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HIGHLIGHTS to do when cataract 05 What and glaucoma co-exist? out Ophtec’s brand 08 Check new toric lens sneak peek at ASRS 14 A2021...

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he 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021) kicked off on October 8 and featured a welcome from Prof. Rudy Nuijts, president of ESCRS. We likely don’t need to inform you that the ophthalmic summit industry has been a tumultuous one lately — so making the decision to have an in-person conference was a bold one indeed. As Prof. Nuijts noted, the organization decided to make this conference a hybrid model way back in March. We applaud the move and Cont. on Page 3 >>

GEUDER kindly invites you to a LIVE DEMO at ESCRS BOOTH NO. A42 / HALL 12 DMEK RAPID Advantages of Preloaded Descemet Membrane and Implantation Techniques Prof. Peter Szurman, MD Augenklinik Sulzbach, Germany K. Heimann Eye Research Institute (KHERI) Saturday, 9 Oct, 11:00 - 11:30


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09 October 2021 | Issue #1

Vision

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CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Dr. Auffarth began by paying homage to his mentor, Dr. David J. Apple, a pioneer of IOL pathology. Since all ophthalmology is built on those that came before, we like to see recognition of the giants of the past by the giants of the present. Dr. Auffarth is continuing and extending Dr. Apple’s work by working on optics, biomaterial chemistry, and more. Dr. Auffarth’s understudies are spread throughout the world, with more than 100 full-time research fellows scattered around the world. It’s wonderful to see legacies spread and grow. So, back to the “free lunch” analogy. What does he mean?

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Essentially, in optics, you can’t have it all. In treating presbyopia, for example, Dr. Auffarth noted there are three interrelated concepts to balance: visual quality, depth of field and dysphotopsia. Increasing depth of field and range of vision has its tradeoffs, and you can maximize visual quality by minimizing optical aberrations. ee

Our friend Dr. Ruth LapidGortzak brought these titans of ophthalmology to our attention to introduce the speaker for whom the award given in this session was named: Cornelius Binkhorst, who created an iris-supported lens — which was revolutionary at the time — and on the forefront of cataract surgery. Dr. LapidGortzak also gave a nod to Jan Worst, recently passed as of 2015, who “was a genius man who really invented a lot of stuff,” as Dr. LapidGortzak put it.

The 2021 ESCRS Binkhorst Medal Lecture was given by Dr. Gerd Auffarth. Dr. Auffarth is a holder of numerous titles, has received more than 200 awards for his scientific work, and has published more than 300 peerreviewed publications. To list all of his achievements here would be a bit of overkill, so let’s just say he’s been a busy and successful ophthalmologist.

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And sweet this conference shall be, we expect — and its location in Amsterdam is significant because of the massive contribution to optics made by the Dutch. From the inventor of the microscope Anton van Leeuwenhoek, to other lens makers like Baruch Spinoza, ophthalmologists like F.C. Donders, and Herman Snellen, who gave us critical tests in the field.

Chromatic aberration is something to take into account as well. Longitudinal chromatic aberration (LCA) causes shorter wavelengths to be focused in front of longer wavelengths, resulting in a difference of focus.

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The Dutch punch above their weight ophthalmologically

The Binkhorst Award Lecture: There’s no free lunch in optics

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With 100 exhibiting companies, 117 exhibitors and sponsors — 10% of whom are virtual only — and 26 symposia, including 4 online only, the hybrid model appears to be a robust one. Rather than choose between ice cream or cake for dessert, well, why not both?

field are inextricably linked. Interestingly, while halo is caused by optics, flare and starburst are caused by something else. In terms of halo, the greater the defocus, the greater the intensity of the dysphotopsia. Hence the term “no free lunch.”

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The “hybrid” part of the model shows robust attendance in both virtual and face-to-face attendance. Statistics provided by Prof. Nuijts show around 2,500 fully virtual participants, and just over 4,000 in-person attendees — essentially a 40/60 split. That’s quite reasonable on all counts, and demonstrates that ophthalmic conferences don’t have to make a choice between being in-person or online only.

Dr. Lapid-Gortzak literally grew up in ophthalmology: Her mother brought her to the clinic since there was no daycare when her mother was in residency. Connections run deep — her mother was the teacher of Prof. Nuijts.

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are happy things are getting back to normal — though normal now includes a hybrid online component. And why wouldn’t it?

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>> Cont. from Page 1

Glare/flare, halo and starburst are directly related, almost like a mathematical model, Dr. Auffarth calmly exclaimed. Dysphotopsia and depth of

Both the cornea and the natural lens contribute to LCA, as can IOLs. IOL materials can create different effects in LCA in dispersion, which can be expressed in diopters. Refractive optics produce a given amount of aberration, but diffractive optics can be used to manipulate aberration — to reduce and disperse it.

