly occurs in the first hours after surgery and is less likely once the capsule fuses, though fibrosis may result in late rotation.

Steps during surgery that may help prevent early rotation include waiting for full haptic extension, completely removing viscoelastic and maintaining anterior chamber stability.

Resting patients for an hour after surgery may also be helpful, Dr Findl said. Generally speaking, rotation risk drops substantially after about 15 days due to fusing of the anterior and posterior capsule.

When implanting toric IOLs in younger patients, long-term axis shift should be considered, Dr Findl said. With-the-rule astigmatism begins to shift toward againstthe-rule around age 36, continuing until about age 69, mostly due to changes in the anterior corneal surface possibly from reduced eyelid tension. Therefore, patients in their 40s or early 50s should be undercorrected for with-the-rule astigmatism,

and fully corrected or even over-corrected for against-the-rule errors to improve long-term visual outcomes.

MULTIFOCAL IOLS Multifocal IOLs are not advisable for patients at risk of central visual field reduction due to macular degeneration, retinal disease or glaucoma, due to the risk of reduced visual acuity and contrast sensitivity, said Béatrice Cochener-Lamard MD, PhD, of the University of Brest, France.

MIOL complications occur mostly in the short term, Dr Cochener-Lamard said.

Patients with capsule ruptures are at higher risk of cystoid macular oedema. Patients who are younger (less than 54 years old), male and with long axial (over 24 mm) length are at higher risk for retinal detachment, according to a retrospective study on 1,500 patients followed for fiveto-10 years). Nd-YAG capsulotomy for PCO did not increase retinal risk significantly, but it should not be done earlier than six months after surgery and after eliminating all other causes of visual impairment.

Primary open-angle glaucoma presents an MIOL challenge due to reduced contrast sensitivity while pseudoexfoliation increases the chances of lens dislocation, Dr Cochener-Lamard noted. Any intraoperative complication that compromises good and safe positioning of the multifocal IOL justify to switch for a monofocal implantation.

Failure to neuro-adapt is the unpredictable cause of MIOL failure, Dr Cochener-Lamard said. Other factors are decentration, IOL opacification, large pupil size and, first of all, dry eye. These should be considered before surgery. All can induce dysphotopisa, haloes, glare, diplopia, poor visual recovery, all occurring actually in short term.

Finally, while there are no reports of explantation after 10 years, what happens to MIOLs after 20 years is unknown, so care should be taken in implanting them in young patients, she added. Success of the surgery is determined by proper patient selection and exhaustive information, and talk of the longterm is required.

Thomas Kohnen: kohnen@em.uni-frankfurt.de Rudy Nuijts: rudy.nuijts@mumc.nl Oliver Findl: oliver@findl.at Béatrice Cochener-Lamard: beatrice.cochener@ophtalmologie-chu29.fr

CATARACT & REFRACTIVE

17

Negative dysphotopsia Optical modelling applied to elucidate the cause of bothersome visual symptoms.

Cheryl Guttman Krader reports

MODELLING RESEARCH Because the pseudophakic eye is an unusual imaging system, the ray-tracing calculations for studying negative dysphotopsia uses special calculations with the Zemax optical design software. In addition, Dr Simpson has used simulated text rather than just a uniformly bright object field to gain a better understanding of far peripheral vision (Figure 2).

Courtesy of Michael J Simpson PhD

R

esearchers appear to have moved towards a hypothesis that explains the cause for negative dysphotopsia, the dark shadows that are perceived in the temporal visual field by some pseudophakic patients. Confirmation of the hypothesis, however, requires further study to fill gaps in data for a variety of related parameters, said Michael J Simpson PhD. Speaking at the 37th Congress of the ESCRS in Paris, France, Dr Simpson discussed optical modelling work he has been doing with ray tracing to understand far peripheral vision and to characterise the aetiology of negative dysphotopsia. Dr Simpson is an optics expert from Arlington, TX, USA. He told attendees that while negative dysphotopsia has been considered an artefact associated with certain IOLs or surgical techniques, it is probably actually a fundamental property of the optics of the pseudophakic eye (Figure 1).

“In the phakic eye, the crystalline lens pushes the iris forward, and all light passing through the pupil enters the lens and forms an image. With an IOL, however, the lens is very much smaller, and there is also a gap between the iris and lens. The result of these differences is that at large visual angles the main image goes dark because light no longer enters the lens, and a shadow region is created in the periphery,” Dr Simpson said.

“Light that misses the lens illuminates the shadow as the pupil opens so that the shadow rapidly disappears. This sensitivity to pupil size may explain why negative dysphotopsia can be so bothersome to patients.”

This explanation for the cause of negative dysphotopsia is consistent with patient complaints, which only arose after small incision surgery using phacoemulsification and foldable IOLs improved capsule clarity, which probably provided a direct path to the peripheral retina, Dr Simpson said.

Figure 1 (below): A view of the right eye from above; Figure 2 (top): Simulated images of a peripheral region of the visual field for a pseudophakic eye with a 2.5mm diameter pupil. Visual angles are only very approximate.

The results from the modelling showed that light missing the IOL comes from a lower visual angle and experiences lower power so that it forms a larger image. The research also demonstrated the effect of pupil size on negative dysphotopsia as well as the potential that different lens styles may have different effects. In addition, it has provided information about how the IOL haptic junction can affect negative dysphotopsia and the changes that occur with sulcus implantation of a piggyback IOL. “Whereas earlier discussions indicated that the cause of negative dysphotopsia was unknown, patients are likely to be reassured if told that the dark shadows they are seeing have a known cause. Although sulcus implantation of a piggyback IOL may be effective sometimes in reducing or eliminating negative dysphotopsia, the new evaluations may help with management of the issue.”

FUTURE DIRECTIONS Dr Simpson stated that there is a basic need to improve characterisation of vision in the far periphery, which is largely a neglected topic. There is also a need for more clinical data relating to negative dysphotopsia.

“According to the literature, negative dysphotopsia seems to be mainly visible when the pupil is small. We need to know at what visual angle and at what pupil diameters the shadow becomes bothersome for patients, and studies should not group together multiple lens styles,” Dr Simpson said.

Perimetry is the main test that is used

to measure peripheral vision in general, but typically pupil diameter is neither controlled nor measured, and there is no mechanism for dealing with a peripheral double image.

“With complete patient data and optical modelling, we should be able to verify the cause of negative dysphotopsia and understand why only some patients complain about this symptom. This new knowledge is then likely to lead to longer term solutions,” Dr Simpson said.

The current work has been accepted for publication by the Journal of Cataract & Refractive Surgery (JCRS).

Michael J Simpson: mjs1@outlook.com EUROTIMES | MARCH 2020

18

CATARACT & REFRACTIVE

IOL power calculation innovations Improving accuracy by using intraoperative OCT to measure ACD. Cheryl Guttman Krader reports

I

ntraoperative optical coherence “If you look at series of very short tomography (OCT) measurement of or very long eyes, not even 50% have a anterior chamber depth (ACD) in refractive outcome within 0.5D of target,” the aphakic eye improves prediction said Dr Hirnschall. of postoperative IOL position Use of continuous anterior and therefore holds promise for segment OCT to measure the improving the predictability ACD in the aphakic eye is of refractive outcomes after based on the concept that it cataract surgery. It will not, will provide a more accurate however, completely eliminate determination of where the the chance of a refractive IOL will sit after surgery than surprise, said Nino Hirnschall the effective lens position that MD, PhD, at the 37th Congress of is determined with conventional the ESCRS in Paris, France.

IOL formulae using preoperatively Nino Hirnschall “Modern IOL power formulae that measured parameters.

MD, PhD use preoperative ACD for predicting The OCT-based measurement IOL position are already very good, but of “intraoperative ACD” represents the I believe they can be improved in the distance between the corneal endothelium future by introducing intraoperative ACD and the anterior lens capsule. In measurements of the aphakic eye,” said Dr an initial study, Dr Hirnschall and Hirnschall, Vienna Institute for Research in colleagues reported that its use resulted Ocular Surgery, Hanusch Hospital, Vienna, in significantly better prediction of the Austria. postoperative IOL position compared “Yet, our research shows that there are with conventional IOL power calculation still some refractive surprises that cannot formulae. be explained by intraoperative OCT. Therefore, I believe that no matter what REFINING THE MEASUREMENT kind of measurements and techniques that In the initial study, a capsular tension we use, there will always be the small ring (CTR) was implanted in all eyes chance of a >1D refractive surprise in eyes to maintain a taut capsule during the with a very special anatomy.” measurement. Although there is weak

TARGETING THE MAIN SOURCE OF ERROR With the goal of further optimising postoperative refractive outcomes, Dr Hirnschall and colleagues have been focusing on improving prediction of postoperative IOL position, recognising that it is the main source of error in IOL power calculations and particularly in eyes that have a very short or very long axial length (AL).

evidence that having a CTR implanted has no relevant influence on the refractive outcome, Dr Hirnschall suggested that it would be best to eliminate its use in the second part of the study considering it adds cost to the surgery.

As another limitation, the initial study was done with a time domain OCT system that has only moderate resolution. As a next step, Dr Hirnschall and colleagues implemented a swept-source OCT device into the operating microscope that

Modern IOL power formulae that use preoperative ACD for predicting IOL position are already very good, but I believe they can be improved Nino Hirnschall MD, PhD EUROTIMES | MARCH 2020

If you look at series of very short or very long eyes, not even 50% have a refractive outcome within 0.5D of target Nino Hirnschall MD, PhD provides higher resolution. Its use also enabled the identification and elimination of adhesions between the capsule and iris that can affect ACD, and it incorporates an additional fixation check to assure measurement of the patient’s visual axis.

In a study including 70 eyes comprised mostly of very long or very short eyes that did not receive a CTR, the researchers found that use of intraoperative ACD outperformed preoperatively measured variables – i.e., ACD + lens thickness (LT), ACD, AL and LT – for predicting postoperative IOL position. Analyses of postoperative refraction predictions using different variables combined with AL showed that intraoperative ACD + preoperative ACD + LT + AL performed the best, with 96% of eyes predicted to be within 0.5D of their target refraction.

“This is a very good result, but it is not 100%, and it seems that although you think you know where the IOL will sit after surgery, there are outliers that cannot be explained by the intraoperative measurements,” Dr Hirnschall said.

Going forward, Dr Hirnschall and colleagues are aiming to address the role that vitreous hydration has on predicting postoperative IOL position.

“Significant vitreous hydration, which is seen in 2% of patients, remains as an unpredictable factor that could influence ACD,” he said.

CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 46 ISSUE:1 MONTH: JANUARY 2020

SWEPT-SOURCE OCT IMPROVES FORMULA ACCURACY Preoperative biometry measurements using swept-source optical coherence tomography (SS-OCT) can be used to improve the refractive outcomes of IOL power calculation, researchers report.

Italian investigators took preoperative measurements using the OA-2000 (Tomey Inc.) in a consecutive series of 150 eyes undergoing cataract surgery with one IOL model (AcrySof SN60WF; Alcon Laboratories, Inc.). They then entered the measurements into several formulas including: Barrett Universal II, Emmetropia Verifying Optical (EVO), Haigis, Hoffer Q, Holladay 1, Holladay 2, Holladay 2 with axial length adjustment, Kane, Olsen, Panacea, SRK/T, T2, and VRF. The SS-OCT biometry enabled accurate IOL power calculation, improving refractive outcomes, because all formulas yielded a prediction error within 0.50D in at least 80% of eyes. The Barrett, EVO, Holladay 2 with axial length adjustment, Kane, RBF and T2 achieved the highest percentages (≥88%).

G Savini, et al., “Comparison of formula accuracy for intraocular lens power calculation based on measurements by a swept-source optical coherence tomography optical biometer”, 46(1): 27-33.

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

2018 OBSTBAUM AWARD BEST ORIGINAL ARTICLE

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

COSMETIC IRIS IMPLANTS Cosmetic iris implants carry risks for several ocular complications and decreased mean visual acuity in otherwise healthy young people, a multi-centre study concludes. Although originally developed to manage congenital or traumatic iris defects, the implants are also used to change the colour of patient eyes.

The aim of this retrospective series was to report complications in patients managed in France after cosmetic implantation. An analysis of questionnaires collected from throughout France showed that only a small minority of patients did not experience any complications, while 92% did have at least one complication.

The most common problem was corneal decompensation, followed by glaucoma. Most, 81.5%, required explantation.

