CAKE 31: Mastering the Anterior Game by Media MICE

LETTER TO READERS

calculations, and offers decision support that is on average, on the routine case... rather good. It will get better. Anyone advising you to resist this is advising you to hand-crank a car that comes with a starter motor. But notice where all of it sits. The intelligence world draws a line between collection and judgment. Signal intelligence tells you what was said; it takes an officer to decide what it means, which sources to believe and what to do next. Everything AI currently does in our field—every summary, every flag, every suggested plan—lives on the collection-and-processing side of that line. The decision, and the accountability that comes with it, does not move.

THE

SOURCE

Still Matters

Artificial intelligence can summarize yesterday’s knowledge. Tomorrow’s breakthroughs still begin with people. Dear Readers, Intelligence agencies have a habit of declaring the human source obsolete. They did it in the 1960s, when spy satellites promised to photograph everything worth knowing. They did it again in the 1990s, when signals interception scaled to the whole planet, and once more when data mining arrived after 9/11. Each time, the same correction followed: collection became cheap, and judgment became the bottleneck. A satellite can photograph the missile base in exquisite detail. It cannot tell you what the general intends to do with it. Medicine is now running the same experiment, and ophthalmology is close to the front of the queue. Let me be fair to the machines, because they’ve earned it. AI already drafts the discharge summaries, the referral letters and the correspondence that used to consume your evenings. It handles coding and billing with fewer errors than tired humans manage. It triages fundus photographs, flags the diabetic retinopathy that would otherwise wait weeks for grading, refines IOL power

There’s a structural reason for this, not just a sentimental one. A model is an archive with a fluent interface. It can only report what the record contains, and the record was written by people: the surgeon who modified a technique and told her colleagues; the trialists who designed the study that settled the argument; the voices who set the standards, chair the committees, train the fellows and tell a company—to its considerable irritation—that the device isn’t ready. Tomorrow’s record will be written the same way. A system trained on yesterday’s literature cannot, by definition, be the author of next year’s. And here the espionage analogy earns its keep one more time. The hardest work in intelligence was never the intercepts. It was knowing which sources to trust: finding them, testing them and keeping those relationships alive over years. Ophthalmology works identically. Practice doesn’t change because a paper was published; it changes when trusted voices discuss that paper in corridors, closed groups and advisory rooms, and decide it holds up. As machine-generated words become effectively infinite, the trusted expert voice becomes the scarce asset. The quiet work of connecting the right voices to the right conversations—between clinicians, and between clinicians and industry—becomes more valuable, not less. I write this from the analyst’s desk, not the field. My doctor title comes from a PhD in brain development. In some respects, I’ve spent my career writing the briefings rather than running the operations. Which means I know precisely which part of my job the machines can now do. It isn’t the part that matters. That is even more true of yours. The agencies learned it the hard way, and medicine will too. You can automate the signals. You cannot automate the source. In the age of artificial intelligence, ophthalmology will still run on human intelligence: yours. Best, Mark Hillen, PhD Director of Communications ELZA Institute, Zurich, Switzerland Editor-At-Large | CAKE

COVER STORY

KUDOS

Engineering Precision

Teaching Beyond Borders

Rethinking phaco, fragment by fragment

Cataract Surgery, Vitreous Floaters and Contrast Sensitivity

The Eight-Chop Files

From IOL delivery to sustained glaucoma therapy

Mentorship, mama-bear leadership and closing Europe’s training gap

Why visual acuity is not the whole story

38 CATARACT

Why ESCRS Membership Matters at Every Stage of An Ophthalmology Career

Most ophthalmologists know ESCRS for its Congress. Members know it for everything else.

ANTERIOR SEGMENT

The Slit Lamp. Reinvented Elara 900: Twelve months of clinical validation & innovation

ENLIGHTENMENT

One Platform. One Workflow

The METIS 900 platform continues to expand its digital workflow

06 08 12

Mission Aborted The art of knowing when to stop

Optical Engineering Rethinking the eye as an integrated visual system

The Quest For True Accommodation

Restoring dynamic focus with injectable lenses

16 19

Unmasking Demodex

One Billion Reasons

Loose Cannula

Essilorluxottica Showcases an Integrated Scientific Ecosystem Across The Eye Care Continuum at ARVO 2026

Rethinking blepharitis in everyday practice

The Case of the Corneal Disguise

A lesson in complex anterior segment decision-making

20 22

Beyond Trabeculectomy

A challenging PACG case

Slit Lamp Mastery, Accelerated No patients, no pressure, no problem. How virtual reality is teaching residents to master the slit lamp before they ever meet a real eye.

SEPTEMBER 2026

The first-ever global summit for eye health

Cannula detachment may be the most under-reported complication in cataract surgery, and the law is quietly catching up with it.

At ARVO, EssilorLuxottica presented over 20 peerreviewed scientific abstracts, underscoring the depth of its research and its contribution to the global scientific community.

REFR AC T I V E & C ATA R AC T S U R G ERY

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oculus.de/escrs The availability of products and features may vary by country. OCULUS reserves the right to change product specifications and design.

ADVISORY BOARD MEMBERS

Matt Young CEO & Publisher

DR. HARVEY S. UY University of the Philippines; Peregrine Eye and Laser Institute, Manila, Philippines harveyuy@gmail.com

Gloria D. Gamat Chief Editor Diana Truong Managing Editor Andrés Pacheco Art Director

DR. FRANCIS MAH Scripps Clinic Medical Group La Jolla, California, USA Mah.Francis@scrippshealth.org

DR. WILLIAM B. TRATTLER Center For Excellence In Eye Care Miami, Florida, USA wtrattler@gmail.com

DR. CATHLEEN MCCABE The Eye Associates Sarasota, Florida, USA cmccabe13@hotmail.com

PROF. BURKHARD DICK University Eye Hospital Bochum Bochum, Germany burkhard.Dick@kk-bochum.de

PROF. DR. SORCHA NÍ DHUBHGHAILL Brussels University Hospital (UZ Brussel) Brussels, Belgium

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Chris McBride Editorial Creative Lead Nhat Vo Olivia Gunawan Yura Yu Graphic Designers Writers Chow Ee-Tan Hazlin Hassan Kendra Bruning Marhiel Garrote Michaela Perez Sam McCommon Tan Sher Lynn Artwork credits to: Andrés Pacheco, Chris McBride, Lieu Truong, Nguyen Ho, Nhat Vo, Thoi Le, Yura Yu Dr. Aaishwariya Gulani Mr. Amar Alwitry Dr. Arun Gulani Dr. Franziska Weiglein Dr. Dr. Ronald D. Gerste Prof. Dr. Ulrich Welge-Lüssen Dr. Shilpa Ghosh Contributors Ruchi Ranga Societies Relationships & Conference Manager International Business Development Brandon Winkeler Robert Anderson Sven Mehlitz Published by

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SEPTEMBER 2026

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CATARACT

Some cataracts complicate. Others just refuse to cooperate. Here’s how Dr. William Trattler decides when to push through and when to hand off the eye entirely.

THE ART OF KNOWING WHEN TO STOP Modern cataract surgery is one of the safest and most successful procedures in medicine, but not every case behaves. Capsular compromise (where the delicate membrane holding the crystalline lens tears) and dense cataracts (where a hardened, clouded lens raises the surgical stakes) remain two of the field’s toughest scenarios. Here’s how to navigate both without losing sleep…or the eye. KNOWING WHEN TO WALK AWAY Few moments in cataract surgery are more unnerving than a sudden loss of capsular integrity. A posterior capsular tear or significant zonular instability can turn a routine case into a

By Tan Sher Lynn

complex surgical dilemma, especially once placing a single-piece intraocular lens (IOL) in the bag or a three-piece IOL in the sulcus is no longer an option. Careful preoperative screening goes a long way toward avoiding this scenario in the first place, according to Dr. William Trattler (United States). “We look for signs like pseudoexfoliation syndrome, which has a known risk of loose zonules. We also look for patients with a history of wet macular degeneration [AMD] receiving frequent anti-VEGF [anti-vascular endothelial growth factor] injections because there are occasional cases where these injections can inadvertently injure the capsule of the lens,” he said, noting that advanced, dense cataracts carry the highest risk of all.

CAKE

Even with meticulous planning, complications can still occur. When capsular support is lost mid-surgery, Dr. Trattler believes the priority should shift immediately from lens implantation to preserving the health of the eye. An anterior chamber IOL or a scleral-fixated IOL may seem like the next logical step, but he cautions that these should only be attempted by surgeons who are genuinely experienced with them. “Rather than placing an ACIOL [anterior chamber IOL] or attempting an intraoperative conversion to a scleral-fixated lens, I focus on carefully clearing the anterior segment, ensuring that no vitreous remains in the anterior chamber and that all surgical wounds are watertight. The goal is to leave the anterior segment as healthy as possible,” he advised. “In these situations, triamcinolone can be injected into the anterior chamber, if available, to help identify any vitreous strands, which can then be removed with vitrectomy.” Rather than attempting a complex fixation procedure under difficult circumstances, Dr. Trattler prefers to leave the eye temporarily aphakic and refer the patient to a surgeon experienced in scleral-fixated lens surgeries. In his Miami practice, these procedures are typically handled by vitreoretinal specialists once postoperative inflammation has subsided, intraocular pressure is well-controlled, and the eye has stabilized. “Once the eye is healed, the corneal swelling has subsided, and the intraocular pressure is well controlled, a scleral fixated lens can be implanted using one of several techniques,” he said. “Alternatively, if the patient is not a suitable candidate for a scleral-fixated lens, an anterior chamber intraocular lens can be considered.” Managing expectations matters just as much as managing the eye. “These cases can be particularly challenging because patients undergoing cataract surgery have high expectations,” Dr. Trattler said. “They expect to see beautifully right after surgery.” Early referral matters too. Patients can be sent for retinal assessment within the first week to rule out complications such as retinal tears or other sequelae of unplanned anterior vitrectomy, and should be monitored closely for endophthalmitis, given the elevated risk associated with capsular tears and anterior vitrectomy. LESS ENERGY, MORE PATIENCE Not every difficult case starts with a complication in the OR. Some are difficult from the moment the patient walks in. Dense cataracts are a prime example.

His approach starts with a bigger capsulotomy, created via femtosecond laser or manually depending on the case, which makes it easier to manipulate bulky nuclear fragments and improves overall access. MiLOOP (ZEISS; Oberkochen, Germany) is a key part of his technique. “I love using the miLOOP device because it allows me to encircle a very dense lens and efficiently divide it into two pieces, making the remainder of the surgery much easier,” he said. Unlike traditional chopping techniques, which can require considerable force, miLOOP mechanically segments the nucleus before phacoemulsification begins. “It allows you to bisect the lens using minimal force and without applying phaco energy during the segmentation step.” That reduction in ultrasound energy pays off for both the capsule and the endothelium. Still, dense cataracts typically demand more energy than routine cases, which keeps endothelial protection front of mind throughout surgery. “It’s helpful to replenish the viscoelastic inside the eye to protect the endothelium,” said Dr. Trattler. Postoperative corneal edema is common and tends to require more intensive management than in routine cases. “I will often use topical prednisolone acetate every hour for a few days to help reduce the swelling,” he said. If significant edema persists after about a week, Dr. Trattler considers adding the rho-kinase inhibitor Rhopressa (Alcon; Geneva, Switzerland) . “This medication may help support endothelial cell function and recovery. In our experience, it can accelerate the return toward normal corneal thickness and clarity.” Close follow-up rounds out the recovery. “I typically see these patients every one to two weeks while their initial corneal edema resolves and their vision recovers,” Dr. Trattler said. THE BOTTOM LINE You don’t have to muscle through every cataract complication in a single sitting. Know when to stop, adapt and call in reinforcements. When you put the long-term health of the eye first and collaborate when the case calls for it, patients get the best shot at the outcome they came in expecting.

CONTRIBUTOR

Even when capsular support is fully intact, a dense nucleus can significantly increase surgical difficulty, prolong phaco time and place real stress on the corneal endothelium, according to Dr. Trattler.

Dr. William Trattler Refractive, corneal and cataract surgeon at the Center for Excellence in Eye Care (Florida, United States). wtrattler@gmail.com

This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

SEPTEMBER 2026

CATARACT

OPTICAL ENGINEERING RETHINKING THE EYE AS AN INTEGRATED VISUAL SYSTEM Twelve RK incisions, a stubborn cataract and a corneal scar destined for the graft pile. This is one surgeon’s case for engineering the optics, and replacing the anatomy only when necessary, to achieve unaided vision. By Dr. Arun Gulani and Dr. Aaishwariya Gulani

Anterior segment surgery has entered an era of extraordinary technology that has expanded what surgeons can offer. Yet the most complex eyes are still viewed with caution, often relegated to specialty lenses, corneal transplantation or a lifetime of visual compromise. The limitation, however, is rarely technology. More often, it is how we think.

In my previous article in CAKE 29, I described least interventional staging for extreme cases—the Inside-Out and Outside-In approach—emphasizing that successful rehabilitation depends on approaching the eye in the sequence dictated by vision, not anatomy alone.

Having cared for a worldwide referral base of anterior segment pathology and surgical complications for more than three decades, my philosophy has remained unchanged: the severity of an eye should never determine its visual destiny. Rather than grading complexity or chasing improvement in diagnostic images, every eye should be evaluated for its remaining visual potential and rehabilitated through the least interventional pathway capable of restoring functional unaided vision.

technique. The greatest misconception in anterior segment surgery is that technology alone produces better outcomes; mastery comes first.1-5

That sequencing depends on a prior discipline: mastery of each individual

MASTERY BEFORE STAGING Every cataract, corneal, refractive, lamellar and reconstructive technique must be mastered individually before it can be intelligently combined. Like movements within a musical minuet, each procedure has its own rhythm and purpose; like

CAKE

LEGO building blocks, each becomes an interchangeable component whose value depends on how—and in what sequence (the Gulani Planning System, or GPS)—it is assembled into the final visual strategy.6 Only then can a surgeon move confidently across the refractive spectrum, allowing the eye to dictate the order rather than the procedure.

The case below applies that philosophy through optical engineering, treating every intervention as part of one integrated strategy for an eye approached as a single optical system rather than a collection of diagnoses. CASE PRESENTATION A 76-year-old man presented with progressive visual deterioration following a prior 12-incision radial keratotomy (RK), central corneal scar and cataract.

His surgical history also included topography-guided photorefractive keratectomy and phototherapeutic keratectomy, neither of which improved his vision. He had subsequently been advised to pursue lamellar keratectomy before eventual corneal transplantation.

positioning the flatter meridian along the axis of the visually significant stromal scar (Figure 2). This deliberately engineered optical platform, rather than residual refractive error, established the internal refractive foundation for the rehabilitation to follow (Inside-Out philosophy).

Complexity does not always correlate with incision count. Even though I have corrected patients with more than 40 RK incisions, a simple 12-incision RK can sometimes prove more challenging. Examination revealed a visually significant cataract, corneal scarring, marked corneal f lattening, irregular astigmatism and compromised optical quality (Figure 1). Uncorrected visual acuity measured 20/150, with best-corrected vision of 20/100, and manifest refraction— obtained with difficulty but persistence— was +5.50 −2.00 × 051.