“Chromatic aberration is something to take into account as well. Longitudinal chromatic aberration (LCA) causes shorter wavelengths to be focused in front of longer wavelengths, resulting in a difference of focus. ” The type of material used in lenses can change the amount of aberration significantly, Dr. Auffarth noted. For example, hydrophilic materials have a lower impact than hydrophobic materials. From one-quarter of a diopter up to 1 diopter can be induced just by the material. Also, the larger the dispersion of LCA is, the more visual quality is lost, and vice versa. Again, no free lunch. There’s much more to get into here, and we’ll do so in one of our online articles. Dr. Auffarth’s work extends to fMRI evaluation for neuroadaptation of multifocal IOLs. He noted that the vast majority of visual processing occurs in the brain, not the eyes — so there’s much more to examine than the eye itself. For us, there’s much more to ESCRS 2021 to examine as well, and we’re looking forward to it.

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09 October 2021 | Issue #1

The latest portable PXL Systems made in Switzerland by PESCHKE Trade The latest portable PXL Systems made in Switzerland by PESCHKE Trade

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Highlights: PXL options Platinum at 330  Variable treatment different energy levels  Continuous, interval and LASIK modes Highlights:  Self-calibrating and self-adjusting  5” Color touch screen  Variable treatment options at different energy levels  Continuous, interval and LASIK modes The PXL Platinum additionally offers:  Self-calibrating and self-adjusting  5” touch screen EyeColor tracking with adjustable real time camera view

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 Bluetooth communication interface + treatment PDF report The PXL Platinum additionally offers:  Integrated ultrasound contact Pachymeter optional  Eye tracking with adjustable real time camera view treatments are easy to perform, safe for the patient, and can be combined with other medical therapies.  CXL Bluetooth communication interface + treatment PDF report SAFE – EFFECTIVE - FLEXIBLE PXL Sapphire 318  Integrated ultrasound contact Pachymeter optional These fully portable and ergonomically designed systems come with an adjustable table mount and a sturdy transport CXL treatments are easy to perform, safe for the patient, and can be combined with other medical therapies. case. These are open systems, i.e. no activation cards, no barcodes, no treatment fees, and the treatment protocols are SAFE – EFFECTIVE - FLEXIBLE PXL Sapphire 318 included. They are considered being the best high-end portable and user-friendly devices on the market according to Swiss, European and global users. No other portable system comes with an eye tracker and custom treatment mode. These fully portable and ergonomically designed systems come with an adjustable table mount and a sturdy transport case. These are open systems, i.e. no activation cards, no barcodes, no treatment fees, and the treatment Our PXL systems contain a built-in communication technology, allowing to communicate across systems protocols are included. are considered being the best high-end portable and user-friendly devices on the market according to (i.e. exportThey of generated treatment reports). Swiss, European and global users. No other portable system comes with an eye tracker and custom treatment mode. CXL – The Experience Our PXL systems contain a built-in communication technology, allowing to communicate across systems (i.e. export of generated treatment reports). In recent years corneal cross-linking has become the standard procedure for treating patients with progressive

keratoconus and other ectatic corneal diseases because of its effectiveness and lack of serious side effects. A large CXL – The Experience number of major clinical studies has proven the effectiveness of CXL and the lack of serious side effects. More than 85% of the eyes treated with CXL showed a significant increase in BCVA. In recent years corneal cross-linking has become the standard procedure for treating patients with progressive keratoconus and other ectatic corneal treatment diseases because of its effectiveness and lack serious sidedisorders effects. A(such largeas CXL is the only effective non-invasive to stop progressive Keratoconus andof other ectatic number of major clinical studies has proven the effectiveness of CXL and the lack of serious side effects. More than PMD and iatrogenic ectasia) and has a regularisation effect on corneal topography. 85% of the eyes treated with CXL showed a significant increase in BCVA. In addition to its role in treating ectatic corneal diseases, CXL has an established place in the management of CXL is the keratitis. only effective non-invasive treatment tofor stop and other ectatic disorders (suchand as infectious UV light has long been known itsprogressive ability to killKeratoconus different micro-organisms (such as bacterial PMD and iatrogenic ectasia) and has a regularisation effect on corneal topography. fungal). Since keratitis in humans is an important cause of blindness, and antibiotic resistance is an increasing problem worldwide, CXL proves to be an extremely valuable possibility to manage the condition with a satisfactory In addition to its role in treating ectatic corneal diseases, CXL has an established place in the management of Outcome. infectious keratitis. UV light has long been known for its ability to kill different micro-organisms (such as bacterial and fungal). Since keratitis in humans is an important cause of blindness, and antibiotic resistance is an increasing problem worldwide, CXL proves to be an extremely valuable possibility to manage the condition with a satisfactory Outcome.