H El Chehab et al. “Complications of cosmetic iris implants: French series of 87 eyes”, 46(1):34-39, January 2020.

2018 ROSEN AWARD BEST TECHNICAL ARTICLE

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

PCIOL FOR HIGH MYOPIA AND PRESBYOPIA A new posterior chamber phakic IOL (IPCL, EyeOL UK) appears to offer the promise of the correction of both high myopia and presbyopia. In a prospective cohort study, patients with presbyopia and moderateto-high myopia received the lens. Follow-up evaluation conducted up to two-year postoperatively showed high-quality uncorrected distance and near visual acuity after the presbyopic phakic lens implantation.

The mean distance refraction improved significantly from -6.9 dioptres (D) preoperatively to -0.35D. Near vision also improved, with 15 of 17 eyes gaining uncorrected near visual acuity to J1 (Jaeger chart) at the two-year follow-up. The hydrophilic acrylic IOL has a refractive optic and diffractive trifocal pattern on its anterior optical surface to correct distance and near refractive errors. P Stodulka et al., “Posterior chamber phakic intraocular lens for the correction of presbyopia in highly myopic patients”, 46(1):40-44, January 2020.

JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | MARCH 2020

19

CATARACT & REFRACTIVE

Improving calculations Artificial intelligence-based approach seen as the best solution.

Cheryl Guttman Krader reports

A

rtificial intelligence (AI) is here, and it will provide the pathway forward for achieving higher levels of refractive accuracy in cataract surgery, predicted John Ladas MD, PhD. Speaking at the 37th Congress of the ESCRS in Paris, France, Dr Ladas described the work being done to develop a universal “super algorithm” that can improve any existing IOL formula at an accelerated rate.

“Artificial intelligence will transform IOL calculations just like it has transformed countless industries,” said Dr Ladas, Director, Maryland Eye Consultants & Surgeons, Silver Spring, MD, USA. “The shared vision of all cataract surgeons is to keep improving the accuracy of our IOL calculations. Just 10 years ago, the benchmark for success was to achieve an outcome within 0.5D of the target refraction in 55% of eyes. We have shown that we can raise that rate to 86% when we introduce AI, and we think the success rate can be improved even further, exceeding 90% and even reaching 95%.”

He added that major companies are exploring partnerships for adoption of the AI-based method.

“We have already started to develop the infrastructure to develop the methodology and hope to bring it to you soon,” Dr Ladas said.

formulas but they are static in the sense that they can never evolve. The Hill-RBF formula is AI-based, but it is dataset limited, meaning that if you want to add another variable, the formula has to be reinvented,” Dr Ladas said.

“Our approach is a combination of AI plus the framework that is applied to a framework or baseline formula. This can be any existing formula, such as the Barrett Universal II, Haigis, Holladay, SRK/T, Hoffer Q, etc.”

Rather than predicting an outcome, the PLUS AI-based model starts with the input variables for a case and predicts an adjustment from the baseline formula. As other variables emerge, they are weighted appropriately and the algorithm evaluates what the error is from what was predicted.

Findings from a study that included data from 1,471 eyes operated on in a university setting with IOL calculations done using the Barrett formula showed how application of the AI methodology could improve refractive outcomes after cataract surgery, Dr Ladas said.

“In every AI model we used, we found statistically significant improvement in mean absolute error compared with the result achieved using the Barrett formula,” he said.

A BIG DATA APPROACH

The pathway forward relies on accumulating massive amounts of data. To meet this need, Dr Ladas envisions that IOL power calculation will be performed using the optical biometry measurements and the AI-based formula. Then, measurements obtained three weeks postoperatively will lead to algorithm optimisation. Ultimately, he foresees use of a “self-calibrating” biometer that uses objective data from millions of eyes and performs an AI-based lens calculation.

“It can be tailored to individual surgeons or groups and will evolve in perpetuity. No human can write that evolution,” Dr Ladas said.

Now, Dr Ladas and nine other high-volume surgeons are participating in a pilot project in which they will collect massive amounts of data and evaluate how the AI-based system can lead to better refractive outcomes.

Dr Ladas has named the AI method “PLUS” (Precision Ladas Universal Superalgorithm, Advanced Euclidean Solutions). It is a dynamic system that will automatically adjust an IOL formula using data submitted in real time from surgeons all over the world, and it can evolve over time to incorporate new variables that may be determined useful in the future.

“Axial length, corneal power and anterior chamber depth are the standard measurements used in IOL formulas, but there is a list of other biometric parameters that might be considered, such as lens thickness, preoperative refraction, white-to-white distance, posterior corneal astigmatism and equatorial lens position, to name a few. There is no human intelligence that can assimilate all of these factors,” said Dr Ladas.

“Vergence formulas and ray-tracing formulas are great

NEXT STEPS

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& Development

CATARACT & REFRACTIVE

Low-energy SMILE Reduced laser energy improves outcomes in SMILE procedures.

Dermot McGrath reports

R

educing the laser energy settings for small-incision lenticule extraction (SMILE®) procedures results in dramatically improved visual acuity outcomes in the immediate postoperative period, according to a study presented at the 37th ESCRS Congress in Paris.

“Reduced energy settings, with lower energy per spot and wider spot spacing, only recently became available in the United States. After applying these changes, we noticed a dramatic improvement in uncorrected visual acuity on postoperative day one, with patients reliably achieving 20/20 or better,” said Jillian Chong MD.

Reduced energy settings, with lower energy per spot and wider spot spacing, only recently became available in the United States Jillian Chong MD

Although SMILE treatments for myopia and myopic astigmatism have been FDA-approved since February 2017 and October 2018 respectively, American surgeons have been slow to embrace lenticule extraction as their first-choice refractive procedure, noted Dr Chong.

“Despite knowledge that there is a decreased incidence of dry eye and an improvement in biomechanical stability in patients treated with SMILE compared to LASIK, surgeons have been reluctant to switch – partly due to the excellent postoperative day-one visual acuities and overall efficacy of LASIK. There is also a perception that patients treated with SMILE take longer to recover postoperatively,” she said.

Dr Chong noted that the initial FDA approval for myopia was for a laser spot spacing of 3.0μm, which was subsequently extended to a range of 3.0-to-4.5μm for myopic astigmatism. The spot spacing is relevant in SMILE procedures, as there is an increased risk of opaque bubble layer (OBL) formation with higher energy settings. The presence of OBL can interfere with laser penetration and result in more complex and traumatic dissections, which in turn prolong recovery time, she said.

“Our hypothesis was that the wider spot spacing and lower energy settings would

improve the speed of postoperative recovery for patients treated with SMILE,” she said.

Dr Chong’s retrospective study included 262 eyes treated by a single surgeon (D. Rex Hamilton, Santa Monica Eye Medical Group, Los Angeles, CA, USA) over a 12-month period. Patients were divided into three categories: low-energy SMILE (24), highenergy SMILE (129) and LASIK (175), with endpoints being uncorrected visual acuity one day and one month after surgery.

For SMILE outcomes, the difference in uncorrected visual acuity (UCVA) at day one postoperatively was highly statistically significant in favour of the low-energy group. The low-energy group also closely matched the performance of LASIK, with 89% attaining UCVA of 20/20 or better compared to 91% for LASIK and just 24% for high-energy SMILE. At one month after surgery, 100% of low-energy SMILE eyes had UCVA of 20/20 or better compared to 95% for LASIK and 74% for high-energy SMILE. “This improvement may render SMILE more attractive to patients and to refractive surgeons in the United States and increase the adoption rate of this procedure,” said Dr Chong.

Jillian Chong: Jillian.Chong@nyulangone.org

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CATARACT & REFRACTIVE

Toric IOL outcomes Comparative study seeks highest prediction accuracy.

Cheryl Guttman Krader reports

Figure 1. POM3 WTR results by mean centroid error of prediction error for each modality.

Figure 2. POM 3 ATR results by mean centroid error of prediction error for each modality.

Figure 3. POM3 Oblique results by mean centroid error of prediction error for each modality.

oric IOL prediction accuracy varies significantly depending on the tool used to measure corneal astigmatism, reported Qayim Kaba at the 37th Congress of the ESCRS in Paris, France.

He presented results from a prospective cohort study that showed the corneal astigmatism prediction error differed whether the keratometry data used for toric IOL calculations was acquired with the OPD (Nidek), Pentacam (Oculus) or IOLMaster (Carl Zeiss Meditec). Overall, Pentacam topography resulted in the least corneal astigmatism prediction error.

“Keratometry values from these three modalities may be used for toric IOL calculations to determine the most suitable lens for correcting astigmatism, but to our knowledge, no study has compared the accuracy of their predictions,” said Mr Kaba, a medical student in the United Kingdom, presenting the research conducted at Uptown Eye Specialists, Canada.

The investigation included 42 eyes of

26 patients that had reliable topography measurements and no ocular comorbidities.

Postoperative residual astigmatism was determined using vector analysis.

Comparisons between modalities were based on the centroid astigmatism prediction error and with eyes categorised by type of astigmatism. Astigmatism was with-therule (WTR) in 13 eyes, against-the-rule (ATR) in 23 eyes and oblique in six eyes.

Postoperative three-month results showed the centroid error of prediction error in WTR eyes was greatest using keratometry data from the IOLMaster (0.23D@150°) and not significantly different comparing the Pentacam (0.12D@128°) and OPD (0.11D@60°). In the eyes with ATR astigmatism, the centroid error of prediction error was lowest for the Pentacam (0.04D@169°) and not significantly different between the IOLMaster and OPD (0.08D@54° and 0.09D@34°, respectively).

In the cohort with oblique astigmatism, the centroid error of prediction error was identical using the Pentacam and OPD keratometry values (0.02D @148°) and

significantly greater using the IOLMaster (0.13D@142°).

An axis-to-axis comparison was also done, and the analyses showed no statistically significant difference for actual and predicted axis comparison between the IOLMaster, Pentacam and OPD.

T

TOPICS FOR FUTURE RESEARCH Mr Kaba noted that the prediction accuracy using the optical biometer for measuring the cornea might be improved using the newer IOLMaster 700, which differs from the IOLMaster in that it incorporates the posterior cornea to calculate total keratometry. He also noted that the current APACRS toric IOL calculator allows surgeons to input keratometry data from different modalities which can generate a value for use in the power calculation.

“It would be interesting to see if these methods result in higher prediction accuracy for toric lenses,” he said.

Qayim Kaba: qayimkaba@gmail.com

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS EUROTIMES | MARCH 2020

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Courtesy of Qayim Kaba

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CATARACT & REFRACTIVE

Endophthalmitis after surgery Lower endophthalmitis risk in bilateral same-day cataract surgery.

Dermot McGrath reports

B

ilateral same-day cataract surgery is associated with a lower endophthalmitis rate than that of unilateral surgery, according to analysis of more than 1.4 million operations in the Swedish National Cataract Registry.

“We all know that bilateral cataract surgery may have distinct advantages and I think it would be used much more if we did not have the fear of causing bilateral complications, of which endophthalmitis is the most feared,” Per Montan MD told delegates attending the European Society of Ophthalmology meeting in Nice, France.

Dr Montan’s study looked at various risk factors for endophthalmitis using a logistic regression model to analyse data in the Swedish National Cataract Registry over a period from 2002 to 2017.

“Some clear trends are evident. The number of surgeries has increased over the years, as has the use of bilateral cataract surgery. The age of the patients is decreasing and the visual acuity of the operated eye is also a lot higher than it used to be, with surgeons quicker to treat patients that are in the early stage of cataract development.

Finally, we see that the capsular rupture rate is constantly decreasing among our operations, from 2.6% in 2002 to 1.2% in 2010 and 0.8% in 2017,” he said.

As elsewhere in the developed world, the incidence of endophthalmitis has declined steadily over the years in Sweden.

“This is mainly due to the decrease of risk factors that we have been analysing in our registry. Older age over the age of 85 seems to be a risk factor, as is the non-use of intracameral antibiotics and capsular rupture,” said Dr Montan, St Erik’s Eye Hospital, Stockholm, Sweden.

Dr Montan said that over the 16-year period there were 14 cases of endophthalmitis in 92,200 bilateral surgeries, which is a rate of 0.015%, or one case in every 6,000 surgeries. This compared with 412 cases in 1,364,600 surgeries for unilateral procedures, which is 0.03%, or one case of endophthalmitis for every 3,000 operations, a statistically significant difference.