Figure 1. Pre-operation presentation. Courtesy of Dr. Arun Gulani SURGICAL STRATEGY Guided by the philosophy of treating the eye as a unified optical system instead of a collection of diagnoses, I approached this patient’s care as an exercise in optical engineering toward his full visual potential, rather than cataract extraction, corneal rehabilitation, scar removal, or topography and wavefront regularization pursued in isolation. I nstead of ta rgeting i mmed iate emmetropia during cataract surgery, I intentionally aligned a toric intraocular lens at 158 degrees to create a controlled postoperative hyperopic astigmatic state,

Figure 2. IOL configuration. Courtesy of Dr. Arun Gulani With the lenticular optics engineered, the cornea became the final rehabilitation platform. I planned LaZrPlastique®, a customized surface excimer laser treatment, irrespective of the topographic pattern, based on an algorithm integrating vector-oriented refractive data, scar characteristics, residual ametropia, tissue preservation, optical behavior and visual potential.7-9 The procedure was completed with 340 excimer laser pulses and just 31 microns of tissue removal. (Figure 3)

Figure 3. Final clinical image with toric IOL. Courtesy of Dr. Arun Gulani Beyond removing scar tissue and correcting astigmatism, this single customized treatment addressed the optical influence of the scar, corrected the engineered

SEPTEMBER 2026

hyperopic astigmatism, restored a more physiologic corneal contour, preserved tissue and completed rehabilitation of the entire optical system—all while the cornea retained its original RK incisions.10-11 While corneal topography remained a valuable diagnostic tool throughout, the goal was always restoring functional optics rather than improving the topographic image itself. Improved corneal contour, reduced scar density and more normalappearing topography followed (Figure 4) as welcome consequences of restoring refractive harmony, rather than as therapeutic targets in their own right. CLINICAL OUTCOME Postoperatively, the patient’s corneal contour was markedly smoother, with only 0.40 D of residual astigmatism, and the stromal scar was indirectly debulked despite twelve previous RK incisions and multiple prior procedures. Most importantly, he regained excellent functional unaided vision, comfortable night driving and complete independence from glasses and specialty lenses. An eye once headed toward corneal transplantation instead achieved rehabi l itation throug h ca ref u l ly engineered, least interventional surgery. THE TAKEAWAY Beyond the management of an extreme post-RK eye, this case points to a broader philosophy of anterior segment mastery: complex eyes should be deconstructed into manageable optical variables, not intimidate surgeons.12 I often tell visiting surgeons that even the biggest, most intimidating giants can be reduced to “snicker-eating, boxer-shorts-wearing dwarfs” once broken into components that are understandable, strategically manipulable and, ultimately, reconstructable. This is the philosophy behind my KLEAR™ (Kerato-Lenticular Extended Armamentarium of Refractive Surgery): mastery of the complete corneal, lenticular and refractive surgical spectrum that lets

CATARACT

Figure 4. (Left) Preoperative topography. (Right) Postoperative topography. Courtesy of Dr. Arun Gulani the surgeon move freely among techniques, according to the eye’s requirements rather than subspecialty boundaries.13 Every procedure becomes a building block, and every stage prepares the next. Staging, in this framework, is the deliberate orchestration of refractive manipulation until anatomy, optics and vision function

as one harmonious system. Applied with judgment and surgical skill, this approach can restore eyes once destined for progressively invasive surgery to their highest functional visual potential. The future of anterior segment surgery will belong to surgeons who master the intelligence to integrate the full spectrum

of techniques, rather than those who default to template-based approaches and lean on technology to compensate. The eye is a visual system, and our responsibility is to engineer it until anatomy, optics and vision converge on one destination: functional, unaided vision.

REFERENCES 1. Gulani AC, Gulani AA, Gulani YA. LaZrPlastique®: Pioneering a new era in laser vision surgery for universal application and democratization of refractive surgery. Indian J Cat Ref Surg. 2025;1(3):228-237. 2. Gulani AC. LaZrPlastique®: Refractive surgery beyond the procedure. The Ophthalmologist. June 12, 2026 3. Gulani AC. LaZrPlastique®: The non-cutting edge over LASIK. Ophthalmology Times. March 22, 2023. 4. Gulani A. Principles of surgical treatment of irregular astigmatism in unstable corneas. In: Textbook of Irregular Astigmatism Diagnosis and Treatment. SLACK Incorporated; 2007:251-261. 5. Gulani AC. Corneoplastique™: Art of vision surgery. Indian J Ophthalmol. 2014;62(1):3-11. 6. Gulani AC. Corneoplastique™. Tech in Ophthalmol. 2007;5(1):11-20. 7. Gulani, AC, Pandya R, Gulani A, Gulani Y. Innovative Keratoconus Surgical Algorithm: A refractive approach to restoring vision. Indian J Cat Ref Surg. 2024;1(2):101-101 8. Gulani, A, Gulani AC. Staged Cataract Post Scar Removal: A case report. Cureus. 2020;12(7):e9145. 9. Gulani, AC. Shaping the Future and Reshaping the Past: The art of vision surgery. In: Copeland and Afshari’s Principles and Practice of Cornea. Jaypee Brothers Medical Publishers; 2013:1252-1273. 10. Gulani, AC. Introducing the Gulani Planning System. Eyeworld. 2017. 11. Gulani, AC. KLEAR™ – A new concept in refractive surgery. Ocular Surgery News. April 2018. 12. Gulani, AC. sTOP the Train Wrecks. Review of Ophthalmology. Ed: Arturo Chayet, MD. 2022;30-31. 13. Gulani, AC. Raising cataract surgery procedure to an art and an experience. Ophthalmology Times. 2024;49(10):11-13.

CONTRIBUTORS Dr. Arun Gulani Dr. Aaishwariya Gulani

Founding director of the Gulani Vision Institute and global CEO of Gulani Surgical Suites.

Third-year resident at the Hamilton Eye Institute, University of Tennessee.

gulanivision@gulani.com

aaishag14@gmail.com

CAKE

CATARACT

RESTORING DYNAMIC FOCUS WITH INJECTABLE LENSES The search for true accommodation has inspired decades of brilliant engineering, yet the eye continues to have the final say. Injectable accommodating lenses could be the next big leap…or the next lesson in biological humility. By Marhiel Garrote

Cataract surgery has become remarkably good at restoring vision. One function, though, has stubbornly resisted replacement: true accommodation. Today’s presbyopia-correcting intraocular lenses (IOLs) deliver excellent visual acuity and real spectacle independence. But they achieve it by extending or distributing focus, not by restoring physiologic accommodation. That distinction has kept generations of surgeons, scientists and engineers chasing the same elusive goal. For decades, the dream has been an IOL that does more than replace the crystalline lens—one that actually recreates what it does. Injectable accommodating lenses are the latest attempt, joining a long line of concepts designed to restore dynamic focusing after cataract surgery.

THE EYE’S LAST UNSOLVED TRICK At the 30th European Society of Cataract and Refractive Surgeons Winter Meeting (WESCRS 2026), Prof. Mayank Nanavaty (United Kingdom) put the problem plainly: “Traditional IOLs actually only give pseudo accommodation.”1 It’s a simple statement, but it explains why accommodating IOLs continue to draw so much attention. Multifocal, trifocal and extended-depth-of-focus lenses have transformed postoperative vision, yet they do so by manipulating optics rather than restoring physiologic accommodation. The ciliary muscle still works after cataract surgery, but converting its residual force into consistent, repeatable accommodation has shown to be far harder than expected. 2

CAKE

For Prof. Nanavaty, that leaves a real gap in cataract surgery. “There is an unmet need to correct accommodation in pseudophakic eyes,” he said.1 That’s why the search has never really stopped. Rather than simply extending range of vision, researchers are still chasing something more ambitious: restoring the eye’s ability to change focus. Every new accommodating platform is another attempt to solve another problem, just from a different angle. MANY ROADS, ONE DESTINATION If accommodating IOL research has taught us anything, it’s that innovation has never been in short supply. Researchers have explored many routes toward that missing piece—lenses that translate, dual-optic designs, deformable materials, fluid-filled optics and injectable biomimetic gels. 2 Different engineering strategies, one biological goal. One of the most ambitious approaches is capsular bag refilling. Instead of replacing the crystalline lens with a solid implant, this technique fills the capsular bag with a flexible injectable material designed to preserve the eye’s native accommodative architecture. In theory, maintaining that anatomy could allow the remaining accommodative apparatus to function more naturally.3 Other accommodating platforms have also produced encouraging results. Dual-optic systems such as Synchrony (Johnson & Johnson Vision; Florida, United States) and deformable lenses like the Lumina (AkkoLens International; Breda, Netherlands) have shown improvements in functional near vision and accommodative response in selected patients.4,5 Still, no single platform has emerged as the definitive answer. Differences in lens design, study methodology and even how accommodation is measured make comparisons difficult. WHERE BIOLOGY PUSHES BACK The challenge once seemed purely mechanical. Build a lens that moves, changes shape or responds to ciliary muscle forces, and accommodation would follow. Biology had other ideas. Lens epithelial cell proliferation, capsular fibrosis, capsule contraction and posterior capsule opacification remain formidable barriers to long-term accommodative performance. These postoperative changes not only reduce visual quality, they also alter the very biomechanics accommodating lenses depend on. That distinction matters because, unlike conventional IOLs, accommodating platforms rely on freedom of movement. Even modest fibrosis or capsular contraction can restrict optic displacement, reduce accommodative amplitude or eliminate movement altogether.6

And once movement is compromised, success depends not only on the implant itself, but on how the capsular bag heals around it. That reality has already surfaced across multiple accommodating technologies. Capsular bag opacification and fibrosis have been reported even in systems specifically designed to preserve accommodative movement.6 STRENGTH AS WEAKNESS Injectable and capsular bag-refilling concepts illustrate this challenge particularly well. Their greatest strength—preserving the native capsular bag—is also their biggest liability, since that same tissue naturally remodels after surgery. Maintaining longterm capsular flexibility and mechanical responsiveness may be just as important as the lens design itself. The evidence to prove it out, however, is still catching up. Longterm clinical data remains limited, and researchers are still learning how different designs interact with postoperative wound healing over time. “We are yet to see large sample studies on any of these,” Prof. Nanavaty noted.1 BEYOND BETTER ENGINEERING Injectable accommodating lenses remain one of cataract surgery’s most ambitious ideas, because they aim to restore something the natural lens once did effortlessly. Whether that goal is achieved may depend less on building a lens that can move, and more on preserving that movement long after surgery.

Editor’s Note Prof. Mayank Nanavaty’s insights in this article is based on his presentation at the 30th European Society of Cataract and Refractive Surgeons Winter Meeting (WESCRS 2026) held in Helsinki, Finland, from 6-8 March 2026.

REFERENCES 1. Nanavaty M. Injectable accommodating lenses: Status and challenges. WESCRS lecture. Helsinki, Finland. March 2026. 2. Dick HB, Gerste RD. Future intraocular lens technologies. Ophthalmol. 2021;128(11):e206-13. 3. Nishi O, Nishi K, Nishi Y, Chang S. Capsular bag refilling using a new accommodating intraocular lens. J Cataract Refract Surg. 2008;34(2):302-9. 4. McLeod SD, Vargas LG, Portney V, Ting A. Synchrony dual-optic accommodating intraocular lens. Part 1: optical and biomechanical principles and design considerations. J Cataract Refract Surg. 2007;33(1):37-46. 5. Alio JL, Simonov A, Plaza-Puche AB, et al. Visual outcomes and accommodative response of Lumina accommodative intraocular lens. Am J Ophthalmol. 2016;164:37–48. 6. Floyd AM, Werner L, Liu E, et al. Capsular bag opacification with a new accommodating intraocular lens. J Cataract Refract Surg. 2013;39(9):1415-20.

SEPTEMBER 2026

ANTERIOR SEGMENT

THE METIS 900 PLATFORM CONTINUES TO EXPAND ITS DIGITAL WORKFLOW Spanning optical precision, customizable controls, and 3D heads-up visualization: Haag-Streit’s surgical microscope is already centered around workflow and usability. With further developments in the pipeline, METIS 900 proves that when it comes to digital evolution, it’s not done yet. Sponsored by Haag-Streit

Premium cataract surgery has always demanded precision, and precision demands control. Haag-Streit’s (Köniz, Switzerland) METIS 900 platform was built to deliver exactly that. First came the METIS 900 “surgical control center,” launched in March 2025, delivering a rock-solid optical foundation. In the same year, its “surgical cockpit” came in the form of the METIS 3D Digital Heads-Up Module (METIS HU), arriving at AAO 2025 in the United States before its global release in March 2026. The investment in digital continues at pace, with further developments set to close the platform’s biometry-to-OR workflow loop. BUILT TO EVOLVE When the METIS 900 launched in March 2025, it was designed explicitly as a platform—modular in architecture, built to grow through digital addition rather than hardware replacement. That philosophy earned it the GOOD DESIGN® Award 2025, and the engineering behind that recognition is visible in what the architecture enables.

Its optical foundation is a stable, best-in-class red reflex delivered by an optimized coaxial illumination system. From capsulorhexis to nuclear disassembly and capsular polishing, the system maintains brilliance and clarity throughout surgical maneuvers and varying eye positions, while limiting intraocular luminosity to reduce light exposure. High-CRI LED illumination is engineered to provide true and accurate color reproduction while lasting the lifetime of the scope, emitting less heat and energy than traditional xenon or halogen equivalents. The METIS 900 also functions as a fully configurable “surgical control center”. Motorized controls replace manual adjustments, while programmable “presets” allow the system to adapt instantly to individual surgeon preferences and specific procedures. For combined cataract and MIGS cases, a single touch of the hand switch tilts the microscope to a pre-programmed glaucoma angle and toggles back with a second, sterile touch. At the same time, a wireless foot switch provides control of up to 14 functions.

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Dr. Yuri McKee (United States), medical director and managing partner at East Valley Ophthalmology, was the first surgeon worldwide to use the METIS 900 in human surgery. “We really need to start thinking about the microscope as a platform just like we think about so many other things that we use, like our phones, even our cars,” he said. “These platforms can be expanded on in the future because they’re digital with enormous technology,” Dr. McKee continued. “We’ve started with the rock-solid quality of a Haag-Streit microscope, and now we can expand this platform without buying a new microscope every five years.” Surgeon longevity is also a consideration built into the design. “Every surgeon should be able to set this microscope exactly to what’s correct for them in surgery so that their spine is straight, their neck is straight, and they’re looking straight ahead during surgery,” he said. “You can’t have your career ruin the rest of your life.” Dr. Kenichiro Yamazaki (Japan), founder and chief surgeon of Omiya Nanasato Eye Institute, and the first surgeon in Japan to perform femtosecond laser-assisted cataract surgery, typically operates with a depth-of-field setting of three and a red reflex intensity of 67%. Even at 20% illumination, he finds the METIS 900 delivers clear visibility alongside video quality suited to clinical documentation and presentation. “Its stable, brilliant red reflex provides the optical clarity and brightness required for my procedures,” he said. At those reduced illumination levels, some patients can leave the OR with less assistance, potentially due to lower light exposure during surgery. A SHARED SURGICAL VIEW METIS HU adds a 55-inch 3D 4K monitor and compact floor stand to the METIS 900 ecosystem, shifting the surgical view from the eyepieces to a shared screen. Surgeons can switch to the heads-up view and return to the oculars at any point, without altering their workflow. At the core of the system is a 3D stereo 4K camera designed to continuously adapt to changing light conditions. Transitioning to the screen transforms the operating environment: an upright sitting position reduces cervical and lumbar strain during long surgical lists, and assistants, trainees, and OR personnel observe the surgical field on the same 3D monitor as the operating surgeon, eliminating the need for a separate optical path. Digital quick zoom reveals fine detail with a single tap of the foot switch, while digital red-free filtering enhances retinal visualization without additional hardware. METIS HU also supports surgery at lower microscope light levels by amplifying the image digitally—an advantage particularly relevant for longer or combined procedures.

“Screen-based surgery with METIS HU is simply a delight, whether in the anterior segment, posterior segment, or with combined surgery,” said Dr. Christopher Riemann (United States) of Cincinnati Eye Institute. “The resolution is superb, and the unique feature of being able to actively adjust the camera settings intraoperatively provides a level of control that surgeons will love. We can’t fix what we can’t see, and with METIS HU, we can see beautifully.” Dr. Edward Meier (United States) of Apex Eye Clinical Research echoed the assessment. “The METIS HU has wonderful image clarity that is as good as a regular light path microscope. There is no significant image lag,” he said, noting that digital illumination allows surgeons to brighten the image while operating at lower microscope light levels—maintaining the surgical view and red reflex while reducing patient light exposure. “As a purpose-built, heads-up scope, the ergonomics are fantastic,” Dr. Meier added. “At the end of a long day, my neck and back are much less tired than when using a traditional microscope.” WHAT’S NEXT FOR METIS 900? The path to a fully integrated digital workflow continues with software developments currently undergoing final touches in Haag-Streit’s R&D kitchen. The next chapter centers on closing the platform’s biometry-to-OR workflow loop via intraoperative toric alignment guidance within a single digital ecosystem, all operated through a unified interface. IOL GUIDE: FROM THE BIOMETER TO THE OR For cataract surgeons placing premium toric IOLs, this development aims to provide a direct digital alternative to the paper-based data chain that has traditionally connected preoperative planning to intraoperative alignment. The workflow originates in Haag-Streit’s EyeSuite IOL planning software, where incision locations, capsulorhexis diameter, and the target axis of the toric IOL are defined. Within the Haag-Streit planning workflow, the data transfers to the METIS 900 via USB or network—no duplication of data or effort required. Once released, Haag-Streit’s IOL Guide will mark the latest chapter in a platform built across two years of sequential launches. What began in March 2025 as an optical surgical foundation will continue, allowing a surgeon to join at any point and extend as practice demands. SEE THE METIS 900 AND METIS HU IN ACTION Delegates attending ESCRS and AAO 2026 will have the opportunity to experience the METIS 900 and METIS HU firsthand and gain a deeper understanding of the technologies shaping the future of the OR. To learn more about the METIS 900 platform, visit haag-streit.com/METIS-platform.

