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SPECIAL FOCUS GLAUCOMA

June 2019 | Vol 24 Issue 6

Update on

MIGS CATARACT & REFRACTIVE | CORNEA | RETINA PAEDIATRIC OPHTHALMOLOGY


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

Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

GLAUCOMA

4 The latest on

minimally invasive glaucoma surgery

8 Management of

co-existing cataract and glaucoma

10 Using optical

coherence tomography angiography to assess glaucoma

13 Wearable VR device may

decrease glaucoma burden

14 Selective laser

trabeculoplasty for primary open-angle glaucoma

CATARACT & REFRACTIVE 16 Common complications with small-incision lenticule extraction

17 Trifocal vs EDOF lenses:

which is best for spectacle independence?

18 The latest on phakic intraocular lenses

19 Phaco vs FLACS – the debate rumbles on

25 We report from the

2019 ASCRS ASOA Annual Meeting

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

26 The benefits of

3D displays for cataract surgery

www.eurotimes.org

27 Femtosecond or

microkeratome – which is best for LASIK?

28 JCRS highlights

CORNEA 31 Looking forward to

the 2019 EuCornea Medal Lecture

32 IOL power calculations improve outcomes for repeat patients

P. 52

33 CXL combined with

intracorneal ring segments for ectatic corneas

34 Evaluating biomechanical properties in corneal surgery

PAEDIATRIC OPHTHALMOLOGY 36 Update on WSPOS

RETINA 37 Clinicians should get ready to use gene therapy for choroideremia

REGULARS 41 ESCRS Board elections 47 Travel 48 Henahan Prize Shortlist: Chaos Reigns

50 Henahan Prize Shortlist: A Symbiotic Relationship

52 Hospital diary 53 Industry news 54 Books 55 Calendar

38 The exciting potential of deep learning and AI for treating eye disease

40 Panretinal

photocoagulation reduces the risk of vision loss in PDR

Supplement June 2019

Included with this issue... IMPROVING outcomes Refractive IOL WITH

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Treatment Planning & Postoperative Management

ESCRS Forum Supplement

EUROTIMES | JUNE 2019


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EDITORIAL A WORD FROM DAVID GARWAY-HEATH MD

GUEST EDITORIAL

David Garway-Heath

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)

The latest in glaucoma A look at exciting advances and effective treatments

I

t is my great pleasure to introduce this issue of EuroTimes, which has a special focus on glaucoma. Glaucoma is the most frequent cause of irreversible blindness worldwide. With that in mind, it is imperative that efforts to arrest or slow its development are as effective as possible. New treatments must be rigorously tested and their efficacy proven. One of the most exciting advances over the past decade has been the rise of minimally invasive glaucoma surgery (MIGS). My colleague at Moorfields Eye Hospital, Mr Keith Barton, discusses the latest in MIGS, along with Dr Ike Ahmed, who coined the term MIGS, and Dr Philippe Denis, President of the French Glaucoma Society. They look at the various devices on the market, what procedures are suitable for which patients and what can be learned from the withdrawal of the CyPass Micro-Stent, both from the One of the most perspective of industry and everyday practice. exciting advances They also look to the over the past decade future, and the potential of sustained-release drughas been the rise of delivery devices for lowering minimally invasive intraocular pressure. glaucoma surgery Apart from MIGS, this issue also features (MIGS) articles examining the latest in selective laser trabeculoplasty for primary open-angle glaucoma, the power of OCT angiography in assessing glaucoma, innovative new IOPlowering agents and a wearable brain-based device called that incorporates virtual reality and could help improve diagnosis and prevent vision loss. Also included in this issue are the first shortlisted entries for the John Henahan Writing Prize. The prize, now in its 12th year, is named in honour of John Henahan, who edited EuroTimes, the official news magazine of the ESCRS, from 1996 to 2001. The topic for discussion is ‘How To Balance Ophthalmology And Family Life', and each one tackles this question with insight and flair. Finally, as President of the European Glaucoma Society, I look forward to meeting our colleagues at the forthcoming ESCRS Glaucoma Day, on Friday 13 September. This will take place at Paris Expo, Porte de Versailles, immediately preceding the 37th Congress of the ECSRS. Registration is open and the programme will be announced very soon.

David Garway-Heath, President, European Glaucoma Society EUROTIMES | JUNE 2019


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SPECIAL FOCUS: GLAUCOMA

Update on

MIGS New devices and treatments are adding to the effectiveness of minimally invasive glaucoma surgery. Aidan Hanratty reports

L

earning when and in whom to perform minimally invasive glaucoma surgery (MIGS) is key to unlocking its potency and efficacy, believes Keith Barton FRCS, Moorfields Eye Hospital, London. In contrast to trabeculectomy, in which the surgeon will make a small hole in the sclera allowing fluid to drain from the aqueous humour through to a bleb under the surface of the eye, MIGS involves either the careful placement of a tiny device in the eye or the use of very small instruments. MIGS is appropriate in various groups of patients. Patients with glaucoma that is manageable but who can’t (or won’t) adhere to eye drops in order to maintain intraocular pressure EUROTIMES | JUNE 2019

The interesting thing with MIGS using an ab interno approach is that when you do the surgery you don’t manipulate the conjunctiva a lot Philippe Denis MD

(IOP), and patients with glaucoma who are undergoing cataract surgery are candidates. Also, patients who need modest lowering may benefit from MIGS procedures that can reduce IOP in a way that is safer than traditional surgery. Furthermore, we now see more potent subconjunctival MIGS procedures that may compete with

trabeculectomy in their ability to lower IOP substantially, but safer. When dealing with patients who have cataract and glaucoma, Ike Ahmed MD explains it in the following words: “The good news is that cataract surgery can also potentially lower the pressure a little bit. While I’m in there I have the opportunity


to do something that is very safe that provides an opportunity to eliminate more medications than if I didn’t do it, in a very safe manner that doesn’t really increase the risk of surgery in my experience.” It was Dr Ahmed, Assistant Professor, University of Toronto, Canada, who first coined the term MIGS back in the early 2000s. “I can put a stent, the smallest stent in the world, to sit very quietly inside the drainage channels to provide a bypass from the blockage internally, draining naturally in your eye, so you don’t feel it, you don’t see it, it doesn’t impact the vision result, and the recovery is quite similar with the opportunity to lower medication,” he continues. Philippe Denis MD, President of the French Glaucoma Society, sees MIGS as a midway point between medical treatment and “classical” surgery, such as trabeculectomy or non-penetrating deep sclerectomy. “The interesting thing with MIGS using an ab interno approach is that when you do the surgery you don’t manipulate the conjunctiva a lot and the scleral dissection is very limited, so you can leave a space in the conjunctiva to do classical surgery in the future, if you need it.”

MILLION-DOLLAR QUESTION There is a range of different options when it comes to MIGS, with different devices entering different parts of the eye. Choosing a favoured device is “the one-million-dollar question”, according to Dr Denis. “There are three ways of inserting MIGS within the eye: we can reduce intraocular pressure by using the trabecular pathway, the supraciliary space and also the conjunctival route. It’s difficult to say which MIGS is the best, because there is no head-to-head comparison between the implants, these studies are lacking.” Instead, each device is brought to market following a range of trials, generally comparing the glaucoma surgery performed alongside removal of a cataract with removal of the cataract alone. Dr Denis believes that we still need to establish uniformity of clinical trials evaluating MIGS (criteria of eligibility, safety and efficacy endpoints). The indications for each device may be defined by these considerations.

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Courtesy of Philippe Denis MD

SPECIAL FOCUS: GLAUCOMA

The XEN Gel Implant (Allergan)

The iStent from Glaukos works by incising and then stenting Schlemm’s canal to increase trabecular outflow. It gained FDA approval in 2012, and at just 1mm, it is the smallest FDA-approved device ever implanted in the human body. A review of the literature regarding this device was carried out and published in 2016 (iStent® Trabecular Microbypass Stent: An Update, J Ophthalmol. 2016; 2016: 2731856). This review examined the results of a series of trials and case series involving implantation of the device. Primarily performed alongside phacoemulsification, use of the iStent led to a consistent lowering of IOP as well as a reduced dependence on medications. “The stenting ones are obviously attractive because you’re slipping a very small device gently into the trabecular meshwork, and when you look across the data, it appears that the Hydrus is probably the best of the bunch in terms of efficacy,” says Dr Barton, a Consultant Ophthalmologist and Glaucoma Specialist at Moorfields Eye Hospital. In the Horizon study (Ophthalmology. 2019 Jan;126(1):29-37), the Hydrus Microstent (Ivantis) demonstrated superior reduction in modified diurnal IOP and medication use among subjects with mildto-moderate primary open-angle glaucoma who received a Microstent combined with phaco compared with phaco alone. The Microstent is an 8mm-long crescent-shaped scaffold that improves aqueous outflow by bypassing the trabecular meshwork. The CyPass Micro-stent (Alcon), meanwhile, is a 6.5mm-long suprachoroidal shunt that can also be installed post-phaco. While results two years post-surgery showed little difference in endothelial cell loss between the CyPass and cataract surgeryonly groups, at five years, the CyPass group experienced “statistically significant endothelial cell loss compared to the group who underwent cataract surgery alone”, according to an Alcon media release. “Out of an abundance of caution,” the CyPass was voluntarily withdrawn in August 2018. “Specifically with the CyPass, it seems to

be primarily a positioning-related issue,” says Dr Ahmed, “which doesn’t seem to be related or common with the other procedures we do in the trabecular meshwork. This device sits in a different position, so with some placements, the alignment and the rigidity of the device, the position of the device I think made it at increased risk.

BALANCING ACT “It does remind us that nothing is benign, nothing is ever completely risk free,” continues Dr Ahmed. “I think it’s always a balancing act, we know for example with other glaucoma surgeries like tube shunts, it’s well known that endothelial cell loss may occur; however, the risk-benefit is different in those patients, because those patients are typically more advanced.” In a media release dated August 29, 2018, Dr Stephen Lane, Chief Medical Officer at Alcon, was quoted as saying: “We intend to partner with the FDA and other regulators to explore labelling changes that would support the reintroduction of the CyPass Micro-Stent in the future.” In terms of bleb-forming devices, the XEN Gel Implant (Allergan) was approved in 2016. It is inserted into the anterior chamber, passed ab interno, and then tunnelled through sclera to deploy the device within the subconjunctival space. A recently published study (‘A multicentre interventional case series of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery’, Eye (Lond). 2019 Mar;33(3):469477) showed a reduction of both IOP and medication use at 18 months, with adverse events described as “uncommon”. A previous study (‘Efficacy, Safety, and Risk Factors for Failure of Standalone Ab Interno Gelatin Microstent Implantation versus Standalone Trabeculectomy’, Ophthalmology. 2017 Nov;124(11):15791588) showed that there was no detectable difference in risk of failure and safety profiles between standalone ab interno microstent with mitomycin C [an antiEUROTIMES | JUNE 2019


SPECIAL FOCUS: GLAUCOMA scarring agent] and trabeculectomy with mitomycin C. A report from the XXXV Congress of the ESCRS in Lisbon, Portugal, suggested that the XEN worked best when implanted as part of a standalone procedure. “Although XEN placement is a convenient operation to combine with cataract surgery, our data suggest that combining phaco with XEN is slightly less effective for IOP lowering than XEN alone,” said Jan Van der Hoek MD, FRCOphth, Scarborough General Hospital, Scarborough, UK. Because of the position of where the bleb is formed, Dr Barton believes that the InnFocus MicroShunt (Santen) has a big efficacy advantage of other devices. “You can ramp up the dose of mitomycin C quite high in order to get quite dramatic efficacy, without the bad side-effects,” says Dr Barton. Traditional trabeculectomy can lead to infection and discomfort, he adds, but the blebs formed with the MicroShunt are further back. The MicroShunt is 8.5mm long and acts by allowing aqueous humour to drain from the anterior chamber into sub-Tenon’s space. It can be performed with or without cataract surgery. Trials are currently under way with a view toward gaining FDA approval. Moorfields Eye Hospital, where Dr Barton practises, was an investigative site for an FDA pivotal study, and it was provided with an endothelial cell counter, specifically for that study. “The FDA is the one body that’s looking at [MIGS] more than anybody else.” At present there are no guidelines in Europe regarding the use and practice of MIGS, but in the USA, the FDA published Premarket Studies of Implantable Minimally Invasive Glaucoma Surgical (MIGS) Devices in 2015.

NUMBERS ADD UP Cost is an important factor. In a public hospital, numbers add up. “I could sell the MicroShunt and the XEN easily to the finance director,” says Dr Barton. “‘These are similar to trab and they take a third of the time so you can do three times as many cases in the operating theatre.’ Operating theatre space is a premium cost, therefore his eyes light up and he says ‘great, we’ll do them’.” Dr Ahmed feels that the benefit of newer bleb-forming procedures like the Microshunt and Xen extend beyond the OR, and include less postoperative management, visits, interventions and complications as has been shown in recent studies (Schlenker et al, Ophthalmology Glaucoma 2018). “Improved postoperative recovery and safety lead to a reduction of postoperative costs and can greatly enhance the patient’s quality of life,” says Dr Ahmed. “In the long run, we need proper cost-effectiveness studies, which I believe will show better visual recovery, less damage to the structure of the eye, better comfort and less complications leading to a better quality of EUROTIMES | JUNE 2019

The iStent Inject

life for our patients. This may lead to better cost-effectiveness (which is a balance of cost and quality of life).” Things are harder to quantify with the iStent, which Dr Barton believes improves quality of life. “Obviously it’s very attractive to the greater NHS, to improve patients’ quality of life, but firstly we need to prove that there is a quality of life benefit in the longer term and secondly, they’re expensive.” Because it remains a relatively young procedure, the long-term success (or failure) of MIGS is yet to be seen by those in charge of finance. The cost of the procedure must also be weighed up against long-term expenditure on drops and other medications. It is another balancing act. “Anybody on a couple of glaucoma medications, if the device is free, [MIGS] wouldn’t be unreasonable. The question is how much you’re prepared to pay, and it’s as simple as that. There’s controlled glaucoma, where you’re not worried about the glaucoma, they’re on a bunch of medications, they’re having cataract surgery, that will bring the pressure down a bit, but can you improve on that with a MIGS? And if you’ve got a cheap and easy-to-implant device then it’s reasonable to put it in.” The major benefit of MIGS is to address adherence issues with medications. “Studies have shown that most patients don’t take their medications regularly or properly, which has shown to risk progression,” says Dr Ahmed. So in the long-run, MIGS may provide a safe way to address adherence and thus reduce progression or need for more aggressive (and riskier) surgery. What comes after MIGS? Something that always comes up when discussing glaucoma, be it MIGS or other approaches, is eye drops for IOP. Topical medications are effective, but only if they are administered correctly. This requires accurate placement of the drop on to the eye, an appropriate interval between doses and the correct number of administrations per day. For older patients especially, this is not always possible. What if there existed a slow-release system that

could last for months at a time? “The iDose Travoprost is filled with a special formulation of travoprost, a prostaglandin analogue used to reduce IOP, and designed to continuously elute therapeutic levels of the medication from within the eye for extended periods of time. When depleted, the iDose Travoprost can be removed and replaced in a similar, subsequent procedure.” This is from a Glaukos press release announcing sustained IOP reduction and a favourable safety profile after 12 months. “The question is how long they’ll last and how many times you have to change,” says Keith Barton. “If they lasted a year that would be acceptable, but if they only last three months, this is a return to the operating room each time.” Allergan, meanwhile, is developing the Bimatoprost SR (Sustained-Release) Implant, a biodegradable implant for the reduction of IOP. A phase III clinical study showed a 30% reduction of IOP over 12 weeks, meeting the predefined criteria for non-inferiority to the study comparator, timolol. An Allergan press release said that this shows the potential for most patients to remain treatment-free for a year after the last implant was inserted – a KaplanMeier estimator showed figures above 80% requiring no retreatment after three cycles of implant – and the implant was well tolerated in most patients. Further trials are under way and more reports are due later this year. Other new technologies include punctal plugs and contact lenses that live beneath the eyelid and release drugs over time. What’s most exciting for Dr Ahmed is some of the durability effects seen with bioerodible intraocular implants, as well as the potential for a combination of effects from surgery and sustained-release systems. “I can put a very safe MIGS device in, and get you to a certain point, and I can do a sustained-release implant and get you further and get you down where you need to go with a one-two punch, I think that synergy is potentially amazing.”