Ergonimic, flexible table mount

The PXL systems come in a sturdy transport case


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

Cataract and Refractive and Glaucoma Surgery, Oh My! D by Sam McCommon

ay 1 of the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021), a hybrid conference, featured the traditional Journal of Cataract and Refractive Surgery (JCRS) symposium. Now, you may not be surprised to hear that cataract and refractive surgery was covered in this symposium — but you may also not be surprised to hear that glaucoma was involved too. The level of surprise is up to you, really. Just how bombastic of a headline are we supposed to write here?

For now, we’ll start with the two presentations on managing cataract and glaucoma — because crossover episodes are popular on TV, so why not in ophthalmology?

good reason. He headed up a significant study in selective laser trabeculectomy (SLT) in the form of the laser in glaucoma and hypertension (LiGHT) study which, in our view at least, has elevated him to a fair bit of celebrity.

He began his talk with a problem: Cataracts and primary open-angle glaucoma (POAG) frequently co-exist. They’re both age-related diseases with exponential increase in prevalence with age. So, Prof. Gazzard asked, why not simply treat lens opacity and then IOP? For example, why not use phaco and then follow up with medication or laser or surgery as needed?

Managing coexisting cataract and glaucoma: Laser, meds or MIGS?

The answer here is that phacoemulsification alone — even clear lens extraction — has been shown to reduce IOP. As Prof. Gazzard noted, 61% of lens extraction patients were drop-free after phaco at three years versus the control group. It’s more cost-effective long-term, to boot.

Prof. Gus Gazzard, from the University College of London, has been a regular in recent symposia and publications, and for

Even compared to MIGS procedures like the iStent (Glaukos, California, USA),

clear lens extraction holds up well. One study presented by Prof. Gazzard shows 50% of phaco-only patients are drop-free compared to 61% of phaco plusiStent patients; similarly, another study shows the same 50% versus 72%, respectively. Yes, MIGS add some drop-free-ness to patients’ lives, but not that much more than phaco alone. Prof. Gazzard continued that, at 36 months postoperatively, phaco patients exhibited a mean 16.5% or 4mmHg reduction in IOP. The higher the presurgery IOP, the higher the reduction. Phaco alone is even associated with a reduction in IOP at three years postoperatively. There are a web of interactions that muddy the waters in dealing with lens opacity and IOP. These include the interactions between cataract surgery and IOP reduction, bleb function or later trabeculectomy success. But what’s so wrong with medical Cont. on Page 6 >>

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09 October 2021 | Issue #1

>> Cont. from Page 5

treatment? Why discount drops? As Prof. Gazzard noted, there are noticeable barriers in compliance, persistence and adherence to medical use. A whopping 33% of patients discontinue or change their treatments within the first year, there are reduced surgical success rates following medication, there’s the risk of tachyphylaxis, and then there’s the ongoing cost of medication. Those all add up. Additionally, as we’re learning more and more, preservatives found in eye drops can do bad things to the eyes. Benzalkonium chloride (BAK), commonly found in eye drops, is associated with worsening ocular surface disease, direct and indirect ocular damage, and chronic inflammatory diseases. If that doesn’t make you say yikes, well … you should probably say yikes. Of course, there are many other treatments for glaucoma and hypertension than just phaco. We’ve heard Prof. Gazzard argue in favor of SLT before, and we’re struggling to find arguments against him. He suggests

offering SLT to all newly diagnosed POAG/OHT as a primary treatment. Furthermore, he suggested that it should be considered for patients not happy on their drops, and noted that it can be successful with repeat treatment. However, it’s probably less successful for those with uncontrolled IOP on multiple medications. What about phaco and trabeculectomy, though? Prof. Gazzard notes that phaco after trabeculectomy presents a significant failure rate, to the tune of 50% fewer patients achieving pressure control one year after surgery. Phaco combined with trabeculectomy is controversial, with a greater complication and lower success rate than the treatments alone. MIGS, however, seems to hold up much better against phaco patients. Prof. Gazzard favors a Hydrus stent (Ivantis, California, USA).

Managing cataract and glaucoma with phaco and MIGS Dr. Kuldev Singh, from Stanford University, argued that, while modern cataract surgery does indeed lower IOP,

MIGS procedures can be combined with cataract surgery. Specifically, canalbased implantable MIGS procedures are generally safe. But why not just use a combination of medications and lasers? Simply put, as Dr. Singh said, patients don’t take their meds. This is especially true of patients with mild to moderate glaucoma, which becomes more problematic over time as glaucoma is an age-related disease, set to grow exponentially over the next several decades. With people living longer, this leads to more serious roadblocks down the … well, road. Dr. Singh pointed out that each eye only undergoes one cataract surgery procedure — you can’t remove a lens twice. Adjunctive implantable canalbased MIGS procedures have been shown to safely lower IOP greater than cataract surgery alone, he said, and there is only one opportunity per eye to do such a combined procedure. Furthermore, a phaco/MIGS procedure does not preclude future IOP lowering options. Ultimately, he said, the decision should be made by the patient. Whereas traditional medicine relied on provider-led treatment decision-making, the internet has allowed patient empowerment through information. This development has led to the current doctor-patient relationship, which resembles more of a partnership between the patient and healthcare provider in treatment decision making. In summary? Dr. Singh suggests cataract surgery combined with canal-based MIGS and further treatment guided by postoperative observation. It all has to be personalized, of course.

