ESCRS Today - 18 September 2022 by EUROTIMES

ESCRSToday

of the ESCRS opens in Milan

The ESCRS has also made sustainability a top priority for the Society by reducing waste and lowering the Congress’ carbon“Whatfootprint.wehave done is set some goals for the annual congress in terms of zero emissions, zero waste, and social responsibility. We are doing this with the help of a company

The ESCRS will continue to innovate and fine-tune its mission to better serve the interests of its members in the coming years, Prof Oliver Findl, President, told delegates at the opening ceremony of the 40th ESCRS Congress in Milan.

Welcoming almost 9,000 delegates from all over the globe, Prof Findl said this year’s Congress offered a first-rate scientific programme and a wide range of symposia, courses, and wet labs covering most major fields of ophthalmology.

ESCRS Today is a daily newspaper packed with highlights of the day’s main events and industry symposia.

18th SEPTEMBER

WE’LL GO FIRST

OPENING CEREMONY

WELCOME 202240thCongress

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“At this year’s Congress, we have 9 main symposia, 378 free papers, 490 e-Posters, 102 instructional courses, 104 wet labs, and a very well-supported trade exhibition with over 218 exhibiting companies taking part. In total, we have over 12,795 people on site here in Milan, which shows things are almost back to normal after the pandemic,” he said.

The phenomenal success of the ESCRS has been built on a culture of innovation and a desire to keep pace with the evolving needs of its members over the 40 years of its existence, explained Prof Findl.

“It is important to continually adapt and introduce new features to the Congress. This year we have introduced an iNovation Day for the first time, which is designed to facilitate greater interactivity between clinical experts and business partners in addressing unmet clinical needs within the next few years.”

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Several locations in Milan. flowerburger.it

Its motto is ‘Good for Body, Soul, and Planet’. Pescatarian, vegan, and gluten-free offerings. Milanese specialties, including risotto.

Delicious sustainability

CIBÒ

Delegates at this year’s Congress are encouraged to adopt a healthy attitude towards sustainable eating. The prime goal is to reduce the consumption of animal protein, particularly beef, because of the inordinate amount of resources used and the large amount of methane and carbon dioxide created during production and delivery.

FLOWER BURGER

The ESCRS is working with the caterers to offer healthier and climate-friendlier food and drink options for official and private events. The aim is to eliminate red meat and serve at least 50% of scrumptious vegetarian and vegan options.

Via Pastrengo, 18 – M2/M5 Garibaldi, M5 Isola www.capraecavolimilano.it

called GDS-Movement which specialises in congress sustainability, and we are setting concrete targets for future events. We are counting on all our members and delegates to play their part in this vital initiative,” heProfsaid. Findl also outlined several new ESCRS initiatives for the coming years, including the development of new guidelines for cataract and refractive surgery and the creation of a new patient portal to provide patients with information and education. Digital health is another priority area, with a Digital Research Fund announced for 2023 to support the development of open access databases and the collection of high-quality healthcare data.

Cibò offers a stylish Mediterranean take on vegan cuisine. A huge menu of tempting and affordable whole food and organic wine.

Here are a couple of suggestions that come highly recommended:

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Speaking on behalf of the local organising committee, Paolo Vinciguerra gave some background on Milan’s rich ophthalmic history—in particular, the first corneal transplant, which Prof Galeazzi completed in Italy in 1956. Dr Vinciguerra urged delegates to savour the cultural delights of Milan, a city that offers many attractions to delegates once the serious business of the Congress wasThisaccomplished.year’sRidley Medal Lecture, “How the Digital World is entering our practice”, was delivered by Béatrice Cochener-Lamard from France.

On a more sombre note, Prof Findl highlighted the work of the ESCRS to support colleagues in Ukraine with the provision of travel grants, observerships, free registration for the Congress in Milan, and above all, much-needed medical supplies to help those directly affected by the conflict.

What we have done is set some goals for the annual congress in terms of zero emissions, zero waste, and social responsibility.

CAPRA E CAVOLI

18th SEPTEMBER | ESCRSToday 3

SOULGREEN

If you want to carry this idea outside the conference centre, you will find Milan, a city renowned for sublime cuisine, has risen to the challenge of providing excellent vegan and vegetarian restaurant options.

A Michelin star restaurant, mostly vegetarian, but with some meat and fish choices. A splurge in trendy Isola.