Courtesy of Philippe Denis MD

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SPECIAL FOCUS: GLAUCOMA

M A N AG E M E N T

of co-existing cataract and glaucoma In part 1 of this series, we look at general principles of cataract and glaucoma and the basics of trabeculectomy. Soosan Jacob MD reports

C

ataract and glaucoma may co-exist in the same patient and management depends on various factors, aims being effective IOP control and safety. Surgery is decided based on grade of cataract, severity of glaucoma, cause for decreased vision and target intraocular pressure (IOP). A great deal of variation exists in choice of management among different surgeons. Part 1 of this multi-part article deals with general principles as well as the trabeculectomy technique. Subsequent parts will deal with other glaucoma surgeries.

CATARACT SURGERY ALONE The patient should be assessed to know if visual loss is due to glaucoma, cataract or both. Very dense cataracts interfere with accurate glaucoma assessment. Though improvement on potential acuity meter helps rule out macular involvement, advanced field loss is not detected until fixation is involved. Early cataract affects visual quality more in patients with glaucoma and cataract extraction may be of benefit. Conjunctival incisions should be avoided to maximise virgin conjunctiva and clear corneal phacoemulsification is preferred. Cataract surgery alone may decrease IOP slightly, with reduction being greatest in those with higher preoperative values. The “cataract alone� approach avoids risks of glaucoma surgery such as hypotonic maculopathy, shallow anterior chamber (AC), infection etc, especially in eyes with mild, medically well controlled glaucoma on single/ double drug. Close follow-up is EUROTIMES | JUNE 2019

required to assess the need for glaucoma surgery later. Minimally invasive glaucoma surgery (MIGS) may be more safely combined in these patients as cataract surgery alone may not control IOP and sometimes may even result in loss of control. Cataract surgery carries higher risk with small pupil, rock hard cataracts, high myopia, pseudoexfoliation etc. and any ensuing vitreous loss can decrease success rate for subsequent glaucoma surgery. Angle closure may occur secondary to increasing size of the lens with age and can be treated effectively with phacoemulsification. Risk of fixation loss following postoperative IOP spike in patients with advanced glaucoma should be kept in mind and should be strictly avoided by good surgical technique as well as with the use of beta blockers and carbonic anhydrase inhibitors. Retained viscoelastic, postoperative inflammation and steroid usage are risk factors.

GLAUCOMA SURGERY ALONE This may be opted for in eyes with uncontrolled glaucoma despite maximum medical therapy/ laser trabeculoplasty. Surgical options include trabeculectomy, non-penetrating surgeries, glaucoma drainage devices and in mild cases, MIGS. However, cataract formation may be hastened and loss of IOP control is possible following subsequent cataract surgery resulting in need for further medical or surgical management. Initial glaucoma surgery should therefore aim at lower target pressure so that subsequent cataract extraction still

retains IOP within an acceptable range. Postoperative inflammation should be avoided after cataract surgery to prevent decrease in bleb function.

COMBINED SURGERY Combined surgery is more convenient to the patient and can give better results with lesser need for medications as compared to cataract surgery alone. Though older studies indicate trabeculectomy has a greater IOP reduction than combined surgery, subsequent cataract surgery may result in loss of this beneficial effect. Phacotrabeculectomy has been shown to have an equal pressure-lowering effect when used in conjunction with mitomycin C (MMC) but lesser when used with 5-fluorouracil. Antimetabolites can increase success rate but may be associated with complications such as thin, avascular leaking bleb, overfiltration, shallow AC, overhanging bleb, scleral melt, blebitis and endophthalmtis and should be used only as recommended. Combined surgery avoids postoperative pressure spikes in advanced cases; however, this may still occur, especially with retained viscoelastic, blood/ fibrin in AC or tight flap sutures. Choice of glaucoma surgery depends on the stage of glaucoma. Trabeculectomy is the most commonly performed glaucoma filtration surgery worldwide and can be combined with phacoemulsification. Two-site surgery is more effective and safer than single-site. Trabeculectomy: This may be opted for in medically uncontrolled patients. The Moorfields Safer Surgery System gives guidelines for effective IOP control while minimising complications and


SPECIAL FOCUS: GLAUCOMA failure. Surgery is preferred in the superior quadrant to allow mechanical protection of the bleb by the upper lid, to decrease risk of inflammation and blebitis as well as to avoid diplopia with an exposed peripheral iridectomy (PI). A 6-8mm peritomy with about a 10-15mm posterior dissection to all sides gives a fornix-based conjunctival flap and avoids the ‘ring of steel’ scarring as well as cystic bleb formation associated with limbusbased conjunctival flaps. This, together with stopping side cuts of a 3.5x4.5mm half thickness scleral flap short of the limbus, allows a diffuse, posteriorly filtering bleb. Gentle, focal cautery to arrest bleeding and avoiding creating the flap over large perforating aqueous veins is important. Lamellar dissection is done just into the clear cornea and an antimetabolite is applied under the scleral and conjunctival flaps before entering the eye. MMC (0.2-0.5mg/ ml, concentration depending on risk factors) is applied for two-to-three minutes over a large area, avoiding contact with conjunctival wound edges, followed by a thorough wash. An inferotemporal paracentesis or needle entry is made for forming the AC when required and an AC maintainer may be used. When combined with phaco, the phaco ports are placed so as not to intersect the scleral flap. Side port may be used later for placing AC maintainer. After phaco and IOL implantation, a sclerostomy is made using blade and scissors or with single punch using 0.5mm Descemet membrane punch. The PI is made holding the scissor parallel to limbus to get an iridectomy that covers the extent of the sclerostomy. PI is avoided by some to decrease risk of postoperative inflammation/ hyphema and subsequent postoperative IOP

A: Conjunctival peritomy and scleral flap are followed by application of MMC

B: Sclerostomy and PI are done

C: Sutures are applied (conventional/ releasable/ adjustable)

D: A posteriorly directed flow and diffuse bleb are attained

spike/ bleb fibrosis. However, this is at the cost of an increased risk of iris adhering to and occluding the ostium. Preplaced 10-0 nylon sutures at the flap corners are then tied and aqueous flow on irrigation as well as stability of AC on stopping irrigation act as a guide to the tightness of sutures as well as need for more sutures. The use of releasable and adjustable scleral flap sutures allows the ability to increase flow postoperatively.

A nylon suture on a round-bodied needle is finally used to apply continuous sutures to close the conjunctiva and phaco ports are checked for any leak. AC is formed again after removing speculum. 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

24th ESCRS Winter Meeting

M arrakech

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

Save the Date

21 – 23 February 2020 Marrakech, Morocco

EUROTIMES | JUNE 2019

9


10

SPECIAL FOCUS: GLAUCOMA

OCT-A in glaucoma Blood vessel perfusion and density may better diagnose and predict progression. Howard Larkin reports

A

dvances in optical coherence tomography (OCT) enabling detection of blood flow and blood vessel density across larger areas of the retina may make OCT angiography (OCT-A) a more powerful tool for assessing glaucoma than relying on structural measures such as retinal nerve fibre layer (RNFL) thickness generated by conventional OCT, David Huang MD, PhD, told the Glaucoma Subspecialty Day at the 2018 American Academy of Ophthalmology Annual Meeting in Chicago, USA. OCT-A algorithms in development may even help simulate the location and severity of visual field defects, making it easier to identify and track patients at the highest risk of progression, said Dr Huang, of the Casey Eye Institute, Oregon Health and Science University, Portland, Oregon, USA.

WHERE TO LOOK In 2014, OCT-A studies by Dr Huang and colleagues established that glaucoma reduces perfusion at multiple levels of the optic nerve head and that capillaries of the superficial disc and lamina cribrosa are greatly attenuated (Jia Y et al. Ophthalmol 2014; 121:1322). More recently, OCT-A has revealed that glaucoma capillary loss is most pronounced in the nerve fibre layer plexus and the ganglion cell layer plexus, together known as the superficial vascular complex (SVC), than in the intermediate and deep capillary plexuses, together known as the deep vascular complex (Campbell P et al. Sci Rep 2017;7:42201). Studies with projection-resolved OCT-A also have found greater mean reduction in vessel density in the macular

I postulate this is possible because OCT-A can detect reduced perfusion related to lower metabolism in sick ganglion cells... David Huang MD, PhD SVC than in the intermediate or deep plexuses of glaucoma patients, and the 22% in the SVC is statistically significant (p<0.001), while lesser losses in the deeper layers are not (Takusagawa HL et al. Ophthalmal 2017;124:1589). Macular SVC low perfusion areas also correlate with ganglion cell complex thinning and visual field defects. As a result, focusing on capillary loss in the SVC can generate good diagnostic accuracy, as high as 0.98 in his study, Dr Huang said. Nonetheless, some published studies have found poor diagnostic accuracy with OCT-A imaging of the macula, Dr Huang noted. However, these were done using scans of 3mm-to-4mm square in the central macula, which is not greatly affected. A larger 6mm square scan area is needed for effective OCT-A, he said.

OCT-A V STRUCTURAL OCT Some studies using a larger OCT-A scanning field have demonstrated higher accuracy diagnosing early glaucoma vs normal based on disc and peri-papillary vessel density than peripapillary nerve fibre layer thickness. This ranges from 0.84 for fellow eyes of unilateral glaucoma to 0.96 for pre-perimetric glaucoma patients for OCT-A vs about 0.77 for RNFL in both studies (Yarmohammadi A et al. Ophthalmol 2018;125:578. Akil H et al. PLOS ONE 2017;12:e0170476).

“I postulate this is possible because OCT-A can detect reduced perfusion related to lower metabolism in sick ganglion cells prior to apoptosis and structural thinning,” Dr Huang said. Overall, OCT-A has been shown to correlate with visual field loss more closely than nerve fibre layer thickness, correlating at R2=0.697 vs R2=0.035 (Liu L et al. JAMA Ophthalmol 2015;133:1045), Dr. Huang said. OCT-A has also been shown to be more sensitive for advanced glaucoma cases, correlating with SAP mean deviation down to about -15dB compared with about -10dB for nerve fibre layer thickness (Yarmohammadi A et al. Ophthalmol 2016;123:2498). This may be because perfusion continues to drop off after the structural thickness floor has been reached, Dr Huang said. Based on this correspondence, Dr Huang has recently begun an attempt to simulate visual field performance based on perfusion measured by OCT-A in eight segments that follow nerve fibre trajectory based on extended Garway-Heath sectors (Tan O et al. Transl Vis Sci Technol 2018;7:16). “This project is still early and so far, we are finding fairly good correspondence with early and moderate glaucoma but not so good in advanced cases.” He plans to report progress as the project continues. David Huang: huangd@ohsu.edu

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ESCRS

Glaucoma Day 2019 Friday 13 September

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SPECIAL FOCUS: GLAUCOMA

Virtual reality for glaucoma Head-mounted VR goggles use light to stimulate targeted areas in the patient’s visual field. Colin Kerr reports

A

wearable brain-based device called NGoggle that incorporates virtual reality could help improve glaucoma diagnosis and prevent vision loss. Duke University researchers funded by the National Eye Institute (NEI) have launched a clinical study testing the device in hopes that it could decrease the burden of glaucoma. The device consists of head-mounted virtual reality goggles that use light to stimulate targeted areas in a patient’s visual field. “Current methods for glaucoma screening and monitoring are relatively primitive,” said Felipe Medeiros MD, PhD, a study investigator, a co-founder of NGoggle, Inc, and a professor of ophthalmology at Duke University School of Medicine. Standard screening tests measure pressure within the eye. Although elevated intraocular pressure is the main risk factor for glaucoma, not all cases of the disease are associated with high pressure. Screening for glaucoma based on single intraocular pressure measurements may fail to detect up to 80% of the patients with the disease, Dr Medeiros said. “That’s because many people develop optic nerve damage from glaucoma at relatively low intraocular pressure levels. In addition, pressure fluctuates widely throughout the day and on different days, making it difficult to rely on a single measurement for diagnosis and screening. Importantly, many subjects may also have high intraocular pressure and never develop damage to the optic nerve.” Standard automated perimetry (SAP) is usually used to monitor glaucoma progression. SAP requires patients to click a button when lights are randomly shown for a brief time in their peripheral vision. In contrast to SAP, the NGoggle objectively assesses peripheral loss of vision without requiring subjective input from the patient. NGoggle gauges brain activity in response to signals received from the eyes. Diminished activity may indicate functional loss from glaucoma. The virtual reality goggles are integrated with wireless electroencephalography (EEG), a series of electrodes that adhere to the scalp to measure brain activity. Within a few minutes, the NGoggle algorithm captures and analyses enough data to report how well each eye communicates with the brain across the patient’s field of vision. The device’s virtual reality capabilities can be greatly leveraged, Dr Medeiros said. People could be tested for glaucoma as they play a VR-based video game or explore a virtual art gallery. “The possibilities are endless for making it an engaging experience, which would go a long way toward ensuring that people use it and receive the treatment they need,” he said. bit.ly/ET-NGoggle

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Current methods for glaucoma screening and monitoring are relatively primitive Felipe Medeiros MD, PhD

EUROTIMES | JUNE 2019

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14

SPECIAL FOCUS: GLAUCOMA

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Study supports SLT as first line of therapy in newly diagnosed glaucoma. Roibeard Ó hÉineacháin reports

I

nitial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication in the management of primary open-angle glaucoma (POAG) or ocular hypertension (OHT), suggest the results of the Laser in Glaucoma and Ocular Hypertension Trial (LiGHT). The study results were presented by Gus Gazzard MD, FRCOphth, Moorfields, Eye Hospital NHS Foundation Trust, London, UK, during the 36th Congress of the ESCRS in Vienna. The prospective, unmasked, multi-centre, randomised controlled trial involved an intent-to-treat population of 718 previously untreated patients with POAG or OHT recruited at six centres in the UK between 2012 and 2014. The trial comprised two treatment arms: initial SLT followed by conventional medical therapy as required, and medical therapy without laser therapy, Dr Gazzard told a Glaucoma Day session during the Congress. At three years’ follow-up, 78% of eyes in the laser first group had drop-free disease control using stringent real-world target IOPs for at least three years. Of those, 77% needed only one SLT. In addition, only 4.6% had disease progression compared to 7.2% in the medication first group, and no eyes in the SLT group required trabeculectomy compared to 1.8% in the medication first group. There was also less disease progression and lower costs in the SLT group. In the medication first group, 65% were at target on only one medication. However, the mean scores on the healthrelated quality of life (HRQL) (EQ-5D) five-level scale were no different between groups. In the SLT first treatment group, patients received 100 shots of the laser over 360 degrees. If that failed to achieve the target IOP, they underwent a maximum of one repeat laser treatment. If IOP was still not at target, patients received topical medication and, if necessary, surgery. In both groups, all standard available topical treatments were permitted according to a pre-specified intervention protocol, beginning with prostaglandin analogues, then beta-blockers followed by alpha-agonists or carbonic anhydrase inhibitors. The target intraocular pressure (IOP) was set at baseline, according to disease severity and lifetime risk of loss of vision at recruitment, and adjusted on the basis of IOP control, optic disc examination and visual field testing. Dr Gazzard noted that based on the study’s findings he would recommend offering SLT to all new OHT and POAG patients of all races, taking due consideration of risks entailed by treating eyes with comorbidities. They include an increased risk of IOP spikes in eyes with pseudoexfoliation syndrome and cystoid macular oedema in patients with diabetes mellitus. Gus Gazzard: g.gazzard@nhs.net

EUROTIMES | JUNE 2019

In the SLT first treatment group, patients received 100 shots of the laser over 360 degrees Gus Gazzard MD


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CATARACT & REFRACTIVE

SMILE complications Most challenges can be managed without affecting final visual outcome. Howard Larkin reports

W

ith more than one million small-incision lenticule extraction (SMILE®) refractive procedures performed worldwide, a profile of the most common complications has emerged. Lenticule extraction difficulties and minor tears at the lenticule incision edge are among the more common complications specific to SMILE. The overall incidence of complications that may affect visual acuity after SMILE is very low and comparable to that of LASIK/ PRK, according to literature review. If well managed, most SMILE complications do not affect the final visual outcome, Mario Nubile MD told the International Society of Refractive Surgery Refractive Subspecialty Day at the American Academy of Ophthalmology 2018 Annual Meeting in Chicago, USA. He reviewed how to prevent and recover from some common SMILE problems.

SUCTION LOSS Performed with a femtosecond laser docked to the cornea with a suction device, suction loss is more common in SMILE than femtoLASIK for two reasons, said Dr Nubile, of the University G. d'Annunzio, Chieti-Pescara, Italy. First, the SMILE cut takes longer, about 25-to-35 seconds. Second, the VisuMax® device uses a low-suction pressure to avoid injury. Suction loss risk factors include conjunctival chemosis, higher cylinder, narrow eyelids, smaller corneal diameter and lid squeezing and is more common in the early learning curve, though suction loss can occur at any time with any surgeon. Average incidence of suction loss reported in the literature ranges between 0.5 and 2%, but it decreases with surgeons’ experience. In cases of suction loss during the side, anterior lenticule plane or first 10% of the posterior surface plane cut, the procedure can usually be recovered by carefully redocking the patient and restarting the procedure, Dr Nubile said. However, if lost after more than 10% of the posterior plane is cut, redocking will usually lead to aberrations near the corneal centre. In these cases, the SMILE

procedure must be abandoned, though conversion to PRK or femto-LASIK is possible.