SEPTEMBER 2026

ANTERIOR SEGMENT

UNMASKING DEMODEX RETHINKING BLEPHARITIS IN EVERYDAY PRACTICE Collarettes at the lash base are pathognomonic, fast to identify and easy to overlook. Professor Marc Labetoulle makes the case for routine lid margin assessment as a standard part of every anterior segment workup. Sponsored by Tarsus Pharmaceuticals

The sign is small, waxy and easy to miss. It sits at the base of the eyelashes, waiting for a clinician to ask the patient to look down. In ophthalmology clinics across Europe, that tiny clue may explain years of chronic ocular surface symptoms, persistent blepharitis, meibomian gland dysfunction (MGD) and may complicate ocular surgery.1-3 Professor Marc Labetoulle (France), head and chair of Ophthalmology at Bicêtre Hospital, Paris-Saclay University, and also working at Quinze-Vingts National Vision Hospital, attributes the diagnostic gap around Demodex blepharitis to clinical habit. Both the tools and the diagnostic sign are already

present in any standard examination room. What is missing, he argues, is simply the routine of looking. “There are patients where we don’t quite understand why they are complaining about their eyes,” he says. “That is typically when we need to be careful, actively looking for Demodex and signs of blepharitis with collarettes.” WHEN NORMAL CAN BECOME TOO MUCH Demodex mites are commonly found on human eyelids and may coexist harmlessly at low densities. Two species are involved. Demodex folliculorum, the longer of the two, is more closely associated with the lash follicles and anterior blepharitis. Demodex brevis is shorter, lives within the meibomian glands and is more closely associated with posterior blepharitis and MGD. Both complete their lifecycle over approximately two to three weeks.1 Overgrowth is the problem. “Demodex is something absolutely normal in the eyelashes,” Professor Labetoulle explains. “It is normal to have some Demodex. What is not normal is to have an infestation of Demodex mites.1 Advancing age, immunosuppression and certain chronic ocular surface disease may all promote Demodex mite overgrowth.1 The result is a shift from harmless colonization to clinically meaningful inflammation, particularly when collarettes, symptoms or ocular surface signs begin to accumulate at the lid margin. THE MITE THAT KEEPS ON GIVING Overgrowth drives inflammation through overlapping pathways. The physical presence and scraping action of mites can damage the follicular epithelium. Bacteria carried on mite surfaces

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and the digestive enzymes they emit may amplify the local inflammatory response. Demodex overgrowth can also reflect and accelerate inflammation, creating conditions that favor further mite proliferation.1 DB does not resolve spontaneously.3 The consequence is a cycle that may persist unless the underlying infestation and inflammation are addressed.2-4 Untreated Demodex infestation can persist and perpetuate inflammation over time.4,5 Inflammation may alter the lid microenvironment, which can create an ideal breeding ground for further mite proliferation. 2

Caught in this vicious cycle, diagnostic paralysis is a clinical luxury few patients can afford. “One of the challenging questions when you see Demodex collarettes is whether the mite is the chicken or the egg. We know it can be both. But indeed, we don’t care which came first—we just have to treat it and see whether the patient improves.” Downstream, the impact extends beyond lid margin irritation. In a retrospective, single-center, observational study of 438 patients, meibum quality and meibomian gland atrophy were both significantly worse in patients with moderate-to-severe DB compared to those with a collarette grade 0, and 96–99% of patients with moderate to severe DB had MGD.² This is consistent with separate reports that patients with DB can have lower-quality meibum, which may exacerbate MGD and contribute to tear film instability.¹ IMPACT OF MISSED OR MISDIAGNOSIS OF DB The Eos study of 754 European eye care patients found collarettes in 54% of consecutive patients seen by an ophthalmologist for any reason, with 32% (257/804) being more severe, having more than ten collarettes per eyelid.3 Demodex blepharitis was reported in 62% of patients aged 70 or older.3

Many arrive already labeled as having dry eye disease. In a crosssectional survey of 113 US patients with confirmed Demodex blepharitis, patients had visited a healthcare provider an average of 3.5 times before receiving a diagnosis.5 In a separate prospective observational study of 311 patients with DB across eight US eye care practices, O’Dell et al. found that more than half had experienced symptoms for four years or more, with 80% reporting negative psychosocial impacts overall, which included concern about their appearance to others, constant worry about their eyes and effects on their mental state, and 47% reporting difficulty driving at night.4

For patients, the result can be years of partial answers and persistent symptoms, a frustrating loop that a 3-second lash margin check might have broken much sooner. THE SURGICAL BLIND SPOT For the anterior segment surgeon, unrecognized Demodex blepharitis may pose risk at two distinct stages. In the first, Professor Labetoulle notes that subclinical lid margin inflammation may be unmasked by surgical stress. The second risk arrives before the first incision. “Because of Demodex blepharitis and modification of the ocular surface, you may have modified the accuracy of intraocular lens calculation for cataract surgery”1,2 , Professor Labetoulle warns. Patients with Demodex blepharitis and MGD commonly report fluctuating vision, a symptom that may reflect the tear film instability caused by impaired meibum secretion.1,2 Chronic lid margin inflammation tells that story through the ocular surface. An unstable tear film may affect keratometry and topography readings used for surgical planning.

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the learning curve is measured in seconds. “When you do not understand why a patient is complaining about the ocular surface, just look at the eyelashes. It takes three seconds, and it can give you a lot of answers.” What sits at the lash line, for a large proportion of patients, may be the explanation behind years of chronic symptoms. In a specialty defined by precision optics and sub-millimeter outcomes, the most consequential diagnostic step may be the one that takes the least time. GL--2600037 08/26

Demodex blepharitis: closing the awareness gap Despite its prevalence, Demodex blepharitis remains underdiagnosed in routine ophthalmic

Before operating, look at the lashes. Patients presenting for anterior segment surgery may have subclinical Demodex blepharitis. Collarettes at the lash base, visible at a standard slit lamp, confirm the diagnosis.

practice. An established educational gap means DB is often absent from the differential in patients presenting with chronic eyelid disease, dry eye or meibomian gland dysfunction. Greater diagnostic awareness and the simple habit of assessing the lash margin can improve clinical decision-making.

Editor’s Note Professor Marc Labetoulle is a paid consultant for Tarsus Pharmaceuticals, Inc. The Eos study was funded by Tarsus Pharmaceuticals, Inc.

REFERENCES 1. Rhee MK, Yeu E, Barnett M, et al. Demodex blepharitis:

THE SLIT LAMP CHECK Incorporating lash margin assessment into an exam adds 3 seconds and requires no additional equipment. The patient looks down, and the upper lash line is examined at the slit lamp, ideally at ×16 magnification. Collarettes, the waxy, cylindrical debris packed around the base of the lash, are pathognomonic for Demodex blepharitis and can confirm the diagnosis without lash epilation or mite counting.6 A brief check of the meibomian gland orifices and tarsal conjunctiva completes the screen.

A comprehensive review of the disease, current management and emerging therapies. Eye Contact Lens. 2023;49:311-318. 2. Yeu E, Koetting C. Meibomian gland structure and function in patients with Demodex blepharitis. J Cataract Refract Surg. 2025;51(5):359-365. 3. Nanavaty MA, Findl O, Carones F, et al. Proportion of patients with Demodex blepharitis in ophthalmology clinics in Europe: The Eos study. Eye (Lond). 2026;40:165-167. 4. O’Dell L, Dierker DS, Devries DK, et al. Psychosocial impact of Demodex blepharitis. Clin Ophthalmol. 2022;16:

“An obvious sign related to the presence of Demodex is itching, or pruritus, of the eyelid border—very different from allergic itch, which is mostly near the caruncle,” says Professor Labetoulle. “With Demodex, patients tell you: ‘It is the base of my eyelashes that is itching.’ When the patient has collarettes in exactly the same location as the itching, it seems reasonable to think there is a clear relationship.”

2979-2987. 5. Gupta PK, Thompson V, O’Dell L, et al. Patient-reported burden of illness and unmet needs in Demodex blepharitis. Patient Prefer Adherence. 2025;19:647-658. 6. Ayres BD, Donnenfeld E, Farid M, et al. Clinical diagnosis and management of Demodex blepharitis: The Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Eye (Lond). 2023;37(15):3249-3255.

For colleagues who have not yet incorporated lash margin assessment into routine practice, Professor Labetoulle believes

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Multiple centers took one look and reached for the scalpel. One surgeon looked closer—and found the cornea had been hiding an accomplice. A LESSON IN COMPLEX ANTERIOR SEGMENT DECISION-MAKING

Ask any surgeon what draws them to the operating room, and you’ll likely hear some version of the same answer: the chance to fix what’s broken. It’s a satisfying instinct, and often the right one. But every so often, a case comes along that tests that instinct rather than rewards it—one where the more skillful move is to pause, look closer and reconsider what “fixing” actually requires.

By Dr. Shilpa Ghosh

the pannus was carefully dissected away (Figure 2), the eye’s visual potential became far more promising than initially anticipated.

Complex anterior segment cases put both surgical skill and clinical judgement on trial. Surgical techniques keep getting more sophisticated, yet the most impactful intervention is sometimes the one you don’t perform. A SECOND OPINION WORTH HAVING A patient presented to our clinic with a dense corneal opacity (Figure 1), having already been evaluated at multiple centers and told, each time, that penetrating keratoplasty was his only route to visual rehabilitation. The corneal scar had, understandably, dominated the clinical picture. What hadn’t been adequately addressed was the status of his limbal stem cells.

Figure 2. Postoperative picture showing the underlying cornea after superficial keratectomy. Courtesy of Dr. Shilpa Ghosh. We performed an amniotic membrane transplantation (AMT) to facilitate ocular surface healing, with a planned simple limbal epithelial transplantation (SLET) as the next stage to restore a stable ocular surface before considering any further optical intervention. THE TAKEAWAY Not every opaque cornea calls for a transplant. The ocular surface should always be assessed as a functional unit, with limbal stem cell status a routine part of preoperative workup. A well-planned staged reconstruction can spare patients an unnecessary transplant while improving both anatomical and visual outcomes.

Figure 1. Preoperative picture showing corneal opacity. Courtesy of Dr. Shilpa Ghosh. On meticulous examination, the findings pointed to underlying limbal stem cell deficiency, which meant a primary corneal transplant was unlikely to succeed. After a detailed discussion of the pathology, prognosis—and the case for a staged approach— we chose not to proceed directly with keratoplasty.

In complex anterior segment surgery, success depends on understanding the underlying pathology and sequencing interventions correctly, not simply on replacing diseased tissue. Sometimes the most important surgical decision is the one you decide not to make. CONTRIBUTOR

A PANNUS IN DISGUISE The first step was a superficial keratectomy, and it delivered a welcome surprise. What had appeared, clinically, to be a dense corneal opacity turned out to be a thick fibrovascular pannus obscuring an otherwise clear underlying corneal stroma. Once

Dr. Shilpa Ghosh Cornea and anterior segment consultant at Apeksha Multispecialty Hospital in Assam, India. ophtha.shilpaghosh.2020@gmail.com

SEPTEMBER 2026

ANTERIOR SEGMENT

BEYOND TRABECULECTOMY A CHALLENGING PACG CASE Advanced glaucoma, one stubborn optic nerve and a patient who wouldn’t touch a bleb with a ten-foot cannula. Dr. Jason Cheng had to get creative, and the angle-based workaround he landed on says a lot about where glaucoma surgery is heading for patients who’d rather keep trabeculectomy as a last resort. By Hazlin Hassan

Not every patient with advanced primary angle-closure glaucoma (PACG) is willing to accept a bleb. When a 41-year-old woman refused trabeculectomy despite severe unilateral disease, Dr. Jason Cheng (Australia) had to find another way to bring her pressure down without closing the door on future surgery. Rather than focusing solely on disease severity, the treatment strategy also had to account for the patient’s age, visual needs and personal preferences, making surgical planning as important as the procedure itself.

A YOUNG PATIENT, AN OLD PROBLEM A year before seeking help from Dr. Cheng in September 2024, the patient presented with intraocular pressure (IOP) of 40 mmHg in her right eye and underwent bilateral laser peripheral iridotomy. Despite treatment with Ganfort (bimatoprost and timolol; AbbVie; Illinois, United States) and Simbrinza (brinzolamide and brimonidine tartrate; Alcon; Geneva, Switzerland), her right-eye IOP remained elevated at 22 mmHg, while the left eye measured 15 mmHg. Best-corrected visual acuity was 6/6 in both eyes, and she had mild myopia (-1.50 D).

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Examination revealed extensive peripheral anterior synechiae (PAS) in both eyes, with the right eye showing advanced glaucomatous optic disc cupping (cup-todisc ratio 0.9). “Structural and functional testing confirmed severe unilateral disease,” said Dr. Cheng.

THREE PROBLEMS, ONE PROCEDURE The surgical strategy tackled several mechanisms in one sitting. Lens extraction deepened the anterior chamber, goniosynechialysis stripped the PAS and reopened the angle, and the iStent inject W restored physiological aqueous outflow.

Visual field testing showed an advanced superior hemifield defect, with a Visual Field Index of 60% and a mean deviation of -18.01 dB (Figure 1).

The degree of optic nerve damage made better IOP control urgent. Meanwhile, the patient’s relatively young age added a complication of its own, since any surgical decision made now wou ld carr y decades of consequences.

“This prompted her to see me for a second opinion,” said Dr. Cheng. After counseling on the risks and benefits, the possibility of surgical failure, and the chance that filtration surgery might still be needed down the line, Dr. Cheng suggested phacoemulsification combined with goniosynechialysis and implantation of an iStent inject W device (Glaukos; California, United States) in the right eye. Rather than a single fix, this approach was designed to target the anatomical drivers of angle closure while boosting the eye’s own outflow pathway.

Sustained IOP control, stable visual function and a favorable refractive outcome at follow-up all point to the value of a carefully planned surgical strategy over a one-size-fits-all approach. SURGICAL PEARLS This case shows that advanced unilateral PACG with severe optic disc damage can be managed successfully in carefully selected patients who want to avoid trabeculectomy. Combining meticulous goniosynechialysis with restoration of the conventional outflow pathway achieved effective IOP control while keeping future surgical options open.

OCT imaging revealed marked retinal nerve fiber layer and ganglion cell complex loss in the right eye, with an average RNFL thickness of just 56 µm and severe superior and inferior neuroretinal rim loss (Figure 1).

THE TRABECULECTOMY OBJECTION Her first surgeon had recommended combined p h a c o e m u l s i f i c a t i o n t r a b e c u l e c t o my with mitomycin-C. As a young, phakic patient, however, she was wary of losing accommodation and reluctant to risk the bleb-related compl ic at ion s t hat come w it h trabeculectomy.

“At the latest review in April 2026, visual acuity was 6/7.5 in the right eye, IOP was 13 mmHg without topical medication, and visual fields remained stable,” he noted.

Dr. Cheng noted that if filtration surgery does become necessary later, performing trabeculectomy or another bleb-based procedure in a pseudophakic eye may offer more predictable outcomes than a combined phaco-trabeculectomy.