Porta Nuova, Piazza Principessa Clotilde – M2 Garibaldi soulgreen.com

An ever-changing menu of all-natural, organic, vegan burgers on rainbow-coloured buns. Have it with fries and a flower milkshake.

The ESCRS is making every reasonable effort to ensure the vital equipment donated by industry partners—and drugs largely purchased from either ESCRS’s reserves or through generous donations from both sister societies and members— reaches the right hands.

ESCRS Managing Director Tom Ogilvie-Graham visited Ukraine and travelled to clinics in Lviv, Kyiv, and Irpin. He delivered an endoscope donated from BVI to Professor Marian Sarakhman at the Lviv Ophthalmic Regional Eye Trauma Centre. Professor Marian’s son, Dmetro, is also a cataract and VR surgeon—to whom the Managing Director is particularly grateful for chauffeuring him between Lviv and the Polish border.

Very soon after the Russian invasion of Ukraine in February of this year, ESCRS executives formulated a plan to determine the needs of Ukrainian ophthalmologists in the war zone, solicit the equipment and supplies to meet those needs, and deliver them to the country.

There is a great deal of selfhelp when it comes to onward distribution in Ukraine and, whilst some clinics may feel we could do more, I am confident we are reaching as many as reasonably possible under the circumstances.

Oliver Findl MD, President of the ESCRS

Professor Andriy Ruban, who runs the Kyiv Centre of Clinical Ophthalmology, helped set up these visits and has been immensely helpful throughout, as have Dr Lyubomyr Lytvynchuk in Giessen and Aneliya Nehanova (who has volunteered to oversee the storage in Krakow and transport across Poland).

ESCRS working to support Ukraine

UKRAINE

ESCRSToday | 18th SEPTEMBER4

That visit also delivered an endoscope to the ophthalmic department of Kyiv military hospital, where it was particularly sad to see young soldiers, who were fully fit only a week or two previously, now totally blind despite all the best efforts to salvage at least some sight.

The ongoing efforts, working with sister organisations and industry, have already provided more than one million euros in support to Ukrainian ophthalmological colleagues in logistics and medical supplies. The supplies are delivered to storage centres in Poland and then transported to Ukraine.

Many organisations and companies have provided generous assistance. The Lions Eye Institute for Transplantation and Research, Alcon, BVI, and Zeiss have all stepped forward with very generous donations of equipment and material. This includes all manner of supplies, such as PMMA IOLs, orbital implants, silicone oil, Decalin, lacrimal probes, surgical loupes, and eye shields and a palette of surgical packs from Zeiss (co-donated with Hartmann). Bausch and Lomb generously provided two Stellaris machines.

HOW TO HELP

In addition to checking on the distribution chain and storage, the ESCRS ensures all administration costs remain as low as possible. For example, the storage in Krakow is provided at a fraction of the market rate, and the storage and local distribution in Lviv is provided for free by Dr Goriachev and Professor Novytsky.

518th SEPTEMBER | ESCRSToday VisitboothB86/B78atESCRS2022

ESCRS delegates are invited to attend a ‘Cataract surgery virtual reality (VR) training experience’, and witness some of the exciting features of the Eyesi Surgical Simulator, first-hand.

“There is a great deal of self-help when it comes to onward distribution in Ukraine and, whilst some clinics may feel we could do more, I am confident we are reaching as many as reasonably possible under the circumstances,” said Oliver Findl MD, President of theOtherESCRS.initiatives include the development of a consultant network under the direction of Dr David Verity and James Hampton in the ESCRS head office. This is well underway and this could be of particular use in the long term, with Ukrainian surgeons being able to discuss more complicated cases, including reconstructive surgery and facial maxillary cases.

This 20-minute training experience will allow trainees to see the surgical field in stereo and high-resolution, while operating with life-like surgical instruments.

EYESI SURGICAL

• ESCRS has established a fund to accept financial donations that will be directed exclusively to support ophthalmology-related relief efforts arising from the conflict in Ukraine. We can accept donations to the fund from ESCRS members, industry partners, and fellow societies.

• For industry partners or fellow societies, please email escrs@mci-group.com for information on how to make your donation.