OPAQUE BUBBLE LAYER When bubbles from laser photodisruption fail to dissipate, they can form an opaque layer that makes it impossible to visualise and perform lenticule dissection. The problem is usually associated with thin lenticules and thicker corneas, and can be minimised through optimal energy settings, Dr Nubile said. The solution is to wait for the bubbles to disappear. This may be accelerated by gently massaging them out from the lenticule interface. Opaque bubble layer formation generally does not affect visual outcomes.

BLACK SPOTS Adherence of water droplets or meibomian secretions on the interface between the suction cone and cornea can locally block photo-disruption, resulting in High risk of suction loss during the laser lenticule dissection due to fluid regional absence of tissue cleavage and conjunctival sliding into the contact glass/cornea interface (top); that appear as black spots on the Inadvertent handling of the instrument during anterior plane dissection causing cap perforation in SMILE (above) cornea. These adhesions must be manually separated during lenticule dissection. However, this However, false plane creation can cause the must be done carefully as it creates a risk of lenticule to stack, making extraction difficult difficult extraction, incision tears and false and risking incomplete lenticule removal, dissection planes, Dr Nubile noted. resulting in irregular astigmatism. This can be treated with topography-guided custom INCISIONAL TEAR, CAP ablation, though corneal haze may result. PERFORATION AND FALSE False planes in the stroma under the posterior PLANE CREATION plane can lead to opacities and permanent These usually occur when instruments face haze. Specialised blunt dissection instruments tissue resistance during lenticule dissection, can help prevent these complications. Dr Nubile said. The overall incidence of incisional tear is 1.8%, cap perforation ECTASIA 0.22% and false plane less than 0.2%. Tears While just seven cases of ectasia after SMILE and perforations usually are minor and have been reported, of which four had can be managed with topical antibiotic form fruste keratoconus, ectasia is a risk. gels and artificial tears, and usually do not For now, patients should be subject to the permanently affect vision. same screening requirements as for LASIK, including residual stromal bed and corneal thickness to reduce risks, Dr Nubile said. Greater care should be taken during the SMILE learning phase, when most complications occur, Dr Nubile concluded. “SMILE is quite a difficult surgery; it is not like a PRK and skill is required to avoid complications.”

...false plane creation can cause the lenticule to stack, making extraction difficult and risking incomplete lenticule removal... Mario Nubile MD EUROTIMES | JUNE 2019

Courtesy of Mario Nubile MD

16


CATARACT & REFRACTIVE

Trifocal vs EDOF debate Trifocal and EDOF IOLs provide good spectacle independence, but which is better? Roibeard Ó hÉineacháin reports

G

reek ophthalmologists debated the relative advantages of trifocal and extended depth of focus intraocular lenses (IOLs) at the 23rd ESCRS Winter Meeting in Athens, Greece. Petros Smahliou MD, FRCS, FEBO, Athens, Greece, argued in favour of trifocal IOLs, pointing out that they tend to provide better near vision than EDOF IOLs. Moreover, because of their diffractive design they are less prone to haloes and glare than older refractive multifocal IOLs, with no more photic phenomena than EDOF lenses. “Trifocal IOLs are a good option for the majority of patients. They benefit more from the excellent near vision and reading ability. Newer diffractive trifocals may be better in near vision and quality of vision outcomes, with less risk of haloes than older diffractive and refractive multifocal lenses,” Dr Smahliou said. He cited a recent trial in which 60 patients were randomised to receive one of two types of trifocal IOL or an EDOF lens. It showed that all yielded similar monocular and binocular uncorrected distance visual acuity (UDVA). There were no significant statistical differences for uncorrected intermediate visual acuity (UIVA) but trifocal IOLs outperformed the EDOF IOL in uncorrected near visual acuity. He added that bench test comparisons show that at in trifocal and EDOF IOLs with apertures higher than 2.0mm, the tendency is toward more negative spherical aberrations with the pupil enlargement. However, the bifocal and EDOF IOLs show higher absolute values of spherical aberrations in comparison with the trifocal IOL, especially for large pupil diameters. “There is no ideal IOL. However, we have to take into account the patients’ needs, so the EDOF lenses have the advantage in the intermediate vision, and the trifocals in the near vision,” he said. Elisabeth Patsoura MD, MRCOphth, Athens, Greece, argued in favour of EDOF IOLs. She noted that there is space for new EDOF designs as multifocal IOLs (MIOLs) traditionally reduce contrast sensitivity, cause photopic phenomena and are less suitable for eyes with concurrent disease. New EDOF technologies control both chromatic and spherical aberrations to improve quality of vision without compromising contrast sensitivity. In addition, pinhole optic models have a potential use with irregular corneas. EDOF IOLs also appear to be more tolerant to defocus than MIOLs. In the Concerto trial, patients undergoing bilateral implantation of the Symfony EDOF IOL achieved UDVA equal or better than many MIOLs, UIVA similar or better than trifocal IOLs but similar or worse UNVA than that reported with trifocal diffractive models. Nevertheless NVA was comparable with MIOLs when a mini monovision approach was aimed for. In addition, 91% of patients reported no use or occasional use of glasses for distance and near, and 90% reported minimal or no photopic phenomena. Interestingly, despite worse NVA in most trials the extended range IOL group was no more spectacle dependent than the trifocal group for near tasks. She added that bench testing requires careful interpretation for their clinical relevance as special eye characteristics and visual cortex response are not taken in account. Although improvements are needed, EDOF designs are evolving and are likely to surpass MIOLs. Patient selection can never be overstressed.

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CATARACT & REFRACTIVE

Phakic IOL update Phakic IOLs remain an option, but problems remain with endothelial cell loss and cataract. Roibeard Ó hÉineacháin reports

ENDOTHELIAL CELL LOSS Dr Nuijts reviewed a prospective, clinical cohort study designed to evaluate the long-term change in endothelial cell density (ECD) in a total of 507 eyes of 289 patients implanted with the Artisan Myopia or Artisan toric phakic IOL.1 The researchers found that from six months to 10 years postoperatively, mean ECD decreased by -16.6% in eyes with the myopic implant and by 21.5% in eyes with the toric implant. That is equivalent to an additional 10.9% decrease in ECD in the myopic group and 15.8% in the toric group, when corrected for physiological loss of 0.6% per year, he noted. Among eyes with 10 years of follow-up, the proportion requiring explantation because of endothelial cell loss was 1.0% in the myopic group and 3.8%, in the toric group. The total explantation rate among all eyes over the complete follow-up was 6.0% in the myopic group and 4.8% in the toric group. Mean time to explantation was 11.97 years in the myopic group and 7.4 years in the toric IOL group. EUROTIMES | JUNE 2019

1,0

0,8

0,6

120 months Courtesy of Rudy Nuijts MD, PhD

I

ris-fixated and sulcus-fixated phakic intraocular lenses can provide high ametropes with corrections beyond the range of corneal refractive procedures, but eyes with the implants have an accelerated endothelial cell loss and remain prone to changes in refraction as the natural lens ages, according to review on the literature presented by Rudy Nuijts MD, PhD, Maastricht University Eye Clinic, Maastricht, the Netherlands. The original phakic IOLs were introduced in the early 1990s. They included the iris-fixated Artisan (Ophtec) lens, the sulcus-fixated implantable collamer lens (Visian® ICL, Staar Surgical) and a series of anterior chamber lenses. Over the years all of the angle-supported anterior chamber IOLs have been withdrawn from market because of endothelial cell loss, leaving only the iris-fixated and sulcus options, Dr Nuijts told the 23rd Winter Meeting in Athens, Greece. Dr Nuijts and associates have followed a cohort of 379 eyes implanted with the Artisan Myopia lens and 293 eyes implanted with the Artiflex Myopia lens at the Maastricht University Eye Clinic from 1998 to 2016. The Artisan/Verisyse IOL, introduced in 1991, has a PMMA optic of 5.0mm or 6.0mm in diameter, depending on the amount of correction required and provides correction for -1.0D to -23.5D of myopia. The Artiflex/Veriflex, introduced in 2004, has PMMA haptics and a polysiloxane optic of 6.0mm in diameter, and is designed to correct -2.0D to -14.5D. The research shows that at 10 years’ follow-up 95% of eyes had uncorrected visual acuity (UCVA) of 20/40 or better and 46% had a UCVA of 20/20 or better. In addition, 39% gained two or more lines of best-corrected visual acuity (BCVA), but 11.0% lost more than two lines. In terms of stability, owing to the naturally occurring thickening of the crystalline lens and continued increase in axial length, there was a myopisation of around -0.4D over five years (p <0.01) and -0.82D over 10 years. Correspondingly, in terms of predictability, after five years 68.4% were within 1.0D of target refraction and 46.2% were within 0.5D. At 10 years only 47.9% within 1.0D and 23.1% were within 0.5D. Furthermore, over 10 years of follow-up, the mean corrected distance visual acuity (CDVA) decreased by +0.06 logMAR, or roughly half a line (p<0.01), and UDVA decreased by +0.16 logMAR, a whole line.

Survival Probability

18

0,4

Artisan Myopia Artisan Toric 0,2

0,0 0

50

100

150

200

Survival Time, Months

POSTERIOR CHAMBER PIOLS The remaining phakic IOL is the sulcus-fixated Implantable Collamer Lens (ICL). Approved in 1991, the lens is composed of pig collamer and has a 5.8mm optic and overall diameters ranging from 12.1mm to 13.7mm. It is designed to correct up to -18.0D of myopia and up to +10.0D of hyperopia, and -0.5D to -6.0 D of astigmatism. Dr Nuijts noted that although he has no personal experience with the ICL, studies conducted to date with the latest version of the lens show 68-to-95% achieving visual acuity and 0-7% losing two or more lines of BCVA. In studies with up to five years’ follow-up, the mean loss in ECD has ranged from 0.5-to-9.5% with V4 ICLs. Research where patients were followed very meticulously suggests that the annualised endothelial cell loss was three-fold higher than natural physiological loss. The percentage of patients developing cataract reported in the literature ranges from 0-to-9.4%. Studies with longer follow-up tend to show a higher incidence of the complication. That corresponds to the continuous decrease in vaulting that occurs as a result of the growth of the crystalline lens. “Although there are no randomised trials comparing the two lenses, cohort studies show slight advantage of refractive and visual outcomes with the ICL compared to the Artisan. Endothelial cell loss is variable, but in both IOL types an annualised loss of two-to-three times the physiological loss of 0.6% per year was shown. ICL history has shown an increased rate of anterior subcapsular cataract,” Dr Nuijts concluded. 1. Jonker SMR, Berendschot TTJM, Ronden AE, Saelens IEY, Bauer NJC, Nuijts RMMA. Long-Term Endothelial Cell Loss in Patients with Artisan Myopia and Artisan Toric Phakic Intraocular Lenses: 5- and 10-Year Results. Ophthalmology. 2018 Apr;125(4):486-494. Rudy Nuijts: rudy.nuijts@mumc.nl


CATARACT & REFRACTIVE

PHACO vs FLACS FLACS is newer than phaco, but is it better? Roibeard Ó hÉineacháin reports

F

emtosecond laser-assisted cataract surgery (FLACS) allows the automation of many critical steps of cataract extraction. The question of whether that in turn provides adequate additional benefit to the patient or surgeon to justify its considerable expense compared to standard phacoemulsification was debated at a symposium held at the 23rd Congress of the ESCRS in Athens Greece. Dimitrios Mikropoulos MD, PhD, took standard phaco’s corner. He maintained that FLACS does not provide patients with better visual outcomes or fewer complications than standard phaco, nor does it enable surgeons to do anything that they could not do with the older technique. A number of studies have evaluated bestcorrected visual acuity and uncorrected distance visual acuity after both methods. Generally, the differences following FLACS or phaco were minimal to non-existent, said Dr Mikropoulos, OPHTHALMICA Institute, Thessaloniki, Greece. A meta-analysis of studies comparing outcomes of FLACS and microincision cataract surgery (MICS) in 14,567 eyes detected no statistically significant differences between the two groups in terms of visually important parameters. However, the study did find that eyes in the FLACS group had significantly higher prostaglandin concentrations and significantly higher rates of posterior capsular tears (M Popovic et al. Ophthalmology 2016;123(10):2113-26.). A European Registry of Quality Outcomes (EUREQUO) found that visual and refractive outcomes in 2,984 eyes that underwent

FLACS were no better than those in 4,987 eyes that underwent phaco. Intraoperative complications were similar in the two groups but postoperative complications were more frequent in the FLACS group. The laser has been shown to create a well-shaped and reproducible capsulotomy geometry and circularity. However, a study in which excised anterior capsules underwent scanning electron microscopy shows that the edge of femtosecond lasercreated rhexes are much less smooth than after manual capsulotomy. In the same study there was a 10-fold higher incidence of anterior capsulorhexis tears (1.87% vs 0.12%) reported with FLACS compared to standard phaco (Abell et al, Ophthalmology. 2014;121(1):17-24), Dr Mikropoulos said.

EVOLVING TECHNOLOGY In defence of FLACS, Pantelis A. Papadopoulos MD, PhD, FEBO, FEBOSCR, argued that the technology has evolved since many of the studies comparing the procedure with conventional phaco. The studies are outdated and those comparisons may no longer hold true. They also overlook the greater ease it allows the surgeon in several stages in the cataract surgery. “For the experienced surgeon, it adds perfection and safety to his/her surgical technique. For the inexperienced surgeon it helps him or her to proceed to the later steps of the operation without complications,” said Dr Papadopoulos, director of Ophthalmology Clinic of Athens Metropolitan Hospital, Athens, Greece. He added that although FLACS has some contraindications, such as small

pupils, corneal scars and filtration blebs, it is indicated in some of the more difficult cases, such as eyes with pseudoexfoliation, narrow anterior chamber, floppy iris syndrome and intumescent cataract. He noted that despite the meta-analysis study showing no difference between FLACS and MICS in terms of visual outcome, there was a statistically significant difference in favour of FLACS for effective phaco time (p<0.001), capsulotomy circularity (p<0.001), postoperative central corneal thickness (p=0.02) and corneal endothelial cell reduction (p=0.006). Dr Papadopoulos emphasised that each femtolaser machine has different pros and cons. Many of the meta-analysis studies included many cases at the learning curve of FLACS and there may be some bias in the selection of data. Moreover, the hardware and software of femtolasers are constantly evolving, he added. He noted that adjustments of the laser spot separation and energy, improvement in the lasers’ tracker systems and the selection of a larger size for capsulotomy have reduced the initially reported higher rate of capsule complications. There are also several new applications for the femtosecond laser including posterior capsulorhexis for the prevention of posterior capsule opacification or in case of a posterior polar cataract, as well as refractive adjustment of intraocular lenses that have already been implanted. Dimitrios Mikropoulos: dmikropoulos@hotmail.com Pantelis A. Papadopoulos: drpap.eyesurg1@gmail.com

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Management of Glaucoma with Subthreshold Laser Therapy

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

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

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Sunday 15 September

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Lunchtime Symposia

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13.00 – 14.00

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ORBIS International Symposium: Eye Care for Refugees Moderator: R. Walters

Sunday 15 September Evening Symposium 18.15 – 19.45

UK

R. Walters UK Refugee eye care: introduction N. Weil USA Eye care for refugees: the challenges

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

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

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

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Monday 16 September Evening Symposium 18.15 – 19.45

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CATARACT & REFRACTIVE

Renewed commitment New look, renewed surgeon focus as Nick Mamalis MD takes the helm at the American Society of Cataract and Refractive Surgery. Howard Larkin reports

R

enowned cataract surgery researcher, teacher and clinician Nick Mamalis MD took over as president of the American Society of Cataract and Refractive Surgery from Thomas W Samuelson MD at the 2019 ASCRS ASOA Annual Meeting in San Diego, USA. At the joint meeting with the American Society of Ophthalmic Administrators (ASOA), the two organisations introduced new logos and renewed their commitment to serving the needs of surgeons. “I am honoured and excited to play a leadership role in shaping our future,” said Dr Mamalis, who is professor of ophthalmology at the John A Moran Eye Center of the University of Utah in Salt Lake City, USA, where he also directs the world-renowned Ophthalmic Pathology Laboratory founded by David Apple MD. With Thomas Kohnen MD, PhD, Dr Mamalis is editor of the Journal of Cataract and Refractive Surgery, and is co-director of the Intermountain Ocular Research Center, where he researches intraocular lenses and postoperative inflammation.