Figures 2a-c. Courtesy of Dr. Jason Cheng “Intraoperative gonioscopy demonstrated successful engagement and mechanical release of the PAS using the iStent inject W insertion sleeve tip, restoring visualization of the trabecular meshwork and permitting implantation of the stent system,” Dr. Cheng reported (Figures 2a-c). Residual reflux bleeding from Schlemm’s canal confirmed access to the conventional outflow pathway, he added (Figure 2c). THE PAYOFF The result held up both anatomically and functionally. Postoperatively, the patient achieved emmetropia in the operated eye while remaining mildly myopic in the fellow eye, producing a functional monovision outcome.

For surgeons managing advanced PACG, the takeaway is simple even if the anatomy isn’t. Disease severity, ocular anatomy, patient age and personal priorities all belong in the decision-making. Meticulous technique paired with careful patient selection, as this case shows, can deliver meaningful pressure reduction without slamming the door on tomorrow’s options. CONTRIBUTOR Dr. Jason Cheng Glaucoma consultant at Sydney Eye Hospital and Liverpool Hospital, and senior lecturer at the University of New South Wales and the University of Sydney. chengophthalmology@gmail.com

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ANTERIOR SEGMENT

SLIT LAMP MASTERY, No patients, no pressure, no problem. How virtual reality is teaching residents to master the slit lamp before they ever meet a real eye. Sponsored by Haag-Streit

Learning to use a slit lamp effectively has always been tricky. The instrument sits at the very heart of ophthalmic diagnosis, but mastering its controls while learning to interpret subtle clinical signs takes time, patience, and plenty of hands-on experience. For many residents, the gap between textbook learning and working with real patients can feel like a chasm. Fortunately, that gap is shrinking. The Eyesi Slit Lamp from Haag-Streit (Köniz, Switzerland), a high-fidelity virtual reality simulator, is meaningfully flattening the learning curve, delivering realistic, structured training that helps beginners and advanced learners alike reach clinical competence faster. PRACTICALLY THE REAL THING Trainees looking through the Eyesi Slit Lamp’s microscope see exactly what they’d expect with a live patient in front of them. The simulator offers the same controls and degrees of freedom as the trusted Haag-Streit BQ 900, with slit width and length, beam inclination, rotation, and filters all behaving true to form. The result: Simulation makes the leap to the real exam room feel natural rather than jarring. A CURRICULUM THAT GROWS WITH THE LEARNING Unlike static textbooks, which can only offer a handful of snapshots, the Eyesi Slit Lamp provides a rich library of anterior and posterior segment cases. Beginners work through structured courses covering proper handling and illumination technique, with the system offering real-time guidance toward the ideal view.

Gamification elements, immediate visual and auditory feedback, and detailed performance reports help learners progress efficiently. After each virtual exam, the simulator highlights correct findings and flags anything missed, enabling deliberate practice without a tutor needing to hover. TRAIN YOUR WAY Structured exam steps ensure nothing gets overlooked early on. But once the fundamentals click, users can train in whatever order suits them, skipping optional beginner steps or drilling down on advanced techniques. The result is more efficient training that respects each resident’s pace and skill level. A COMPLETE SOLUTION FOR BUSY PROGRAMS For educators, the Eyesi Slit Lamp offers much more than just simulation. Objective performance metrics are available at a glance through a web-based portal, making it easy to monitor entire classes or track individual progress. Supplementary online courses—complete with videos, images and quizzes— extend the learning experience beyond the device and give educators added flexibility in the classroom. Optional modules for fundoscopy, gonioscopy and the newly released SLT Module further expand its capabilities, while support for both self-directed and collaborative training makes the Eyesi Slit Lamp a genuine asset for modern training environments. Yes, the Eyesi Slit Lamp is a simulator. But it’s also an entire training regimen, minus the late nights spent hunting for willing patients.

Advanced modules introduce a broad spectrum of pathologies and standard grading systems. Trainees can even adjust the “age” of a virtual cataract with a few clicks to explore disease progression, a level of nuance no textbook can match.

Visit haag-streit.com/eyesi-slit-lamp to learn more.

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Virtual reality could change medicine forever…unless politics, sabotage and murder get there first. Deadly Vision imagines what happens when innovation becomes too dangerous to succeed. In Dr. Todd Severin’s own words…

the kuei-shen‒the phantoms of the deceased trapped between the world of the living and the dead. Too frightened to move, he’d lay immobilized, watching as the shape-shifting kuei transformed, taking the forms of lions and dragons. He’d see the kuei-shen as they descended upon him, feel them as they entered his flesh, melting into his soul. The chill of their deathly presence within. He’d carried those visions throughout his adult life. Still, no number of childhood nightmares could prepare him for what he faced now. Chan’s eyes shot from the hallway to the suitcase lying upon his bed, lid propped half-open, socks and underwear dangling over the edge. He rushed to the case, stuffed in two pairs of grey slacks, then dashed back to the closet. Glancing at the rows of cotton shirts, he shoved the stripes aside and grabbed the white Oxfords. Less eye catching, he thought, more anonymous.

Thursday, October 12 4:59 p.m. Robert Chan froze in place, staring at the shadows in his hallway. From the bedroom where he stood, Chan couldn’t see the shadows’ origin, just the elliptical darkness, spreading across the walls, creeping down the hall. As the sun descended beyond the distant Golden Gate Bridge, a chill seized the air, but Chan didn’t feel it. His eyes were fixed on the hallway, studying the growing shadows, searching for signs of movement, or a flicker.

Anonymity had never been one of Chan’s concerns before. As a young and hungry engineer in the Medical Applications Division of CyberTech Systems, he’d done everything in his power to avoid it. In the cutthroat world of Silicon Valley, anonymity in the corporate workplace was the high-tech kiss of death. In order to advance to the high-paying executive levels, Chan had to stand out, be noticed. And he did. Clocking in a string of over fifty consecutive 80-hour weeks, his work habits routinely drew the notice of the upper levels of CTS management. His ascent through the ranks of engineers was unprecedented. But that was before he found the files. Now, all he hoped for was to get out alive. CONTRIBUTOR

A sign they came from something alive. Shadows had always terrified Chan. As a child, long after his parents had gone to sleep, he’d lie motionless in bed, his face half-hidden by the blankets, staring at the ceiling. Moonlight, filtering through the branches scratching outside his window, cast a dance of light and darkness above him. Lurking within this specter of shadows, he’d see the spirits of his grandmother’s tales,

Dr. Todd D. Severin President and CEO of East Bay Eye Centers (California, United States), and award-winning author. tseverin@aol.com

SEPTEMBER 2026

COVER STORY

RETHINKING PHACO, FRAGMENT BY FRAGMENT One Japanese surgeon spent two decades quietly rebuilding phacoemulsification from the studs up, splitting the nucleus into eight pieces before ultrasound ever fires a shot. As active fluidics takes over the OR, his fragment-first approach might be exactly what the new phaco devices are waiting for. By Michaela Perez

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Phacoemulsification has followed the same basic workflow for half a century. Divide and remove: the phaco tip and a second instrument working together in the anterior chamber, splitting while aspirating and aspirating while splitting.

Each of these limitations, in Dr. Sato’s view, are consequences of a workflow that could be redesigned.

Dr. Tsuyoshi Sato (Japan) looked at that workflow and saw something worth questioning.

THE IDEA BEHIND THE EIGHT The Eight-Chop Technique addresses all four limitations through a single conceptual shift: complete the nuclear division before phacoemulsification begins.

While performing Phaco Prechop, the problem crystallized. The instrument was too large. Insertion was difficult. And despite its elegant premise, most surgeons who attempted it ran into complications and gave up.

Using a dedicated instrument called the Eight-Chopper, the nucleus is divided into eight independent fragments within the capsular bag before ultrasound ever begins. Only once division is complete does phacoemulsification start.

The concept, however, was sound. The execution needed rethinking. So Dr. Sato redesigned the process from the ground up, developing a smaller, sharper instrument family, simplifying the surgical sequence and building in safety features that Phaco Prechop lacked. More than 20,000 surgeries later, the Eight-Chop Technique is his answer. THE PROBLEM WITH CONVENTIONAL TECHNIQUES Before understanding what the Eight-Chop Technique does, it helps to understand what Dr. Sato believed conventional techniques were doing wrong. He identified four specific limitations that drove his thinking. First, nuclear division and phacoemulsification proceed simultaneously in conventional techniques, creating a situation where the surgeon must manage two demanding tasks at once throughout the procedure. Second, most conventional chop techniques rely on sheardominant forces that may fail to achieve complete full-thickness fracture—particularly in hard nuclei where the posterior plate resists division, requiring additional manipulation at precisely the most dangerous moment. Third, the simultaneous use of a phaco tip and a second instrument means both are active in the anterior chamber throughout surgery, increasing the risk of inadvertent contact with the capsule, iris and corneal endothelium, and transmitting mechanical stress to the zonular apparatus. Fourth, because fragmentation is incomplete before aspiration begins, fragment size and geometry stay inconsistent, reducing followability and occlusion stability—particularly under the low intraocular pressure (IOP) conditions of modern active fluidics systems.

Ultrasound is repositioned not as energy used to divide the nucleus, but as a means of emulsifying and aspirating fragments that have already been divided - Dr. Tsuyoshi Sato

“Ultrasound is repositioned not as energy used to divide the nucleus, but as a means of emulsifying and aspirating fragments that have already been divided,” Dr. Sato explained. Division first. Aspiration second. Two stages that are clearly separated. The downstream effects are immediate. Because fragmentation is complete before aspiration begins, the surgeon can focus entirely on each stage without managing competing demands. Because fragments are pre-formed and uniform, followability and occlusion stability improve. Because the second instrument is not required during aspiration, anterior chamber manipulation is reduced. And because the nucleus is divided before ultrasound energy is applied, the energy required for removal is substantially lower.¹ THE FORCE THAT MAKES IT WORK What makes the Eight-Chop Technique mechanically distinct from every chop-based predecessor is how it generates fracture. Conventional chop techniques rely on shear force, with two instruments moving toward each other to split the nucleus between them. This works well in softer nuclei, but in hard nuclei the posterior plate often resists full-thickness division. Surgeons are then forced into repeated lateral separation maneuvers at precisely the moment when capsular and zonular stress is most dangerous, transmitting

SEPTEMBER 2026

COVER STORY

traction forces to structures that are already under maximum load.¹ Dr. Sato’s technique uses wedge-induced fracture. The Eight-Chopper tip is inserted closed into the nuclear center, then opened, generating tensile force that radiates outward through the full thickness of the nuclear structure. Not a compressive blow from outside. A force that opens from within. “This mode of force transmission becomes more effective as the nucleus gets harder,” he noted. That single sentence reverses the conventional risk calculus. Where phaco-chop grows less reliable and more dangerous in hard nuclei, the wedge mechanism becomes more effective. For Grade IV and V nuclei, where the posterior plate is thickened and sclerosed, the Lance-Chopper delivers the wedge force toward the posterior aspect, achieving full-thickness fracture that shear-based techniques often cannot.¹

The technique does not require adaptation for harder cases, because the physics already compensates. THE GEOMETRY OF EIGHT Four quadrants leave fragments too large for optimal followability. Six is geometrically difficult to achieve evenly through sequential bisection. Beyond eight, procedural complexity rises without meaningful clinical return. Eight is the practical optimum. Division proceeds through sequential bisection— hemispheres first, then quadrants, then six segments, completing at eight—a repeatable geometric sequence requiring no modification regardless of nuclear density.1,2 Each fragment becomes an independent, mobile unit within the capsular bag before phacoemulsification begins. The downstream consequences compound. Smaller fragments mean shorter aspiration times, less ultrasound energy, lower irrigation volume and reduced burden on the corneal endothelium. Fragment size also matters increasingly in the era of active

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fluidics, where anterior chamber stability under low IOP conditions depends heavily on fragment followability and occlusion behavior at the phaco tip. “Small nuclear fragments generated through eightfold division are more easily controlled from a fluid-dynamic perspective,” Dr. Sato explained, “potentially suppressing surge events while contributing to reductions in irrigation volume and cumulative ultrasound energy.”¹ The geometry of eight was not chosen arbitrarily. It was optimized for the surgical environment cataract surgeons are increasingly working in. WHAT THE DATA SHOWS More than 20,000 cases across two decades tell a consistent story, one that holds across the full spectrum of cataract complexity. In standard cataract cases, corneal endothelial cell density (CECD) loss at 19 weeks has averaged approximately 1%,

with cumulative dissipated energy (CDE) values ranging from 5.0 to 9.2 and operative times of 3.7 to 5.4 minutes.¹

Independent multicenter validation, which he expects will emerge organically as adoption grows, remains the necessary next step.

In hard nuclear cataracts—Emery-Little Grade IV to V—mean CECD loss was 3.7% at 19 weeks, with all Grade V cases completed without complications.¹

A TECHNIQUE IN SEARCH OF ITS MOMENT Dr. Sato began developing this technique in 2002. He has published clinical series across eight cataract subtypes and designed an instrument family—the Eight-Chopper I, Eight-Chopper II and Lance-Chopper (ASICO; Illinois, United States), each calibrated to a different range of nuclear hardness.

In pseudoexfoliation syndrome, where zonular weakness routinely prompts insertion of a capsular tension ring, Dr. Sato completed every case without one, a finding he attributes directly to the reduced rotational manipulation that complete prefragmentation allows.¹ The technique’s performance in two additional challenging populations is worth noting. In white cataracts—where direct nucleus-to-posterior-capsule contact and absent epinucleus create inherent surgical risk—CECD loss was 6.7% at 19 weeks with a posterior capsule rupture rate of approximately 1.9%.¹ In diabetic eyes, where preexisting endothelial vulnerability compounds surgical risk, CECD loss was 5.1% at seven weeks, falling to 2.1% at one year.¹ A consistent secondary finding across multiple subtypes has been sustained postoperative IOP reduction—persisting through mid- to long-term follow-up—which Dr. Sato attributes to the technique’s reduced ultrasound energy and irrigation volume, minimizing stress on aqueous outflow tissues.¹ Across all subtypes, irrigation fluid usage averaged just 20 to 30 mL per case.

Compared with figures reported for other techniques, this is roughly five to ten times lower. Frankly, this result was almost too good, and I did not even expect it. - Dr. Tsuyoshi Sato

“Endothelial cell loss at 19 weeks has been approximately 1%,” he said. “Compared with figures reported for other techniques, this is roughly five to ten times lower. Frankly, this result was almost too good, and I did not even expect it.” The honest caveat is that this remains single-surgeon, singlecenter data with no randomized comparators.¹ Dr. Sato has chosen not to conduct direct comparative trials on ethical grounds; he is unwilling to randomize patients toward techniques he considers inferior.

Only one ophthalmologist has ever observed his surgery. None have mastered the technique. The parallel with Phaco Prechop is not lost on him. That technique generated only four published papers in three decades; not because the concept was flawed but because the gap between published evidence and surgical adoption proved wider than anticipated. “There is a considerable distance between demonstrating a technique’s superiority through clinical data and publications, and actually making other surgeons want to try using it themselves,” he said. For surgeons who want to learn, Dr. Sato’s guidance is specific and staged. The foundation is mastery of at least one conventional nuclear division technique first—ideally phaco-chop—so the surgeon understands the problem the Eight-Chop Technique is solving. The capsulorhexis must be at least 6 mm. Corneal incisions only. Dedicated instruments, no substitutes. The learning phase demands faithful imitation before any personal adaptation. “If a learner adds their own personal adaptations partway through the learning process, the characteristic flow unique to the Eight-Chop Technique breaks down, and the technique cannot be properly internalized,” he warned. He recommends beginning with routine Grade I to II nuclei before progressing to harder cases. Surgical videos on his YouTube channel demonstrate the technique across the full spectrum of nuclear hardness and challenging subtypes, and he has indicated he welcomes surgeons to observe directly at his clinic in Matsudo.

The technique itself is complete. What motivates me most now is the question of how to correctly pass it on.

SEPTEMBER 2026

COVER STORY

“The technique itself is complete,” Dr. Sato said. “What motivates me most now is the question of how to correctly pass it on.” He is also acutely aware that a technique this carefully built deserves to outlast its creator. BUILT FOR WHAT’S COMING Active fluidics systems maintain anterior chamber stability under low IOP conditions by dynamically controlling irrigation pressure in real time. Under these conditions, fragment followability and occlusion stability become critical determinants of surgical efficiency. Larger, irregular fragments—the product of incomplete prefragmentation— become progressively harder to manage as IOP drops, increasing the risk of surge events and anterior chamber instability.