Cataract surgery virtual reality (VR) training experience

• We can accept these donations through bank transfer. If you are an ESCRS member and wish to contribute, please simply log in to https://donate.escrs.org using your membership details to access information on how to donate, which is a straightforward process.

Places are limited, visit https://tinyurl.com/ye7az4v6 to secure your place, or visit booth B86/B78 to check availability.

https://tinyurl.com/ye7az4v6

By collecting data, surgeons can monitor their results over time and anonymously compare with other colleagues, clinics, and countries. Cataract, refractive, and patient-reported outcomes are all available in one web-based platform.

CATARACT & REFRACTIVE

It has already released 16 publications to date, and more are in the pipeline.

“EUREQUO provides a means to audit surgical results and encourages surgeons to make adjustments to their techniques and improve their outcomes,” said Mats Lundström MD, PhD, the original driving force behind EUREQUO and now a member of the EUREQUO Steering Committee.

Further information on EUREQUO is available at www.escrs. org/about-escrs/registries/eurequo/

Such a big registry is very suitable for studies of rare events in terms of complications or preoperative conditions, Dr Lundström noted. To this end, the registry has generated studies on cataract surgery outcomes in eyes with previous corneal refractive surgery, risk factors for dropped nucleus and posterior capsule rupture, and cataract surgery in eyes with previous vitrectomy.

The number of cataract extractions reported to the database in 2021 was 219,672, with a mean patient age of 74 years and 57% women. In 7.9% of the cases, the preoperative corrected distance visual acuity (CDVA) was 0.1 or below, and in 49.1%, the CDVA was 0.5 or better. In 25.3%, there was a co-existing eye disease in the surgery eye.

Dr Lundström said the EUREQUO Steering Committee is constantly updating the platform with new parameters to reflect the development of new surgical techniques and trends in the field. The committee is also committed to analysing the aggregate data of the database and developing new scientific papers.

For its part, the ESCRS believes that a continuing audit of surgical outcomes is necessary to ensure the best care for patients—by making comprehensive data available for visual outcome comparisons.

Looking to the future, EUREQUO plans to continue expanding into new regions and adding more surgical data. Earlier this year, the registry started to include data on refractive surgery in the Netherlands as well as cataract data from France.

The registry also contains data about surgical difficulties, type of operation, IOL optic biomaterial, and surgical complications. For 74,781 cases, follow-up data were also reported. A refractive surgery was reported for 1,801 eyes.

With more than 3.6 million cataract cases and over 150,000 refractive surgeries now recorded since its launch in 2008, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) continues to yield extremely valuable data on surgical practices and outcomes.

Funded by the ESCRS, with initial support from the EU, EUREQUO is one of the largest international IT projects in ophthalmology, connecting surgeons all over the world and building a network to facilitate the exchange of expertise. All ESCRS members can access the registry free of charge.

ESCRSToday | 18th SEPTEMBER6

EUREQUO registry provides a mine of valuable data

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Similarly, international ophthalmology conferences also have a major carbon footprint. Transport, venue, catering, workshops, and presentations all contribute towards increased carbon emissions. Again, a balance must be established in an effort to maximise education whilst reining in personal interests such as tourism.

This essay was the winner in this year’s ESCRS Henahan Prize Essay Competition. Writers were asked to address the question, “What can the field of ophthalmology do to meet the pressing challenges of climate change, sustainability, and social equity?”

equivalents (CO2e) and can be used to estimate the impact of cataract surgery. The LCA of a cataract surgery is 181.8 kg CO2e, with the greatest portion (54%) generated from the procurement of supplies. This LCA is the equivalent of driving a car for 500 km, a significant carbon footprint.

The aggregate of these issues contributes significantly to climate change. The effects of pollution, as studied by King’s College London, show that on high pollution days, there are 673 additional out-of-hospital cardiac arrests and hospital admission for stroke and asthma. If we were to apply these figures to the population of poorer countries, whilst the impact may be the same, their inability to access affordable healthcare generates an international injustice. Therefore, we need to push for global change.

HENAHAN

BY GEORGE LIU MD

Our problems, a global issue.