NEW LOOK The new ASCRS logo and tag line, “For Surgeons. For You”, reflects the society’s renewed commitment to its core missions of education, advocacy and philanthropy that promote better vision, outcomes, and quality of life for patients.

ASCRS HONOREES For his pioneering work including developing the continuous curvilinear capsulorhexis, ASCRS inducted Howard V Gimbel MD, MPH, of Canada, into the ASCRS Ophthalmology Hall of Fame. Phillips Thygeson MD was inducted posthumously for work including discovering the causes of trachoma. Hal Kushner MD of Florida, USA, received the first ASCRS Distinguished Member Award. Before becoming an ophthalmologist, Dr Kushner served as a flight surgeon for the US Army in

Vietnam, where he was held as a prisoner of war for more than five years after a helicopter crash. Richard Litwin MD received the ASCRS Foundation Chang Humanitarian Award, for his decades of work reducing cataract blindness in the developing world.

ESCRS AT ASCRS

ESCRS President ESCRS President Béatrice Cochener-Lamard MD, PhD, co-chaired a combined symposium Béatrice Cocheneron handling cataract surgery complications at the ASCRS ASOA Annual Meeting Lamard MD, PhD, in San Diego, USA, which featured tips on preventing and recovering co-chaired a combined posterior capsule breaks from Thomas Kohnen symposium on handling cataract surgery complications In the elite TOPGUN competition, that featured tips on preventing and ESCRS was ably represented by Boris recovering posterior capsule breaks from Malyugin MD, PhD, of Russia, Filomena Prof Kohnen, of Frankfurt, Germany, J. Ribeiro MD, PhD, of Portugal, Sathish and saving unstable lenses with capsular Srinivasan FRCSEd, FRCOpth of the hooks from Guy Kleinmann MD, of UK and Pavel Stodulka MD, PhD, of Rehovot, Israel. the Czech Republic. Pitting eight of the best phaco instructors from Europe and Asia against eight from North and South America, the rollicking session included high-flying video and phaco pearls from contestants, and partisan put-downs from opposing team judges in a unique Nick Mamalis MD, President of the American Society of Cataract and Refractive Surgery educational format.

I am honoured and excited to play a leadership role in shaping our future

EUROTIMES | JUNE 2019

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CATARACT & REFRACTIVE

Cataract surgery in 3D Use of heads-up 3D displays does not affect surgical duration or complication rate. Roibeard Ó hÉineacháin reports

C

ataract procedures performed using the TrueVision® threedimensional display system are as safe and efficient as procedures carried out with conventional binocular surgical microscopes, according to a study presented by Vasilios Diakonis MD, PhD, at the 23rd ESCRS Winter Meeting in Athens, Greece. The retrospective chart review study included 2,320 eyes of consecutive patients who underwent cataract surgery from August 2016 to July 2017 using either the TrueVision 3D display system or a conventional binocular microscope for visualisation purposes, said Dr Diakonis, Eye Institute of West Florida, Largo, Florida, USA. In the 3D display group, 870 eyes underwent femtosecond laser-assisted cataract surgery (FLACS) and 803 eyes underwent conventional phacoemulsification surgery. In the conventional microscope group 355 eyes underwent FLACS and 292 eyes underwent traditional phaco. There was no statistically significant difference between the two groups concerning surgical technique, Dr Diakonis noted. Patients included in the study had cataract without any preoperative clinical findings that could influence the outcomes or duration of surgery. Eyes receiving toric intraocular lenses were also excluded as intraoperative IOL positioning could create a bias for surgical duration, he added. There was no statistically significant difference between the two groups in terms of surgical duration. The mean surgical time was 6.48 minutes (range, from 3 to 28 min) in the 3D view group and 6.52 min (range, from 3 to 26 min) in the conventional surgical microscope group. There was also no statistically significant difference between the complications rates of the two groups, which was 0.72% and 0.77%

Heads-up surgery using the TrueVision 3D system

There was no statistically significant difference between the two groups concerning surgical technique Vasilios Diakonis MD, PhD

in the 3D view and microscope groups, respectively. Complications for both groups included posterior capsular rapture, vitreous prolapse with need for anterior vitrectomy and three-piece sulcus IOL implantation. He noted that heads-up surgery with the TrueVision system is more ergonomic than conventional surgery with a binocular research. It does not require the surgeon to lean down to the microscope’s eye pieces, straining the neck and back muscles, which can lead to work-related disability in the long term. In addition, since the whole

surgical team has the same view of the surgery, it is useful in training and for the workflow during surgery. “Heads-up cataract surgery through a three-dimensional visualisation display has similar safety and efficiency to the gold-standard surgical microscope. Implementation of this technology may overcome work-related disabilities and provide a new educational tool in ophthalmology,” Dr Diakonis concluded. Vasilios Diakonis: diakonis@gmail.com

Convenient Web-Based Registry

Cataract, Refractive and Patient Reported Outcomes in One Platform

www.eurequo.org EUROTIMES | JUNE 2019

EUREQUO is free of charge for all ESCRS members

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

Courtesy of Vasilios Diakonis MD, PhD

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CATARACT & REFRACTIVE

Unresolved issue of blade vs laser Clinical benefit of femtosecond laser in flap creation remains unclear. Roibeard Ó hÉineacháin reports

F

emtosecond lasers have a clear advantage over microkeratomes in terms of precision in LASIK flap creation, but whether that translates into a clinical benefit for the patient remains an unresolved question, as studies comparing the two technologies have yielded contradictory and inconclusive findings, said Mercè Morral MD, Institute of Ophthalmic Microsurgery, Barcelona, Spain. “The theoretical advantages of using a femtosecond laser in LASIK procedures are that the laser may produce thinner, more accurate, reproducible and uniform flaps with a more planar architecture, and minimal thickness and edge variations. “However, most studies comparing outcomes between femtoLASIK and microkeratome LASIK have been inconclusive, with similar visual outcomes and complication rates for both groups,” said Dr Morral, who presented the paper at the 23rd ESCRS Winter meeting on behalf of José L. Güell MD, who was unable to attend. She noted, moreover, that microkeratomes have some theoretical advantages over femtosecond lasers. For example, histological analysis comparing the stromal surface quality after application of the two technologies suggests that the microkeratome provides a smoother cut than the laser and might be associated with a lower induction of total higher aberrations and spherical aberration. However, that is still under debate, as the higher frequency of newer femtosecond lasers means they provide a much smoother cut than the older lasers. She added that although IOP becomes more elevated during flap creation with a microkeratome, the procedure is much quicker, requiring only 20 seconds of suction. Creating LASIK flaps with a femtosecond laser takes longer and is associated with a higher rate of posterior vitreous detachment. In addition, the time between the cutting of the flap and the commencement of photo-ablation with the excimer laser is only 10-to-30 seconds with a microkeratome, compared to four-to-10 minutes with a femtosecond laser. Dr Morral noted that femtosecond lasers appear to have an advantage over microkeratomes in terms of epithelial ingrowth owing to the vertical architecture of the edge of the flap. She reported that in Dr Güell’s opinion, the only situation where the microkeratome has a real practical surgical advantage is when you need to create a new flap in a cornea after a previous LASIK procedure. With the femtosecond laser it can be much more difficult to identify the interface of the newly cut laser-created flap from that of the flap in the previous surgery, which in turn may cause problems in lifting the flap. Mercè Morral MD

...the laser may produce thinner, more accurate, reproducible and uniform flaps with a more planar architecture...

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CATARACT & REFRACTIVE

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

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

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL:45 ISSUE: 5 MONTH: MAY 2019

FLACS BETTER FOR SHALLOW AC EYES? Eyes with shallow anterior chambers present challenges to the cataract surgeon. A prospective randomised clinical study compared intraoperative performance and postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with shallow anterior chambers. The study randomised 182 cataract surgery patients who were followed up at one day, one week, and at one, three and six months. The cumulative dissipative energy was significantly lower in the FLACS group. Patients undergoing FLACS maintained clearer corneas, showed less increase in central corneal thickness, lower anterior chamber inflammation and better uncorrected distance vision in the early postoperative period. VK. Sharma et al., “Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in eyes with a shallow anterior chamber”, Vol. 45, Issue 5, pp 547-552.

IOL CALCULATION IN KERATOCONUS PATIENTS A recent study compared the refractive accuracy of different formulas for intraocular lens power calculation in 41 eyes with keratoconus. The investigators measured preoperative keratometry, anterior chamber depth and axial length with optical biometry. IOL power formulas included the Barrett Universal II, Haigis, Hoffer Q, Holladay 1 and SRK/T formulas. Subjective refraction was assessed at one month. The mean prediction error, median absolute error and percentage of eyes within ±0.50 dioptres (D), ±0.75D and ±1.00D were calculated. All formulas led to hyperopic refractive outcomes. The SRK/T was the most accurate formula. The results were worse in advanced stages of the disease. The researchers note that the SRK/T formula tends to overestimate IOL power in eyes with steep corneas, which could be useful in patients with keratoconus. G. Savini et al., “Intraocular lens power calculation in eyes with keratoconus”, Vol. 45, Issue 5, pp 576-581.

TRIFOCAL COMPARISON Is there an IOL that can provide good near, middle and distance vision? A prospective case series compared outcomes in 160 patients who had bilateral phacoemulsification and implantation of a trifocal AcrySof IQ PanOptix, AT LISA tri 3M, FineVision or the bifocal Tecnis ZLB00 IOL. By six months postoperatively, there were no statistically significant between-group differences in the spherical equivalent, UDVA, CDVA, DCNVA, reading performance or CSF under photopic and mesopic conditions. The defocus curves at 100%, 50%, and 15% of contrast showed that trifocal IOLs, especially the AcrySof PanOptix, had better intermediate performance than the bifocal IOL and comparable outcomes at far and near distances. There were no statistically significant differences in the postoperative NEI VFQ-25 questionnaire scores between the four IOL groups. A. Martínez de Carneros-Llorente et al., “Comparison of visual quality and subjective outcomes among 3 trifocal intraocular lenses and 1 bifocal intraocular lens”, Vol. 45, Issue 5, pp 587-594. JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | JUNE 2019


ESCRS

Practice Management

& Development

23–24 September 2019

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

Moderator: K. Morrill FRANCE

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

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

Moderator: R. Solar UK

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

Next-Generation Marketing

Diversification: Your Key to Digital Success

GDPR – Lessons Learned

ESCRS Innovation Prize

Ask the Experts

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

Optimising Patient Flow in a Busy Practice

How to Negotiate

www.escrs.org


10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

2 Days 7 Courses 8 Focus Sessions 3 Free Paper Sessions EuCornea Medal Lecture Friday 13 September | 10.30 – 11.30 (At the Opening Ceremony)

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

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


CORNEA

Get involved with clinical research The 2019 EuCornea Medal Lecture will be delivered by Sadeer Hannush. Aidan Hanratty reports

T

he 10th EuCornea Congress will take place 13-14 September 2019 at the Paris Expo Porte de Versailles in Paris, France. The programme will include updates on ectatic disease and viral keratitis, sessions on corneal ulcers and ocular allergy and the ESCRS/EuCornea Joint Symposium on Cataract Surgery in Eyes with Diseased Corneas. One of the highlights of the Congress will be the EuCornea Medal Lecture, which will be delivered this year by Sadeer Hannush MD, USA. Dr Hannush is Attending Surgeon on the Cornea Service at Wills Eye Hospital and Professor of Ophthalmology at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, USA. Dr Hannush’s areas of interest are full and partial thickness corneal transplantation (endothelial and deep anterior lamellar keratoplasty), permanent keratoprosthesis surgery (artificial cornea), complex cataract and Sadeer Hannush MD anterior segment reconstructive procedures, and laser vision correction. He lectures both in the US and around the world on these topics, and his written work appears across the peer-reviewed literature and ophthalmology texts. Dr Hannush has also taken part in several clinical trials sponsored by the National Institutes of Health. Therefore, he is ideally placed to deliver this year’s Medal Lecture titled “Clinical Corneal Research: Why It Is Important to Get Involved”. For Dr Hannush, the answer is simple: “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.” His personal journey through clinical corneal research has seen him involved with studies such as ‘Prospective Evaluation of Radial Keratotomy’, ‘Collaborative Corneal Transplantation Studies’, ‘Herpetic Eye Disease Studies’, 'Cornea Donor Study’, 'Corneal Preservation Time Study’, ‘Long-term Survival of Permanent Keratoprosthesis’, and the ‘Keratoprosthesis Crosslinking Study’. Each of these studies asked a ‘simple’, ‘high-impact’ question that could be answered with a well-defined answer. The key common factor in all of them, according to Dr Hannush, is collaboration, something that is essential to research that is robust and sound. The lecture will draw on Dr Hannush’s three-decade post-training experience in the areas of cornea and external disease, maintaining a private practice while being actively involved in academic medicine as Attending Surgeon at Wills Eye Hospital and Professor of Ophthalmology at Thomas Jefferson University in Philadelphia. This year, at its annual meeting in San Francisco, the American Academy of Ophthalmology will award Dr Hannush the prestigious Life Achievement Award in education. For more information and details on registering to attend the Congress, please visit http://www.eucornea.org/paris-2019

Universal Slit Lamps With Pioneering Features

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CORNEA

IOLs after LASIK Formula incorporating posterior cornea data improves cataract visual outcomes. Howard Larkin reports

F

or patients with previous corneal refractive surgery, an intraocular lens (IOL) power calculation formula that incorporates both posterior and anterior cornea measurements can significantly improve cataract surgery visual outcomes over conventional formulae, Graham D Barrett MD told the 2019 American Society of Cataract and Refractive Surgery/American Society of Ophthalmic Administrators Annual Meeting in San Diego, USA. Posterior corneal measurements obtained using swept-source OCT or Scheimpflug cameras can be added as an option when using the online Barrett True K Formula for prior myopic or hyperopic LASIK/PRK/RK, Dr Barrett said. This is important because traditional keratometry measures only the anterior cornea and accounts for posterior cornea power based on a ratio of the radii of the two surfaces. However, LASIK and other corneal surgeries change this ratio unpredictably, complicating IOL power calculations, Dr Barrett explained. In a multi-centre retrospective analysis of 60 eyes with previous myopic LASIK that underwent cataract surgery, 70% ended up with refractions within 0.5 dioptre of the spherical power predicted

EUROTIMES | JUNE 2019

by the Barrett True K TK formula, which incorporates posterior corneal data. This is similar to outcomes in virgin eyes using conventional formulae, and significantly better than the 63.3% recorded in this study for the standard Barrett True K formula that uses a theoretical model to predict posterior lens power (p=0.02). Other formulae in current use were even less accurate in this challenging post-refractive population, with the Haigis TK at 50.0% (p=0.01), Shammas at 46.7% and Haigis L at 31.7% within 0.5 dioptre (both p=0.0001) of predicted spherical target.

POSTERIOR CORNEAL ASTIGMATISM Measuring the posterior cornea may also help reduce residual astigmatic error in patients with astigmatism, Dr Barrett said. In a retrospective analysis of 16 eyes, of which two received non-toric IOLs and 14 Alcon AcrySof SN6AT toric IOLs, 75% of toric outcomes were within 0.5 dioptre of target using the Barrett True K Toric with measured posterior cornea astigmatism (PCA), compared with 68.8% for the Barrett formula using predicted PCA. The Holladay toric calculator without PCA and the Holladay with

In this most challenging patient subset, post-refractive patients with residual astigmatism, custom posterior corneal data seems to be of some benefit Graham D Barrett MD AK regression analysis achieved 62.5% and 56.3% respectively. However, these differences did not reach statistical

significance, possibly due to the small sample size. â&#x20AC;&#x153;In this most challenging patient subset, post-refractive patients with residual astigmatism, custom posterior corneal data seems to be of some benefit,â&#x20AC;? Dr Barrett said. He believes incorporating posterior cornea measures into power calculations can improve visual outcomes for all kinds of cataract surgery.