Dr Montan said that the difference may potentially be due to selection bias, with younger and healthier patients being chosen for bilateral surgery. Using multivariate analysis, he reported that the endophthalmitis rate was 5.4 times higher in the case of capsular rupture, 5.0 times higher in the case of no intracameral antibiotics, 1.9 times higher for patients aged 85 or older and only half for bilateral surgery as compared to controls.

While the regression analysis showed that bilateral surgery was an independent protective factor against endophthalmitis, Dr Montan cautioned against reading too much into this.

“We need to dig more into the age factor as we know that patients undergoing same-day bilateral surgery are much younger than the rest. Surgical difficulties may also have an impact as this was an item introduced to the registry only since 2008. We are also using different intracameral antibiotics so that might be interesting to study in that context. There are also surgeon factors that may potentially be extracted from the registry because we know that the experience of the surgeon plays a role,” he concluded.

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Per Montan: per.montan@sll.se EUROTIMES | MARCH 2020

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CATARACT & REFRACTIVE

Enhancing toric IOL outcomes Study finds no benefit from adding a pseudophakic measurement.

Cheryl Guttman Krader reports

CALL FOR ENTRIES

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EUROTIMES | MARCH 2020

P

erforming another intraoperative aberrometry (IA) measurement after toric IOL implantation does not seem to improve the refractive outcome compared with obtaining a single measurement in the aphakic state, but it does add significant time to the case, said David Lubeck MD, at the 37th Congress of the ESCRS in Paris, France.

He reported results of a prospective, randomised, contralateral eye-controlled study showing that obtaining a second IA measurement in the pseudophakic state added more than three minutes of OR time to each case and did not increase the likelihood of an eye having less than 0.5D of residual refractive astigmatism at one month.

“It appears from this study that performing aphakic IA alone is sufficient to provide excellent clinical results with toric IOLs,” said Dr Lubeck. He presented the data on behalf of Satish S Modi, MD, who performed the study at Seeta Eye Centers, Poughkeepsie, NY, USA. The study included 35 patients with a mean age of 73.6 years presenting for uncomplicated bilateral cataract surgery with implantation of a toric IOL. An IA measurement was performed in the aphakic state in each eye and one eye was also measured with IA in the pseudophakic state.

The primary outcome of the study analysed the magnitude of residual refractive astigmatism at one month and found no statistically significant difference in this endpoint between the two measurement groups. There were also no statistically significant differences between groups in other refractive outcomes or keratometric data at one month, in mean refractive sphere, MRSE, average keratometry, or average keratometric cylinder.

“Impressively, 94% of eyes in both groups had ≤0.50D of residual refractive astigmatism,” Dr Lubeck said of Dr Modi’s study.

Based on the aphakic IA measurement alone, 61 of 70 eyes had a spherical equivalent refraction within 0.5D of the intended target, and the refraction was more than 1D from intended in only two eyes.

Data on the time required for IA measurement was also noted in each case. The mean time for the aphakic measurement was not significantly different comparing the two study groups, but the overall mean time was significantly shorter than the mean time needed for the pseudophakic measurement.

On average, the aphakic measurement took 51 seconds to complete whereas the mean time for one pseudophakic measurement was 71 seconds. In the pseudophakic state, however, each eye was measured an average of 3.4 times, and the mean total pseudophakic measurement time was 226 seconds (3 minutes 46 seconds).

The first aphakic measurement was done on both eyes; the eye randomised to just the aphakic measurement had the shown toric axis marked manually on the limbus and the implant was placed at that axis. The contralateral eye was randomised to an additional pseudophakic measurement. Though one pseudophakic measurement took 71 seconds, an average of 3.4 measurements were required to achieve the “NRR”, indicating no further rotation was required.

CATARACT & REFRACTIVE

‘Game-changing’ IOL The light-adjustable IOL should provide a premium monovision solution.

Cheryl Guttman Krader reports

A

light-adjustable IOL (Light Adjustable Lens, RxSight) is game-changing technology that should overcome some of the barriers to greater adoption of premium refractive lenses and create a paradigm shift in refractive cataract surgery, according to David F Chang, MD. Speaking at the 37th Congress of the ESCRS in Paris, France, he outlined benefits of using the light-adjustable lens (LAL) for post-refractive eyes and for presbyopia correction, and ways that it could transform the experiences of patients and surgeons in a win-win situation.

Dr Chang said that with the LAL, cataract surgeons will be able to achieve LASIKlike refractive outcomes because the power adjustments are done postoperatively, when the effective lens position and posterior corneal astigmatism no longer need to be estimated. The newly commercialised

LAL offers both spherical and toric power adjustment, which renders many preoperative and intraoperative diagnostics superfluous for these patients. He noted that postoperative adjustability is particularly advantageous for post-refractive eyes, in which IOL power calculation is least accurate.

Dr Chang added that the LAL provides a premium monovision approach for presbyopia correction, by delivering emmetropia in one eye, and the ability to increase or decrease the amount of myopia in the second eye postoperatively. “Minimonovision is popular because patients can achieve functional convenience without haloes and starbursts, or loss of contrast sensitivity,” said Dr Chang, clinical professor of ophthalmology, University of California San Francisco, USA. However, it is hard to know how much myopia the patient will want or tolerate in the near eye. “With the

LAL, patients can try pseudophakic minimonovision, and either increase or reverse the anisometropia after trying it,” he explained.

This is analogous to the way that contact lens patients can vary the amount of myopia in the near eye. “The light-adjustable lens is a great option for people who prioritise quality of vision, and don’t want the risks of starbursts and haloes”, he said.

“We often fail to recognise how stressful preoperative decision-making is for cataract patients, who have no way of previewing different IOLs or trying out different refractive targets,” said Dr Chang. “They are confused by the optical terms we use and by not really knowing how much they will be able to see without eyeglasses. Adjustability allows them to try out different refractive targets postoperatively before selecting the outcome they want.”

David F. Chang: dceye@earthlink.net

BIOMECHANICS MEETS TOMOGRAPHY H EY C O R VI S ST I just took a look at the tomography.

These values call for caution.

I don’t think I would operate.

H I P E N TA C A M The biomechanics looks good, though.

The cornea is very stable.

I don’t see any problem with operating.

O. K . TO G E TH E R N O W Tomography and corneal biomechanics together make the decision easier: Surgery could be an option.

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RETINA

Highly myopic macular holes Newer techniques lead to better outcomes in myopic macular holes.

Dermot McGrath reports

R

ecent advances in diagnostic instruments and vitreoretinal surgical techniques have led to improved anatomical and visual outcomes for patients with various macular pathologies associated with high myopia such as maculoschisis and macular holes, according to José García-Arumí MD, PhD. “We have made a lot of progress in the surgical treatment of these patients over recent years. Small-gauge surgery with internal limiting membrane (ILM) fovealsparing dissection and gas tamponade is a good option for symptomatic myopic foveoschisis, with inverted flap dissection technique increasing the rate of macular hole closure and visual acuity improvement,” he told delegates attending the 19th EURETINA Congress in Paris, France.

In a broad overview of the natural history, surgical indications and expected outcomes of myopic maculoschisis and macular holes, Prof García-Arumí, Instituto de Microcirugía Ocular, Barcelona, Spain, explained that there is an incidence of between 8 and 34% of maculoschisis in eyes with high myopia.

“It is a slowly progressive condition, combined sometimes with foveal detachment, lamellar or full-thickness macular hole, epiretinal membrane or vitreomacular traction. We know that 50% of these patients will develop macular hole or macular hole retinal detachment (MHRD), which can cause severe visual impairment and greatly impact on their quality of life,” he said.

Surgery is indicated if there is a decrease of visual acuity or foveal detachment.

“We need to bear in mind that foveal detachment is a risk factor for postoperative macular hole and worse postoperative visual acuity,” said Prof García-Arumí.

SPARING THE FOVEA The recommended surgical approach for such cases is vitrectomy with posterior hyaloid dissection, foveal sparing ILM peeling and gas tamponade.

“We know from studies that there is a greater incidence of macular holes with complete ILM peeling compared to a fovealsparing ILM peeling technique. Postoperative EUROTIMES | MARCH 2020

We need to bear in mind that foveal detachment is a risk factor for postoperative macular hole and worse postoperative visual acuity José García-Arumí MD, PhD visual acuity is also better in patients treated with the foveal-sparing technique,” he said.

Similarly, the studies in the scientific literature show that gas tamponade resulted in a higher resolution of foveoschisis in a shorter period of time than patients treated without gas, he added.

Prof García-Arumí noted that myopic macular hole is associated with posterior staphyloma in eyes with over 10D of myopia.

“There is not a detached posterior hyaloid in some cases because of vitreoschisis, and the diagnosis is frequently difficult due to RPE and choroidal atrophy. We see an evolution of myopic retinoschisis in 25% of patients. Asymptomatic macular hole is more prevalent in eyes with higher degrees of myopia and pronounced posterior staphyloma. Myopic macular holes may also be associated with a rhegmatogenous retinal detachment surrounding the hole,” he said.

Surgery is usually advocated in myopic macular holes, said Prof García-Arumí, “because we can improve the visual acuity and decrease the risk of retinal detachment”.

Nevertheless, the closure rates of myopic macular holes are reduced with the presence of posterior staphyloma and foveoschisis or in axial lengths of over 30mm, he said.

The anatomic success rate of myopic macular hole closure has improved in recent years with the introduction of the inverted ILM flap technique first described by Michalewska et al in 2010. In this approach, the ILM is not completely removed from the retina but is left in place, attached to the edges of the macular hole. This ILM remnant is then inverted to cover and fill the macular hole before fluid-air exchange is performed.

The superior results with the inverted ILM flap technique have been borne out by numerous studies in the scientific literature, said Prof García-Arumí.

“In our own series of patients in 2018, the rate of closure was 92% in the inverted flap group and 81% in the standard ILM group, but the differences are much greater in the other studies that have compared the two techniques,” he said.

GOOD STAINING ESSENTIAL One of the pearls for smooth surgery in these patients is to always stain the ILM properly, said Prof García-Arumí.

“Staining is critical because the ILM is very thin in these patients, and the RPE does not give a good contrast to really assess the quality of the ILM and perform the dissection around the macular hole,” he said.

Retinal detachment in myopic macular holes is more likely in highly myopic eyes with posterior staphyloma, and tangential traction from the vitreous cortex. There is also a higher risk of detachment if the macular hole is associated with foveoschisis, he said.

While there is no standard treatment for retinal detachment due to macular hole, Prof García-Arumí said his own preferred approach is vitrectomy with gas, silicone oil, ILM dissection and inverted flap technique with adjunctive buckling.

“The overall success rate is poorer than conventional retinal detachment, but it is interesting to note that Wakabayashi et al in 2018 had a 92% anatomic reattachment and closure rate with inverted flap technique compared with 39% for standard ILM peeling,” he said.

While macular buckling can be indicated when vitrectomy and inverted flap fails, the high risk of complications means that it is less frequently employed, he concluded.

José García-Arumí: jgarcia.arumi@gmail.com

th

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RETINA

The Amsterdam

D E B AT E S

Vitrectomy methods, uveitis work-ups topics of spirited debates.

Leigh Spielberg MD reports

T

he Amsterdam Retina Debate has become a veritable institution within EURETINA, appearing every year to cater to host experts willing to debate controversial or unresolved topics that have no obvious “right” or “wrong” answer.

Chaired by Professor Sarit Lesnik-Oberstein of the Netherlands, this year’s debate took place at the 19th Annual EURETINA Congress in Paris. It treated delegates to two separate battles: the first concerned the relative merits of cryotherapy versus laser in vitrectomy, while the second considered the extent to which extensive investigation is needed in uveitis cases.

Arguing against the statement, “Cryotherapy is Superior to Laser in Vitrectomy,” Paul Sullivan, Moorfields Eye Hospital, London, United Kingdom, started with a 77% majority in the pre-debate voting.

“Numerous randomised controlled trials have shown no significant difference between cryotherapy and laser, but does this mean that they are equally effective?” asked Dr Sullivan.

“In order to prove the superiority of one over the other, we would need a sample size of at least 868 eyes,” making such a study unlikely.

To make his case, Dr Sullivan focused on what he considers the inferior safety profile of cryotherapy. “Whereas retinal laser affects only the retina and the underlying retinal pigment epithelium, cryotherapy, which must be applied exteriorly, damages the conjunctiva, sclera, choroid and retina.”