As active fluidics becomes the standard rather than the exception, a technique built around complete prefragmentation may turn out to be the technique this future was quietly waiting for.

Each generation has moved in the same direction: less energy, more mechanical efficiency, greater safety. The Eight-Chop Technique takes that trajectory to its logical endpoint.

THE BIGGER PICTURE Beyond the clinical results, Dr. Sato is making a conceptual argument about where cataract surgery is heading.

The data is preliminary. The concept is not. For the cataract surgeon willing to look past the learning curve, the videos are online, the paper is published and the surgeon is ready to teach.

He draws on cognitive load theory to argue that simultaneous two-handed instrument management imposes a burden that reduces surgical precision. When a surgeon must operate the phaco tip and a second instrument at the same time—while making continuous division and aspiration decisions—cognitive demands compound, and precision suffers.

The Eight-Chop Technique’s pre-formed, uniformly small fragments are inherently better suited to this environment. Because nuclear division is completed mechanically before phacoemulsification begins, ultrasound energy requirements are intrinsically reduced, further supporting stable anterior chamber dynamics under low-IOP conditions.¹

By separating division from aspiration, each stage becomes organized around a single primary instrument. Division belongs to the Eight-Chopper. Removal belongs to the phaco tip. The holding hand supports rather than operates—closer in principle to the bimanual stabilization used across microsurgery than to the dualinstrument coordination conventional phaco demands.

In a contralateral-eye comparative study using active f luidics, the technique demonstrated favorable performance across a range of IOP settings, with fragment followability remaining consistent even as irrigation pressure was reduced.¹

Dr. Sato positions the Eight-Chop Technique as the fifth generation of cataract surgery—following sculpting, divide-and-conquer, phaco-chop and prechop—two conceptual steps beyond where most surgeons currently operate.²

Twenty thousand surgeries afterwards, one technique is still waiting for its moment. REFERENCES 1. Sato T. The Eight-Chop Technique in cataract surgery: a conceptual and narrative review of a segmentation-first strategy. Clin Ophthalmol. 2026;20:624182. 2. Sato T. Eight-chop technique. Sato Eye Clinic. Accessed on July 28, 2026.

CONTRIBUTOR Dr. Tsuyoshi Sato Director of Sato Eye Clinic and developer of the Eight-Chop Technique. perfect-eightchop@sato-ganka.com

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INDUSTRY UPDATE

HOW LONG DOES SLT REALLY LAST? A 9-YEAR GLAUCOMA STUDY WEIGHS IN THE FIRST SLT SESSION HELD THE EDGE, WHILE PRESSURE CONTROL AND VISUAL FIELD RISK TOLD SLIGHTLY DIFFERENT STORIES. By Marhiel Garrote

Selective laser trabeculoplasty (SLT) can control intraocular pressure (IOP) for years, but that durability fades with a repeat visit. In a long-term study published in the American Journal of Ophthalmology, researchers from UCLA’s Stein Eye Institute found that an initial SLT outlasted repeat treatment by nearly two years before meeting treatment-failure criteria. THE STUDY Researchers analyzed 500 eyes treated with SLT between 2002 and 2021, following patients for a mean of 9.6 years. Of these, 428 eyes underwent initial SLT and 72 received repeat treatment.*

more likely in eyes with higher baseline medication use, thinner central corneas and higher laser energy settings.* The authors cautioned against reading the energy finding as evidence that higher SLT settings harm vision. Since energy levels weren’t randomized, higher settings were likely used in more resistant or higher-risk eyes to begin with.* Notably, repeat SLT was not independently linked to visual field progression after adjustment, despite its shorter IOP control overall.*

Treatment failure was defined broadly: less than a 20% IOP reduction, an IOP of at least 21 mmHg, escalation of glaucoma medications, or the need for another pressure-lowering laser or surgery.* Visual field (VF) progression was assessed separately at five years using three progression methods, with at least two required to agree before an eye was classified as progressing.* THE RESULTS Initial SLT lasted a median of 4.6 years, compared with 2.7 years after repeat treatment. By year five, 47.0% of initially treated eyes still met success criteria, versus 33.3% of repeat-treated eyes. By year 10, those figures fell to 32.7% and 16.4%, respectively.* After adjustment, repeat SLT remained linked to a higher risk of treatment failure. Prior glaucoma surgery carried an even stronger risk, while moderate to advanced glaucoma and asthma were also tied to shorter treatment survival.* Higher laser energy intensity, meanwhile, was linked with a lower risk of IOP-based failure. IOP variability also improved after initial SLT, from 2.9 to 2.4 mmHg, though it did not change significantly after repeat treatment.* Visual field outcomes told a slightly different story. Of 302 eligible eyes, 34 (11.3%) showed progression at five years. Progression was

LIMITATIONS The study was retrospective, with SLT technique and energy settings left to physician judgment, and these treatment differences may have influenced the results.* The five-year visual field analysis also excluded eyes that needed additional laser or glaucoma surgery before that point, which may have underestimated progression. And since most patients were already on glaucoma medications, the findings may not translate as cleanly to SLT used as a first-line treatment.* THE TAKEAWAY SLT can keep IOP in check for years, but the first treatment appears to have the longer legs. Repeat SLT lost durability sooner, while visual field progression followed its own set of risk factors entirely. Pressure control, it seems, is only one part of the long-term picture. Editor’s Note A version of this article was first published on MediaMICE.com.

REFERENCES *Lee K, Morales E, Caprioli J. Long-term outcomes of selective laser trabeculoplasty on intraocular pressure control and visual field progression. Am J Ophthalmol. ePub ahead of print: August 12, 2026.

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KUDOS

ENGINEERING PRECISION FROM IOL DELIVERY TO SUSTAINED GLAUCOMA THERAPY How two South Korean companies are quietly engineering solutions to ophthalmology’s most stubborn problems.

In ophthalmology, precision is never abstract. A few microns determine whether a lens centers properly. A force profile too abrupt can stress delicate tissue. A missed dose can mean months of unchecked pressure. These are the margins two separate South Korean companies have built their businesses around. RET, Inc. (Cheongju, South Korea) specializes in cataract treatment solutions and ophthalmic medical device OEM/ ODM services, with a focus on preloaded intraocular lens (IOL) delivery systems. With Us Vision (Cheongju, South Korea) is an entirely separate company, specializing in glaucoma treatment technologies built on nanotechnology, currently developing sustained intraocular drug delivery platforms. Different diseases. Different technologies. Different problems to solve. But both companies share a conviction that the way a device is engineered determines whether it performs once or performs reliably, every time. WHAT SURGEONS ACTUALLY WANT Ask any experienced cataract surgeon about their ideal injector, and you’ll get a surprisingly specific answer. They want control. They want ergonomics that don’t fight them mid-procedure. And they want a

Sponsored by RET, Inc.

device that behaves the same way on the tenth case as it did on the first.

System Regulation and European Medical Device Regulation (MDR).

That consistency is harder to engineer than it sounds.

“In the current regulatory environment, innovation must be supported by structured development processes,” RET’s CEO explained. “Alignment with regulatory requirements begins at the earliest stages of design.”

RET specializes in the precision engineering and assembly of preloaded IOL delivery systems for global OEM/ODM partners. Premium IOL portfolios now routinely include toric, multifocal and extended depthof-focus platforms. But here’s what matters: even the most advanced optics can’t achieve their intended clinical performance if the delivery system doesn’t provide controlled and predictable deployment. Even minor deviations in injection dynamics can affect outcomes. A spike in plunger force can stress delicate haptic structures. Asymmetric cartridge geometry biases how the lens unfolds. Rotational instability can alter final positioning. Surgeons experience injector performance as “feel”—a subjective sense of how the device handles. But behind that feel is quantified engineering. RET’s modular platform architecture supports both push-and-back and screw-type injection mechanisms, adapting to varying surgical preferences across global markets. Development is built around regulatory rigor from day one— verification testing, risk analysis, process validation consistent with the U.S. Food and Drug Administration (FDA) Quality

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In a field where device failures have real consequences, that discipline is increasingly necessary. THE PROBLEM NOBODY’S FULLY SOLVED Shift the lens—quite literally—to glaucoma, and a different challenge comes into focus. The management strategy for the disease is straightforward: control intraocular pressure (IOP) over the long term. The medications work. The surgery helps. But there’s a weak link: the patient. Real-world adherence to topical IOP-lowering medications is notoriously inconsistent. Elderly patients managing multiple drops throughout the day, working adults trying to remember mid-morning doses, parents juggling medications—life gets in the way. Drops get missed. Pressure fluctuates. Even in treated eyes, those fluctuations have been associated with disease progression. Minimally invasive glaucoma surgery (MIGS) can reduce medication burden, but postoperative pharmacologic support is often still needed. The cycle continues.

This is the clinical gap With Us Vision is engineering its way into. TWO YEARS FROM ONE PROCEDURE With Us Vision is a nanotechnolog ybased company developing a drug delivery system-integrated glaucoma platform that pairs surgical deployment with controlled intraocular drug release, targeting approximately 12 months of therapeutic availability from a single procedure. The concept is elegant. Instead of relying on a patient to instill drops reliably every day for years, the device does it from within. A compact drug reservoir embedded within the injector architecture delivers medication through nanotechnology-enabled microchannel diffusion pathways in a biocompatible polymer matrix—gradual elution, consistent release, designed to maintain therapeutic levels for up to a year. Compare that to topical therapy. Patients instill drops. Drug levels spike. Hours pass. Levels drop. The resulting peaks and troughs create variability, and variability creates risk. With Us Vision’s platform is designed to reduce those large fluctuations. “Glaucoma is a lifelong condition requiring long-term control,” said leadership at With Us Vision. “Our goal is not simply to develop a device, but to contribute to a therapeutic approach that supports sustained disease management.” Getting there is anything but straightforward. With Us Vision’s preclinical development focuses on release curve calibration, polymer

stability in aqueous environments, structural durability within the anterior chamber, and predictable degradation or retention characteristics. The development strategy is already being structured with global regulatory submissions in mind: FDA pathways, European MDR requirements, South Korea MFDS standards, biocompatibility testing under ISO standards, risk management, design controls and full traceability.

with clinical reality. What separates durable innovation from short-lived novelty is often less about the idea and more about the execution: the quality systems, the

TWO COMPANIES, ONE ENGINEERING PHILOSOPHY RET applies much of the same regulatory discipline to its injector development—built in from the beginning, validated before commercialization. It’s a coincidence of philosophy, not a shared operation: two independent companies arriving at the same conclusion from different directions. What makes both particularly interesting is how each, on its own, thinks about the future. Neither is building a single product; each is building a platform. RET’s modular injector architecture is designed to adapt across IOL types, surgical preferences and regulatory environments, making it a natural long-term partner for global ophthalmic manufacturers. With Us Vision’s nanotechnology-based reservoir and diffusion framework is conceived with broader applications in mind—the same controlled-release architecture could potentially extend beyond glaucoma to other chronic conditions where sustained intraocular therapy offers advantages. The ophthalmic device world is full of promise that doesn’t usually survive contact

documentation, the willingness to subject technology to rigorous scrutiny before a device enters an OR. Both RET and With Us Vision, independently, have internalized this. Their development frameworks center on structured design controls, biocompatibility testing, risk management aligned with ISO standards and full process traceability. These aren’t flashy attributes, but they’re the ones that predict longevity. For the global ophthalmic community— surgeons, device partners, healthcare systems—the emergence of these two distinct companies represents an opportunity to engage with engineering teams tackling some of the field’s most persistent challenges, each from their own corner of ophthalmology. The microns matter. The pressure curves matter. The 12-month release profile matters. And behind all of it, the engineering discipline to get it right matters most—whether the goal is a perfectly seated lens or a year of stable pressure control.

SEPTEMBER 2026

KUDOS

From a determined young doctor in Italy to PresidentElect of the European Board of Ophthalmology, Miss Anna Maino has devoted her career to raising standards in ophthalmic education, ensuring future generations enjoy opportunities she once had to seek abroad. By Chow Ee-Tan

MENTORSHIP, MAMA-BEAR LEADERSHIP AND CLOSING EUROPE’S TRAINING GAP Some people spend their careers climbing the professional ladder. in my hands, saying, ‘I get it! I get it now! It makes sense...and it’s Others spend theirs building better ladders for the people who beautiful,’” she recalled. follow. More importantly, Mr. Ansons taught her that clinical excellence When Miss Anna Maino left Italy to pursue specialist training and personal fulfilment could go hand in hand. “Watching in the United Kingdom more than two decades ago, she made a him made me realize that it was possible to be an outstanding promise to herself: that if she ever reached a position of influence clinician while maintaining curiosity, enjoying cultural pursuits in ophthalmic education, she would create better opportunities and finding a healthy work-life balance, despite facing challenges for those who came after her. in his personal life,” she shared. Today, as President-Elect of the European Board of Ophthalmology (EBO), she is doing exactly that. AN UNLIKELY SURGEON Born and raised in Altamura, southern Italy, Miss Maino knew from an early age that she wanted to become a surgeon, despite coming from a family with no medical background. “My late father…wanted me to become a structural engineer specializing in earthquake engineering,” she recalled. “I have always been very determined. I often joke that I must have been the only doctor in history whose parents were disappointed on graduation day.” That determination led her to study medicine at the University of Bari, where a lecture in ophthalmology changed the course of her career. “It offered the perfect combination of surgical precision, clinical medicine, technology, intellectual challenge and the opportunity to improve people’s quality of life in a very tangible way,” she remembered. A CALLING TAKES SHAPE After ophthalmology training in Bari, Miss Maino accepted a research fellowship at Moorfields Eye Hospital in London before completing specialist training in Manchester. She later undertook a fellowship in pediatric ophthalmology and strabismus at Moorfields, eventually becoming a consultant in Stockport and joining Manchester Royal Eye Hospital in 2016, where she now specializes in strabismus in both children and adults. One of the people who most influenced her career was the renowned strabismus surgeon Mr. Alec Ansons. Strabismus initially struck her as impenetrable, until one day it clicked into place. “I still remember going to Alec holding the orthoptic report

A PROMISE FULFILLED Although Italy had given her an excellent medical education, Miss Maino realized she needed to leave home to gain the surgical training she was seeking. Somewhere over the Adriatic, on the flight out, she made herself a promise that would shape the rest of her career. “’Today, you are nobody,’ I told myself. ‘But if one day you become somebody, you must change this,’” she reminisced. “No talented young ophthalmologists should have to leave home simply to receive high-quality surgical training.” Twenty-five years on, she is helping make that vision a reality. As President-Elect of the EBO, Miss Maino has contributed to developing the European Training Requirements for Ophthalmology, helping define standards for specialist training across Europe. She is now working to establish structured European fellowship programs that will allow young ophthalmologists to gain advanced subspecialty training across different countries. “It has taken me 25 years, but I am finally in a position to fulfil that promise,” she said. Miss Maino believes patients deserve the same high standard of eye care regardless of where their ophthalmologist trained, and sees technology as central to closing that gap. “By embracing digital education and artificial intelligence, we can make ophthalmology teaching available to trainees regardless of where they live or work,” she noted. Her vision is both ambitious and simple: “My job will be done when young European ophthalmologists cross borders to pursue opportunities, not because they have no other option.”

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LEADING WITH PURPOSE Alongside her clinical practice, education and international leadership responsibilities, Miss Maino believes balance is less about perfection than about making thoughtful choices.

to be remembered as the first female consultant ophthalmologist in Stockport, and for paving the way for the women who followed. But the answer that best captures her character is how she wants her trainees to remember her.

“Very few people truly ‘balance’ all these responsibilities perfectly,” she said. “It’s about making conscious choices, accepting that priorities change over time, and being comfortable that not everything can be done equally well every day.”

“I hope my trainees and fellows will remember me as a ‘Mama Bear’,” she said. “Someone who challenged them to achieve their full potential, made them laugh, celebrated their successes and always, always, always had their back.”