CORNEA

Treating ectatic corneas Study gives insight into benefits and drawbacks of CXL approaches. Roibeard Ó hÉineacháin reports

C

orneal cross-linking (CXL) combined with intracorneal ring segments (ICRS) appears to provide ectatic corneas with greater improvements in vision than CXL alone or CXL combined with topographyguided photorefractive keratectomy (PRK). However, this approach involves a higher risk of adverse events, according to results of prospective single-centre trial presented at a Cornea Day session of the 23rd ESCRS Winter Meeting in Athens, Greece. The study included 204 patients who underwent CXL alone, 126 who underwent CXL and intracorneal ring segment implantation (CXL-ICRS), 122 who underwent CXL with topography-guided PRK (CXL-TG-PRK) using the Dresden (Epi-on) protocol at the KEI centre from 2013 to March 2015, said Allan Slomovic MD, Cornea Surgeon, Kensington Eye Hospital (KEI), Professor of Ophthalmology, University of Toronto, Toronto, Canada. All eyes in the study fit at least one of the following criteria: an increase in manifest cylinder greater or equal to 1.0D, an increase in steepest keratotomy equal to or greater than 1.0D and had needed glasses or contact lenses with or without evidence of topographical corneal steepening. In addition, all eyes had a corneal thickness greater than 400 microns in the treatment zone and a best-corrected visual acuity between logMAR 0.18 and 0.7.

At a follow-up of one year, the logMAR best spectacle-corrected visual acuity (BSCVA) had improved from 0.1536 to 0.0952 in the CXL alone group, a gain of around 1.2 lines. The CXL-ICRS group improved from 0.2683 to 0.1952, a gain of around 2.3 lines. The CXLTG-PRK group improved from 0.20911 to -0.1322, a gain of around 1.7 lines. The CXL-ICRS group gained a mean of around five more letters of BSCVA than the CXL alone group (p<0.0001) and around three more letters than the CXL-TG-PRK group (p=0.0164). The difference between the CXL-alone group and the CXL-TGPRK group, around two letters, did not reach statistical significance. There was a significantly greater mean reduction in K Max in the CXL-TG-PRK group (3.6924D) and the CXL-ICRS group (3.2149D) than in the CXL alone group (0.0533D) (p=0.001). However, there was no statistically significant difference between the decrease in K Max between the CXL-ICRS and the CXL-TG-PRK groups. Adverse events in the CXL-ICRS group included one case of suture abscess, one case of corneal ulcer, seven cases of corneal scarring and four cases of extrusion. In the CXL-TG-PRK group there was one case of sterile corneal melt and this patient experienced a loss of greater than three lines of BSCVA. Allan Slomovic: allan.slomovic@utoronto.ca

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EUROTIMES | JUNE 2019

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CORNEA

Evaluating the cornea in SMILE Corneal stiffness remains intact after SMILE lenticule creation. Roibeard Ó hÉineacháin reports

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

Submission Deadline Monday 29 July 2019

Practice Management

ESCRS

34

& Development

For further details visit: www.escrs.org

EUROTIMES | JUNE 2019

ignificant changes occur in biomechanical properties following femtosecond laser flap creation during LASIK procedures, but not after lenticule creation during small lenticuleextraction procedures (SMILE®) procedures, said Ahmed Ghoneim MD at the 23rd ESCRS Winter Meeting in Athens Greece. In a prospective study, Dr Ghoneim and his associates at Tanta University, Tanta, Egypt, used the Corvis ST Scheimpflug tonometer (Oculus) to evaluate the changes in the cornea’s biomechanical properties before and immediately after corneal lenticule creation or LASIK flap creation. The study involved 50 eyes of 25 patients aged 20-to-30 years with -4.0D to -8D of myopia who underwent SMILE and 50 eyes of 25 patients aged 20-to-32 years of age with -4.0D to -9.0D of myopia who underwent femto-LASIK. They found that although the Corvis corneal biomechanical index (CBI) was not changed significantly following lenticule creation, changing only from 0.0 to 0.07, it was changed significantly following LASIK flap creation, from 0.0 to 0.94.

BIOMECHANICAL INDEX He noted that the Corvis-ST uses an ultra-high-speed Corvis ST Scheimpflug tonometer camera to measure a range of the corneal biomechanical parameters during a constant collimated air pulse. The main parameters are deformation amplitude, applanation time, applanation length, corneal velocity, peak distance, radius and intraocular pressure values. These parameters are calculated together to determine the cornea’s biomechanical index, which research has shown to be highly sensitivities in differentiating between healthy and keratoconic or ectatic eyes. The study also showed that the deformation amplitude – which refers to the maximum amplitude when the cornea is flattened to its greatest deformation by the air-jet puffed by the Corvis ST – was also not significantly changed after SMILE lenticule creation. There were, however, significant changes in the deformation index after LASIK flap creation with the femtosecond laser. He added that the deformation amplitude also tends to increase in thinner corneas.

STRIPPING TECHNIQUE Dr Ghoneim noted that the intralamellar small gas bubbles due to the vaporisation of tissue are visible in the Scheimpflug camera images, but these do not appear to influence corneal biomechanical parameters. He added that he has developed his own stripping technique for the easy and rapid removal of the lenticule during SMILE. It facilitates a crucial step of the surgery through visualisation of the edge of the lenticule, thereby increasing the ease of its removal. In this way it can give the beginner surgeon confidence in the SMILE technique and possibly reduce the duration of the learning curve.


WS P OS SUBSP EC IALT Y DAY Preliminary Programme

Friday 13th September | 08.20 – 18.30 08.20 – 08.30

Welcome and Introduction D. Bremond-Gignac

FRANCE

08.30 – 09.55

Paediatric Ocular Surface Disease FRANCE , S.Wei Leo SINGAPORE

D. Bremond-Gignac

10.00 – 10.30 Free Papers I

D. Godts

BELGIUM

BREAK (10.30 – 11.00)

11.00 – 12.25

Paediatric Retina

Y. Fong Choong

MALAYSIA

12.30 – 13.00 A. Adio

Free Papers II

NIGERIA ,

M. Tekovcic-Pompe

SLOVENIA

LUNCH (13.00 – 14.30)

14.30 – 15.55

Strabismus and Neuro-Ophthalmology Y. Morad

ISRAEL ,

A. Fernandez

COLOMBIA

16.00 – 17.45

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

17.50 – 18.30

Video Symposium M. Younis LEBANON , L. Welinder DENMARK

www.wspos.org


36

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

WSPOS Update Preparations are well advanced on the programme for the next WSPOS Subspecialty Day. Colin Kerr reports

P

reparations are well advanced on the programme for the next WSPOS Subspecialty Day on Friday September 13 2019 preceding the 37th Congress of the ESCRS in Paris, France, at the Paris Expo, Porte de Versailles. Registration is now open for this event at http://www.wspos.org/registration2019. Among the topics that will be discussed at the Subspecialty Day are Paediatric Ocular Surface Disease, Paediatric Retina, Strabismus and Neuro-Ophthalmology and Paediatric Cataract and Visual Screening. The programme co-ordinators are Dominique BremondGignac, Muhammad Younis and Manca Tekavcic-Pompe. Distinguished faculty includes Frederic Chiambaretta, Neil Lagali, Paolo Nucci, Craig Luchansky, Angela Fernandez, Darius Hildebrand, Alain Spielmann, Alejandra Daruich, Huban Atilla, Saurabh Jain, Jennifer Huey, Cameron Parsa, Venkateshwar Rao Bhoompally, Yair Morad, Alki Liasis, Luis Javier Cardena, Ramesh Kekunnaya, Arnaud Sauer, Sumita Agarkar, Asimina Mataftsi, Roberto Caputo and Laurence Lesueur. Planning for the 5th World Congress of Paediatric Ophthalmology and Strabismus (WCPOS V) is also under way and WSPOS has announced the three keynote lecturers for the Congress. David Mackey from Australia will present the NonStrabismus Keynote Lecture, Burton Kushner (United States) will present the Strabismus Keynote Lecture and Marie-José Tassignon from Belgium will be the Keynote Kanski Medal Lecturer. The WSPOS website has recently undergone a rebrand and the society encourages all members to visit http://www.wspos. org for updates about the society. The website highlights news and video content including the newly launched WSPOS Masters in Surgery Archive. The archive is open to all WSPOS members and membership of the society is free.

INNOVATION PRIZE

www.wspos.org

EUROTIMES | JUNE 2019

WSPOS is also honoured to have received the Innovation Prize from the Swiss Academy of Ophthalmology. Prof Daniel Mojon presented the prize to WSPOS co-founders Prof David Granet (San Diego,USA) and Prof Ken Nischal (Pittsburgh, USA) for their contribution to improving the living conditions of many children with visual disorders and strabismus around the world through the founding of the World Society of Paediatric Ophthalmology and Strabismus (pictured above).


RETINA

A D VA N C E S

in choroideremia Gene therapy treatment set to enter the clinic. Dermot McGrath reports

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ith gene therapy for choroideremia approaching regulatory approval in the next few years, clinicians should start actively preparing their patients to benefit from this potentially sight-saving treatment, according to Dyon Valkenburg MD. “Choroideremia will be treatable in the coming years, so we need to start selecting and preparing our patients now. There are still a lot of unanswered questions in terms of whether we will also provide this therapy for the worst affected female carriers, and also regarding the most opportune time to administer gene therapy. There are also wider societal questions relating to the costbenefit of such treatments for the relatively small number of patients involved,” he told delegates attending the 9th EURETINA Winter Meeting in Prague. Choroideremia is an X-linked, recessive disease resulting in progressive degeneration of the retina, the retinal pigment epithelium (RPE) and the choroid, Dr Valkenburg explained. Its prevalence is estimated to be approximately one in every 50,000-to-100,000 people. “The choroideremia gene function encodes for Rab Escort Protein 1 (REP1), which is essential in intracellular trafficking, escort and prenylation. When the trafficking is disrupted, cell apoptosis occurs leading to remodelling of the affected retinal cells, with degeneration of choroid and RPE followed by photoreceptor loss,” he said. In males, the condition gradually advances and starts with night blindness and eventually results in progressive loss of peripheral vision and total blindness in the late stages, although some extreme peripheral field detection may remain, said Dr Valkenburg. Clinical diagnosis is based on characteristic fundus appearance with extensive chorioretinal atrophy and a residual island of retinal tissue in the posterior pole, defective dark adaptation, peripheral visual field loss, an electroretinogram pattern of rod-cone degeneration, and a family history consistent with X-linked inheritance.

Although X-linked diseases tend to occur in males, it is now well established that choroideremia may also present in female carriers, said Dr Valkenburg. He cited a recent study carried out at two clinical centres in the Netherlands and one in the United Kingdom that looked at the phenotype of 50 choroideremia carriers. “Thirteen of the patients had night blindness, 18 had decreased visual acuity, and the median age at which visual acuity started to decline was 59.5 years. All had abnormalities on fundus autofluorescence imaging (FAF) which seemed to be more severe with age and six of them exhibited a male atrophy pattern,” he said. The results of the first gene therapy clinical trial for choroideremia, carried out by Prof Robert MacLaren of Oxford, United Kingdom, which were first published early in 2014 showed very promising results, and surpassed the expectations of the researchers involved, noted Dr Valkenburg. Prof MacLaren’s team used an adenoassociated virus-2 (AAV2) vector construct encoding REP1 to deliver a functional version of the CHM gene into the retinal pigment epithelium and photoreceptor cells. “Of the 12 patients who followed the protocol the visual acuity remained largely

stable with a mean improvement of two or three ETDRS letters, and retinal sensitivity improved slightly, as did fixation. The results were very promising overall and indicate that the gene therapy may be able to halt the disease progression,” he said. Although initial trials have helped to answer some of the fundamental questions relating to the safety of gene therapy in treating inherited retinal disease, more questions concerning the benefits of early intervention, optimal dosing, surgical technique and cost-benefit utility remain, said Dr Valkenburg. “The long-term effect of gene therapy treatment is still unknown. The longest follow up in RPE65 related retinal disease is about nine years but it is still unknown if a single or multiple treatments need to be administered to sustain a long-term effect. “Secondly, the cost-utility issue is still an issue for these therapies as they are very expensive and the quality-of-life gains may seem modest in relation to the expense incurred. So we need to ask ourselves as a society: what are we willing to pay for such therapies in the future?” he concluded. Dyon Valkenburg: dyon.valkenburg@radboudumc.nl EUROTIMES | JUNE 2019

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Artificial intelligence: Retina and beyond The future is now: exciting potential of artificial intelligence applications in ophthalmology. Dermot McGrath reports

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eep learning and advanced artificial intelligence (AI) applications hold exciting potential in diagnosing and treating a wide range of eye diseases and are already making an impact on current clinical practice, according to Adnan Tufail MBBS, MD, FRCOphth. “There is little doubt that AI is probably at the peak of the famous hype curve at the moment and everybody from big pharma to the retinal physician wants to be a part of the revolution,” he told delegates attending the 18th EURETINA Congress in Vienna. The current AI hype is being driven by the confluence of deep learning algorithms, massive datasets and powerful and relatively inexpensive computers, said Dr Tufail. “The difference now is that we’re no longer talking about this in the future tense – the technology is already with us, even though we may not be aware of it,” he said. Examples of current AI applications include Warren Hill’s online biometry formula, which uses neural networking to approximate IOL power based on input parameters, pattern recognition and machine learning, visual field progression models using machine learning and several diabetic retinopathy (DR) screening programmes that use a deep learning approach.

Close-up of an OCT machine performing a scan

VALIDATION ISSUES With regulatory authorities struggling to keep up with the rapid development of AI healthcare applications, independent validation is important for large-scale deployment of such algorithms, said Dr Tufail. One such validation project in the United Kingdom recently tested a number of automated retinal analysis systems for DR using data from more than 20,000 patients and more than 100,000 images. Two of the four systems tested, Retmarker and EyeArt, achieved acceptable sensitivity for referable retinopathy and false-positive rates compared with human graders as reference standard. EUROTIMES | JUNE 2019

Close-up of an OCT machine performing a scan


RETINA

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The difference now is that we’re no longer talking about this in the future tense – the technology is already with us, even though we may not be aware of it “The fastest of these algorithms is capable of processing 600,000 images a day, which would save the National Health Service (NHS) around £10 million a year compared to manual grading,” he said. Other interesting developments on the horizon include the integration of machine learning software into specialised devices, such as the home-screening OCT system currently being developed by Peter Maloca at the University of Bern, Switzerland, as well as surgical robotic systems with advanced AI capability. Although there is understandable anxiety about the role of technology in day-to-day practice, Dr Tufail said that the benefits will ultimately far outweigh the risks. “It will definitely impact on our working practices for screening, referral, diagnostic support, to detect abnormalities beyond the human range, and help us to manage clinic flow better. The bottom line is that AI is not going to put us out of a job, but we need to embrace this technology to make us the best retinal specialists that we can possibly be,” he said.

REVOLUTIONARY AI SYSTEM In a separate presentation, Pearse A. Keane MD, FRCOphth, gave an update on a potentially revolutionary AI system developed by researchers at Moorfields Eye Hospital NHS Foundation Trust, DeepMind and University College London (UCL) Institute of Ophthalmology. “The system can recommend the correct referral decision for a wide range of eye diseases such as age-related macular degeneration and diabetic eye disease as accurately as world-leading experts,” said Dr Keane. Using two types of neural network – mathematical systems for identifying patterns in images or data – the AI system quickly learnt to identify 10 features of eye disease from highly complex optical coherence tomography (OCT) scans. It was then able to recommend a referral decision based on the most urgent conditions detected. “The system gives us a huge amount of quantitative information from the scans.

Courtesy of Pearse A. Keane MD, FRCOphth

Adnan Tufail MBBS, MD, FRCOphth

Pearse Keane, consultant ophthalmologist, analysing an OCT scan (top); An OCT scan of the right eye

It then makes a referral decision – urgent, semi-urgent, routine referral or observation only, as well as diagnosing the different disease categories. We have trained this algorithm on more than 50 different types of retinal diseases,” said Dr Keane. The algorithm can, for instance, recognise choroidal neovascularisation (CNV), not only in the context of wet AMD, but also in the context of myopia, inflammatory CNV, central serous retinopathy (CSR) and so forth. Similarly with macular oedema, it can recognise diabetic macular oedema, macular oedema stemming from uveitis and other subtypes, he said.