Leaps and bounds

Lions and tigers and cataracts and glaucoma?

There have been significant advancements made in all forms of cataract and refractive surgery, and the relationship between glaucoma and these conditions is one that is set to be more important in coming years as the world’s population ages. The more tools doctors have in their toolkit, the more prepared the ophthalmic community is to handle changes. Kudos to the presenters in this symposium, and we look forward to delving deeper into their ideas further in the future.


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A curcumin-based adjuvant treatment for retinal inflammatory disease CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

High retinal bioavalability Reduced retinal vascular leakage Clinically detectable effects Recommended dosage: 2 capsules once daily

For more info please contact www.alfaintes.it


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09 October 2021 | Issue #1

Get vision at all distances with the Precizon Aspheric Presbyopic IOL.

Ophtec Introduces a Brand New Toric Implant by Elisa DeMartino

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his year is a milestone for the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021), which is being held for the first time in a hybrid format, both in-person and virtually. Let it be known though, that this year also marks a milestone in hybrid presbyopia correction! Earlier this summer, Ophtec B.V. (Groningen, the Netherlands) released a toric version of their Precizon Aspheric Presbyopic intraocular lens (IOL), designed to correct both presbyopia and astigmatism with improvements on some of the main challenges of treatment. Ophtec exhibited their new IOL on Day 1 of ESCRS 2021 and Media MICE was there to check it out in-person. Walter Nazaire, Ophtec’s energetic and

informative export manager, welcomed us warmly to their booth to describe what exactly makes Ophtec’s premium IOLs so innovative.

A more natural vision experience Like previous lenses in the Precizon IOL family, the latest toric version utilizes Ophtec’s patented Continuous Transitional Focus (CTF) technology to shape the entire anterior and posterior lens surfaces using multiple segments. Transitional zones of the CTF optic offer a full range of vision from near to far with a smooth transition that enables natural

vision at all distances. This creates an elongated focus between two sharp focus points that delivers excellent intermediate vision as well. The multifocal CTF optic is an elevated concept that Ophtec considers one of its key selling points. “It’s not like bifocal IOLs, with one segment for far and one for near,” Mr. Nazaire told us. “If the lens is decentered, you don’t have the segment for near or far. Here, it’s a totally different concept.” The unique concept of the multi-segmental optic between close and distance transitions between both powers; it defocuses near and far off vision to then deliver excellent intermediate sight.

Addressing toric alignment problems For toric lenses, combining this feature with the transitional conic toric (TCT) surface creates a tolerance of misalignment in the lens because of the different conic constants being calculated — not only on the horizontal and vertical axis, but between 0- and 90-degrees, as well.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

In an ideal world, candy would be healthy, we would all be millionaires, and toric IOLs would always be perfectly aligned on the intended axis and thus, work really, really well. Unfortunately, we don’t live in a perfect world, so this Media MICE writer can’t eat chocolate for breakfast, lunch and dinner — and more importantly, in a significant number of cases, IOLs rotate a few degrees before stabilizing. The effect of misalignment severely reduces visual acuity: for every degree of rotation, vision quality reduces by 3%. That is, if a lens is misaligned by 5-degrees, vision would be affected by about 15%. Ophtec patented their unique TCT solution to overcome this shortcoming of standard toric IOLs and the unique design is considerably more forgiving of misalignment. In comparison, when Precizon’s toric lens is rotated by 5-degrees, it results in an 8% quality of vision reduction instead. This is all thanks to those good ol’ CTF segments, which allow an equal and steady light distribution in case of rotation or tilt. When it comes to the non-toric Precizon multifocal lenses, they can be installed and swiveled depending on where the visual axis is — removing this issue altogether.

Starbursts: Yes to the sweets, no to the glare Ophtec is proud to report that their Precizon lenses reduce the symptom of glare and halo in vision, especially in night-vision, due to the refractive multisegment optic. “When we started our multifocal project four years ago, we looked at what was available on the market and finally decided to go for a different technology. We didn’t go for trifocal because we knew from market feedback that these kinds of diffractive optics induce halos and glare. So we stuck to a refractive concept,” Mr. Nazaire explained. “For me the best achievement we have with this lens is definitely the low ocular lens inducement of glare and halos,” he enthusiastically continued, “because this can be tricky for patients receiving other IOLs. Definitely at night for truck drivers or taxi drivers, having glare and halos around the light is not convenient. Once

the lens is implanted you cannot correct the glare and halo. So, I’m pleased we have this IOL providing those features.” Thanks to the segment method instead of concentric rings, these dreaded photonic phenomena are reduced to let patients adapt more easily to their new vision.