Rather than viewing her different roles as competing demands, she sees them as complementary. “My clinical work informs my teaching, my educational roles improve the way I lead teams, and my international work exposes me to new ideas that ultimately benefit my patients,” she explained. “Even playing guitar or lifting weights has made me a better surgeon!”

For Miss Maino, titles and positions matter far less than integrity. “I would walk away from any position, no matter how prestigious, if accepting it meant compromising patient care or lowering the standards of ophthalmic education in Europe,” she said. “At the end of the day, what matters is being able to look yourself in the mirror and know you always did the right thing for your patients, your residents and your profession.”

Family life, too, has taught her valuable leadership lessons. “Many of the negotiation techniques honed with stubborn toddlers work remarkably well in the boardroom,” she noted. “And if you can navigate the self-centeredness and propensity for drama of teenagers, you’ll have no trouble handling your colleague with the big ego.”

Twenty-five years after that flight across the Adriatic, the promise she made to herself has become her professional mission: to keep building better ladders. CONTRIBUTOR

Above all, she believes leadership is never a solo effort: “Success is not about doing everything yourself. Leadership is a collective effort rather than an individual achievement.” MAMA BEAR Ask Miss Maino what legacy she hopes to leave behind, and she speaks less about titles than about people. Professionally, she hopes

Miss Anna Maino Consultant eye surgeon at Manchester Royal Eye Hospital, president-elect of the EBO, and president of the Digital Education Committee, AAPOS. pa.annamaino@consultantcare.com

SEPTEMBER 2026

KUDOS

CATARACT SURG E RY, VITREOUS FLOATE RS AN D

CONTRAST SE NSITIVITY WHY VISUAL ACUITY IS NOT THE WHOLE STORY By Dr. Franziska Weiglein, Dr. Dr. Ronald D. Gerste and Prof. Dr. Ulrich Welge-Lüssen

Excellent acuity—yet an unhappy patient? Following successful cataract surgery, vitreous f loaters that were previously unnoticed may become visually significant. They can impair perceived visual quality despite a wellpositioned intraocular lens (IOL) and good postoperative acuity by increasing straylight and reducing contrast sensitivity. This article examines the clinical relevance of vitreous opacities and discusses a noninvasive supportive treatment option for affected patients.

procedure typically leads to significant improvement in visual acuity and high levels of patient satisfaction. However, some patients still report impaired visual quality even when they have good postoperative visual acuity.3 This is because visual acuity, as measured under standardized high-contrast conditions, provides only a partial representation of visual performance in everyday life. It does not accurately reflect how well patients see under low-light

are increasingly recognized as important additional outcome measures.4,5 CONTRAST SENSITIVITY AS AN IMPORTANT MEASURE OF VISUAL QUALITY Contrast sensitivity is the ability to detect subtle differences in brightness between an object and its background. This ability is particularly important for vision in lowlight conditions, foggy conditions, while driving and in situations involving glare. Reduced contrast sensitivity may cause vision to appear dull, hazy or lacking in clarity even when conventional visual acuity remains good. A Core Outcome Set published in 2024 explicitly identified contrast sensitivity as a clinically important postoperative outcome.5 The ophthalmic literature increasingly emphasizes that the assessment of surgical success is shifting towards a more comprehensive evaluation of visual function, rather than relying solely on visual acuity. The clinical relevance of this topic was also discussed in relation to the clinical relevance at the International Congress of the German Society of Ophthalmic Surgery (DOC 2026) in Nuremberg, where Christina Leydolt (Vienna) presented a paper on contrast sensitivity in relation to different IOL designs.6

Cataract remains a leading cause of blindness worldwide, and cataract surgery is one of the most frequently performed surgical procedures globally.1,2 The

conditions, in the presence of glare or at reduced contrast levels. Consequently, contrast sensitivity, intraocular straylight and patient-reported visual symptoms

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IOL design and contrast sensitivity The implanted intraocular lens affects the postoperative optical quality. Monofocal IOLs focus incoming light onto a single

focal point and remain the reference standard for contrast sensitivity. In contrast, multifocal and other presbyopia-correcting IOLs distribute incoming light across multiple focal points. While they may offer greater spectacle independence, they can also be associated with reduced contrast sensitivity and photic phenomena such as halos and glare.7 Consequently, patient satisfaction depends on more than just the visual acuity achieved. Satisfaction may be reduced despite good objective outcomes due to photic disturbances and impaired functional visual quality.8 VITREOUS OPACITIES AS AN ADDITIONAL SOURCE OF VISUAL DISTURBANCE Vitreous floaters are a major cause of such less-than-perfect functional outcomes. They are a common occurrence, affecting an estimated two out of every three individuals. With increasing age, the vitreous partially liquefies and the collagen fibres may aggregate to form small opacities. These opacities are perceived as spots, strands, rings or shadows and are commonly referred to as vitreous floaters.9

Floaters are particularly noticeable against bright, uniform backgrounds. Following cataract surgery, any pre-existing vitreous opacities may become more apparent because the previously opaque crystalline lens has been replaced with a clear IOL. Consequently, patients may achieve excellent high-contrast visual acuity yet still perceive their vision as distorted, hazy or lacking in contrast. Effects on straylight and contrast sensitivity Vitreous opacities can scatter light, casting shadows onto the retina. This effect can reduce image contrast while increasing glare and visual disturbance. In a study using the C-Quant straylight meter, eyes with symptomatic vitreous f loaters exhibited higher straylight values than corresponding unaffected fellow eyes.10 Similarly, a recent study using the Vitreous Floaters Functional Questionna i re demonstrated a n association between subjective floater burden, objectively measured vitreous opacity density and contrast sensitivity.11 These findings help to explain a common postoperative scenario: although the

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cataract surgery is technically successful, the IOL is well positioned and visual acuity is good, the patient remains dissatisfied with the perceived quality of vision. Additional straylight may be particularly relevant in IOL designs with a lower contrast sensitivity reserve, although studies directly investigating this interaction remain limited. VitroCap®N as a non-invasive supportive option The initial management of uncomplicated vitreous f loaters consists of patient education, observation and regular ophthalmic follow-up. VitroCap®N offers a non-invasive adjunctive approach. This food supplement contains L-lysine, vitamin C, zinc, grape seed extract and citrus bioflavonoids. Since 2013, five clinical studies have reported the beneficial effects of VitroCap®N.12-16 The first of these was an observational study involving 24 participants. After three months of supplementation with one capsule daily, 87.5% of participants reported an improvement in their floater symptoms, and the mean symptom score decreased from 3.63 to 1.33.12 Subsequent studies

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have also reported improvements in patient-reported symptoms.13-15 The strongest evidence to date comes from the randomised, double-blind, placebocontrolled FLIES study published in 2021. Sixty-one participants with symptomatic vitreous floaters were observed over a period of six months. Those receiving the targeted micronutrient formulation reported an improvement in their symptoms. Reductions in floater area as measured by imaging and improvements in contrast sensitivity were also observed.16 Furthermore, a survey of 96 German and Austrian ophthalmologists found that the food supplement was rated as either “predominantly helpful” or “very helpful” in managing vitreous floaters.17

These findings suggest that VitroCap®N could be used as a non-invasive adjunctive treatment for patients with symptomatic vitreous f loaters. By potentially alleviating f loater-related visual disturbance and enhancing contrast sensitivity, supplementation could help maintain functional visual quality and postoperative patient satisfaction following cataract surgery. CONCLUSION Cataract surgery generally achieves excellent clinical outcomes and high levels of patient satisfaction. However, good high-contrast visual acuity alone does not guarantee optimal visual quality.

impact upon postoperative visual function. Vitreous floaters can increase straylight and reduce contrast sensitivity without these effects being adequately reflected by conventional visual acuity testing. Therefore, when patients are dissatisfied despite having undergone technically successful cataract surgery, the assessment should extend beyond refraction, IOL position, the cornea, macular status and posterior capsule opacification, and should also include vitreous opacities, straylight and contrast sensitivity. In this context, VitroCap®N represents a non-invasive adjunctive approach, with an overall response rate of around 70% across five clinical studies.

Contrast sensitivity, straylight, glare and vitreous opacities can all have a significant

REFERENCES 1. Steinmetz J, Bourne R, Briant P, et al. Causes of blindness and vision

9. Milston R, Madigan MC, Sebag J. Vitreous floaters: etiology,

impairment in 2020 and trends over 30 years, and prevalence of

diagnostics, and management. Surv Ophthalmol. 2016;61(2):

avoidable blindness in relation to VISION 2020: the Right to Sight:

211–227.

an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021;9(2)–e160. 2. Yoshizaki M, Ramke J, Zhang JH, et al. How can we improve the quality of cataract services for all? A global scoping review. Clin Exp Ophthalmol. 2021;49(7):672–685. 3. Seifried M, Höh H. Healthcare research of cataract surgery: analysis of patients’ satisfaction following cataract surgery in Mecklenburg-Vorpommern, Germany. Klin Monbl Augenheilkd. 2017;234(8):965–974. 4. Sparrow JM, Grzeda MT, Frost NA, et al. Cataract surgery

10. Castilla-Martí M, van den Berg TJ, de Smet MD. Effect of vitreous opacities on straylight measurements. Retina. 2015;35(6): 1240–1246. 11. Nguyen JH, Boneva SK, Nguyen-Cuu J, et al. Vitreous Floaters Functional Questionnaire for vision-degrading myodesopsia from vitreous floaters. JAMA Ophthalmol. 2025;143(11):925–931. 12. Gerste RD, Kaercher T. Mit diätischen Mitteln gegen eine lästige visuelle Störung. Z Prakt Augenheilkd Augenärztl Fortbild. 2013:344. 13. Marchenko LN, Dalidovich AA, Kachan TV, et al. Experience

patient-reported outcome measures: a head-to-head comparison

of VitroCap® use in vitreous degeneration. Ophthalmol East Eur.

of the psychometric performance and patient acceptability of the

2015;25(2):123–128.

Cat-PROM5 and Catquest-9SF self-report questionnaires. Eye. 2018;32(4):788–795. 5. Tarricone R, Rognoni C, Ciarlo A, et al. Systematic review for the development of a core outcome set for monofocal intraocular lenses for cataract surgery. Front Med. 2024;11:1339793. 6. Leydolt C. Kontrastsehen nach Cat-OP? Was ist relevant bei

14. Sobol M, Oseka M, Kaercher T, et al. The effect of oral supplementation with L-lysine, hesperidin, proanthocyanidins, vitamin C and zinc on the subjective assessment of the quality of vision in patients with vitreous floaters. J Alzheimers Dis. 2018;64:1034. 15. Varganova TS, Veryasova AG, Erysheva ED, et al. VitroCap

welchen IOLs? Vortrag H 3.2. In: 38. Internationaler Kongress

efficacy in patients with vitreous body destruction. Ophthalmol J.

der Deutschen Ophthalmochirurgie, DOC 2026; 2026 Jun 18;

2019;12(2):67–72.

Nürnberg, Deutschland. 7. Cao K, Friedman DS, Jin S, et al. Multifocal versus monofocal

16. Ankamah E, Green-Gomez M, Roche W, et al. Dietary intervention with a targeted micronutrient formulation reduces the visual

intraocular lenses for age-related cataract patients: a systematic review

discomfort associated with vitreous degeneration. Transl Vis Sci

and meta-analysis based on randomized controlled trials.

Technol. 2021;10(12):19.

Surv Ophthalmol. 2019;64(5):647–658. 8. Botta J, Barsam A, Dmitriew A, et al. Factors influencing outcome satisfaction after cataract surgery: patient-reported insights from the

17. Wirth F, Roche W, Osęka M, et al. Nutritional intervention in floaters: evaluating the efficacy of VitroCap®N from the perspective of eye care professionals. J Alzheimers Dis. 2025;106(Suppl 1).

RayPro database. BMC Ophthalmol. 2024;24:528.

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WHY

ESCRS MEMBERSHIP MATTERS AT EVERY STAGE OF AN OPHTHALMOLOGY CAREER

Most ophthalmologists know ESCRS for its Congress. Members know it for everything else. By Marhiel Garrote

Picture a young ophthalmologist at their first European Society of Cataract and Refractive Surgeons (ESCRS) Congress. The auditorium seats thousands. The faculty list reads like a who’s who of global cataract and refractive surgery. The science moves fast enough to be both exhilarating and humbling. And somewhere between the main stage and the corridor conversations, a quiet question forms: how do I become part of this? ESCRS has spent over three decades working to make that question easier to answer. For trainees and young ophthalmologists, the answer is refreshingly simple: it starts for free. MORE THAN A CONGRESS Most ophthalmologists know ESCRS through its Annual Congress—one of the world’s premier ophthalmology meetings, drawing professionals from over 130 countries. For ESCRS CEO Tom Ogilvie-Graham (United Kingdom), though, the Congress is just the starting point. “That’s only one part of what we do,” he says. Behind the flagship event is a charitable, member-led organization that reinvests every surplus into education, research, fellowships

and professional development, guided by more than 200 board members and faculty volunteers, all driven by mission rather than commercial agenda. The mission is deceptively simple: connect people, knowledge and innovation to improve patient outcomes worldwide. “Whether it’s a trainee attending their first Congress, an experienced surgeon adopting a new technique or a researcher collaborating across borders, ESCRS provides a community where people can learn, contribute and grow,” said CEO Tom Ogilvie Graham. For many members, that sense of belonging becomes as important as the educational resources themselves. FROM THE AUDIENCE TO THE STAGE Dr. Joaquín Fernández (Spain), Secretary of ESCRS and Chair of the General Purposes Committee, has watched the same pattern repeat itself more times than he can count. A young colleague arrives at their first Congress, uncertain where they fit. They attend a Young Ophthalmologists session, ask a

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question or introduce themselves to someone they admire. The first year, they’re taking notes in the audience. A few years later, they’re presenting their own work. Later still, they’re mentoring someone who reminds them of themselves. “The most important change is not always a line added to a CV,” said Dr. Fernández. “It is often the confidence that comes from discovering that one’s questions, experience and research have value within the wider community.”

Where the Learning Hub builds knowledge, EUREQUO interrogates practice. For a young surgeon still forming clinical habits, both are formative. ESCRS also backs early-career researchers with dedicated funding: Clinical Research Awards, Pioneer Research Awards, the Peter Barry Fellowship for international research experience and more. Young Ophthalmologists sit as observing members of the ESCRS Research Committee, with a formal place in the Society’s scientific direction from the start.

That shift happens, he added, when membership becomes “participatory rather than transactional.” In other words, when members stop simply using resources and begin contributing to the community. Encouraging that transition, he said, is what ESCRS is ultimately designed to do. DIFFERENT PATHS, ONE COMMUNITY ESCRS membership is open to professionals across the ophthalmology community, from cataract and refractive surgeons to trainees, young ophthalmologists, and vision scientists. Dr. Fernández is clear that the structure is about relevance, not hierarchy. “The purpose of having categories is to give people an appropriate route into ESCRS and a meaningful pathway through the Society,” he said. A trainee may need foundational education, observerships and the confidence that comes from performing on an international stage. An experienced surgeon may seek advanced scientific exchange and research collaboration. A vision scientist may particularly value the crossover with clinical questions surgeons face daily. Different needs, one community. For eligible trainees and doctors under 30, membership is free. For surgeons and vision scientists, it starts from €170. As Dr. Fernández noted, “for someone attending one of our major meetings, the registration savings alone may represent a substantial part of the membership fee.” THE DEEPER VALUE Membership extends beyond discounted Congress registration. Through the ESCRS Learning Hub, members can revisit surgical videos, Congress sessions, webinars and CME-accredited education whenever they need it. Subscriptions to EuroTimes and the Journal of Cataract and Refractive Surgery keep the scientific conversation going long after Congress ends. Then there’s Europe’s Registry of Quality Outcomes (EUREQUO), the benefit Dr. Fernández considers the most overlooked of all. “It gives participating surgeons a structured way to examine outcomes, compare practice with wider data and contribute to a culture of continuous quality improvement,” he said.