Dr Sullivan also highlighted the serious dangers of severe overtreatment due to the difficulty of visualising recently treated regions. “I have also seen eyes in which the optic nerve and the macula had been frozen and thus scarred, leading to profound vision loss,” although he admitted that these were rare complications and generally only occurred in the hands of very inexperienced surgeons.

“Indirectly, cryotherapy both promotes inflammation and enhances intravitreal dispersion of viable retinal pigment epithelial cells, both of which are thought to increase the risk of proliferative vitreoretinopathy (PVR),” he said.

Rumana Hussain, St Paul’s Eye Unit, Liverpool, United Kingdom, argued against the topic’s current consensus. She started by countering Dr Sullivan’s safety concerns, referring to the book he wrote on vitreoretinal surgery, in which he states that “cryotherapy is safe and effective”. She also cited the risk of lens touch and the possibility of laser over-treatment, leading to retinal necrosis and new retinal breaks.

Dr Hussain then highlighted the therapeutic advantages.

“Laser can’t be used in the presence of subretinal fluid, it is difficult to use for blonde fundi and it cannot be used to treat adequately in the presence of lens or media opacities,” she said.

“Cryotherapy’s applications extend from retinal detachment repair to the treatment of more difficult entities like vasoproliferative tumours.”

EUROTIMES | MARCH 2020

Despite a lively, entertaining and well-researched defence of cryotherapy, the audience stuck with their pre-debate opinions and selected laser as the superior modality for retinal treatment.

UVEITIS: HOW MUCH INVESTIGATION NEEDED? The second debate, “Uveitis Always Needs Extensive Investigation”, pitted Lisa Faia MD, Associated Retinal Consultants, Michigan, USA, against Emmanuel Ramos de Carvalho, Moorfields Eye Hospital, London, United Kingdom.

Prior to the debate, delegates voted against the notion that uveitis always needs to be extensively investigated. Dr Faia argued convincingly against the “shotgun approach”.

“There is no single, pre-determined work-up for the uveitis patient. Instead, testing for each individual should be focused and efficient, and based on the ocular examination, patient history and associated signs and symptoms.”

She cited stress to the doctor, patient and healthcare system that could be incurred by unnecessary testing.

“False positives cause patient anxiety, such as in a case in which a patient who was referred to me had become convinced that he had lupus simply because an unnecessary test of his ANA was borderline positive,” said Dr Faia.

In addition, unnecessary testing can be expensive, and we are morally obligated to follow up on false positives with additional testing.

Dr Faia emphasised that extensive testing is warranted when the diagnosis remains unknown, when the disease does not respond to treatment as predicted, or when new symptoms arise.

Dr Ramos de Carvalho maintained that the relative rarity of uveitis warranted a maximal approach to get to a correct diagnosis.

“Otherwise, we risk missing severe diseases in individual patients. We are only able to make a specific diagnosis in 61% of anterior uveitis cases and 15% of intermediate uveitis cases.”

In posterior uveitis, even though tough a specific diagnosis can be made in 78%, the other 22% could represent very dangerous associated pathology, so further investigations are crucial.

“There is a wrong assumption amongst ophthalmologists that uveitis typically is a manifestation of ‘something else’ and the ‘something else’ must be identified, regardless of cost,” said Dr Ramos de Carvalho. He believes that doctors should investigate solely whenever it is felt that uveitis could be a manifestation of a serious systemic disease.

“Starting with a thorough examination, we can proceed to an intelligent differential diagnosis and selected investigations to arrive at the correct diagnosis and deliver the appropriate treatment.”

In the end, the audience agreed with Dr Faia.

Paul Sullivan: Paul.Sullivan@moorfields.nhs.uk Rumana Hussain: Rumana.hussain@liverpoolft.nhs.uk Lisa Faia: lfaia@arcpc.net Emmanuel Ramos de Carvalho: e.decarvalho@nhs.net

RETINA

Imaging for pathologic myopia Wide-field OCT leads to greater clarification in pathologic myopia.

Dermot McGrath reports

R

ecent advances in ocular imaging technology, in particular wide-field optical coherence tomography (OCT), have greatly facilitated the clarification of pathologies and pathogenesis of pathological myopia and related complications, according to Kyoko Ohno-Matsui, MD, PhD. Addressing delegates attending the 19th EURETINA Congress in Paris, Dr Ohno-Matsui, professor in the Department of Ophthalmology and Visual Science and chief of the High Myopia Clinic at Tokyo Medical and Dental University, Japan, focused on the utility of widefield OCT in imaging posterior staphyloma.

“Posterior staphyloma is the posterior outpouching of the wall of the eye and is a hallmark lesion of pathologic myopia. However, despite its importance we really had no reliable standardised methods to detect and analyse staphyloma,” she said.

Although 3D magnetic resonance imaging (MRI) has been successfully employed in detecting staphyloma, it is costly to use and is not viable as a screening device in routine clinical practice, said Dr Ohno-Matsui. Similarly, the limited scan length and depth of traditional OCT is unable to visualise the entire extent of wide and deep staphyloma.

Using a prototype ultra wide-field swept-source OCT (Canon Corp.), Dr Ohno-Matsui said it was possible to scan up to 24mm horizontally and to a depth of 5mm and to generate detailed three-dimensional reconstructions of posterior staphylomas.

She noted that the morphologic hallmarks of the posterior staphylomas on OCT include a smoothly configured border with a gradual thinning of the choroid from the periphery toward the edge of the staphyloma and a gradual rethickening of the choroid in direction toward the posterior pole. There is also a gradual thickening and inward protrusion of the sclera at the staphyloma edge.

“Wide-field OCT can provide tomographic images of posterior staphylomas in a resolution and size unachievable so far, and may ultimately come to replace 3D-MRI in assessing posterior staphylomas. The spatial relationship between eye deformity, vitreous changes and retinal complications is clearly visible in a threedimensional way,” she said.

Dr Ohno-Matsui showed several examples of highlydetailed staphyloma images obtained with wide-field OCT and demonstrated how the 3D OCT movie enables clear visualisation of the entire shape of the staphyloma.

“Unlike with 3D MRI, the spatial relationship between staphyloma and the optic disc and macular retinal vessels is clearly visible with wide-field OCT. This greatly facilitates the understanding of how visually important tissues are damaged by eye deformity due to staphyloma,” she said.

Widefield OCT is also useful in visualising and understanding other features commonly found in pathologic high myopia such as retinoschisis, abnormal vitreous layers and atypical posterior vitreous detachment, she said.

Kyoko Ohno-Matsui: k.ohno.oph@tmd.ac.jp EUROTIMES | MARCH 2020

29

RETINA

Digital 3D microscopy Two years of surgery using a digital 3D microscope convinces surgeon.

Leigh Spielberg MD reports

A

fter using a digital 3D microscopy system for two years, Peter Stalmans MD is convinced that the new technology confers several advantages compared to the traditional analogue setup.

Dr Stalmans, Leuven University Hospital, Belgium, discussed both the advantages and disadvantages of 3D system during a session of the 19th Annual EURETINA Congress in Paris. He discussed 3D microscopy in general and the ZEISS ARTEVO 800 system in particular.

A 3D digital operating microscope consists of a 3D camera system, a 3D monitor and 3D glasses. The camera is incorporated into what looks like a traditional operating microscope. The 3D monitor is positioned in front of the surgeon at approximately 1.2 metres’ distance. The 3D glasses are worn by the surgeon and instrumentation nurse, and confer the ability to see the screen’s image in three dimensions.

“A digital microscope allows us to operate with much less light. In 90% of vitrectomy cases, the surgery can be performed with 10% or less of the maximal endolight,” said Dr Stalmans, citing a study published in RETINA in 2017.

“Besides the increased safety in terms of retinal light toxicity, the lower light requirement represents an advantage for 27G surgery, in which low illumination can be a limiting issue due to the decreased diameter of the light fibres. “ The low light requirement of the 3D digital microscopes confers other advantages as well. Because of the increased light sensitivity of the digital microscope, the microscope diaphragm size can be decreased. A smaller diaphragm size increases the depth of field. This eliminates the need to adjust the focus during anterior segment surgery and gives a better overview during posterior segment surgery, he noted.

An oft-cited advantage of so-called heads-up surgery is reduced surgeon fatigue and cervical spine injury.

“A study published by Eckardt et al in RETINA in 2016 demonstrated that 91.7% of surgeons preferred the ergonomics of the heads-up technique, and I agree,” said Dr Stalmans.

In an occupation in which 60% of ophthalmologists in the United States complain of back and neck pain due to EUROTIMES | MARCH 2020

Courtesy of Peter Stalmans MD

30

surgery (ASRS PAT-survey), this could represent a major improvement on the current model. In heads-up surgery, the surgeon is not required to adopt and maintain a particular posture to see through the microscope.

“There are, however, things to bear in mind,” Dr Stalmans informed delegates.

“The use of a 3D digital microscope will require you to rearrange the layout of your operating room.”

This is because the (large) 3D monitor needs to be placed approximately 1.2 metres from the surgeon. This distance is required to avoid so-called accommodation-convergence disparity.

Ambiguity between accommodation and vergence cues is a well-known limitation in many stereoscopic display technologies and can lead to disorientation and nausea.

“This positioning of the screen requires the instrumentation nurse to be facing in the same direction as the surgeon, which represents an adjustment for many operating rooms. Side-assisting on a 3D screen takes time to learn.”

Latency time used to be a limiting issue with digital microscopes, one which turned surgeons off to the idea of using it. The latency time could be up to 90 milliseconds, which was perceived as a lag between actual movement of the instruments and the movements’ appearance on the monitor.

“Newer microscopes’ latency time is less than 50 milliseconds, which is beyond the threshold of human

perception. You don’t notice it at all,” Dr Stalmans assured delegates.

He also noted that the visualisation itself is excellent, even when circumstances are less than ideal, such as in an air-filled eye.

He admitted that 3D digital visualisation might never be universally adopted.

“Not everyone likes 3D imaging. Some surgeons may still prefer to work with traditional microscope oculars.”

This is something that the designers of ARTEVO 800 have anticipated, in case there might be disparity in preferences within a single vitreoretinal practice. The fact that some surgeons would like to use it and others would prefer to use the traditional oculars is not a problem.

“The ARTEVO 800 has a hybrid mode in which the surgeon can use the oculars and the nurse can continue to use the 3D screen, so that the operating room layout need not be altered for every surgeon,” continued Dr Stalmans. This is a distinct advantage over previous iterations of 3D digital microscopes, in which switching between 3D visualisation and ocular visualisation was time-consuming and could lead to mechanical failures.

“In hybrid mode, 70% of the available light is sent to the oculars and the remaining 30% is sent to the 3D screen,” explained Dr Stalmans. “The 70% equals the amount of light available through the previous generation of microscopes.”

Dr Stalmans encouraged delegates to give the 3D digital microscope a try.

Peter Stalmans: Peter.Stalmans@uz.kuleuven.ac.be

RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 243 ISSUE: 2

AFLIBERCEPT INDUCES FASTER VASCULAR OUTGROWTH IN RETINOPATHY OF PREMATURITY PATIENTS Infants with retinopathy of prematurity (ROP) treated with aflibercept have a faster vascular outgrowth rate (VOR) but a wider retinal vascular development border (RVDBM) than those treated with bevacizumab. In 51 eyes of 27 infants who received aflibercept, VORs measured in between two sequential follow-up fluorescein angiograms (FA) were significantly higher both in nasal (p=0.042) and temporal sides (p=0.033) than in 38 bevacizumabtreated eyes of 19 infants. However, the ratios between the distance from the centre of the disc to the RVDB and the distance from the centre of the disc to the centre of the macula were significantly higher in the bevacizumab group in the first FA and the second FA examinations. A Vural et al, “Comparison of Vascular Outgrowth Rate and Retinal Vascular Development Border after Intravitreal Injection of Aflibercept or Bevacizumab to Treat Retinopathy of Prematurity”, Ophthalmologica 2019, Volume 243, Issue 2.