Precizon offers ease of use for patient and surgeon alike It’s quite clear by now that the Precizon family of IOLs grant considerable vision benefits for the patient in terms of glare reduction, misalignment tolerance and kappa angle tolerance, but there are also some additional features for the surgeon. “We have a fully independent, pupilindependent IOL, but it’s not enough,” said Mr. Nazaire. “So, what we learned from our experience with different companies is that it’s not only about the lens, it’s about the preoperative management. How do you measure your cylinder, how do you calculate your cylinder with different formulas, different calculators? And you need to bring this knowledge to your customers.”

“One of my customers, a surgeon, decided to go for a Precizon IOL in his eye — it was really an achievement to have one of our customers willing to receive our implants. And he’s very pleased about it!”

The future of IOLs The key takeaway is that Precizon IOLs are a route toward more natural vision at all distances for the patient. As we in the real world are well aware, there’s no magic pill — or magic implant — to solve all problems. But, as our expert reminds us, with careful preoperative management for these premium lenses — and taking into consideration the patient’s demands and compromises, their measurements, eye dryness and other factors that might affect sight — the Precizon Presbyopic and its hybrid toric counterpart are excellent solutions that maximize patient visual acuity and quality of life along with it. Fortunately, the return of ESCRS has coincided wonderfully with the release of the newest Precizon lens, and we here at Media MICE wish only the best for the future of their product. With COVID restrictions easing in many countries and more patients able to seek in-office care, we’re excited to see many more success stories come out of Ophtec.

The expert holds that treating astigmatism isn’t just about getting the right lens. With regard to the toric IOL, it’s a different market approach because when it comes to management Arms of astigmatism, arou leng nd the w more factors th, th o ank s rld can r are involved. e to pr e s by t u r n t o t h opia This includes - corr eir norm a ec tin having enough g IOL l s. knowledgeable staff, the right equipment, and the right measurements to take into account cylinder and astigmatism management. “We are good at self service for calculation. Like other companies, we have an online calculator, but we also have a dedicated department where our colleagues work, and our customers can ask any questions.” In some cases, the advantages of patient and surgeon merge when, as in a case recounted by a pleased Mr. Nazaire, the surgeon is the patient.

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09 October 2021 | Issue #1

Managing Herpetic Keratitis by Tan Sher Lynn

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erpetic keratitis is the most frequent cause of blindness due to corneal disease in the United States and the most common source of infectious blindness in the Western world. Leading experts in corneal disease discussed the diagnosis, medical treatment and cataract surgery considerations for this significant disease on Day 1 of the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021).

Diagnosing herpetic keratitis According to Dr. Marc Labetoulle from

Le Kremlin-Bicêtre, France, about 600,000 in the U.S. and 90,000 in the U.K., Italy and France are affected by herpetic keratitis — and its prognosis is not excellent due to its tendency for recurrence. “Diagnosis is mostly based on slit lamp findings, although it is not so easy because the spectrum of herpetic keratitis is very diverse. It can be epithelial, with different forms like superficial punctate keratitis, dendritic, geographic, limbal or archipelago keratitis. It can be endothelial with different forms like disciform, diffuse

or linear. It can also be stromal or neurotrophic,” he said. Dr. Labetoulle stressed that it is important to distinguish between different types of herpetic keratitis from the very beginning in order to ascertain the correct diagnosis, which is crucial for long-term management. For example, steroids are contraindicated in cases of epithelial and replicative, as well as stromal (necrotizing) and neurotrophic herpetic keratitis. In terms of differentiating between necrotizing and non-necrotizing stromal keratitis, in the former, the cornea is white and opaque and the light of the slit lamp cannot go through, while in the nonnecrotizing form, the cornea is opalescent but translucent. He noted that ideally, biological testing should be used to ascertain the diagnosis.


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

“Serum levels of antibodies are not informative. Conventional diagnostic methods like virus in cultured cells and immunofluorescence are not used anymore because they are timeconsuming, poorly reproducible and not cost-effective. The choice today is gene amplification or PCR, which is by far the most effective method. Possibly, in the future, combining PCR with antibodies in tears could be helpful. “In clinical practice, sampling should be made in case of presumed viral keratitis, such as when an atypical pattern is observed during the slit lamp examination, if there is an atypical medical history, and if the condition is resistant to treatment. A good sampling is an early sampling. Real collaboration with the microbiologist is useful as it is not possible to search and find everything yourself,” he advised.