CEO Tom Ogilvie-Graham hears the same story often enough to recognize it as a pattern. “One comment I hear regularly is from members who tell me they originally joined because of the Congress, but stayed because they discovered everything else the Society offers. That’s exactly the journey we’re trying to create.” THE CASE FOR JOINING NOW The instinct to wait—to join once the practice is settled, once the schedule allows—is understandable. Both doctors suggest otherwise. “I’d encourage young ophthalmologists to think beyond where they are today and consider where they want to be in 10 or 20 years,” said CEO Tom Ogilvie-Graham. “Joining ESCRS isn’t simply about accessing benefits. It’s about becoming part of an international community committed to helping each other learn, collaborate and advance the profession.” Ultimately, he added, “ESCRS belongs to its members.” The earlier you join, the longer it belongs to you. Dr. Fernández is equally direct: “Trainee Membership is a starting point, not a separate destination.” The pathway grows with you, from free membership to full surgical status, from first attendance to podium presenter, from participant to mentor. With trainee membership available at no cost, the greatest barrier is rarely financial. It’s simply deciding not to wait. And the podium, as it turns out, comes to those who show up early. To find the membership category that matches your stage of training or practice, visit ESCRS — Become a Member.

SEPTEMBER 2026

KUDOS

ELARA 900: TWELVE MONTHS OF CLINICAL VALIDATION & INNOVATION Bold claims are easy to make at a product launch. A year of clinical data and a steady stream of upgrades are harder to argue with. Sponsored by Haag-Streit

For over a century, the slit lamp has sat at the center of every ophthalmic examination—trusted, ubiquitous, and essentially unchanged. “The slit lamp is an instrument that everybody takes for granted,” said Prof. Dr. med Gerd Auffarth (Germany), of University Hospital, Heidelberg. “You just never consider that it could get any better.” That assumption shattered at ESCRS 2025 in Copenhagen, where Haag-Streit (Köniz, Switzerland) unveiled the Elara 900 with a three-part promise: see more, work smarter, feel better. Ahead of ESCRS 2026 in London, a year of clinical use and major software updates have put that promise to the test. PROJECTED LIGHT, NOT REFLECTED Elara 900’s optical architecture rests on “P-Type” illumination— light projected directly onto the eye rather than reflected through a mirror—yielding fewer aberrations and a crisper image.¹ Dr. Sunil Mamtora (United Kingdom) of Bristol Eye Hospital didn’t expect to be impressed. He had long considered the BQ 900 (Haag-Streit) unbeatable. “I didn’t think it could get any better,” he said. But then he looked through the Elara 900’s oculars. “When you focus on that corneal slit—the resolution, the dynamic range, the effect that you see there—it’s quite astonishing.” In a study he led with 20 ophthalmologists at the Royal College of Ophthalmologists’ Annual Congress 2025, 70% reported improved visualization with the Elara 900 over the BQ 900. The remainder saw no difference. Notably, none preferred the older slit lamp system.² The same illumination system enables infrared* imaging for meibomian gland assessment—functionality that previously required a separate device.¹ Elara 900´s latest software update sharpens this further with higher-contrast infrared

imaging, more stable live-camera streaming, and slit rotation in one-degree increments.³

“PRESETS” AND SPEED Traditionally, switching between examination steps meant manually adjusting illumination color, filters, slit width, and magnification one by one. Elara 900’s “presets” collapse all of that into a single operation—up to six customizable exam configurations, each covering multiple parameters at once, summoned with a single scroll of a wheel.¹ Prof. Auffarth evaluated the system across 20 residents and consultants, finding that mean exam time dropped from 4.85 minutes on a traditional slit lamp to 3.9 minutes—a gain he attributes directly to “presets”.² For Dr. Yuri McKee (United States) of East Valley Ophthalmology, the projector architecture offers a practical long-term advantage: “It’s going to be long lasting—you’re not going to be changing bulbs,” he said, adding that removing the light tower also makes the device significantly more compact. Less hardware. Less maintenance. More room to focus on the patient.

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TACKLING THE “SLIT LAMP SLUMP” The ergonomic toll of slit lamp use is well documented: surveys suggest up to 79% of eye care professionals report frequent neck pain, and the instrument’s fixed optical path has long been implicated in forward head posture.4,5

The platform also supports live video mirroring to a bedside screen—letting family members follow the examination in real time. “You can quickly show the patient exactly the degree of their cataract,” Dr. McKee noted. “They just had to take your word for it before. Now they can actually see it.”

ESCRS Past President Prof. Filomena Ribeiro has a name for it: the ‘slit lamp slump.’ “If we don’t address this, it can lead to chronic problems that will shorten careers,” she said. “This is no longer just a nice thing to have, but essential.”

A PLATFORM BUILT TO KEEP IMPROVING Product Manager Theo Reininger (Switzerland) signaled at the Copenhagen launch that the Elara 900 was designed to evolve. “This is also a platform that we are further developing over the upcoming year,” he said, “making sure that with new features, the value of the product is further improved over its lifespan.”

Elara 900 addresses this with a 20-degree inclined eyepiece and an optical path 23% shorter than comparable systems, bringing the patient closer and reducing examiner reach.1,4 In Prof. Auffarth’s cohort, 70% of examiners rated the Elara 900 more ergonomic than a traditional slit lamp, with none preferring the older design; neck-comfort scores edged higher at 3.66 out of 5, versus 3.40.⁴ In Prof. Ribeiro’s 10-clinician evaluation, every participant reported improved posture and 80% rated setup and headrest comfort as significantly better.⁴ A separate internal comparison of 40 patients favored the Elara 900 over the BQ 900 across all four domains—comfort, space, handle support, and patient positioning—with the advantage growing to 90% versus 20% among larger-framed patients.⁴

A year of expanding clinical evidence and connectivity upgrades suggests that commitment is being honored. Dr. McKee’s summary cuts to what matters for any purchasing decision. A slit lamp is a long-term investment and, as he put it, “there’s one place that you really don’t want to shortchange yourself. You really want to make sure you love your slit lamp.” *Availability may vary by region. To learn more about Elara 900, visit haag-streit.com/elara.

SEE IT, SAVE IT, SEND IT Prof. David Goldblum (Switzerland) of Pallas-Kliniken ties the integrated imaging capability to something more clinical than convenience. Patients retain visual information far better than verbal descriptions—what he calls the picture superiority effect. He recalled a patient who consented to a biopsy, later confirmed as melanoma, after viewing his own slit lamp images. “Sharing photographs with our patients will enhance their understanding and their confidence in us,” Prof. Goldblum said. Prof. Maria Kugelberg (Sweden) sees the same tool accelerating education, with shareable video replacing a delayed second opinion. “Some nurses and opticians have their own outpatient care and they can capture an image if I’m not there and show me later,” she shared, as an example. The documentation workflow may be the platform’s most transformative feature. Dr. Mamtora described capturing and routing an image to the patient record “within 10 seconds”— a workflow he likens to photographing a meal and posting it to Instagram.² The latest software update adds DICOM connectivity, pulling scheduled patients from a worklist and exporting images directly to a storage server, closing a gap that early adopters had flagged.³

REFERENCES 1. Haag-Streit AG. Elara 900 product brochure. HS-Art. No. 1511.7021019.02020, 2nd edition, 2026. 2. Elara 900 Brings the Slit Lamp Into the 21st Century.” Sponsored report, 43rd Congress of the European Society of Cataract and Refractive Surgery (ESCRS), Copenhagen, September 12–16, 2025. 3. Haag-Streit Group. “InSight” Distributor News: Software Version 1.3 release notes. 2026. 4. Haag-Streit AG. Elara 900 white paper series—ergonomics. Edition 2026-05. 5. Wasserman JB, Bustos KM, Coombs SD, et al. Effect of slit lamp table design on neck position and the prevalence of neck pain in eye care professionals. Work. 2022;72(1):181-188.

SEPTEMBER 2026

ENLIGHTENMENT

THE FIRST-EVER GLOBAL SUMMIT FOR EYE HEALTH Eye health has spent decades begging for scraps of the healthcare budget. This November, it gets a global stage, a UN mandate and a return on investment most finance ministers would kill for. By Sam McCommon

One billion is a large number. Most people would tell you it’s hard to visualize a billion of anything—such large numbers are often lost to abstraction. But the one billion people worldwide living with avoidable or treatable sight loss1 are far from an abstract concept. These are real human beings whose lives are affected by preventable sight loss and, collectively, they make up more than 12% of the world’s population. For those billion people, the difference between seeing and not seeing is the difference between opportunity or exclusion, productivity or poverty, and independence or dependence. The United Nations (UN) Resolution on Vision—unanimously adopted by all 193 UN member nations on July 23, 2021—set the stage for new expectations, especially regarding finances in developing countries. Five years later, the evidence is crystal clear: investing in eye health is one of the wisest decisions any government or institution can make.

So, on November 2, 2026, the first-ever Global Summit for Eye Health will take place in Antigua and Barbuda, one of the key sponsors of the 2021 resolution. World leaders will face a simple, urgent question: Will they turn ambition into action via formal, measurable pledges? The Summit will be hosted alongside the Commonwealth Heads of Government Meeting, and is held in collaboration with the World Health Organization and supported by the International Agency for the Prevention of Blindness (IAPB). Bangladesh, Guyana and Nigeria are joining as co-hosts, broadening regional representation and injecting global political momentum. At the summit, leaders are expected to unveil concrete commitments to strengthen eye health services and accelerate progress toward universal eye care access.

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THE ECONOMIC CASE FOR PLEDGING The humanitarian case for pledging towards vision care is clear: better vision means healthier, happier people, which in turn leads to stronger communities and nations. But what may surprise some leaders is the economic opportunity that investments in vision care can unlock. The Value of Vision: The Case for Investing in Eye Health, launched in September 2025 at the UN General Assembly, noted some striking statistics1: • The one billion people living with avoidable sight loss could deliver a $447 billion annual boost to the world economy. • Targeted investment of $7 billion in low- and middle-income countries between 2026 and 2030 could generate $199 billion in economic benefits—a return of 28:1. • That same $7 billion would also lead to a collective 3.3 million more years of schooling, 80,000 years of life gained, 211,000 transport injuries averted and more. Improved eyesight also leads to reduced rates of depression and a general improvement of the human condition.2 The need is striking. Despite making up around 10% of patient consultations, eye health currently represents less than 1% of health budgets in many low- and middle-income countries. Meanwhile,

90% of sight loss cases are preventable or treatable through low-cost interventions like cataract surgery or glasses.3 Prime Minister Gaston Browne of Antigua and Barbuda spoke plainly when he issued the invitation to world leaders at a reception hosted by the Duchess of Edinburgh at St. James’s Palace, saying, “This is not only a profound human challenge—it is an economic one. Because the evidence is clear: expanding access to vision care would create millions of jobs and unlock substantial gains in education, productivity and wellbeing. Investing in eye health is not charity. It is an investment in inclusive growth, resilience and shared prosperity, particularly for small states like Antigua and Barbuda.” Jessica Thompson, deputy CEO of IAPB, reiterated the 28:1 return on investment and elaborated, “This is one of the best healthcare investments possible and I urge governments and leaders to seize the opportunity and submit bold, measurable commitments ahead of the Summit in November.” ACT, ALLOCATE, ACCELERATE The pledges the Summit is asking for aren’t symbolic. They’re formal, concrete, public commitments to specific actions, resource allocation and measurable targets. In plain English, this means “getting stuff done” rather than simply talking. The three words you see above—act, allocate, accelerate—are the Summit’s three organizing pillars. World leaders are being

SEPTEMBER 2026

ENLIGHTENMENT

asked to integrate eye health into national development and health plans. This means increasing sustainable financing and scaling proven, cost-effective solutions like cataract surgery and refractive treatments. Commitments from leaders will be published and presented at the Summit, providing a public framework for accountability and benchmarks in the following years. “By bringing leaders together in Antigua and Barbuda we hope that countries, businesses and civil society make formal public commitments to take specific actions, allocate resources or achieve measurable targets in pursuit of our shared goal of ending avoidable sight loss,” said IAPB CEO Peter Holland.

MOMENTUM ALREADY BUILDING The momentum towards the Summit is already building. In March 2026, leading ophthalmological societies from India, Indonesia, Nepal and Sri Lanka signed the Jaipur Declaration. This urges governments and partners, like NGOs, to accelerate action and reaffirm support for the WHO 2030 targets of a 30% increase in effective cataract surgical coverage and a 40% increase in refractive error coverage.

Co-host ministers are already underlining their determination to “make change happen at speed and scale,” as Prof. Muhammad Ali Pate of Nigeria put it. Leaders who attend or who support the process from their capitals have the opportunity to secure better education, more robust workforces, healthier communities and more resilient economies. The cost of inaction is measured, of course, in lost sight, but it is also measured in lost human potential. The Global Summit for Eye Health on November 2 is the moment to make the world see the value of vision and leave a legacy to be proud of. Future generations will look back on it as a pivotal moment in improved vision care.

REFERENCES 1. Stern J. The Value of Vision: The case for investing in eye health. IAPB Vision Atlas. September 24, 2025. Accessed on August 4, 2026. 2. Global Summit for Eye Health. Making the world see the value of vision. IAPB. Accessed on August 4, 2026. 3. Global Summit for Eye Health. World Bank collaboration sets foundation for scaling investment in eye health. IAPB. April 16, 2026. Accessed on August 4, 2026.

Similarly, April saw a critical meeting in Bangkok, where 70 leaders from government, development partners and the eye health community gathered for a South Asia and Western Pacific Regional Consultation. Dr. M.A. Muhit, the Bangladesh State Minister for Health and Family Welfare, called on nations across the region to advance cooperation, share expertise and make meaningful contributions to the upcoming Global Summit this November. Financial institutions are also backing the movement towards broader eye care. The World Bank and the Vision Catalyst Fund (VCF) are working together to build a new financing approach that will help integrate eye care into national health systems. The IAPB is a founding partner of the VCF, alongside other international eye health organizations. Catalytic philanthropic capital can unlock larger-scale government and World Bank financing to help integrate eye care into national plans. “This new financing mechanism is an important milestone on the road to the first-ever Global Summit for Eye Health,” Thompson noted. A LEGACY OF VISION The Summit is both the culmination of world action and a beginning towards improved coordination and accountability. It offers leaders a once-in-a-generation platform to take paper commitments and make them a reality. The tools, evidence and political architecture are all coming together. What’s needed next is the will to pledge and act—specifically, measurably and publicly.

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ENLIGHTENMENT

Cannula detachment may be the most under-reported complication in cataract surgery, and the law is quietly catching up with it. The problem, turns out, wasn’t the people in the room. It was the device in their hands. By Mr. Amar Alwitry

SEPTEMBER 2026

ENLIGHTENMENT

It happens in a heartbeat. You’re hydrating the wound or injecting viscoelastic when the cannula, perfectly behaved until that instant, parts company with its syringe and is driven into the eye under the very pressure you’re applying. What follows ranges from a startled pause to posterior capsule rupture, vitreous loss, a dropped nucleus, a retinal tear or an eye that never sees well again.

Then comes the silence. Everyone in the OR knows what just happened, and everyone reaches for the same verdict before a word is spoken: someone didn’t tighten it properly. Then comes the silence. Everyone in the OR knows what just happened, and everyone reaches for the same verdict before a word is spoken: someone didn’t tighten it properly. The scrub practitioner who assembled the syringe feels the heat. The surgeon, whose name is on the operation note, carries the consequence. The cannula, the actual instrument of harm, is dropped into the sharps bin, and with it goes any chance of an honest reckoning. A COMPLICATION HIDING IN PLAIN SIGHT If you’ve felt that particular sinking feeling, you are in overwhelming company. In a survey of 551 ophthalmic surgeons I published in the Journal of Cataract & Refractive Surgery last year, 84% had experienced cannula detachment, 78% had witnessed resulting patient harm, half reported ocular damage at the most recent event alone, and 87% said a safety device was needed.1

We have built a connection whose security depends on friction, then a procedure that removes it. Detachment isn’t a freak event, it is the predictable behavior of a lubricated thread under hydraulic load. THE UNDER-REPORTING TRAP The published figures are almost certainly the visible tip of a very large iceberg: the system that should be capturing these events cannot see them. If a syringe plunger seizes, that’s a device failure. A report is filed. A manufacturer investigates. If a cannula fractures, same story. But when the junction between two perfectly compliant devices lets go, nobody owns it. There is no adverse-event category for “the interface failed,” and no manufacturer feels responsible, because neither component malfunctioned on its own. The event is logged as an intraoperative complication, attributed to technique and absorbed into the noise. Then there is shame. No surgeon or scrub nurse wants to file a report that reads, in effect, I didn’t tighten the cannula. So they don’t. In more than thirty serious medicolegal cases of cannula detachment I have personally reviewed, a regulatory adverse-event report was filed in precisely none of them. Not one. The complication is both endemic and invisible, and the invisibility is what has let it survive untouched for so long. THE LAW IS MOVING Here, I have to put on my medicolegal hat. The standard of care in negligence is not fixed. The Bolam test4 asks what responsible practice was at the time, but the time keeps moving, and the standard moves with it. Once an effective, affordable safeguard exists and is known to exist, continuing without it stops being a defensible clinical choice and starts being an indefensible one.