CENTRAL CHOROIDAL THICKNESS LOWER IN CENTRAL RETINAL VEIN OCCLUSION DME PATIENTS Anti-vascular endothelial growth factor (anti-VEGF) therapy appears to reduce central choroidal thickness (CCT) in patients with central vein occlusion-related macular oedema and the effect may be magnified in those with systemic hypertension, according to a new study. In 27 CRVO patients with macular oedema who underwent anti-VEGF treatment, CCT was significantly lower among 17 hypertensive patients than in the 10 normotensive patients but also gradually became thinner with additional drug injections in all of the patients. In addition, at final visit the mean CCT in HT patients was significantly lower (209.0µm) than in non-HT patients (256.1 µm). T Kida et al, “Long-Term Follow-Up Changes of Central Choroidal Thickness Thinning after Repeated Anti-VEGF Therapy Injections in Patients with Central Retinal Vein Occlusion-Related Macular Edema with Systemic Hypertension” Ophthalmologica 2020, Volume 243, Issue 2.

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

SD-OCT PREDICTS OUTCOME OF ANTI-VEGF TREATMENT IN CNV SECONDARY TO MYOPIA Spectral-domain optical coherence tomography (SD-OCT) can help predict outcome of anti-VEGF treatment for myopic choroidal neovascular neovascularisation (mCNV) according to an investigator-led prospective trial. In 20 treatment-naïve patients who received intravitreal injections of ranibizumab, better baseline visual acuity (VA), lower spherical equivalent, better inner/outer segment line and external limiting membrane integrity showed a significant positive effect on BCVA outcome. Less fluctuation in CRT (worst minus best CRT) indicated better BCVA at 12 months.

M Guichard et al, “Outcome Predictors of SD-OCT-Driven Intravitreal Ranibizumab in Choroidal Neovascularization due to Myopia”, Ophthalmologica 2019, Volume 243, Issue 2.

l

l

l

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

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

Ophthalmologica is the peer-reviewed journal of EURETINA

EUROTIMES | MARCH 2020

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32

GLAUCOMA

Neuroprotection clinical trials Novel study designs shorten study times, moving therapies closer to reality. Howard Larkin reports

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EUROTIMES | MARCH 2020

I

nnovative study designs and integrating therapeutic testing with biomarkers have advanced several neuroprotective and neuroenhancement compounds to clinical trials, which could advance glaucoma therapy beyond prevention through IOP control, Jeffrey L Goldberg MD, PhD, told the AAO 2019 Glaucoma Subspecialty Day in San Francisco, USA. Preliminary analysis of a phase II randomised controlled trial of a Ciliary Neurotrophic Factor implant shows a statistically significant increase in nerve fibre layer (RNFL) thickness with no serious or treatment-limiting adverse effects after one year, said Dr Goldberg, who is professor and chair of ophthalmology at Stanford University, Palo Alto, California, USA. The trial involves 54 patients in three sites randomised 1:1 to sham surgery with no implant, with opportunity for the control group to cross over to treatment in an open-label extension.

Dr Goldberg presented a case from the study in which a female patient in the treatment group experienced significant thickening of the RNFL, which is typical of both the current treatment group as well as in 11 patients treated in an earlier phase I study. This patient also showed improvement in Humphrey visual field tests more than the treatment group as a whole. The sham design of the current trial will help filter out variability and any learning effects influencing these results, he noted.

A further trial extension is planned to add an arm with two implants in treated eyes, Dr Goldberg said.

“We are asking the question: would two implants, or double the dose, have a more detectable effect?”

A parallel phase II trial of the same implant was positive for photoreceptor neuroprotection for patients with macular telangiectasia type II at two and three years, and is in phase III development under the FDA, he added.

An eight-week phase I/II randomised clinical trial of nerve growth factor eye drops for glaucoma using a stronger formulation of Oxervate (Dompe), which is approved for neurotrophic keratitis, has also been conducted. An anti-C1q intravitreal injection for glaucoma has completed a phase Ib randomised study, removing the inflammatory factor that is strongly associated with glaucoma and other neurodegenerative diseases, Dr Goldberg noted. A phase Ib randomised study of virtual reality visual stimulation approach using VR goggles to stimulate RGC cells or balancing inter-eye competition is also in the works.

These studies can produce results in a shorter time than previous neuroprotection studies by focusing on rapidly progressing patients and clustering visual field tests to hedge against variability in 12- to 18-month tests, and by studying sick, but not dead, RGCs in shorter neuroenhancement studies, Dr Goldberg said.

Both types incorporate new exploratory biomarkers to Jeffrey L Goldberg MD, PhD cross validate results.

We are asking the question: would two implants, or double the dose, have a more detectable effect?

GLAUCOMA

Mixing MIGS and meds Balancing medical and surgical options may improve outcomes.

Howard Larkin reports

T

he wide range of surgical and medical glaucoma treatments developed over the past 15 years provide new options for combining therapies. Technologies including aqueous humour outflow imaging are helping identify combinations that may improve outcomes, Alex Huang MD, PhD, told the Glaucoma Subspecialty Day at the annual meeting of the American Academy of Ophthalmology (2019) in San Francisco, USA. However, the efficacy and safety of such combinations must be verified by clinical trials, and few combining the two have yet been conducted, added Dr Huang, Assistant Professor, Doheny Eye Institute, Department of Ophthalmology, University of California – Los Angeles, USA. He reviewed three areas in which MIGS-Med combinations are being investigated.

Fundamental aqueous humour outflow biology (long known from histological staining of outflow anatomy) suggests that muscarinic agonist miotics, such as pilocarpine and acetylcholine, work by stimulating contraction of the ciliary muscle, pulling the scleral spur, which acts as a lever opening the trabecular meshwork, Dr Huang said. Therefore, combining them with MIGS canal procedures such as the trabectome (NeoMedix) and the Kahook Dual Blade (New World Medical) was originally hypothesised to keep the angle open, further enhancing outflow and preventing peripheral anterior synechiae.

However, a large 12-month retrospective study found no difference at all in IOP reduction, complications or PAS formation between eyes undergoing trabectome with and without postoperative pilocarpine, whether done alone or with phacoemulsification cataract surgery, Dr Huang said.

(Esfandiari et al. F1000Research 2018, 7:178.) “This is a case where [combining MIGS and meds] didn’t work.”

In addition to relaxing the trabecular meshwork, cytoskeletal relaxing agents including netarsudil (Rhopressa, Aerie) and nitric oxide-donating drugs (Vyzulta, Bausch + Lomb) may enhance the efficacy of trabecular bypass or ablation by relaxing distal collector channels and reducing episcleral venous pressure, Dr Huang said.

Preclinical research he has conducted with Dan Stamer PhD of Duke University shows increased distal outflow in response to such drugs. OCT imaging also has shown them to increase outflow pathways size in distal channels still blocked after 360-degree trabeculotomy, suggesting a synergistic effect, Dr Huang said. “While the clinical data is not there, there is promise to use distally targeting IOP-lowering drugs combined with trabecular MIGS.” Steroids after MIGS is vexing as it can be impossible to tell if failure to reduce IOP is due to steroid effect or procedure failure without stopping steroids, Dr Huang said. Steroidresponse after MIGS is real and can be profound. His research shows that steroids cause distal pathway scleral to proliferate, get larger and change morphology, just as do trabecular meshwork cells, suggesting a similar IOP-raising mechanism of action. The solution is to quickly taper steroids after trabecular MIGS. Dr Huang concluded that the future is bright for combined MIGS-meds procedures, but more research is needed.

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Alex Huang: ahuang@doheny.org EUROTIMES | MARCH 2020

33

34

PAEDIATRIC OPHTHALMOLOGY

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

2–4 October 2020 RAI Amsterdam, The Netherlands

Friday 2 October 2020 David Mackey AUSTRALIA

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

Saturday 3 October 2020 Burton Kushner USA

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

Sunday 4 October 2020 Marie-José Tassignon BELGIUM

Kanski Medal Lecture A Thing of Beauty is a Joy Forever

Registration & Hotel Bookings Open

www.wspos.org

Ocular surface disease in children Devastating impact of OSD in paediatric population.

Dermot McGrath reports

O

cular surface diseases (OSD) in paediatric patients can have a severe impact on children’s quality of life, so rapid intervention with targeted treatment is essential to avoid vision-threatening complications associated with more severe forms of OSD, according to Dominique Brémond-Gignac MD, PhD. “These are young and active patients and ocular surface disease can really have a devastating impact on their quality of life. Fortunately we do have a large arsenal of treatment options available to us with some recent innovative therapies showing promise in the treatment of some of the less common and more severe forms of OSD,” she told delegates attending a World Society of Paediatric Ophthalmology and Strabismus (WSPOS) symposium held during the European Society of Ophthalmology (SOE) meeting in Nice, France.

Allergic diseases are among the most common ocular surface disorders in children, said Prof Brémond-Gignac, and can take multiple forms. Mild-to-severe seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) are common, as are mild acute forms of ocular allergy, usually accompanied by seasonal allergic rhinitis.

More serious, however, are vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), both of which are rare diseases and may lead to visual impairment, she said. VKC primarily affects boys from 3-to-16 years of age and is characterised by serous discharge and corneal complications such as superficial punctate keratopathy (SPK) and shield ulcers. AKC is rare in children and often presents with clinical features such as keratitis, hyperaemia, thickened dry skin, papillae, Dennie-Morgan folds and blepharitis, she said.

“Differential diagnosis is important between these two diseases as the prognosis is not the Dominique same. VKC tends to end with adolescence, which is not the case with AKC, and the Brémond-Gignac MD, PhD treatment strategy is not the same,” she said.

While topical corticosteroids are effective in moderate-tosevere disease, their use must be carefully controlled to reduce the risk of severe adverse effects such as cataracts, glaucoma and secondary corneal infections, said Prof Brémond-Gignac, as well as steroid dependence.

“We need more targeted and appropriate treatment with less steroid use where possible to avoid iatrogenic complications such as glaucoma and cataract in these young patients,” she said.

To that end, she said that the recent VErnal KeratoconjunctiviTIs Study (VEKTIS) study found that steroid-saving topical cyclosporine A was effective in the treatment of VKC and significantly improved signs and symptoms without significant side-effects.

Another topical agent, tacrolimus, also holds promise in the treatment of severe VKC refractory to topical antihistamine agents and topical cyclosporine, she added.

Dominique Brémond-Gignac: dominique.bremond@aphp.fr

EUROTIMES | MARCH 2020

PAEDIATRIC OPHTHALMOLOGY

Effectiveness of IOLs in infants IOL implantation provides good results in patients less than six months.

Roibeard Ó hÉineacháin reports

World Society of Paediatric Ophthalmology and Strabismus

I

OL implantation in infants less than six months of age with congenital cataracts can be safe, cost-effective and as easily managed over the long term. This approach compares favourably with an aphakia with contact lenses approach, although each eye and each patient are different and socioeconomic factors must also be taken into consideration, said Ramesh Kekunnaya FRCS, Head, Child Sight Institute, LV Prasad Eye Institute Hyderabad, India.

Speaking at the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) Subspecialty Day in Paris during the 37th Congress of the ESCRS in France, Dr Kekunnaya noted that in the multi-centre randomised controlled Infant Aphakia Treatment Study (IATS), eyes that underwent IOL implantation had significantly higher rates of intraoperative complications (28% vs. 11%; p=0.031), adverse events (77% vs.

25%; p<0.0001), and additional intraocular reoperations (63% vs. 12%; p<0.0001) during the first postoperative year than those who remained aphakic and received contact lenses. All the above infants had unilateral congenital cataract.

On the other hand, there was no significant difference between the groups in terms of visual outcome (Plager et al, Ophthalmology. 2011 Dec;118(12):2330-4).

In the IOL group, iris prolapse was the most common intraoperative complication. Visual axis opacification was the most common adverse event, occurred in 69% of eyes. Clearing of visual axis opacification was the most common additional intraocular reoperation. Glaucoma occurred in 12% of eyes.

A study conducted in LVPEI, Hyderabad, India, supported the efficacy of IOLs in bilateral congenital cataract cases but also showed that postoperative complication rates may not always be as high as in the IATS study. The series included 69 eyes of 38 infants with a mean age of 4.6 months After a mean follow-up of 51 months (range: 36-84), the median bestcorrected visual acuity was 0.74 logMAR in eyes with bilateral cataracts and 0.87 logMAR in eyes with unilateral cataracts.

He noted that there were no postoperative complications in 70% of patients. The most common postoperative complication was visual axis opacification necessitating membranectomy in 13 eyes, (18%), followed by pigmentary IOL deposits (11 eyes, 15%) and IOL decentration and glaucoma in four eyes each (5.6%).