Medical treatment When it comes to medical management of herpetic keratitis, Dr. Lies Remeijer of the Rotterdam Eye Hospital in the Netherlands said that it depends on whether the condition is caused by viral replication, or both viral replication and pathologic immune response. “If it is viral replication alone, no monotherapy is significantly better than the other. Nevertheless, we need to be aware that topical medications differ in intraocular penetration, which is important when we are treating stromal

keratitis,” she said. She noted that the Herpetic Eye Disease Study (HEDS)* has shown that there’s no place for systemic therapy when topical therapy is already used, as it will not prevent future stromal keratitis or iritis. “When there’s both viral replication and pathologic immune response, we know that, from HEDS, additional oral antiviral therapy in stromal keratitis without epithelial defect shows no difference in time to resolution and best corrected visual acuity (BCVA). Oral antivirals are also ineffective in the acute phase of stromal keratitis. However, in the acute phase of herpetic stromal keratitis (HSK) with epithelial defect and anterior herpetic uveitis, there is a trend of effect. Oral antiviral prophylaxis significantly reduces recurrences of HSK during therapy and there is no rebound after discontinuation of therapy. However, prolonged low dose antiviral prophylaxis predisposes to the development of resistance,” she noted. She added that indications for steroids include moderate to severe inflammatory reaction, active necrosis, active neovascularization, and when the visual axis is threatened. “In conclusion, the guidelines of HEDS (1994-1998) are of paramount importance in treating herpetic keratitis, but it needs some refinement regarding the moment to start steroids and prevent unnecessary endothelial loss. We need to think whether the topical steroids that

we use are really reaching into the deeper layers of the cornea,” she said.

Cataract surgery in herpetic keratitis Performing cataract surgery in eyes with herpetic keratitis can increase the risk for intraoperative and postoperative complications. Hence, according to Dr. Beatrice Frueh from Switzerland, a quiet eye is required for at least three months before performing cataract surgery in eyes with herpetic disease. “If not, the surgery should be delayed. The cornea should also be sufficiently transparent and you need to know if the patient can tolerate contact lens. You need to be open-minded for a possible second surgery, which would be a corneal transplant,” she said. Dr. Frueh noted that everyone, especially HIV patients, are at risk for herpetic keratitis reactivation. Factors that cause cataract surgery to trigger a recurrence include stress and fatigue, corneal incision, postoperative inflammation or prostaglandins, and postoperative drops. In regards to choosing an intraocular lens (IOL), he advice is to keep things simple. “Avoid multifocal or extended depth of focus (EDoF) lenses. Refrain from toric lenses. If contact lenses are well-tolerated, implant a non-toric lens. And inform the patient about possible unsatisfactory refractive or visual results,” she said. She stressed that one should not be afraid of avoiding cataract surgery if one cannot see enough. And in cases of vitreous loss because of poor visualization, one should perform anterior vitrectomy and consider secondary lens implantation combined with corneal transplantation. “Cataract surgery after herpetic keratitis or uveitis can be successful if the eye is quiet, a prophylaxis with systemic antivirals is given (starting a few days before surgery and at least until local steroids are given), and the view through the cornea is good enough to operate safely,” she concluded.

Herpetic keratitis is the most frequent cause of blindness due to corneal disease in the United States and the most common source of infectious blindness in the Western world.

* The Herpetic Eye Disease Study Group. A controlled trial of oral acyclovir for the prevention of herpetic simplex stromal keratitis or iritis in patients with epithelial keratitis. The Epithelial Keratitis Trial. Arch Ophthalmol 1997;115:703.

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09 October 2021 | Issue #1

Early Detection Key in Glaucoma Care by Hazlin Hassan

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ew medical therapies and the importance of early detection were some of the hot topics discussed by experts during the Glaucoma Symposium on Day 1 of the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021).

“Glaucoma is not easily detectable and can thus go undiagnosed, thereby leading to an irreversible loss of vision. Patients experience vision defects in tasks involving central and near vision. Glaucoma is also a significant predictor of depression,” he warned.

Keeping an eye out for glaucoma

“The only sure way to diagnose glaucoma is with a complete eye exam. A glaucoma screening that only checks eye pressure is not enough to find glaucoma,” he added.

Glaucoma is a leading cause of irreversible vision loss, but if intraocular pressure (IOP) is lowered in time, patients either don’t go blind, or the rate of progression is significantly slowed down, said Prof. Roberto Bellucci, former ESCRS president and professor of ophthalmic surgery in Verona, Italy.

The prevalence of glaucoma is high, affecting almost 8 million people in Europe. However, he noted that the number of genes that directly cause glaucoma is limited and that most people who carry genetic risk factors for glaucoma do not develop the disease,

so he does not routinely perform genetic testing. Some of the tests for glaucoma include tonometry, applanation tonometry, phematonometry, gonioscopy and ultrasound pachymetry.Recent studies show that optical coherence tomography angiography (OCTA) may help track progression in advanced primary open angle glaucoma (POAG) in meaningful ways, he shared. “Most vision loss due to glaucoma can be largely prevented if diagnosed and treated early. Adequate testing is required to diagnose glaucoma and establish a baseline. Progression is detected using photographs, imaging and visual fields. New technologies assist in diagnosis and tracking of disease progression,” said Prof. Bellucci. “There is technology. We must use it.”