Globally, approximately 43 million people are blind. A third of this population is blind due to cataracts—and this figure is set to increase due to the ageing population. However, the only definitive treatment for cataracts is surgery. A technique called Life Cycle Analysis (LCA) quantifies the emissions generated across the life cycle of a product in units of carbon dioxide

In ophthalmology, patients often present with chronic disorders needing multiple consultations (generating travel emissions), and often, surgical procedures are the only solution. Whilst there is a beneficial high turnover of surgical cases in ophthalmology, this also incurs increased waste generation, which is exacerbated by unsustainable practices such as disposable equipment, including substantial amounts of plastic and iron ore. To make matters worse, an NHS investigation showed that children were being exploited to manufacture surgical equipment in Pakistan. So perhaps reusable sterilised equipment is the way forward? Whilst this appears to be the obvious answer, a study in Chicago, Illinois, US, showed that the use of ethylene oxide was likely causing higher rates of cancer in residents living near the sterilisation factory site. Furthermore, disposable equipment is often significantly cheaper to manufacture compared to reusable equipment, which incurs further sterilisation costs. Therefore, how can we safely balance sustainability and public health whilst making surgery financially viable?

Nostra Culpa PRIZE

ESCRSToday | 18th SEPTEMBER8

The United Kingdom’s National Health Service (NHS) contributes towards 5% of the country’s carbon footprint. They are not alone. If global health services formed their own country, they would be the fifth-largest carbon emitter on the planet. This is a global issue.

George Liu is a 4th Year Medical Student, Chelmsford, Essex, Tongdean Eye Clinic, UK. GeorgeLiu.Surg@gmail.com

Variations in the LCA of cataract surgery depend on the surgeon, but there is no correlation between surgical outcomes and environmental cost, as shown in different locations around the world. Thus, suggesting that opportunities for more sustainable practice are available without having to sacrifice the quality of care. The Aravind case study showed that cataract surgery was achievable at 5% (23 km by car) of the LCA in the West with no increased risk and significantly reduced waste. However, efforts to pursue a similar case study in the West would be limited by regulations and Western patient perceptions of needing over-personalised care. More recently, the ophthalmic community has increasingly moved to Immediately Sequential Bilateral Cataract Surgery (ISBCS), which has reduced travel emissions that would normally be incurred from a second cataract surgery. Whilst this is a fair improvement, the combination of the Aravind study and ISBCS would provide the most sustainable outcome.

Whilst our community may strive for change, we are limited by our lack of actionable data. However, the recent development of applications, such as “Eyefficiency”, encourages research into the environmental impact of cataract surgery by individual surgical units, thus generating the actionable data needed for change.

In a similar vein, these advances should be utilised in virtual consultations and other modalities to educate our patients. Ufonia artificial intelligence software conducts telephone postphacoemulsification consultations and greatly reduces anxious patients presenting to “Accident and Emergency” unnecessarily.

With the boom in technology during the pandemic, healthcare events are more accessible than ever—from the comfort of one’s own home. Therefore, conferences should be hybrid by default, offering in-person attendance for local delegates and virtual attendance for international delegates. For those in attendance, efforts should be made to offset travel-related emissions. Those using renewable energy should be rewarded with reduced registration fees.

OUR SOLUTIONS, A WORLDWIDE EFFORT

Everything exists in fine balance, and we are currently tipping the scale towards an unsustainable future. We should encourage selflessness and sustainability and change our culture of viewing Earth as an infinite resource. We must grasp these opportunities to stop climate change and accept that evolution may include regression in some aspects of our lives. Our response will determine our survival.

Yet the endophthalmitis rate for 2 million consecutive patients at Aravind was 0.04%—identical to the overall rate for 8.5 million cases from the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) registry. And for 335,000 phaco cases using intracameral moxifloxacin, the Aravind rate was just 0.01%.

By and large, surgeons are on board. In a survey of more than 1,000 ophthalmic surgeons, 10 times as many preferred a reusable instrument over single-use if the cost were the same. The overwhelming majority prefer greater reuse of supplies where appropriate, less wasteful packaging, and labelling the gives more discretion in what may be reused.

MedicalFriday.waste accounts for

Sustainability is good medicine, iNovation speakers say

10% 5%

ESCRSToday | 18th SEPTEMBER10 SUSTAINABILITY

It’s more than just an abstract concern, Dr Chang added. The World Health Organization has declared climate change the greatest threat to public health in the coming years. Physicians have a responsibility to do what they can to mitigate it.

“We are wasting 20 times more to reach this demoralizing conclusion: the perception we are doing things to make things safer is not making any difference other than to create more waste and cost,” Dr Chang said.