In the IATS study, the total cost of management was calculated to be around 5% higher in the lOL group compared to the contact lens group, which was mainly attributable to the higher number of unplanned surgeries in the IOL group.

However, cost estimates vary considerably internationally and can be much more favourable for IOL implantation in lower income countries.

Ramesh Kekunnaya: rameshak@lvpei.org

The most common postoperative complication was visual axis opacification necessitating membranectomy in 13 eyes...

At WSPOS, we believe that “Expertise Resides ALL Over the World”

Free Membership Membership to WSPOS is available for FREE on www.wspos.org Join our society and become part of one of the largest networks of paediatric ophthalmologists in the world.

You’ll gain access to our wide library of videos, including our “Masters in Surgery” archive and also get the chance to collaborate on our global case report quiz.

Contact Info: WSPOS, Temple House, Temple Road, Blackrock, Co. Dublin, Ireland Tel: +353 1 288 3630 Fax: + 353 1 209 1112 Email: wspos@wspos.org

Ramesh Kekunnaya FRCS EUROTIMES | MARCH 2020

35

OCULAR

Step on board the Flying Eye Hospital Non-profit brings doctors across the world.

Aidan Hanratty reports

O

rbis is an international nonprofit that brings people together to fight avoidable blindness. Its efforts include improving the skills of ophthalmology faculty in underdeveloped regions, establishing wetlabs, launching fellowship training programmes and developing subspecialty education hubs.

As well as long-term sponsorships and training programmes in countries worldwide, in 2019 ESCRS sponsored three young ophthalmologists to travel on the Orbis Flying Eye Hospital Associate Programmes to Vietnam and Myanmar and sponsored two ophthalmologists from Ethiopia to attend their 37th Congress of the ESCRS in Paris, France.

TRAINING THE TRAINEES Basak Bostanci Ceran MD first learned of the Orbis Flying Eye Hospital (FEH) when she was completing her fellowship in the United States. Her mentor, Professor Samuel Masket, was a participant and spoke highly of the programme. The FEH had EUROTIMES | MARCH 2020

visited her home country of Turkey so it was already an idea she was familiar with, and when she was asked if she would like to apply to volunteer, she didn’t think twice.

“As an ophthalmologist, I want to do the best I know, which is doing surgeries or training other people. Training the trainees and giving education without taking or without expecting something really opened my eyes and opened my heart,” she said.

Dr Basak travelled to Huế in Vietnam for one week, where she worked with local fellows and residents early in their careers.

She helped train them using a cataract eye simulator, as well as helping out during postoperative procedures and giving a lecture on cataract surgery.

Upon returning from Vietnam, she reflected on how different her everyday experience was. “It is very easy to complain when you’re just sitting in your home town, thinking that some surgeons from particular universities or surgery centres have more than you do. But when you go to Vietnam and see what they don’t have, you feel very grateful for everything.”

Courtesy of Basak Bostanci Ceran MD

36

Basak Bostanci Ceran MD performs a postoperative evaluation in the local hospital in Huế, Vietnam

While the hospitals in Vietnam may not be as well-equipped as those in Europe, the visiting hospital more than makes up for any shortcomings.

OCULAR The FEH is equipped with a classroom that seats 46, with 3D technology on hand to make students feel like they are in the operating room, as well as a fully functional operating room for hands-on training.

For some in fact it’s almost like a second fellowship. Working with a series of experts from around the world, young ophthalmologists can impart their own wisdom as well as absorbing so much more.

“There is a permanent exchange with different parts of the world,” said Mehdi Shajari MD. “It’s just astonishing, it never stops improving when you just talk to the people, because it’s all about details in surgery, right? So, a little change in your incision, a little change in the fluids you use can make a huge difference.”

Dr Shajari also travelled to Huế, where he worked with Professor Jeffrey Caspar MD of the University of Sacramento. They trained local residents hands on but also walked them through the surgeries in details on a monitor, advising how they could improve technique.

37

Imran Yusuf aboard the Flying Eye Hospital, demonstrating the EyeSi vitreoretinal simulator

Imran Yusuf lecturing to local ophthalmologists

subspecialty clinic. His future plan is to establish a full-fledged vitreoretinal centre; at present, the vitreoretinal subspecialty clinic sees 8,000 patients.

At the ESCRS Congress in Paris, he attended wetlabs in the area of basic phaco training, which he said would help refine his technique. He also attended talks on ocular trauma and manual small-incision cataract surgery (MSICS).

On his return, he hoped to share this new knowledge with his residents and students throughout the course of their interactions. “During lectures, morning seminar presentations, during discussions at the OPDs and in the operation theatre practical training sessions with residents.”

Dr Argaw Aberra Shire is a fourth-year

It’s just astonishing, it never stops improving when you just talk to the people, because it’s all about details in surgery, right?...

Mehdi Shajari MD

resident at Hawassa University in Ethiopia.

Having volunteered alongside European doctors offering medical care to people in the region he saw that there was a lack of eye care provided at a local level. “With little expense you could give sight for a lot of people who need care. That’s how I went to ophthalmology,” he told EuroTimes.

Dr Argaw was most impressed by updates on topics such as Selective Laser Trabeculoplasty as a treatment for openangle glaucoma; techniques of repair for iridodialysis/traumatic iris defects; and new technology for gonioscopy. He also took the opportunity to try phacoemulsification, as he usually uses MSICS in his practice.

He was most impressed by the scale of the Congress. “I have been to national or subregional conferences but this is the largest congregation I’ve been to yet,” he said.

“You have all the experts here from all over the world, not only from Europe – you have people from Asia, especially India, from the United States, from countries in Latin America. So, this is one of the best opportunities for a novice individual like me.” http://orbis.org/ EUROTIMES | MARCH 2020

Courtesy of Geoff Bugbee

AN AUDACIOUS IDEA Imran Yusuf, Specialist Registrar in Ophthalmology and PhD student at Oxford, UK, travelled with Orbis to Mandalay in Myanmar. He was most excited about seeing the Flying Eye Hospital itself. “It always seemed to me an audacious idea – to put an eye theatre on a plane.”

He was not disappointed. “I could not believe the quality of the infrastructure: 4K screens with the Ingenuity 3D surgical viewing system (so that all participants can watch the surgery in 3D as if they were the surgeon), live audio interaction with the surgeon in real time, an EyesSi vitreoretinal simulator, indirect ophthalmoscopy simulator, a mini lecture theatre and the supporting components of the Flying Eye Hospital (such as clinic area, anaesthetic room, sterilisation area and recovery).”

Dr Yusuf lectured aboard the FEH as well as training local residents in the use of the indirect ophthalmoscopy and the EyeSi simulator.

Dr Asamere Tsegaw Woredekal has been involved with Orbis for many years. Over the past 15 years he has seen first-hand the work they have done in helping to turn a small unit at the University of Gondar in Ethiopia to a big, tertiary ICU centre.

Dr Asamere’s training in India and Germany was partially supported by Orbis (as well as by international NGO Light for the World), and upon his return to Gondar he established a retina

38

INDUSTRY NEWS

INDUSTRY

NEWS

Kerstin Kirchhübel, Christian Kirchhübel, Rainer Kirchhübel, Rita Kirchhübel and Matthias Kirchhübel celebrating 125 years of Oculus

125 years of Oculus Keep learning.

Whenever, wherever.

OCULUS Optikgeräte GmbH celebrated 125 years with a special meeting in its headquarters in Wetzlar, Germany.

The company, which produces devices across the ophthalmic spectrum, from trial lenses and visual field tests to topography and tonography, has been based in the “optic town” of Wetzlar since 1947.

The company has created several products that have had a high impact on the world of ophthalmology. In 1985 it presented the SDI BIOM system, a non-contact wide-angle viewing system for vitreoretinal surgery, a system that is still in use today. In 2002 the company announced the Pentacam, the world’s first rotating Scheimpflug camera. It remains one of the company’s flagship products, alongside the Pentacam HR and AXL models.

A tour of the Oculus facility showed the full scope of its manufacturing processes, from robotic operations to handheld burring and assembly. https://www.oculus.de/

MERGER DISCUSSIONS

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 https://elearning.escrs.org EUROTIMES | MARCH 2020

Quantel Medical and the Lumibird group has initiated merger discussions with Ellex, Adelaide, Australia.

“The future success of both companies depends on sharing R&D capability and manufacturing structures, on strengthening our approach to clinical research in order to meet the current and future needs of the ophthalmologists,” said Jean-Marc Gendre, Quantel Medical’s CEO. “The vision is to become the world leader in ophthalmic ultrasound and laser technology solution to diagnose and treat eye diseases” said Marc Le Flohic, Lumibird group’s CEO. https://www.quantelmedical.com/

NEW CORNEA HEALTH FRANCHISE Glaukos Corporation has completed its acquisition of Avedro, Inc. “Avedro will serve as the cornerstone of our new corneal health franchise,” said Thomas Burns, Glaukos president and CEO. “This pairs two highly complementary, hybrid pharma and device organisations, combining Avedro’s novel bio-activated pharmaceutical solutions and R&D capabilities with Glaukos’ global commercial scale, proven marketbuilding and shared reimbursement expertise, and extensive clinical and regulatory infrastructure.” https:// www.glaukos.com/

EXPLORING AMSTERDAM

The nhow Hotel Amsterdam

AMSTERDAM

3

TO READ...

THE GOOD THIEF’S GUIDE TO AMSTERDAM BY CHRIS EWAN The first of the successful ‘Good Thief’ series begins in “a dim-lit brown bar on a northern stretch of the Keizersgracht canal” as an unknown American asks Charlie to steal two monkey figurines for him. Charlie is a mystery writer with a side-line (or is it vice versa) as a thief. This assignment is a baffling proposition as, to judge by the ‘sample’ figurine he is given, they are apparently worthless. Charlie decides to rise to the challenge. The writing flows, the characters are well developed and the details of how to pick a lock work surprisingly well alongside the atmospheric description of Amsterdam. The Good Thief’s Guide is light on gore but heavy on humour. Charlie makes a pleasant travelling companion if you are on your way to Amsterdam.

Available both in Kindle and print at Amazon.

RECIPES FROM MY DUTCH KITCHEN

BY JANNY DE MOOR Dutch cuisine developed over the centuries in the kitchens of fishermen, farmers and the seagoing merchants who introduced the spices and exotic ingredients that still give Dutch food its distinctive edge. Here are more than 75 recipes suitable for today’s home kitchen, from farmhouse cooking to the cosmopolitan dishes that are part of contemporary Dutch life. Information on the culture and traditions of the Netherlands, national festivities, local geography and produce are all part of the story. From Alkmaar Cheese Soup to Creamy Veal Stew with Prunes, from Poffertjes to Frisian Sugar Bread, the book is full of culinary inspiration – and mouth-watering illustrations. Available in hardback on Amazon.

AMSTERDAM, A BRIEF HISTORY OF THE CITY BY GEERT MAK Although this ‘brief history’ stretches to 352 pages in the paperback version, there isn’t a dull paragraph. The author endows the fact-packed account with the contemporary attraction of a well-written news story. The result is a fastpaced overview of a remarkable settlement and how it developed from boggy wetlands to a sophisticated city. Quirky narratives abound, along with observations on the Dutch psyche and political commentary. Many of the intriguing anecdotes are related to the buildings, streets and canals every tourist encounters and these, along with the maps included, make this historical work useful as a guide book, too. Available from Amazon in paperback and Kindle versions.

Hotel with a twist A sensational building awaits delegates in Amsterdam. Maryalicia Post reports.

RAI, the Amsterdam convention centre on Europaplein, is as down to earth – and just about as glamorous – as a wooden shoe. So it was startling to encounter, on a recent visit, a sophisticated structure like a stack of gift boxes from outer space, rising up on its perimeter. It’s the new nhow hotel, designed

by OMA, the architectural firm of Rem Koolhaas. Topping out at 91 metres, its 25 floors hold 650 rooms. It is the largest hotel in the Benelux region OMA Partner Reinier de Graaf, the architect in charge of the project, says he drew his inspiration from Het Signaal, the commercial logos on a skewer that once served as the focal point of the square.

Once Het Signaal stood alone. Now, it’s dwarfed by the proliferation of buildings around it and can be easy to miss. In contrast, the nhow hotel will be difficult not to notice. Not only does it command the surrounding area physically, but there will be a television studio broadcasting daily from the upper floor.