MULTI-CLASS REFERRAL A key feature of the algorithm is its capability to perform multi-class referral decisions, as opposed to the “black box” or end-to-end approach of other deep learning systems, said Dr Keane. “The black box approach usually asks one specific question – AMD or not AMD for example, and then gives a yes or no

response. Our algorithm is capable of more subtle diagnosis taking account of multiple morphological features present – for instance, it can identify a patient with CSR with secondary CNV, which is something that a lot of comprehensive ophthalmologists might not pick up on,” he said. The next step is for the research to go through clinical trials to explore how the technology might improve patient care in practice, and obtain regulatory approval before it can be used in hospitals and other clinical settings. “While this has huge potential it should not be used in the real world to diagnose and treat patients until we have very robust clinical evidence that it will work. We are currently planning prospective clinical studies, and there are also issues of regulatory approval to be addressed. I would estimate three-to-five years before it becomes available,” Dr Keane said. Pearse Keane: pearse.keane1@nhs.net EUROTIMES | JUNE 2019


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RETINA

Panretinal photocoagulation Prompt laser treatment vital in highrisk PDR. Dermot McGrath reports

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

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

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tandard panretinal photocoagulation (PRP) is an established, effective therapy that greatly reduces the risk of severe vision loss in proliferative diabetic retinopathy (PDR) and its neovascular complications, according to Moin Mohamed FRCOphth. “We know from studies that PRP more than halves the risk of severe vision loss in PDR. In the Early Treatment Diabetic Retinopathy Study (ETDRS), the five-year rate of severe vision loss was 6.5% with immediate PRP, which is very good. In the Protocol S study patients had a mean visual acuity of 20/25 after five years, which is also very respectable,” he told delegates attending the 9th EURETINA Winter Meeting in Prague, Czech Republic. Poor outcomes with PRP were typically related to poor baseline vision, more severe PDR and diabetic macular oedema (DME), while patients with better baseline vision who were given a full early treatment dose usually had better outcomes, he added. In PDR, new vessels grow in response to chronic, widespread, progressive retinal ischaemia from chronic hyperglycaemia, noted Dr Mohamed, Consultant Ophthalmic Surgeon at St Thomas’ Hospital, London, United Kingdom. While the exact mechanism for how PRP achieves its therapeutic effect is not clearly defined, plausible theories suggest that destruction of ischaemic retina improves relative oxygenation by reducing the metabolic demand, decreases the production of VEGF and other angiogenic factors and allows an ingress of oxygen from the choroid towards the inner retina, via the laser burns that act as a portal of entry. For a standard PRP, typical laser settings would be 500μm spot size, a 0.1-second exposure and lesions placed one burn width apart. A total of 1,200-1,600 burns are placed in one or more sittings, carefully avoiding the macular area and any areas of tractional elevation of the retina, aiming for a grade 2/grade 3 burn, using a suitable power setting. This ultimately equates to an area, akin to a dose of retinal ablation. When reducing the burn diameter, a commensurate increase in the number of burns must be taken into consideration (remembering that if the diameter is halved, the number must be quadrupled). While pattern-scanning laser is quicker to perform and easier to tolerate for patients, there is now a significant body of evidence showing that it is less effective than standard PRP in inducing lasting regression of retinal neovascularisation in the setting of previously untreated high-risk PDR, and at least a 50% increase in the number of burns is advocated, added Dr Mohamed. He said that treatment should be initiated on a case-by-case basis in patients with early PDR, but that it is critical to intervene rapidly in high-risk cases. “It is vital to treat promptly if high-risk characteristics are present as there is a four-to-six times increased risk of severe vision loss for these patients if not treated,” he said. High-risk PDR defined by the well-established DRS (Diabetic retinopathy Study) as any three of the following four factors, said Dr Mohamed: (1) presence of any active neovascularisation; (2) presence of vitreous haemorrhage or pre-retinal haemorrhage; (3) location of neovascularisation on or within one disc diameter of the optic disc; and (4) size of new vessels > ¼ disc area at the disc or > ½ disc area elsewhere. Moin Mohamed: moin.mohamed@gstt.nhs.uk

EUROTIMES | JUNE 2019


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

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ESCRS

BOARD ELECTION 2019

ESCRS Board elections are held every two years. Board members serve for a term of four years and can be re-elected for one additional four year term. Board members must have been a full member of the ESCRS for at least the last three consecutive years and in order to stand for election candidates must be nominated by five other full members of the Society. There are five positions open on the Board in this election. Seventeen full members of the ESCRS have been nominated for election to the Board and they are profiled on the following pages. Voting opens on 10 June and closes on 2 September. Members entitled to vote will receive a ballot paper in the post by 10 June. The names of the new Board members will be announced at the Annual General Meeting of the ESCRS which will take place during the Annual Congress in Paris in September. Please note that only European full members of the ESCRS are entitled to vote in the Board election.

Nominated Candidates

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Jorge Alió SPAIN

orge Alió MD, PhD, FEBO is Professor and Chairman of Ophthalmology, University Miguel Hernandez, Alicante, Spain, founder of Vissum Corporation, Spain and the Jorge Alió Foundation for the Prevention of Blindness. He is a high-volume surgeon in cataract, cornea and refractive surgery with over 50,000 surgeries performed. His main research interests include lens, refractive and corneal surgery. Pioneer in the area of multifocal, accommodative and toric IOLs, excimer laser refractive surgery, phakic IOLs and corneal regeneration surgery, he is author of over 563 peer review papers, 367 chapters, 93 books; extremely active at congresses with lectures and courses; 2018 Hirsch

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Bruce Allan UK

e all need easy access to information on our treatment outcomes and accurate, up-to-date advice on which lenses, lasers and procedures are performing best. Pooled data from electronic healthcare record (EHR) systems can provide the answers if the right structures are in place. My aim in standing for the ESCRS Board is to promote access to EHR systems for your practices, automated quality systems to keep you in touch with your outcomes, and a framework for using pooled data to answer your clinical research questions. Important foundations have been laid through EUREQUO, but more work is required to widen participation.

factor (h-factor) of 60 (Scopus); LXIII chair of the Academia Ophthalmologica Internationalis; XLIX chair of the European Academy of Ophthalmology; and has received over 103 international and national awards. He is creator and Director of the online course Scientific Methodology in Refractive, Cataract and Cornea Surgery (University Miguel Hernandez). Fellows from all over the world come to his research facilities to be trained under his supervision. “I believe that the ESCRS has the potential to be a global reference in the specialty with a particular focus on the promotion of evidence-based knowledge in cataract, refractive and corneal surgery”.

In particular, data upload should be automated. You, as a busy surgeon, should not have to input data manually. I have been on the staff at Moorfields Eye Hospital since 1998, chair of the UK Refractive Surgery Standards Working Group since 2015, and an EuCornea board member since 2017. I have lectured and published widely and have made many friends in both industry and medicine through teaching and international collaboration. With your support, I believe I have the experience and the energy to contribute strongly as an ESCRS Board member.


ESCRS Board Election 2019

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Michael Amon AUSTRIA

am chairman of the Sigmund Freud Private University and of the Academic Teaching Hospital St. John Vienna. In 2009 I was awarded a professorship by the Medical University Vienna. I was Austrian delegate for EBO and UEMS, board member and congress president of DGII, and president of the Viennese Ophthalmological Society. Currently I am board member of the ESCRS, of the Austrian Ophthalmological Society and head of the Austrian Cataract Committee. In a citation analysis in 2008 I was cited as the 5th most influential author in Europe and 20th worldwide. I am a member of several editorial boards and of the IIIC. I have invented intraocular implants and instruments. With introduction of the term ‘uveal and capsular

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Navid Ardjomand AUSTRIA

avid Ardjomand, MD, FEBO was born in Graz, Austria in 1970, lived in Tehran, Iran until 1979 and graduated from high school in Graz in 1988. He graduated from the Medical School in Graz in 1994 and then trained at the Medical University in Graz and Moorfields Eye Hospital, London, UK. He finished his anterior segment fellowship at Moorfields Eye Hospital in 2004 and was an Associate Professor and consultant ophthalmic surgeon to the Medical University Graz, Austria & University of Saarland until 2017. He is now back at the Medical University and his private practice for anterior segment surgery in Graz, and author of more than 80

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Zsolt Biró HUNGARY

solt Biró, MD, PhD, DSc, FEBO, has been Professor of Ophthalmology at the University of Sciences, Faculty of Medicine, Pécs, Hungary since 2008. Since 1992, he has been a member of the ESCRS, participating in every annual congress, giving lectures and courses. Dr Biró has published a book, written eight book chapters and 180 papers in various peer-reviewed journals. His articles have been cited over 400 times. He has participated in many congresses and given over 230 lectures. He is a member of the Editorial Board and a reviewer for several Hungarian and international journals of ophthalmology.

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Salvador García-Delpech SPAIN

am an anterior segment ophthalmologist from Valencia, Spain, co-Director and co-Founder of Aiken Clinic, as well as faculty at the Hospital La Fe. As Associate Professor of the University, I am very proud teaching residents in ophthalmology every day. I have 74 peer reviewed articles, 100 book chapters, 500 oral presentations in national and international meetings and several patents, such as the fractal diffractive corneal inlay for presbyopia. I am passionate about clinical research and I am very proud of having the Achievement Award of the American Academy of Ophthalmology (AAO). I have been strongly involved in the construction of a better Europe, working with our colleagues at the Federation of

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Andrzej Grzybowski POLAND

ndrzej Grzybowski, MD, PhD, MBA is Professor of Ophthalmology, University of Warmia and Mazury, Olsztyn and Head of Institute for Research in Ophthalmology, Poznan, Poland. His interests are in cataract (lens refractive and anti-presbyopia surgery), vitreoretinal surgery (eye traumas) and endophthalmitis prevention and treatment. He is active in AAO (Global ONE Advisory Board and Museum of Vision’s Program Committee), EVER (chair of lens/cataract section 2018-2023), ISRS (member of the ISRS International Council), ICO (Programme Coordinator for WOC 2011-2018), EURETINA (coopted Board Member 2016-2018), APAO (Programme Coordinator 2017-2019), Polish Presbyopia Club (Chairman). He is deeply interested in ophthalmic history and proposed

biocompatibility’ I underlined my main scientific interest in IOLs and in cataract surgery in compromised eyes. I have performed over 30,000 intraocular procedures, including paediatric cataract, posterior segment, glaucoma and corneal surgery. I have organised main symposia, instructional courses and wetlabs, chaired sessions, presented for iLearn and performed live surgery for the ESCRS since 1993. Since 2012 I have been a member of the Education Committee. In case of my re-election, I would like to further intensify interactive education and assist in enhancing the leading scientific role of the ESCRS globally.

peer reviewed papers. He trained more than 15 eye surgeons, had more than 20 national and international MD and PhD students and was a board member of the Austrian Society of Ophthalmology from 2014 until 2016. “In times of political financial cuts, evidencebased medicine is essential and collaboration between universities and private ophthalmologists is essential for the strength and success of the ESCRS and ophthalmologists. As an international eye surgeon with long academic and clinical experience, my strength lies in my ability to bring people together.”

Dr Biró was President of the Hungarian Society of Cataract and Refractive Surgeons for 6 years and President of the Hungarian Ophthalmological Society for 3 years. He is an Honorary Member of Romanian as well as Polish Ophthalmological Societies. From 2006 until 2009, he was a co-opted Board Member of the ESCRS and he has been a member of the International Intraocular Implant Club (IIIC) since 2005. Since 2015 he has been a member of the ESCRS Video Jury.In December 2012 he received the title ‘Doctor of the Hungarian Academy of Sciences (DSc)’.

European Ophthalmology for more than 12 years, and as an international delegate of the French Society of Ophthalmology. I am happy to think we are closer every day. Responsible for the ProSEO, I am working on improving the professional conditions of ophthalmologists, especially intrusiveness. My contribution to the ESCRS would be to improve professional conditions of ophthalmologists, fight against intrusiveness, create rules to use Big Data and new Artificial Intelligence to help us and our patients, promote new educational programmes in anterior segment for Young Ophthalmologists and continue creating Europe.

the ESCRS Archive (present co-curator) and ESCRS Heritage Lecture. He is Editor-in-chief of Historia Ophthalmologica Internationalis, author of more than 450 peer-reviewed publications with over 50 book chapters, a reviewer for over 20 journals and a member of editorial boards, American Journal of Ophthalmology, Acta Ophthalmologica, PLOS One, Graefe’s Archive for Clinical and Experimental Ophthalmology, Translational Vision Science & Technology (ARVO journal), BMC Ophthalmology and Journal of Clinical Medicine. “My priorities for the future development of ESCRS are evidenced-based recommendations, educational programmes in less-developed parts of Europe and ESCRS surveys to better understand trends in clinical practice and educational needs.”


Nominated Candidates

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Vikentia Katsanevaki

ikentia Katsanevaki, MD, PhD has been active within the ESCRS for the past 15 years. She has been, and continues to be, a member of the Programme Committee, faculty of the refractive surgery didactic course, invited lecturer and faculty of various instructional courses and senior instructor of refractive wetlabs. She has been an elected member of the ESCRS Board since 2015. She has been trained at the University of Crete, Greece and completed a fellowship in cornea and external disease at Moorfields Eye Hospital in London UK.

After long collaboration with the University of Crete and serving as a refractive consultant in a major group practice in Athens, she currently runs a private practice in Athens for cataract and refractive surgery. If re-elected to the Board, she plans to continue building her teaching and organisational experience with major interest in young ophthalmologists.

GREECE

P

Christopher Liu UK

rofessor Christopher Liu trained in ophthalmology in London (Moorfields Eye Hospital), Cambridge, Norwich, and Rome where he learned osteo-odonto-keratoprosthesis. He is a Europhile and speaks English, Chinese, some French and Italian. He is strong in research with nearly 250 publications. He is a world opinion leader in artificial cornea. He developed a PCO model which is now used all over the world. He has over a dozen inventions including a number of cataract and DMEK techniques, and two patents. Christopher has tremendous experience in leadership and management. He was President of MCLOSA, BSRS, SOS and Honorary Secretary of UKISCRS. He has been nominated as

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Volodymyr Melnyk UKRAINE

r Volodymyr Melnyk, PhD is the Head Doctor, CEO and founder of Ophthalmic Clinic ‘Visiobud-Plus’ in Kyiv, Ukraine from 2011 to present. From 2004-2011 he was an ophthalmologist at Kyiv Hospital Eye Microsurgery Center. He performs more than 2500 surgeries per year. He was educated in 1994 – 2000 at Kyiv National Medical University. In 2000 – 2004, residency at the KNMU and from 2005 – 2008 PhD in ophthalmology at the KNMU. His research topic was ‘Optic neuropathy in multiple sclerosis patients’. He is Head of the Society of Ukrainian Ophthalmic Surgeons and a member of Ukrainian Society of Ophthalmologists, Ukrainian Alliance of Ophthalmologists and the ESCRS. He has

A

Ewa MrukwaKominek POLAND

s Professor of Ophthalmology (MD, PhD) I am Head of the Department of Ophthalmology, Head of the Postgraduate Education College of the Medical University of Silesia, Katowice (Poland), Head of the Department in the University Clinical Center where I was previously Medical Director. In the Polish Society of Ophthalmology I have been a Board Member since 2010, President of Cataract and Refractive Surgery Section, Board Member of the Silesian Division. My research focuses include cataract surgery, presbyopia, IOLs, diagnostics, cornea. I am author/co-author of 210 published scientific papers and of more than 550 presentations at International and Polish Congresses. I am a member of the

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Zoltán Nagy HUNGARY

have been working in ophthalmology since 1986. Currently I am Head of the Department of Ophthalmology, Semmelweis University, Budapest and serve also as a Dean of the Faculty of Health Sciences. My main interests are cataract and refractive surgery. I started refractive surgery in Hungary in 1992, performing all kind of refractive procedures. In 1997, I discovered the harmful role of ultraviolet-B during corneal avascular wound healing, which was published in Ophthalmology in 1997. In 2008, I was the first in the world to perform femtolaserassisted cataract surgery. I have published more than 22 papers,

President Elect of UKISCRS. He is a Council Member, Trustee and Examiner of the Royal College of Ophthalmologists and played a key role in the introduction of the CertLRS exam. He has won multiple awards: Department of Health Hospital Doctor of the Year (2005); Membro Merito of Barraquer Institute; UKISCRS Silver Award; and NHS Silver National Clinical Excellence Award. Queen Elizabeth II appointed him Officer of the Most Excellent Order of the British Empire (OBE) in 2018. Christopher will bring skills in organisation, friendly leadership, governance, examining, quality assurance, marketing and PR, social media, and fundraising.

over 20 published papers and over 250 presentations. Major surgical interests include phacoemulsification (over 15,000 procedures in the last 10 years) and combined cataract and glaucoma surgery (over 3,000 procedures in the last 7 years). “My main focus is treatment of glaucoma and cataract patients. I consider surgical technique, designed by me, combined phacoemulsification with modified tunnel trabeculopuncture. More than 3,000 patients were operated with the help of my surgical technique. Many Ukrainian eye surgeons make good use of my technique in their practice. I am an organiser of two annual ophthalmological congresses in Ukraine”.

Editorial Advisory Board in the CRSToday Europe. In ESCRS I have been a member of a Focus Group, co-opted Board Member (2014 – 2015), and since being elected Board member in 2015 I have been active in the Education and Charity Committees, EBO-ESCRS Exam Board, ESCRS Academy speaker and Wetlab instructor during ESCRS Congresses. If re-elected to the Board, I plan to continue these teaching and organisational activities to extend the role of ESCRS in transferring knowledge to ophthalmologists across Europe. I intend to participate in the training of European residents.