Longer-lasting glaucoma treatment Poor adherence, tolerability, and difficulty


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

of administration are major barriers to real life efficacy of treatments, began Dr. Andrew Tatham, University of Edinburgh, U.K. But sustained release formulations may help overcome some of these limitations and deliver high concentrations of the drug to the targeted tissue, where they are really needed. “Potential advantages of sustained release medications include improved adherence, improved tolerability, sustained IOP control and higher concentration at target tissue,” he said. Dr. Tatham then shared the results from a multicenter phase I/II 24-month clinical trial of the bimatoprost implant, involving 75 eyes of adult patients with glaucoma. The study eye in each patient received an intracameral implant with bimatoprost, while the control eye received topical bimatoprost. “A proportion of patients had a very sustained effect. At one year, 38% of patients still didn’t require any kind of rescue treatment and at two years, one-quarter didn’t require any rescue treatment. So, why might this be? One potential explanation is the very high concentration of the drug that reaches the target tissue,” said Dr. Tatham. In the ARTEMIS 1 phase 3, randomized, 20-month study of bimatoprost implant in open-angle glaucoma and ocular hypertension, over 80% of patients treated with 3 cycles remained off

additional treatment at 12 months. However, there remain challenges with sustained release medications. There are risks associated with intraocular procedures, the optimal dosing frequency is still to be determined, researchers have yet to determine which patients will most benefit, and it is unclear if they will be cost-effective. Patient selection will likely involve those with poor adherence or intolerance to topical medication, the potential to be controlled with one medication, and a proven response to the same topical formulation. Patients with low corneal endothelial cell count, uveitis, iridectomy, zonular instability, functioning tube or trabeculectomy, should avoid the use of sustained-release implants. In conclusion, it remains to be seen whether such treatment methods will be cost-effective, and which patients will benefit the most.

Safer surgeries with MIGS With the latest cutting-edge technology in MIGS, patients can look forward to easier, better and safer treatments than ever before. MIGS, or surgery that involves creating a tiny incision to implant a microscopic-sized device, reduces IOP and slows the progression of glaucoma. “Over the last decade, we have seen

a movement toward interventional glaucoma, intervening earlier with safer options that address adherence and getting pressures to a lower level,” said Dr. Ike Ahmed, University of Toronto, Canada. “MIGS has been defined particularly based on a high safety profile with rapid recovery, it’s minimally traumatic, typically internal, and has at least a modest efficacy — this is what differentiates MIGS from the traditional surgical approaches,” he said. He noted that trabeculectomy remains the gold standard for IOP-lowering and ability to titrate downward with early postoperative laser-suture lysis. MIGS are less potent, but provide a non-bleb and safer option for certain patients, and combine synergistically with cataract surgery, with minimal impact to future filtering surgery. Subconjunctival MIGS provide similar to slightly less potent IOP-lowering than a trabeculectomy, but in a more predictable and more controlled way, with less postoperative intensity and improved bleb morphology. “There’s a balance between choosing a procedure, particularly when it comes to safety and efficacy. For most of us, we typically look to use lower-risk, lowerpotency procedures for earlier stages of glaucoma. And typically higher-risk and higher-potency procedures after most procedures perhaps failed, or in a case of more advanced serious disease.” Studies also show that topical glaucoma therapy often results in poor adherence and quality of life, he added. Some key MIGS tips include picking the right patient, positioning of the eye and scope, visualization and access optimization, prevention of hyphema and early postoperative management.

Glaucoma is not easily detectable and can thus go undiagnosed, thereby leading to an irreversible loss of vision.

The future looks bright with more breakthroughs to be expected. “What’s next for glaucoma surgery? Maximizing efficacy while retaining safety and control, enhancing visualization, improving delivery systems, addressing wound healing long-term, drug elution and combination drug devices, IOP sensors and flow modulation, outflow imaging and placement, and additional outflow pathways as a viable target,” said Dr. Ahmed.

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09 October 2021 | Issue #1

Welcome to the Show

A First Glance at ASRS 2021 by Brooke Herron

S

erendipity is defined as “the occurrence and development of events by chance in a happy or beneficial way.” And right now, both the 39th Annual Meeting of the American Society of Retinal Specialists (ASRS 2021) and the 39th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2021) are occurring simultaneously. Serendipitous? Here at Media MICE, we certainly think so. This means we get to cover both events — and both segments of the eye — across continents and time zones at the same time, and deliver the day’s hottest news in a single, neatly wrapped CAKE & PIE Post — our first-ever bi-continental show daily! Indeed, Media MICE has a physical and virtual presence at both events. Our

European delegation (with one added American) is attending ESCRS 2021; meanwhile this correspondent is flying solo in San Antonio, Texas to attend ASRS 2021. So far, these (cowboy) boots on the ground can report that although the ASRS scientific program doesn’t begin until Oct. 9, there is still plenty of action happening on-site at the JW Marriott Conference Center. The exhibition hall is bustling with booth construction — and we can’t wait to see our industry colleagues, along with their innovative products and services.