The interior decor is as fresh and colourful as a tulip field. Its design elements and graphics are drawn from the six cardinal directions to which the building’s corners point: South, East, North, South West, South East and North West. So, for example, Mexican sugar skulls meet Japanese lanterns in the lavish dining area. An underground concourse lined with shops will link the hotel to the exhibition halls.

The new North-South metro line 52, which won the professional Amsterdam Architectural Prize for 2019, is another exciting architectural accomplishment for the city. It took 25 years of intensive work

plus an expenditure of €3.1 billion before the line opened in July 2018. It makes it possible to go from Amsterdam’s Central Station to Europaplein in eight minutes.

The entire route, from Central Station to Zuid, is 9.7km long, including a stretch of 3.2km underground; it necessitated the construction of five underground and two above-ground stations. Each of the stations boasts colourful mosaics referencing the neighbourhood it serves.

Between the escalators at the end of the Europaplein station, some of the thousands of finds recovered during the dig are displayed in a glass case. However, the principle museum of finds is at the Rokin Station. The dates of the objects displayed here range from 1650 to 1850. A website explains more about the objects recovered: belowthesurface.amsterdam.

Het Signaal

EUROTIMES | MARCH 2020

39

THE 2020 ASCRS As an anterior segment surgeon, your practice is comprised of primarily cataract surgical cases. The 2020 ASCRS Annual Meeting will address surgical essentials, potential complications and business-building tips to help attendees enhance their skills and improve patient outcomes.

ASCRS CATARACT SYM-102

Management of Vitreoretinal Complications of Anterior Segment Surgery Sponsored by the ASCRS Retina Clinical Committee

SYM-104

Complications by Proxy Sponsored by the ASCRS Young Eye Surgeons Clinical Committee

SYM-105

Getting You Better IOL Refractive Outcomes – Hearing from Us and You SYM-106

The Cuts are Coming… The Cuts are Coming… INNOVATE! Sponsored by the ASCRS EyeConnect Committee

SYM-108

Management of Complicated Cases in Cataract and Refractive Surgery (presented in Spanish) Co-sponsored by ASCRS and ALACCSA-R

SYM-201

Surgical Essentials: Getting You out of Trouble in Cataract Surgery A Combined Symposium of Cataract and Refractive Societies

SYM-203

Debates and Controversies for the Young Ophthalmologist: How Will You Shape Your Practice?

Co-sponsored by ASCRS and the Vanguard Ophthalmology Society

annualmeeting.ascrs.org

ANNUAL MEETING SURGERY SYMPOSIA SYM-204

ASCRS Efforts to Secure the Future of Your Cataract Reimbursement: An Alternative Option Sponsored by the ASCRS Government Relations Committee

SYM-206

How to Hit a Home Run in Refractive Cataract Surgery Sponsored by the ASCRS Refractive Surgery Clinical Committee

SYM-207

Controversies in Anterior Segment Surgery Sponsored by the Journal of Cataract & Refractive Surgery®

ADDITIONAL ASCRS CATARACT SURGERY PROGRAMMING • 57 Instructional Courses • 24 Paper Sessions/369 Papers • 75 Films • 88+ Posters • 20 Roundtables with Experts • 22 cataract surgery skills transfer sessions ASCRS GENERAL SESSIONS FEATURING CATARACT SURGERY AND MORE! ASCRS Opening General Session featuring the Binkhorst Lecturer Richard Lewis, MD Saturday May 16 | 10:00 a.m. – 12:00 p.m.

ASCRS CATARACT DAY 2020 Sponsored by the ASCRS Cataract Clinical Committee

• SYM-302 Cataract Surgery Essentials: Surviving and Thriving in the Clinic and Operating Room • SYM-303 Advanced Cataract Surgery: Achieving 20/Happy in 2020 • SYM-305 The 2020 ASCRS Cataract Surgery Olympics SYM-304

Drop Free Cataract Surgery: Regulatory Landscape and FDA Perspective Sponsored by the ASCRS FDA Committee

ASCRS Sunday General Session Featuring The Voice of Ophthalmology, Season 3 Featuring Scott Gottlieb, MD, former Commissioner of the U.S. Food and Drug Administration and The Voice of Ophthalmology, Season 3 Sunday May 17 | 10:00 a.m. – 12:00 p.m.

ASCRS Innovators General Session Featuring Charles D. Kelman, MD Innovator’s Lecturer Roy W. Beck, MD, PhD Monday May 18 | 10:00-11:30 a.m.

SYM-401

X-Rounds: Refractive Cataract Surgery to the Max

The Best of ASCRS 2020 General Session Tuesday May 19 | 10:00 -11:30 a.m.

J IN US! At the 2020 ASCRS Annual Meeting. ASCRS. For Surgeons. For You. In addition to the extensive cataract surgery programming be sure to take a advantage of the innovative cornea, refractive, and glaucoma (and more) sessions!

Scheduling subject to change

42

NATIONAL SOCIETY NEWS

Upgraded experience Hellenic Society of Intraocular Implant and Refractive Surgery moves annual conference to facilitate expansion

T

he Hellenic Society of Intraocular Implant and Refractive Surgery (HSIOIRS) is inviting delegates to its 34th International Congress, which will take place at the Megaron Athens International Conference Center on 19-22 March 2020, with the participation of the Egyptian Ophthalmological Society (EOS).

After three decades of continuous presence and educational contribution to ophthalmology, the annual Congress of the Society is “moving” from the familiar space of the Hilton Athens Hotel to the impressive premises of the Megaron International Conference Center, where the 23rd Winter Meeting of the European Society of Cataract and Refractive Surgeons (ESCRS) took place in 2019.

“The dynamics and the extrovert character of the Congress, as well as the innovation and the high scientific level of the program presented, have established this Congress as the most successful Greek event in the field of Surgical

Ophthalmology,” said Miltos Balidis, President of the HSIOIRS. Active and ever-growing participation in the HSIOIRS Congress shows appreciation for the events of the Society and is its biggest motivation.

Speaking in 2019, former President Konstantina Koufala said: “We are proud that many of our Greek colleagues have distinguished themselves in the international field of ophthalmology.

We need to especially mention Professor Ioannis Pallikaris, the “father” of LASIK, who has helped develop refractive surgery worldwide. On the Board of Directors of the ESCRS, Greece is currently represented by our prominent and internationally active colleague Vikentia Katsanevaki.”

For the year 2020 the Society aims to continue the successful course of the HSIOIRS Congress, by offering an upgraded and different experience. This will be achieved not only through the change of the congress venue, but also through many changes and innovations in the content and

The dynamics and the extrovert character of the Congress... have established this Congress as the most successful Greek event in the field of Surgical Ophthalmology Miltos Balidis, President of the HSIOIRS

the structure of the scientific program.

Like every year, the scientific program will be consisted of keynote lectures from distinguished ophthalmologists from all over the world, roundtable discussions, instructional courses, near live surgery videos, free papers, video projections, e-posters and wetlabs.

There will also be an exhibition and trade fair of pharmaceutical companies, surgery products and diagnostic equipment, in a special setting, where there will be direct access through the rooms that all the sessions take place.

“An important and integral part of the success of this Congress is and always has been your participation, as speakers but also as participants,” said Dr Balidis. https://hsioirscongress.gr/

A library of symposia, interviews, video discussions, supplements, articles and presentations Spotlight on: l Toric IOLs and Presbyopia l Glaucoma l Ocular Surface Disease l Corneal Therapeutics

Visit forum.escrs.org for details EUROTIMES | MARCH 2020

CO NE NT W EN T

ESCRS NEWS

ESCRS

NEWS

Thierry Amzallag, Béatrice Cochener-Lamard, Rudy M.M.A. Nuijts and Ruth Lapid-Gortzak

20/20 and beyond ESCRS President Rudy M.M.A. Nuijts reports From 8-11 January 2020 the Annual Conference on Ocular Microsurgery was organised with the theme “Eilat 20/20 and beyond”. It was the 40th anniversary of the meeting and attended by a renowned international faculty. The meeting was organised

by Ehud Assia and Guy Kleinmann and gave an update of the current innovations in various fields of ophthalmology.

The ESCRS was invited to organise an ESCRS Academy on Thursday. During that session I spoke on the ESCRS PREMED study and on the implementation of the results in 2020. It has now become clear that the strategy of a combined postoperative regimen of steroids and NSAID drops is more effective in CME reduction than either of these drops alone.

Thierry Amzallag spoke on improving the results of EDOF IOLs and illustrated the various designs that are currently on the market. Gerd Auffarth discussed optical fundamentals of IOL correction and gave a basic overview of the working mechanism of the various multifocal and EDOF IOLs. Joaquim Murta reported on his research into the mechanisms of neuroadaptation in patients with multifocal IOLs using functional magnetic resonance imaging. It now has become clear that patients show increased activity of cortical areas involved in visual attention and cognitive control in the early postoperative period at three weeks that normalises at six months, pointing at neuroadaptation in our brain.

Béatrice Cochener-Lamard spoke on the new developments in Fuchs’ endothelial dystrophy where DMEK appears to be the preferred endothelial keratoplasty technique. Studies are under way to show the benefit of new techniques like DSO (Descemet Stripping Only) on endothelial cell remodelling, with or without the combination of ROCK inhibitors. Selection and indication for DSO appears not to be straightforward.

Regenerative medicine technology has also found its way into corneal transplantation but many aspects, including costeffectiveness, still need to be investigated.

The application of regenerative medicine in ophthalmology was also the topic of a presentation by Jorgé Alió, who spoke on advanced stem cell therapy for keratoconus. He showed that implanting autologous adipose-derived adult stem cells with or without sheets of decellularised donor human corneal stroma may be effective for the treatment of advanced keratoconus.

In the international video competition ESCRS (Béatrice Cochener-Lamard, Ruth Lapid, Thierry Amzallag, Rudy Nuijts) competed against the teams of APACRS, ASCRS/International and Israel in four categories (lens subluxation, IOL complication, intraoperative challenge and free style) and our past president won her category by using all her French charm!

ESCRS

FREE 5 year members hip for train ees

Membership •

Reduced Registration Fees for ESCRS Congresses

•

Subscription to Journal of Cataract & Refractive Surgery

•

Access to ESCRS Grants, Bursaries and Research Awards

•

ESCRS iLearn Online CME accredited interactive courses

•

ESCRS On Demand Online library of presentations from ESCRS Congresses

•

EUREQUO European Registry of Quality Outcomes for Cataract and Refractive Surgery

•

ECCTR European Cornea and Cell Transplantation Registry

Join today. www.escrs.org

EUROTIMES | MARCH 2020

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tra tio n

by

Cla

ire P

rou vo

st

RANDOM THOUGHTS

Il

lus

44

Mind your

BEDSIDE MANNERS

T

Knowing how to talk to your patients is essential.

Maryalicia Post reports

ime was when a good bedside manner was something a physician had or didn’t have, like a great smile or a firm handshake. Doctors equipped with natural charisma were assured of a loyal band of patients. Others settled for grudging respect. Today ‘bedside manner’ has morphed into ‘patientphysician communication’. It is no longer an optional extra, nor is it restricted to the bedside. As technology plays an ever-greater part in practices such as ophthalmology, the need for the human interface becomes ever more evident.

The concept of the bedside manner dates back to the late 19th Century, when a Dr Osler brought trainee doctors into the hospital to see and talk to patients – and the system of ‘internship’ was born.

Ever since, patients have come to expect good communication with their doctors.

And they’re right to do so. Research EUROTIMES | MARCH 2020

confirms that a good bedside manner measurably affects outcome.

Unhappily, this need goes hand in hand with more pressure on the physician for the finite amount of time he or she has available to spend with each patient. In one disastrous attempt to bridge the gap, a California hospital made video recordings to be played to the patient in place of an ‘evening round’ by the doctor. As a result, one patient was reminded via a video recording that he was past medical help.

The patient died the next day but family members who were in the room when the video played never forgot the shock. (The hospital apologised.)

And there’s an account of one patient’s experience with an ophthalmologist. The doctor’s excitement at discovering that his patient had a very rare condition coupled with his enthusiasm for sharing the discovery with his staff made him forget he was dealing with a human being and a

very vulnerable human being at that.

While the ophthalmologist’s practice may not focus on literal ‘bedside’ scenarios, the need to reassure and connect with patients is as compelling as in any other practice. In his popular blog, Dr Ron Rosa OD offers specific suggestions for the ophthalmologist to consider. They range from the surprising – “Beware of your posture” – to the challenging – “never stop caring”. More generalised tips are at http:// bit.ly/ET-bedside.