1 book and 5 book chapters regarding the clinical results of FLACS. In 2010, I was awarded the Waring Medal. In 2012 I received the Casebeer Award from the ISRS. Within the ESCRS Board I would like to contribute to the scientific programme of the meetings and to the educational programme of the Young Ophthalmologists, being an active teacher of Semmelweis University. ESCRS is a strong society in ophthalmology and I have a strong commitment for education and scientific work. One of the key factors for success is the personal commitment, I would like to work together with the ESCRS Board members.


ESCRS Board Election 2019

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Nic Reus THE NETHERLANDS

fter having completed my residency in 2009, I specialised in cataract surgery at The Rotterdam Eye Hospital (the Netherlands). In 2014, I joined the Department of Ophthalmology at the Amphia Hospital in Breda, the Netherlands. I am currently a member of the ESCRS Programme Committee and act as liaison between the ESCRS and the European Society of Ophthalmic Nurses and Technicians (ESONT). Since 2011, I have been a (senior) course and wetlab instructor at the meetings of the ESCRS. In addition, I am instructor in the Young Ophthalmologists Programme. Furthermore, I have been a board member of the

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Filomena Ribeiro PORTUGAL

am honoured to be nominated for the ESCRS Board election. I have been involved as an ESCRS Co-Opted Board Member and as a member of the Programme and Young Ophthalmologists Committees. I am pleased and willing to express my wish to continue this participation, to expand the Society’s efforts to offer voice and participation to all those who can contribute, being particularly focused on education and research as leverages to the ESCRS. I am the head of the Hospital da Luz (Lisbon) Ophthalmology Department, Professor of Ophthalmology and Biomedical Engineering at the University of Lisbon,

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Sathish Srinivasan UK

am a consultant corneal surgeon at University Hospital Ayr, Scotland and a Professor at the University of West of Scotland. I have served as a board member of UK and Ireland Society of Cataract and Refractive Surgeons since 2009. My interests are in lamellar corneal transplants, and refractive cataract surgery. I have published over 100 scientific papers and have presented in over 90 international meetings. I am a recipient of the Senior Achievement and International Scholar awards from the American Academy of Ophthalmology. I serve as the Associate Editor of the Journal of Cataract and Refractive Surgery.

E

Julian Stevens UK

SCRS is 37 years old and I have been a member for 28 years. I trained at Oxford and Cambridge Universities and completed Fellowship training at Moorfields Eye Hospital where I have been a Consultant since 1996. I have a special interest in cataract and refractive surgery and I have run the Moorfields’ laser refractive, phaco and femtosecond laser cataract surgery courses over many years. I was previously Cataract Training Director and then the first Refractive Service Director at Moorfields. If elected I would like to see an easily searchable internal ESCRS directory of members, where we can easily then

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Jérôme Vryghem BELGIUM

very much enjoyed being an ESCRS Board Member from 2013 – 2017. As the candidate nominated by the Belgian Society of Cataract and Refractive Surgery I want to continue the tradition of Belgian ophthalmologists being a member of the ESCRS Board. I have written many peer and non-peer reviewed articles, organised several scientific sessions and live surgeries, and have regularly been invited to demonstrate my surgical technique during live surgeries abroad. I very much enjoyed attending several ESCRS Academy meetings abroad in the last 6 years. I have organised an instructional course on the prevention and management of complications in LASIK at

Netherlands Intraocular Implant Club (NIOIC) since 2009. In 2005, I received a PhD (cum laude) from the Erasmus University Rotterdam. I have authored 39 peer-reviewed articles. Recent publications have covered straylight and patient-reported outcome measures. If elected to the Board, I would like to build on my teaching, research and organisational experience to further improve the role of the ESCRS in providing the best in education in cataract and refractive surgery, in supporting clinical research, and in offering a platform for European ophthalmologists to exchange their ideas and experiences.

Board of the Portuguese College of Ophthalmology, and past-president of the Portuguese Group of Cataract and Refractive Surgery (CIRP). I participate as an examiner in the FEBOS-CR (EBO-ESCRS Subspecialty exam), I am a member of the Portuguese National Jury of Ophthalmology and director of UEMS-accredited courses. I developed my research activity at Visual Sciences Research Centre mainly in IOL power calculation and eye computational models. I would be grateful to have your vote support and I invite you to contact me with any questions you might have.

I have been an active member of ESCRS since 2009 and my current involvement includes: 1. Co-opted board member 2. Member - Publications Committee (EuroTimes) 3. Evaluation panel member - ESCRS Clinical Research Awards 4. Examiner - European Board of Ophthalmology ESCRS Exams 5. Faculty of ESCRS teaching academy I am totally committed to the mission of ESCRS to enhance education and research. My experience provides me with an insight to the work and dedication required to be active, collaborative and to harvest results. It would be a great honor and privilege for me to serve as your elected board member.

refer patients to fellow ESCRS members. I would like to see further development of the online video library for members, especially for surgical techniques, not just for rare and complex conditions but for “standard” procedures. I would encourage ESCRS members who have ideas to develop or improve the Society to contact me when I can then forward these ideas for continued development. With artificial intelligence and robotics now coming into ophthalmology to change what we do, I want to ensure ESCRS stays as the premier destination for us for the next 37 years.

ESCRS congresses since 2001. Since 2010 I have been the organiser of an annual worldwide expert meeting on the surgical management of keratoconus. My focus of interest, about which I have given several presentations at ESCRS congresses, is micro-incision cataract surgery, trifocal IOLs, topography-guided laser treatments and nanosecond laser cataract surgery. I would like to put forward the need for more didactic sessions at ESCRS congresses, with clear and useful messages for less experienced surgeons. I am convinced that it is an asset for the ESCRS to count some private practice based surgeons amongst the Board Members.


EXPLORING PARIS

PARIS LOCATION

3

TO SAMPLE ...

‘LUST FOR LIFE’ Published in 1935, this book was probably the source of much of what the average person ‘knows’ about Van Gogh. A debut novel by Irving Stone, it was made into a film the following year with Kirk Douglas as Vincent. Reading like a biography, it is, admittedly, fictionalised, but it does follow the available facts and is a good introduction to the stories behind Van Gogh’s masterpieces. To promote the film, MGM produced a short companion film, Van Gogh: Darkness Into Light, visiting the locations used for the filming of Lust for Life. An elderly woman from Auvers-sur-Oise, interviewed in the film, claims to have met Van Gogh when she was a girl and remarks that Kirk Douglas closely resembles the painter. The film is shown occasionally on Turner Classic Movies.

VAN GOGH’S LAST DAYS IN AUVERS-SUR-OISE In the final two months of life, Vincent van Gogh painted 10% of his work – 80 paintings and 64 drawings. Of this output, he is said to have sold only one painting, Red Vineyard at Arles; it earned him 400 francs – at the time, enough to support a family for over a year. That was a few months before his death in 1890. In 1990, his portrait of Dr Gachet, who attended him in Auvers, sold for over $82 million. Now recognised as one of the most important painters in the world, Van Gogh’s work is prized by 32 museums. A 52-minute English-language documentary produced by the Musée d’Orsay, Paris, tells the story of the physical and moral exhaustion of his last months, which may have contributed to his death at the age of 37. The DVD costs €14.50 and is available online from the museum at www.boutiquesdemusees.fr

‘KILLING VINCENT’ Irving Kauman Arenberg MD, basing his book on a review of the available evidence, suggests that Van Gogh did not die by suicide but was murdered – and that the murder was the subject of a gigantic coverup. His book, Killing Vincent: The Man, the Myth and the Murder, presents the evidence he has unearthed using 21st-Century forensic procedures. Dr Arenberg, a retired ear surgeon, is a Van Gogh historian, whose featured “Special Communication” article in the Journal of the American Medical Association (JAMA) in 1990 questioned the diagnosis of epilepsy in explaining the artist’s seizures, suggesting they resulted from Meniere’s disease. Paperback and Kindle versions are available through Amazon.

Red Vineyard at Aries

Immersed in Van Gogh Delegates to EURETINA and ESCRS meetings in Paris can enjoy all things Van Gogh. Maryalicia Post reports The chance to view Vincent van Gogh’s paintings transformed into an ‘immersive exhibition’ has proven to be an outstanding attraction in Paris. Running at the Atelier des Lumières until 22 December 2019, La Nuit Etoilée is a 35-minute light and sound show, an intimate exploration of Van Gogh’s paintings and the environments in which they were created. www.sortiraparis.com This immersive concept has been hailed as ‘thrilling’ and a ‘must see’, but you can treat yourself to an immersive experience of a different kind in the village of Auvers-sur-Oise, only 35 kilometres from Paris. Here, signs posted along the country roads indicate the vantage points from which Van Gogh painted 12 of his famous works. Stand in the room at Auberge Ravoux (closed Monday and Tuesday) in which the painter lived for 70 days – and in which he died. A short walk away, see the field that was the subject of the painter’s last work. Next to it is the graveyard where ivy-clad headstones mark the final resting places of Van Gogh and his ever-supportive brother Theo. (Read Van Gogh’s correspondence with his brother, Gauguin and others at http:// vangoghletters.org/vg) in Dutch with English translation.) At the Auvers Tourist Bureau watch a moving video of the artist’s time in the town and pick up maps tracing Van Gogh’s footsteps. Visit the house of his physician, Dr Paul Gachet, and perhaps the 17th-Century Chateau d’Auvers; it was in its grounds that the destitute, 37-yearold Vincent fired the fatal bullet into his abdomen. He would die two days later in Chambre 5 of the Auberge Ravoux, attended by his brother and Dr Gachet.

Book a meal at the Auberge, now a restaurant called ‘La Maison de Van Gogh’. The room, in which Van Gogh had a table at the back, retains the atmosphere of a simple inn but the food is decidedly more sophisticated. There’s a small book and gift shop. www.maisondevangogh.fr Auvers is a 35-minute drive from Palais des Congrès or an hour from Paris Expo; you can do it in a day but better still, stay overnight in the eight-room Hotel des Iris across from the Maison de Van Gogh. info@hoteldesiris.com. Or choose a b&b from the list on the tourist office website: www.tourisme-auverssuroise.fr. Then, early next morning, see the village almost on your own… just you looking through the eyes of Van Gogh, walking where he walked, seeing what he saw. As an immersive experience, it’s hard to beat.

The Church at Auvers

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YOUNG OPHTHALMOLOGISTS

Chaos Reigns In her shortlisted essay for the 2019 John Henahan Prize, Dr Pallavi Singh looks to her colleagues who seem to balance family and medicine with perfect ease

I

t is tough to write about balancing ophthalmology and family life, when you have barely started a career in ophthalmology and are nowhere near having a family of your own. So, how did I end up writing this essay? Probably because I have always been intimidated by the daunting task of maintaining a perfect equilibrium between career and personal life, and it is fascinating to watch people accomplish this incredible feat so effortlessly, day in and day out. Ophthalmology was always traditionally considered to be less demanding as compared to other medical branches like general surgery. However, nowadays it has become a technologically advanced, all-encompassing field with diversification into aesthetics, trauma, neurology, etc. This has changed the conventional idea of our job. Today, ophthalmologists are busier than ever. The shift towards a busier work environment has made the work-personal life balance question even more pertinent. With this background, I am going to share the lives of two women in ophthalmology with completely different approaches to life, both of whom I have come to greatly idolise. Also, I choose to talk about women, and not men in this context, because even today, the act of juggling a successful career with a family is EUROTIMES | JUNE 2019

more of a conscious (read difficult) choice for women, rather than a default option, as for most men. The protagonist of my first story is my attending consultant with two children, an 8-year-old son and a 2-year-old daughter. Chaos reigns her life. There are projects to be executed, classes to be scheduled, conflicts to be resolved and of course, diapers to be changed. On multiple occasions, I have seen her consoling her kids about broken crayons and such over the phone, before entering the operation theatre for some major surgery. At other times, she has had to rush home for some unexpected sibling skirmish or common cold crisis. What I also observe is that her colleagues often jibe about how she should think of becoming a stay-at-home mother,

considering she is always so occupied with her children. However, amidst the mad mayhem that I have always thought her life is, I notice that she is probably the calmest doctor I had ever come across in my life. In situations, where most others would be furious, she is cool as a cucumber and invariably comes up with ingenious solutions. Flummoxed by the opposing nature of her situation and her personality, I once asked her the secret to her tranquillity, and she answered, â&#x20AC;&#x153;I am at peace because I am happy. Sure, family can be a challenge sometimes, but you learn a lot when you have to fit in the wishes and demands of other people with your own. When at the end of an exhausting day, I get to go back to people who love me regardless of anything, it is worth the effort.â&#x20AC;? The heroine of my second story is my


YOUNG OPHTHALMOLOGISTS

clinical research guide, a single mother of one, and one of the most successful professionals in her field. Ambition guides her life. There are research proposals to be written, conferences to be attended and surgeries to be performed. On multiple occasions, she is the first to reach and the last to leave the clinical laboratory. And even though, most of her colleagues fear and revere her, there are invariable jibes about how she is too ambitious for a woman and may not be doing enough for her family. But despite the harrowing hustle that her life is, I see her plough on and achieve milestones that most others could only dream of, undeterred by any taunts or obstacles. Perplexed by her brazen determination despite domestic responsibilities, I turned to her for advice and she said,

Your work is not only your legacy, but also a part of who you are as a person

â&#x20AC;&#x153;Your work is not only your legacy, but also a part of who you are as a person. I am most content, whenever I see a patient who has benefited from anything I may have contributed, and that is what drives me to do this. My daughter understands that sometimes my patients need me more than she does, and has come to become the single most inspirational force in my life. I attempt to inculcate in her the compassion and dedication that my work has taught me.â&#x20AC;? As I watch these two women tirelessly labour their way through children, relatives, surgeries, research and life in general, I realise that it is never going to be an effortless journey. We will always be placed at the altar of societal judgement, despite the sacrifices we make,

the occasions we miss and the disappointments we face. But every once in a while, there are moments of achievement, emotion, and most importantly joy, that make the struggle worth it. There is no right way to walk the line. Our choices as individuals may differ, but as long as we aim to master the challenge, and not let the challenge master us, I think we will all do just fine. Dr Singh is a Senior Resident at the Dr RP Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

JOHN HENAHAN PRIZE 2019

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YOUNG OPHTHALMOLOGISTS

A Symbiotic Relationship In his shortlisted essay for the 2019 John Henahan Prize, Dr Luke Sansom reflects on the journey he and his family have taken over the years of his career

EUROTIMES | JUNE 2019


YOUNG OPHTHALMOLOGISTS

“I

want to quit!” A look of bemusement came across the face of my supervisor as I told him of my intentions toward the end of my first year in ophthalmology training. It was a moment I had rehearsed in my head for some months and I was clear about two things, I hated ophthalmology and I wanted out. Or so I thought. This may not be the opening paragraph one might expect for an essay on balancing family life and ophthalmology. I must explain the journey that got me to this point, what happened and where I am today. Following specialty recruitment applications, I was incredibly fortunate to receive a national training post in ophthalmology. The post did however require me to move my wife, young son and baby daughter across the country, far from friends, family and familiarity. When we moved, we found the local schools were full, with no places for miles around, and the house we had rented turned out to be small and dated, and we quickly learnt it was cold, mould-ridden and noisy too. We ended up having to register with a local fee-paying school at the cost of nearly one third of my annual take home pay, ouch! My wife was miserable, having left her friends and support network behind. I was working long days, with lengthy commutes on public transport.