We have lived through exactly this transition before, with the instruments in our own hands.

These are not the numbers of a rare edge case, they describe something that has happened to almost everyone reading this. The Royal College of Ophthalmologists has issued two formal safety alerts flagging a continued trend of incidents. 2 Published analysis in Eye this year put the global burden of this single complication at around US$204 million a year, and the United Kingdom alone at £6.56 million.3 THE SLIPPERY TRUTH Here is the detail that ought to keep us awake. We rely, for safety, on a threaded friction fit between cannula and syringe, and then we inject through it one of the most effective lubricants in the building. Viscoelastic coats the Luer threads it passes over; the very substance we are delivering greases the joint we are trusting to hold.

We have lived through exactly this transition before, with the instruments in our own hands. The Luer lock displaced the simple slip fit precisely because a more secure connection became available; at that point, the old way became the negligent way. The logic now points one rung further up the same ladder. Two consequences follow that the profession needs to hear clearly. First, a warning does not discharge the duty. Telling

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surgeons to “hold the hub” or “check it’s tight” does not protect a supplier once a device that actually prevents the failure is on the market, you cannot warn your way out of a hazard you could have engineered out. Second, the exposure does not stop at the surgeon. Under productliability principles, responsibility for a foreseeable, preventable failure reaches back to the people who designed and assembled the pack. As I argued in Eye,3 where a simple, cheap and effective solution is available, failure to use it would be deemed a potential breach of the duty of care owed to the patient, something for the courts to decide, not me. That standard is shifting whether we acknowledge it or not, and the surgeon is the last person who should be left holding the liability. AN ENGINEERING ANSWER FOR AN ENGINEERING PROBLEM To industry’s credit, the problem has been half-acknowledged. One major OVD manufacturer has added a screw cap to its viscoelastic syringe. Another offers a clip on a single product line. Both are tacit admissions that the bare Luer lock isn’t safe enough. But each protects exactly one syringe, the premium viscoelastic, while the five or six other syringe-cannula assemblies on the trolley—for balanced salt solution, intracameral antibiotic, anaesthetic and hydration—are left unguarded. We have armored the one junction that detaches least and ignored the many that detach most.

Declaration of interest The patient safety concern described here arises from many years of clinical and medicolegal practice and predates any commercial interest. In response to it, I have been working with specialist medical device manufacturers towards the development of a device to prevent this complication, and I therefore declare a commercial interest in this area. All data cited refer to independently published, peerreviewed sources.

REFERENCES

1. Alwitry A. Prevalence of cannula dislocation during cataract surgery: a survey. J Cataract Refract Surg. 2025;51(11):1034-1036. 2. Royal College of Ophthalmologists. Ophthalmic Safety Alert: Detachment of Cannulas During Ophthalmic Surgery. London: RCOphth. 3. Alwitry A. Cannula detachment—a solution to a significant patient safety and health economic issue. Eye (Lond). March 24, 2026. 4. Bolam v Friern Hospital Management Committee [1957] 1 WLR 582.

CONTRIBUTOR

This is solvable. It is, in fact, one of those rare chances in surgery to completely prevent a complication rather than merely reduce it. A secondary mechanical capture at the interface, applied universally across every syringe and size, would close the gap altogether. The technology is not exotic. The will to deploy it across the whole pack is what’s been missing.

Mr. Amar Alwitry Consultant ophthalmologist, medicolegal expert and author of Complaints, Litigation and Clinical Errors. amaralwitry@btinternet.com

So, to the people who make and assemble what we use: engineer it out. Not on one flagship product, but across the entire pack. We have spent two decades pointing at the person holding the syringe. The cannula, and the slick of viscoelastic on its threads, has been telling us the truth the whole time. It’s time the industry, and the law, finished the sentence.

SEPTEMBER 2026

ENLIGHTENMENT

ESSILORLUXOTTICA SHOWCASES AN INTEGRATED

SCIENTIFIC ECOSYSTEM ACROSS THE EYE CARE CONTINUUM AT ARVO 2026 Sponsored by EssilorLuxottica

EssilorLuxottica marked a major milestone at ARVO 2026, presenting for the first time an integrated vision care and med-tech ecosystem through a coordinated scientific program spanning the entire eye care continuum. Combining capabilities in vision care and medical technologies—including Heidelberg Engineering, RetinAI and Espansione—the Group demonstrated how it integrates technologies, data and clinical expertise within a unified, science-led ecosystem. This integrated model brings together myopia management and vision science, advanced diagnostics, AI-driven analytics and technology-enabled therapeutic solutions to support more holistic, data-driven patient care. At ARVO, EssilorLuxottica presented over 20 peer-reviewed scientific abstracts, underscoring the depth of its research and its contribution to the global scientific community. “The integration of advanced imaging, AI-driven analytics and therapeutic technologies is transforming how we understand and manage eye diseases,” said Norbert Gorny, Chief Scientific Officer, EssilorLuxottica. “At ARVO 2026, we demonstrated how these capabilities enable a more connected and data-driven approach to eye care, from earlier detection to more informed patient management.”

The integration of advanced imaging, AI-driven analytics and therapeutic technologies is transforming how we understand and manage eye diseases.

STRENGTHENING THE INTEGRATED EVIDENCE BASE IN MYOPIA MANAGEMENT AND VISION CARE Across 12 myopia-focused abstracts from both EssilorLuxottica and independent research, findings from randomized controlled trials, long-term follow-up, real-world clinical practice, combination approaches, and mechanistic research reflected the shift towards integrated evidence in myopia management and more personalized approaches to care. Long-term results from a 7-year follow-up study of Essilor® Stellest® lenses†(spectacle lenses with highly aspherical lenslets or HAL lenses) in China demonstrated sustained efficacy in children and adolescents. The lenses† slowed myopia progression by 2.30 D and axial elongation by 0.92 mm on average for all subjects over seven years.1 The outcomes, observed in adolescents up to 19 years of age, also showed a reduced risk of developing high myopia over

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seven years compared with single vision lenses, highlighting the importance of continued intervention throughout adolescence.

lenses15, potentially supporting the development and evaluation of future myopia control lens designs.

These long-term findings were complemented by data from a prospective, randomized multicenter clinical trial conducted in the United States on Essilor® Stellest® lenses† among children aged 6 to 12, demonstrating a 71% slowdown in myopia progression and a 53% reduction in axial elongation over two years.2 Essilor® Stellest® lenses†received U.S. FDA market authorization in September 20253 and are currently the first and only spectacle lenses authorized in the U.S. for specific pediatric myopia indications.

Additional research explored key areas of vision science and clinical practice. These included ultra-fast light-adaptive lens performance and contrast sensitivity recovery16,17, binocular refraction methodology (Vision-R® 800)18 , and functional near addition requirements in young presbyopes.19

Efficacy was observed across all age groups and baseline myopia levels, with stronger effects seen in younger children.4 The study also demonstrated a favorable safety profile, stable visual acuity, high compliance and retention over two years.5 Analyses indicated no impact on the rate of astigmatism change over two years 6, consistent with previous findings in Chinese pediatric populations.7,8 A review of published evidence across 26 studies, including 17 in China showed consistently lower axial elongation in children wearing HAL spectacle lenses compared with single vision lenses over one year, regardless of study design or location.9 These results highlight the consistent efficacy of Essilor® Stellest® lenses†across clinical settings and populations. Real-world evidence presented at ARVO 2026 and later published in Ophthalmology Science10 further reinforced these findings, showing that different spectacle lens designs slowed myopia progression in clinical practice compared with single vision lenses. HAL spectacle lenses incorporating H.A.L.T.* technology was associated with the largest reduction in axial length in this retrospective cohort study. Real-world evidence in children with low myopia further supported HAL lenses as showing the most robust myopia progression control effects across spectacle lens designs.11 Research presented also highlighted evolving approaches to myopia management. An independent study showed that combining HAL spectacle lenses with low-dose atropine maintained strong myopia progression control over 24 months, compared with atropine alone.12 A large school-based study in Shanghai demonstrated that combined interventions, including HAL spectacle lens wear and increased outdoor time, may help reduce incident myopia and slow axial elongation in myopic and pre-myopic children.13 ARVO 2026 also highlighted EssilorLuxottica’s continued innovation in understanding myopia development and in potentially predicting how well a myopia progression control lens will slow eye growth. Research presented explored how the retina may use chromatic contrast cues to detect defocus, contributing to a growing understanding of the mechanisms involved in myopia progression.14 A separate study demonstrated that retinal contrast metrics may be used to predict the efficacy of myopia control

FROM ADVANCED IMAGING & AI ANALYTICS TO THERAPY: A COLLABORATIVE PATH EssilorLuxottica also presented innovative technologies and products in medical technologies across multimodal imaging with ultra-high resolution OCT, surgical solutions, data management and AI-powered analytics, and therapeutic solutions. Heidelberg Engineering presented their Multimodal Imaging Platform with Ultra-High Resolution OCT‡ designed to deliver unprecedented image quality with enhanced confocal scanning laser ophthalmoscopy imaging20 and with sub-2 µm axial resolution OCT imaging in first-in-human clinical imaging21—marking a new era in imaging. Additional innovation presented by Heidelberg Engineering was Heidelberg OPERA, its fully digital surgical microscope with cutting-edge intraoperative OCT.‡ By providing real-time visualization during surgery, Heidelberg OPERA was designed to enhance surgical precision and contribute to the future of digital ophthalmic surgery. Advancements for the established platforms SPECTRALIS®, ANTERION® and HEIDELBERG EYE EXPLORER with Heidelberg AppWay were also part of the innovative footprint of the company. Heidelberg Engineering aims to empower clinicians and researchers worldwide and enable research in ophthalmology. 200+ posters and papers presented at ARVO using Heidelberg Engineering’s various technologies underline the scientific contribution these technologies have in ophthalmology. Furthermore, Heidelberg Engineering and RetinAI showcased the first true automated DICOM workflow between their respective platforms from advanced multimodal imaging with ultra-high resolution OCT to AI- driven insights. The imaging platform with Ultra High-Resolution OCT enables automated data transfer from image acquisition to secure cloud upload and seamless AIgenerated analysis in the RetinAI Discovery® platform. RetinAI showcased its Discovery platform, an AI-first clinical and research solution, featuring new applications for large scale data analysis and clinical studies using AI-driven retinal analysis. This robust series of abstracts and presentations included RetinAI OCT Atlas®, RetinAI’s latest CE-marked AI model for OCT analysis, predictive modeling of geographic atrophy progression, identification of structural biomarkers associated with functional, visual outcomes, and automated workflows for candidate identification in clinical studies. In addition, RetinAI presented their first AI powered screening model LuxIA®, to detect more than mild diabetic retinopathy (mtmDR) from color fundus images in adult diabetics. The research publications featuring

SEPTEMBER 2026

ENLIGHTENMENT

RetinAI Discovery® collectively signal a paradigm shift in retinal care moving from manual, reactive observation to automated, predictive, and personalized medicine. Espansione Group highlighted the breadth of its light-based therapeutic platform, eye-light® † , which combines Light Modulation™ (LM™ LLLT (PBM)) with Optimal Power Energy™ (OPE™ IPL). Anchoring the program were 12-month follow-up results in intermediate age-related macular degeneration, showing photobiomodulation-induced choriocapillaris perfusion enhancement and outer retinal remodeling. 22 Yet, the scientific footprint extended beyond AMD, as new evidence explored photobiomodulation as a treatment option in chronic central serous chorioretinopathy23, pointing to potential across additional retinal indications. On the ocular surface, periocular LM™ LLLT was evaluated for its capacity to enhance tear film stability and modulate inflammatory biomarkers after cataract surgery24, with preliminary data also presented in patients with Graves’ orbitopathy associated ocular surface disease25 and in a pilot pediatric cohort with meibomian gland abnormalities. 26 Across retinal disease, ocular surface disease, peri-operative care, and other emerging applications, this continuum positions light-based medicine as the therapeutic node within a connected, science-led approach that turns earlier insights into earlier, more informed action.

AN INTEGRATED SCIENTIFIC ECOSYSTEM ACROSS THE EYE CARE CONTINUUM EssilorLuxottica’s presence was anchored by a unified exhibition space, bringing together for the first time its Vision Care and Medical Technologies expertise within a single booth, including Heidelberg Engineering, RetinAI and Espansione. This unified presence reflects a coordinated scientific approach that brings together vision science and medical technologies into a single ecosystem. At the booth, expert-led talks powered by Leonardo, EssilorLuxottica’s learning ecosystem, fostered scientific exchange and evidence-based discussions on key topics shaping the future of eye care. From managing myopia, advanced diagnostics, to enabling technology-driven solutions, the Group demonstrated how its capabilities span the full continuum of eye care. The Group also hosted two Exhibitor Education Forum sessions, bringing together internal and external experts to discuss multi-year clinical outcomes in myopia management and the collaborative pathway from advanced imaging and AI-driven analytics to therapeutic approaches. “ARVO 2026 marks an important step in advancing our research in vision science and ophthalmology,” said Olga Prenat, Head of Medical & Professional Affairs at EssilorLuxottica. “By presenting new clinical and scientific findings across vision care and medical technologies, we strengthen the evidence base for clinical practice—supporting better insights, decisions and outcomes for patients.” By presenting new clinical and scientific findings across vision care and medical technologies, we strengthen the evidence base for clinical practice— supporting better insights, decisions and outcomes for patients.

These developments highlight the growing role of advanced imaging, AI-driven analytics and device-based technologies in enabling earlier insights, enhancing clinical decision-making, and supporting more personalized patient care. “Heidelberg Engineering’s pioneering work in Multimodal Imaging with Ultra High Resolution OCT and fully digital surgical microscopy is opening a new era in imaging and surgery; together with RetinAI’s AI-powered capabilities to generate insights and Espansione’s treatment options, we are transforming science into meaningful impact for patients, clinicians, researchers, and the future of eye care”, said Ettore Mosca, Head of EssilorLuxottica Medical Technologies. Heidelberg Engineering’s pioneering work in Multimodal Imaging with Ultra High Resolution OCT and fully digital surgical microscopy is opening a new era in imaging and surgery; together with RetinAI’s AI-powered capabilities to generate insights and Espansione’s treatment options, we are transforming science into meaningful impact for patients, clinicians, researchers, and the future of eye care.

From Vision Care to Eye Care: EssilorLuxottica's Connected Eye Care Ecosystem | ARVO 2026

Editor’s Note A version of this article was first published on MediaMICE.com.

CAKE

REFERENCES * H.A.L.T. Highly Aspherical Lenslet Target. H.A.L.T. is an acronym for Highly Aspherical Lenslet Target and does not imply a “halt” or “stop” of myopia progression. † Regulatory status and product availability may vary by country. U.S. FDA authorization and indications for use are based solely on clinical trial data from the U.S. ‡ In development. Not for clinical use. Can only be made available once it has regulatory clearance § Essilor® Stellest® 2.0 lenses are currently not available in all countries, including the United States, and have not been cleared by the FDA in the U.S. 1. Li X, et al. Myopia control efficacy of spectacle lenses with highly aspherical lenslets: results of a 7-year follow-up study. ARVO 2026 Annual Meeting; 2026 May 3-7; Ret Denver, CO. Poster 0968

15. Hamlaoui S, et al. Predicting the efficacy of myopia control lenses by simulating their optical effect on the retina. ARVO 2026 Annual Meeting; 2026 May 3-7; Denver, CO. Poster 4646.

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