Perhaps the most useful thing to keep in mind is that you never have a second chance to make a good first impression.

Get the patient’s name right, call them by their last name plus Mr or Mrs (unless they are under 18 or you’re invited to use their first name). Look interested. Don’t retreat behind a screen more than necessary.

And remember that a sincere smile and a welcoming handshake still set the tone for a successful ‘bedside manner’.

45

© Jeremy Thomas

PRACTICE MANAGEMENT

Balancing life and work How can ophthalmologists separate work, life and family time?

EuroTimes Executive Editor Colin Kerr reports

O

phthalmologists may try to achieve a work-life balance that helps them to achieve their goals in both their careers and family life, but is this really possible?

This is one of the questions that will be addressed during the Practice Management and Development Programme at the 38th Congress of the ESCRS in Amsterdam, The Netherlands.

The topic is close to the hearts of Dr Joséphine Behaegel and Dr Luke Sansom, two young ophthalmologists who took part in a recent ESCRS EuroTimes Eye Contact Interview with Professor Sorcha Ní Dhubhghaill. Their conversation focused mainly on the challenges facing trainees, but a lot of their key points can be applied to their older colleagues.

“Medical training can be very demanding and it’s not just limited to working hours,” said Dr Behaegel. “We all have a passion for ophthalmology, but from time to time it can feel like it’s a little too much.”

So how can ophthalmologists separate work, life and family time? “Making a clear distinction between work and life is almost the perfect goal, but it’s probably unachievable,” said Dr Sansom. “Work and life balance is about working with your colleagues and working with your family

to make that balance exist and it’s very individual to each and every one of us.”

Dr Sansom said that he has an understanding with his family that he will work hard and often work late. “When I am at home, my time is theirs and theirs alone so I try not to be on my phone or taking work calls. That doesn’t always happen and sometimes you stay late and there are over-running clinics and that is where the biggest challenge lies,” he said.

“It works the other way and sometimes my wife might be unwell, or as I’m walking out the door, one of the children may fall over and scrape their knee and I may end up in work half an hour late after patching them up. It works both ways, and my work colleagues have to be understanding about the challenges of family life,” he said.

SOCIAL SUPPORT NETWORK Dr Behaegel said having a good family and social support network was also important.

“Family and friends play an important role in the work-life balance,” she said.

“It’s important to know when to grab a coffee with a friend or to phone a friend on your way home. If you’re having a bad day at work or things don’t go as expected, your friends can cheer you up and that’s positive,” said Dr Behaegel. “The problem is that often it’s difficult to meet friends while performing a full-time job.”

The challenges may be even greater for female ophthalmologists who face not only the demands of their work schedules, but also the requirements of raising a family.

Dr Sansom pointed out that a lot of ophthalmologists start their families during their training years, which are already difficult for trainees who face exams, essays and other academic and surgical work.

“Trying to put a family in the middle of all that is really difficult,” he said. “For female ophthalmologists there is also the difficulty of going back to work after having children and the stresses and sometimes guilt of leaving children after going back to work.”

A further challenge faces those with elderly relatives, and Dr Sansom suggests that the institutions where they work need to make allowances for these situations.

Dr Behaegel said there are institutional changes that could ensure better worklife balance. “The quality of the training environment is important. We all have to become skilled physicians, but our mental health is also important. We can feel stronger if we feel our skills are improving and the quality of training has an important role. The head of the department should be flexible by providing protected research time and allowing residents go to conferences. Small things have a huge impact.”

See the interview at http://bit.ly/ET-WLB EUROTIMES | MARCH 2020

46

BOOK REVIEWS

PUBLICATION ANATOMY AND EXAMINATION IN OCULAR TRAUMA EDITOR HUA YAN

LEIGH SPIELBERG MD Books Editor

BOOK

A HANDY GUIDE FOR FURTHER INSTRUCTION

Reviews PUBLICATION MANAGEMENT OF OPEN GLOBE INJURIES EDITORS SEANNA GROB AND CAROLYN KLOEK PUBLISHED BY SPRINGER

A unique, case-based approach to injuries

Considering the dire consequences of open-globe injuries when incorrectly managed, and the potential for preservation of excellent visual function when properly treated, every ophthalmologist should have at least a working knowledge of the topic.

Edited by Seanna Grob and Carolyn Kloek, Management of Open Globe Injuries (Springer) “uses a unique case-based approach to review the intra-operative and perioperative management of patients with severe ocular trauma and open globe injuries”.

Part I (Chapters 1-5) considers the management of open-globe injuries: classification, preoperative management, preoperative counselling, postoperative management and controversies.

What I found particularly interesting was the advice on counselling. “If the extent of their injury, the course of care, and all the possibilities are discussed with the patient in detail prior to globe repair, then the patient will never be too surprised with each step of treatment or any turn of events in the post-operative course.” Saying something like, “there are some contents from the inside of the eye that are on the outside of the eye” may seem drastic, but it helps prepare the patient for what might follow.

“Controversies” is also interesting. In ocular trauma, especially complex cases, many aspects are open for discussion. For example, in which cases should primary enucleation or evisceration be applied, and what is the rationale behind this decision?

The text then proceeds to outline the presentation, management and clinical course of 50 separate cases. These range from the common, such as “Case 1: Linear Corneal Laceration from Scissors” to the complex: “Large Zone II Open Globe from a Finger Injury While Playing Basketball.” Reading cases like these straight through, even the most experienced surgeon can glean useful tips or insights from the course of action and surgical descriptions contained therein.

Of course, evidence derived from randomised, controlled trials is rare or non-existent for many of these injuries, which are often quite unique. The text therefore often includes expert opinions, surgical pearls and a review of lessons learned within the cases.

Intended for all practising ophthalmologists and especially those who are active in the operating room and expected to manage open globe injuries.

A SCIENTIFIC AND PRECISE TEXT

PUBLICATION CORNEAL REGENERATION: THERAPY AND SURGERY EDITORS JORGE L. ALIÓ, JORGE L. ALIÓ DEL PARRIO AND FRANCISCO ARNALICH-MONTIEL PUBLISHED BY SPRINGER

EUROTIMES | MONTH YEAR EUROTIMES | MARCH MONTH 2020 YEAR

PUBLISHED BY SPRINGER

“Once we understand the structure-function relationships in the cornea, we can generate a tissue-engineered corneal substitute to restore, maintain, or improve corneal functions, using different building blocks: cells, scaffolds and bioactive molecules.”

Such is the promise of corneal regeneration, and the topic of Corneal Regeneration: Therapy and Surgery (Springer). Edited by Jorge L. Alió, Jorge L. Alió del Parrio and Francisco Arnalich-Montiel, this 500-page book covers stem cells, regenerative surgery of the ocular surface, stroma and corneal endothelium as well as bioengineering within corneal surgery. Drawing on a vast number of references, the text is scientific and precise.

It is intended for corneal fellows, corneal specialists and especially researchers, both clinical and laboratory, who would like an extensive introduction to corneal regeneration.

Managing ocular trauma is of course impossible without in-depth knowledge of the ocular anatomy relevant to traumatic injuries.

This can be easily forgotten, which is why Hua Yan has edited Anatomy and Examination in Ocular Trauma (Springer), a concise, 130-page text that further instructs on the examination between trauma and surgery.

Chapter 1, “General Anatomy”, is intended for the beginner, but this quickly gives way to Chapter 2, which covers the ocular structure changes when encountered with trauma. This is where the topic gets interesting, such as how the optic nerve can avulse in cases of blunt trauma.

Examination of visual function (Chapter 3), physical situation (4) and imaging (5) help direct management. Intended for nurses, residents, fellows and general ophthalmologists, it is a handy guide to have around.

PUBLICATION CLINICAL ATLAS OF OPHTHALMIC ULTRASOUND EDITORS ABDULRAHMAN H. ALGAEED AND IGOR KOZAK PUBLISHED BY SPRINGER

HANDY REFERENCE FOR RARE PATHOLOGIES Clinical Atlas of Ophthalmic Ultrasound (Springer), edited by Abdulrahman H. Algaeed and Igor Kozak, is a true atlas, focused on typical displaying echographs explaining what is being displayed and correlating them with the clinical, radiographic, histopathologic and examinations and surgical management in applicable cases.

This 66-page atlas is a handy reference guide for anyone who is tasked with conduction of echographic examinations in the clinic. Considering the relative rarity of so many of the pathologies for which echography is utilised, an atlas like this can always be used to refer to.

The book was written for ophthalmologists, radiologists, echographers and ophthalmic oncologists.

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

CALENDAR

↙

LAST CALL

MARCH 2020

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

34th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

19–22 March Athens, Greece https://www.hsioirs.org/en/34th-internationalcongress-of-hsioirs-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/

The 34th Asia Pacific Academy of Opthamology Congress 2020 (APAO 2020) will take place in Xiamen, China in April

APRIL

MAY

NEW Delhi Ophthalmological Society 71st Annual Conference 2020 (DOS 2020)

ARVO 2020

3 – 5 April New Delhi, India http://dosonline.org/confrences /annual-conference

NEW 6th San Raffaele OCT Forum 2020 3 – 4 April Milan, Italy https://www.octforum2020.eu/

NEW Brazilian Retina and Vitreous Society 45th Meeting 2020 (BRAVS 2020)

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

ASCRS•ASOA Symposium and Congress

22 – 25 April São Paulo, Brazil http://retina2020.com.br/

15–19 May Boston, USA www.ascrs.org

NEW 34th Asia Pacific Academy of Opthamology Congress 2020 (APAO 2020)

18th SOI International Congress

22 – 26 April Xiamen, China http://2020.apaophth.org/

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

27–30 May Milan, Italy https://www.congressisoi.com

NEW European Paediatric Ophthalmological Society 2020 (EPOS 2020) 28 – 30 May Copenhagen, Denmark https://epos2020.dk/

EyeAdvance 2020

29–31 May Mumbai, India https://www.eyeadvance.org/ The Delhi Ophthalmological Society 71st Annual Conference 2020 (DOS 2020) will take place in New Delhi, India in April

EUROTIMES | MARCH 2020

47

48

CALENDAR

MAY

The Nordic Congress of Ophthalmology 2020 (NOK 2020) & 21st Retina International World Congress 2020 will take place in Reykjavík, Iceland in June

14th EGS Congress

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

JUNE NEW Nordic Congress of Ophthalmology 2020 (NOK 2020) & 21st Retina International World Congress 2020 4–6 June Reykjavík, Iceland https://www.nok2020.com/

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

XXI International Congress of the Brazilian Society of Ophthalmology

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

JULY

NEW 33rd Asia-Pacific Association Of Cataract & Refractive Surgeon Annual Meeting 2020 (APACRS 2020) July 9 – 11 Suntec City, Singapore https://apacrs-snec2020.org/

July 9 – 12 Utah, USA https://aecosurgery.org/ 2020-summer-symposium/

23–28 July Seattle, USA www.asrs.org

SEPTEMBER NEW 50th Cambridge Ophthalmological Symposium 2020 (COS 2020) 2–4 September Cambridge, UK https://www.cambridge-symposium.org/

5th International Glaucoma Symposium

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

NEW Ophthalmic Anesthesia Society 34th Annual Scientific Meeting 2020 (OAS 2020)

11–13 September Chicago, USA https://eyeanesthesia.org/page-1271154

OCTOBER

NOVEMBER

20th Euretina Congress

AAO Annual Meeting 2020

11th EuCornea Congress

100th SOI National Congress

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

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

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

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

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

38th Congress of the ESCRS

↙

NEW American-European Congress of Ophthalmic Surgery Summer Symposium 2020 (AECOS 2020)

JULY

ASRS 2020

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

Watch the latest video content from ESCRS and EuroTimes, FREE on the ESCRS Player l

Advanced Instructional Courses

l

Eye Contact Interviews

l

Video of the Month

l

Video Journal of Cataract, Refractive & Glaucoma Surgery

l

Young Ophthalmologists Videos: “My Early Surgeries”

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Online Museum

EUROTIMES | MARCH 2020

Go to: player.escrs.org

38th Congress

Amsterdam 2020 3-7 October, RAI Amsterdam

Abstract Submission Deadline: 15 March 2020 Preliminary Programme & Hotel Bookings

www.escrs.org

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