Science is neat Undoubtedly, the majority of attendees at a medical conference are going to think science is pretty cool. And how fortuitous

— Day 1 of ASRS 2021 is absolutely packed with pleasing scientific morsels. One major topic is diabetic retinopathy. With two dedicated sessions and numerous experts presenting, both offerings are full of the latest data and trial results, as well as tips on diagnostics, management and treatments. For example, one study to be presented by Dr. Shawn Kavoussi during the Diabetic Retinopathy 1 Symposium, reveals that diabetic macular edema (DME) patients with a suboptimal response to anti-VEGF demonstrate significant improvements after subsequent treatment with the dexamethasone 0.7mg implant. Next, during the aptly named Diabetic Retinopathy 2 Symposium, make sure


CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments

to check out Intravitreal Gene Therapy for Diabetic Macular Edema With ADVM022: First-Time Data Presentation of Prospective, Randomized Phase 2 INFINITY Trial. According to the abstract, “ADVM-022 is designed to provide stable and sustained therapeutic levels of aflibercept following a single IVT injection.” This novel investigational approach aims to address unmet clinical needs among patients with retinal conditions who require repeated antiVEGF therapy. As it says in the title, this is the first time this data has been presented — and with gene therapy causing quite a stir lately — we can’t wait to see these results.

Drugs address compliance During the Pharmacology Symposium on Day 1, a variety of therapies (backed by clinical data) will be presented. One of these addresses a concern often faced by ophthalmologists: patient compliance. In this vein, Dr. K. V. Chalam will provide results from Efficacy and Safety of ‘Dropless Vitrectomy Surgery’ and Comparison of Outcomes to Standard of Care Topical Therapy. According to the abstract, attainment of good outcomes in vitrectomy surgery depend (in part) on patient compliance. Here, the investigators assessed triamcinolone acetonide–moxifloxacin intravitreal injections and found them to be an effective method to control intraocular inflammation after vitrectomy surgery. Further, this injection is not inferior to standard postoperative topical therapy and “is a promising substitute for standard eyedrop therapy, especially for patients non compliant with eye drop usage.” This could certainly be beneficial for patients who experience trouble with their drops — and help improve overall outcomes.

ROP: When antiVEGF fails If the children are our future, they’d better be able to see. And for those babes with retinopathy of prematurity (ROP), there are a couple of solutions: laser and anti-VEGF. During the Pediatric Retina — ROP Symposium, Dr. Lucy Xu will present the findings from Clinical

Features and Outcomes of Infants With Retinopathy of Prematurity Who Fail AntiVEGF Therapy — which won the Fellows Forum Award. In this study, the authors looked at anti-VEGF treatment in ROP due to its advantages over lasers. And while antiVEGF enjoys a 80-94% success rate with a single dose in these patients, previous reports do not often provide detailed descriptions of those failed cases. (In case you can’t wait, they found that the most common manifestations of treatment failure were recurrent plus and recurrent stage 3 ROP.)

Microscopic creepy crawlies Sometimes the things you can’t see can hurt you. In this case, it’s pesky bacteria and microbes that create ocular issues — which can sometimes be very severe, like in infectious endophthalmitis. And although these tend to be rare occurrences, clinicians need to be able to identify and treat them with haste to avoid sight-threatening complications. Thus, the Inflammatory & Infectious Diseases Symposium covered these topics, including the relationship between bacterial dispersions and face masks, as

well as clinical features and risk factors for acute retinal necrosis. Of course, inflammatory conditions like uveitis also receive quite a bit of attention here, too.

Receptions and awards Naturally, it wouldn’t be an annual meeting without the recognition and accolades for those who contribute to advances in ophthalmology — in this case, all things retina. Thanks to COVID-19, last year’s awards were not presented, so on Day 1, make sure to congratulate those who won for their achievement during the 2020 Awards Ceremony. (Plus, tune in on Day 2 for the 2021 Awards Ceremony to give those folks a round of applause.) Looking to mix and mingle — while checking out some of the latest research? Of course you are. Then head over to the Scientific Poster Q&A and Exhibit Hall Reception, where we’re betting there’s good times, as well as networking, to be had. With that, this preview of what promises to be an exciting annual meeting is a wrap. Tomorrow the “real” coverage begins, with daily reporting from the scientific sessions and more. Each day, CAKE & PIE Post will present highlights from both ASRS 2021 and ESCRS 2021, so check back to get the latest news, for both the anterior and posterior segments. Yee-haw! (We are in Texas, after all…)

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CAKE & PIE POST (ESCRS & ASRS 2021 Edition) - Issue 1  

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