I had the job that I had so desperately always wanted, so why was I so dissatisfied and unmotivated

The school fees made it financially unviable to run a car. I was also often working extra shifts in the emergency department to generate extra money. Family life was at a low point, we had little money and even less time to spend together, happiness was very much at a premium. Surely work could provide me with some relief and form of escape from the pressures of family life. It seemed not. My new colleagues were all welcoming, kind and supportive and without them I’m sure I would have tried to quit sooner still. Despite their efforts I found the work very challenging. There was new equipment, new terminology and new diseases to learn, and fast. I was finding cataract surgery hard, really hard. Operating was the one thing I had enjoyed the most during my medical training, but here I was hating every minute and struggling terribly. Each day I felt like I was drowning in new challenges, unable to ever catch my breath. I could see my trainee colleagues were excelling, where I very clearly was not. I had the job that I had so desperately always wanted, so why was I so dissatisfied and unmotivated. I had convinced myself that I’d be much happier doing something else and that quitting was my best option. After a protracted period of reflection, I came to realise that I was so unhappy in my work because my family felt stressed, unsupported and disillusioned. I blamed myself and I felt a great sense of guilt. Moreover, I hadn’t been there to support them through their struggles. The times I was home, I often felt so fatigued from the stresses of my working day that I was unable to give them the attention and love that they so desperately craved. I felt that if I couldn’t properly care for my own family how could I reasonably be expected to care for my patients or anyone else. Thankfully my supervisor listened to me and encouraged me to give it more time. I reluctantly agreed. I was glad I did. My

wife and I set to work trying to transform our family life. We managed to move to a lovely house, get my son into an excellent state school and we started making friends locally. We had a little more time together and most importantly filled that time with the fun, love and happiness that we had been so desperately missing. I still work long hours, have long commutes and cover unsociable oncalls and inevitably miss out on family events. My family accept that I might not always be there, but when I am home, they know that I am theirs and theirs only. From playing football in the garden after an exhaustingly long day, skipping breakfast to instead plait my daughter’s hair to look ‘just like Rapunzel’, or getting up early after a busy weekend oncall to take the kids out so that my wife can have a few child-free hours to see her friends. These small acts of effort, love and kindness are the glue that bond our family together and provide each of us with a stable base to go forward and achieve our goals. I did ultimately stay in ophthalmology training and I could not be happier. These are my reflections on balancing a career in ophthalmology and family life and how in this symbiotic relationship things can go very wrong, but how we owe it to ourselves, to our families and to our patients to find that balance. My greatest failing was not realising soon enough the monumental role my family play in making me fulfilled, happy and resilient and the vital importance this has in all aspects of my life. Dr Sansom is a Specialty Trainee at the York Teaching Hospital NHS Foundation Trust, Yorkshire, UK

JOHN HENAHAN PRIZE 2019

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HOSPITAL DIARY

Music to my ears Patients chatting in the waiting room is a sign that all is well. Leigh Spielberg MD reports

“H

ow big is > pupillary dilation > off to the your gas waiting room until I call them bubble? in for their examination. Mine was Some of those returning for 80% last time, but now it’s the second or third visit start to down to 40% and I can see over recognise the members of their the top. I call it my aquarium, surgical “cohort”: other patients and I hate it. But I think I who were operated on the same might miss it when it’s gone. day and generally return on the And the doctor says a big gas same days for follow-up. bubble is a good sign, and “Oh hello, nice to see you that’s really all that matters.” again. Here for your second It’s like music to my ears. I post-op visit? Are you allowed hear it when I open the door, to drive yet? Today I’ll hear and it provides me with a whether I’m allowed to get back brief, uplifting moment as I on the road.” call in the next patient from At my macular surgery the waiting room. practice in Ghent, I see 24 “My gas bubble is gone, patients on Friday mornings: which is great because we’re six new patients who were flying to Italy this weekend referred for surgery, six who and I wouldn’t want to have to were operated the day before, cancel the trip!” six patients who were operated Patients who are happy with two weeks ago and six more their results, patients who are at who are coming for their week ease, patients whose problems four and hopefully final visit. have been solved, are sometimes “Well, it was nice meeting comfortable enough to start you! Good luck and maybe we’ll chatting with their neighbours run into each other sometime.” in the waiting room. “Yes, we have the same “You had floaters too? I had general ophthalmologist, don’t three little clouds and what we? Maybe I’ll see you there.” Did you have a retinal detachment too? looked like a fly in my right eye Cataract and refractive Macula on or macula off? Mine was and now they’re gone! I hope I surgeons are used to hearing can get my left eye done soon this lovely chit-chat in the macula off. I can’t believe I didn’t too, but first the right eye has waiting rooms. After all, just notice it sooner! to heal. I can’t wait.” about everyone is happy after This casual chit-chat keeps elective anterior segment me motivated as I get back to surgery. work examining patients. Vitreoretinal surgery is another story. The list of potential “Did you have a retinal detachment too? Macula on or macula problems is long. Slow visual recovery after macula-off retinal off? Mine was macula off. I can’t believe I didn’t notice it sooner! detachment. Persistent metamorphopsia or macular oedema But the doctor said that my photoreceptors are recovering and despite anatomically successful pucker peeling. Long-term that they can keep improving until one year after surgery.” gas tamponade, impairing the ability to drive a car for weeks “No, I had a macular hole, and I also got a gas bubble. I was on end. Hypermetropic anisometropia or ocular hypertension happy to hear that my other eye probably will never develop a due to oil tamponade. Fortunately, these are uncommon macular hole because the vitreous has already safely detached.” occurrences in this era of small-gauge surgery. On the first day after surgery, patients are generally quiet But even if it all goes as planned, the experience generally isn’t and reluctant to interact with their waiting-room neighbours. very pleasant for patients. General anaesthesia can cause fatigue They might be tired, even afraid. The surroundings are or nausea, which is why I’m moving towards performing more unfamiliar, the experience is new and their eye might be a bit procedures under sub-tenon anaesthesia. Scleral sutures cause uncomfortable. Especially ill at ease are patients who were foreign-body irritation, so I try to minimise their use as much as referred for retinal detachment repair. They were likely to have possible. So, when I overhear the light-hearted conversation in the experienced acute visual loss, which is frightening for anyone, waiting room, I can get a sense that all is well. followed by urgent surgery. If everything looks good at the third post-op visit, I refer Regardless of the pathology, the only thing any patient wants patients back to their general ophthalmologists, at which point I to hear on day one after surgery is that everything inside their get to say my favourite thing to patients: “Good-bye, have a nice eye looks good, so they can get on with their lives. day, and I hope, for your sake, that I never have to see you again!” But by the second or third postoperative visit, most patients are usually more at ease. They know the routine: front-desk Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent sign-in > IOP measurement > auto-refraction > macular OCT University, Belgium Illustration by Eoin Coveney

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EUROTIMES | JUNE 2019


INDUSTRY NEWS

NEWS IN BRIEF SUSTAINABLE GROWTH Alcon has completed its separation from Novartis and the company’s shares are now trading on the SIX Swiss Exchange and New York Stock Exchange (NYSE) under the symbol “ALC.” “For more than 70 years, Alcon has been dedicated to helping people see brilliantly and now, as an independent company, we are pursuing even more opportunities to further that mission,” said David Endicott, Chief Executive Officer of Alcon. “We are poised to achieve sustainable growth and create long-term shareholder value as a standalone company. As a nimble medical device company, we are sharply focused on providing innovative products that meet the needs of our customers, patients and consumers.” https://www.alcon.com

INDUSTRY

NEWS

Automatic measurement

NIDEK has launched the ARK-F/AR-F Auto Ref/Keratometer / Auto Refractometer, which features fully-automatic measurement. By placing the chin on the chinrest, the new NIDEK eye detection camera automatically detects the position of the eyes and measurement starts without pressing any button. Gentle voice guidance facilitates smooth measurement for any operator. “Reliably accurate eye examination equipment with comfortable operability has become worldwide standard,” said Motoki Ozawa, President and CEO of NIDEK. “Our ARK-F/AR-F will impressively change your ‘standard’ with its smooth, fully-automatic and precise measurement and high freedom of installation, in addition to the conventional accurate measurement.” https://www.nidek-intl.com

PATIENT-REPORTED OUTCOMES Rayner has developed RayPRO, a mobile phone and web-based app for collecting patient-reported outcomes (PROs) for three years after surgery. This is a bespoke platform that has been specifically developed to record outcomes after cataract surgery, gathering information on patient satisfaction and visual outcomes with the potential for quality improvement and complying with new legislation on medical devices. RayPRO is free to all Rayner IOL users. Tim Clover, Rayner CEO, said: “Speaking with surgeons, their number one goal is always patient outcome; however, keeping on top of this metric for three years can be a challenge. As consumers, we’ve become accustomed to accessing key information instantaneously day or night on our smartphones. “Being able to offer surgeons the same service for surgical outcomes is the driver behind RayPRO,” said Mr Clover. https://rayner.com/

FDA APPROVAL FOR PRELOADED CAPSULAR TENSION RING OPHTEC USA has received FDA approval for the RingJect™ delivery system design optimisation changes. The OPHTEC CTR is made of PMMA with patented compression moulding technology, making for a durable, flexible device to stabilise the capsular bag in the presence of weakened or compromised zonules. Abraham Farhan, Vice President and General Manager of OPHTEC USA, said: “We are grateful that the FDA has approved the Ophtec RingJect with optimised delivery system enhancements. Our surgeons and patients will continue to benefit from our legacy Capsular Tension Ring (CTR). “We are very excited about the RingJect, as it saves time in surgery and reduces surgical preparation time.” https://www.ophtec.com/

ANTI-INTEGRIN PORTFOLIO Allegro Ophthalmics has announced the expansion of the company’s anti-integrin portfolio with ALG-1007, a topical treatment in development for potential use in patients with dry eye disease (DED). ALG-1007 bolsters Allegro’s existing anti-integrin portfolio, which includes risuteganib (Luminate®), currently being developed for diabetic macular oedema (DME) and intermediate dry age-related macular degeneration (AMD). Allegro has also announced that Richard L. Lindstrom MD, Edward J. Holland MD and Eric D. Donnenfeld MD, have joined the company’s newly formed Cornea Scientific Advisory Board (Cornea SAB) to provide strategy and direction on Allegro’s clinical development pipeline in the areas of corneal disease and dry eye. Dr Lindstrom will serve as Chairperson of the Cornea SAB. https://www.allegroeye.com

RAPID DELEVERAGING Takeda has announced that it has entered into agreements to divest its Xiidra® (lifitegrast ophthalmic solution) 5% product (“Xiidra®”) to Novartis and its TachoSil® Fibrin Sealant Patch (“TachoSil®”) to Ethicon as part of its strategy to focus on business areas core to its longterm growth and facilitate rapid deleveraging following its acquisition of Shire. “These divestitures represent important steps in advancing the growth strategy Takeda outlined following our transformational acquisition of Shire earlier this year,” said Christophe Weber, President and CEO of Takeda. “We are working to strategically simplify and optimise our portfolio, while also rapidly deleveraging and continuing to invest in our growth drivers as a global, valuesbased, R&D-driven biopharmaceutical leader.” Takeda will focus on its key business areas – Gastroenterology (GI), Rare Diseases, PlasmaDerived Therapies, Oncology and Neuroscience. “This focus enables Takeda to continue to deliver highly-innovative medicines and transformative care to patients around the world, creating long-term value for Takeda shareholders,” said a company spokesperson. https://www.takeda.com

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BOOK REVIEWS PUBLICATION SURGICAL MANAGEMENT OF CHILDHOOD GLAUCOMA

LEIGH SPIELBERG MD Books Editor

EDITORS ALANA L. GRAJEWSKI, ELENA BITRIAN, MARIA PAPADOPOULOS AND SHARON F. FREEDMAN PUBLISHED BY SPRINGER

SPECIFIC MODALITIES

BOOK

Reviews PUBLICATION MANAGEMENT OF MACULAR HEMORRHAGE EDITOR LARS-OLOF HATTENBACH PUBLISHED BY SPRINGER

A systematic overview

Macular haemorrhage remains one of the most difficult ophthalmic entities to manage, so I jumped at the chance to review Management of Macular Hemorrhage (Springer). As a vitreoretinal surgeon myself who often encounters this pathology, I could always learn more. Edited by Lars-Olof Hattenbach, this 93-page book quickly points out that “there is currently no consensus regarding the ideal treatment for macular hemorrhage”. There are indeed no easy-to-follow recipes for success. Instead, the text aims to “provide a systematic overview of therapeutic approaches that cover the most important situations a vitreoretinal surgeon might encounter when treating patients with this disorder”. Macular haemorrhage, which is a severe complication of a variety of ocular disorders such as AMD, arterial macroaneurysm and valsalva retinopathy, used to spell the absolute end of useful central visual acuity. However, since the development of various techniques involving intravitreal or subretinal injection of rtPA, choroidal-RPE grafts, gas tamponade and anti-VEGF, the prognosis is significantly better, although still highly variable and frustratingly unpredictable. This book covers not only the surgical techniques but the indications for surgery, making it useful not only for retinal specialists but also for general ophthalmologists interested in providing their patients with correct and efficient referrals in a timely fashion.

Another highly specialised pathology is covered in Surgical Management of Childhood Glaucoma: Clinical Considerations & Techniques, which covers the topic comprehensively and in depth. Starting with perioperative and anaesthetic considerations, the text then describes the various components of the paediatric examination under anaesthesia. As this is a surgical text, not much time is spent on clinical evaluation and diagnostics. Most of the rest of the chapters each focus on specific surgical modalities: goniotomy, trabeculotomy, paediatric trabeculectomy, glaucoma drainage devices and cyclodestruction. Considering the fact that “these highly specialised operations should preferably be performed by trained surgeons in centres with sufficient volume of patients to ensure surgical experience and skill, coupled with safe anaesthesia”, this book is primarily of interest to glaucoma specialists, particularly those interested in paediatric surgery. It is also of great interest to paediatric ophthalmologists, as well as general ophthalmologists.

PUBLICATION CONTROVERSIES IN THE MANAGEMENT OF KERATOCONUS EDITORS ADEL BARBARA PUBLISHED BY SPRINGER

UNCOMPLICATED CASES BRINGING KERATOCONUS INTO FOCUS

PUBLICATION STRABISMUS FOR EVERY OPHTHALMOLOGIST EDITORS SIDDHARTH AGRAWAL PUBLISHED BY SPRINGER

EUROTIMES | MONTH YEAR

EUROTIMES | JUNE 2019 MONTH YEAR

Strabismus for Every Ophthalmologist: the title really says it all. Springer’s new text, edited by Siddharth Agrawal, is not intended for the subspecialist but rather “encourages ophthalmologists who do not usually deal with strabismus patients to identify and manage uncomplicated cases”. So, how does the text manage to do this with what is generally considered a confusing subject? It starts out with a 20-page chapter on the basics of understanding strabismus, followed by another chapter covering the clinical evaluation of strabismus. In the following chapters, specific types of strabismus, such as comitant horizontal, incomitant strabismus and special variants are covered. It also does so by discussing various management options that are often neglected, such as the guidelines for refraction and spectacle prescription in this patient population. But the goal of the book is to allow non-subspecialists to take the next step, to actually manage the patients including surgery of horizontal muscle surgery, botulinum toxin and how to manage complications. As the title suggests, this book could be read and understood by every ophthalmologist. I believe it is of particular use to general ophthalmologists without easy access to dedicated strabismus specialists for referrals, who can instead manage the basics themselves.

The treatment of keratoconus is changing. With the refinement of imaging modalities and the development of new and improved treatment modalities, the possibilities for disagreement among experts has increased. This is apparent in Controversies in the Management of Keratoconus. The text seems to cover everything: monitoring progression, cross-linking (epi-on and epi-off, accelerated, the role of oxygen, biomechanics, moving beyond the Dresden Protocol; paediatric, combination with PRK); the Athens Protocol, intrastromal ring segments, phakic and toric IOLs. It discusses why one might perform a full-thickness penetrating keratoplasty rather than a DALK, the possibility of Bowman layer transplantation in advanced disease and, if surgery is not an option, how to manage with scleral contact lenses. To bring it all into focus, the book closes with a chapter on how to navigate among all these controversies, written by the editor. 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

JUNE 2019

SOE Congress 2019

MaculArt 2019

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

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

JULY ASRS 2019

26–30 July Chicago, USA www.asrs.org

AUGUST

13–16 June Nice, France www.soevision.org

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

NEW Forum Ophthalmologicum Baltic 23–24 August Vilnius, Lithuania www.fob2019.lt

SEPTEMBER 19th Euretina Congress 5–8 September Palais des congrès Paris, France www.euretina.org

10th EuCornea Congress 13–14 September Paris Expo Porte de Versailles Paris, France www.eucornea.org

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

37th Congress of the ESCRS 14 –18 September Paris Expo Porte de Versailles Paris, France www.escrs.org

SEPTEMBER NEW Advances in Glaucoma Research and Clinical Science Meeting 2019 26–28 September Palais des congrès Amsterdam, The Netherlands www.glaucomacongress.com

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

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

NEW EVER 2019

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

Ophthalmic Imaging: from Theory to Current Practice

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

ASRS 2019, Chicago

EUROTIMES | JUNE 2019

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2020

18th SOI International Congress 2020, Milan

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

18th SOI International Congress

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

JULY ASRS 2020

23–28 July Seattle, USA www.asrs.org

JUNE

OCTOBER

NOVEMBER

20th EVRS Meeting 2020

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

AAO Annual Meeting 2020

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

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

OCTOBER

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

38th Congress of the ESCRS

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

20th Euretina Congress 1– 4 October Amsterdam, The Netherlands www.euretina.org

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

Are you ready for the next step? Belong to something energetic. Join us.

www.escrs.org EUROTIMES | JUNE 2019

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

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


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