Much of that waste is unnecessary, said Dr Chang of the University of California–San Francisco, United States. He noted medical waste per phaco cataract surgery in the UK is 20 times that at the Aravind System in India, equal to driving a car 500 km in the UK versus 25 km at Aravind.

If healthcare were a country, it would have the 13th largest carbon footprint in the world. Medical waste accounts for 10% of greenhouse gas emissions in the United States and about 5% in the United Kingdom, Canada, and Japan, noted David F Chang MD at the inaugural iNovation programme Friday.

Much of the difference comes down to reuse of medical supplies and open vials of pharmaceuticals in India, where four patients are typically operated on in the same room at the same time. “In the United States, if I reused anything or did any of these things, I would be shut down because these are considered such dangerous practices that patient safety is at risk,” Dr Chang said.

PHYSICIAN OBLIGATION

and about 5% in the United Kingdom, Canada, and Japan, noted David F Chang MD at the inaugural iNovation programme 10% of greenhouse gas emissions in the United States

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Dr Chang recommended that surgeons check out EyeSustain. org for detailed information on how they can work to reduce waste by changing clinic procedures. For example, drugs from multiuse packages can be used on multiple patients until the expiration date. Doing away with full body drapes, which COVID-19 studies on cross contamination show are unnecessary for cataract surgery, may be another option.

But the overall trend has been in the other direction. It’s driven, in part, by regulations that require single use of many more

EyeSustain.org is sponsored by the ESCRS, ASCRS, and AAO. “It’s a good place to start,” said Sjoerd Elferink MD of the ESCRS Young Ophthalmologists Green Group.

WHAT SURGEONS CAN DO NOW

Industry has responded with initiatives to cut down the amount of packaging, reduce the bulk of items, and move to sustainable sourcing, said Thomas Bosshard, co-CEO, board member, and co-owner of Oertli in Switzerland.

waste and cost.

We are wasting 20 times more to reach this demoralizing conclusion: the perception we are doing things to make things safer is not making any difference other than to create

components, sometimes responding to identified infection risks, such as small gauge cannulas in the Netherlands. European regulations requiring tracking of medical devices throughout their life cycle are another factor adding to the expense of reusing them, industry representatives noted. Risk-averse hospital administrators also tend to favour disposable instruments.

“Although there is no literature to suggest that vitrectomy affects x-thing or y-thing, I think if we can avoid disturbing any of the natural structures—particularly in these youngdevelopment eyes—I’m sure that it should help us in some way or the other in the long run,” said Dr Vasavada of the Raghudeep Eye Hospital and Iladevi Cataract and IOL Research Centre, Amedabad, Jaipur, India.

Optic capture may reduce need for vitrectomy in very young children

POSTER HIGHLIGHTS

Dr Vasavada based his comments on a prospective randomised clinical trial he and his colleagues conducted. It compared five-year outcomes of a conventional in-the-bag IOL implantation—including anterior and posterior capsulorhexis and a limbal anterior vitrectomy with optic capture through the posterior capsule without vitrectomy—in children four years old or younger. Thirty eyes were randomised to the inthe-bag group, of which 27 were followed for five years or more, while 31 were assigned to the optic capture group, of which 28 were followed for at least five years.

PROSPECTIVE STUDY

Overall, there were no significant differences in visual outcomes or complications between the two groups within

ESCRSToday | 18th SEPTEMBER12

While technically challenging, implanting intraocular lenses (IOLs) using an optic capture through the posterior capsulotomy may help avoid the anterior vitrectomy usually performed using an in-the-bag technique in very young children, Shail Vasavada DO, DNB, FRCS, FICO said at a presented poster session Saturday.

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I think if we can avoid disturbing any of the otherhelpeyes—I’mthesestructures—particularlynaturalinyoung-developmentsurethatitshouldusinsomewayortheinthelongrun.

CHALLENGING PROCEDURE

the five-year follow-up period. Visual acuity improved in both groups, and there was no significant difference between them, Dr Vasavada reported.

Two eyes in the in-the-bag group and none in the optic capture group developed glaucoma. Both children affected were under one year old at the time of surgery, and symptoms were controlled with topical medications.

A limitation of the study was the skill required to create a posterior capsulotomy and optic capture without disturbing the vitreous face. If the face is disturbed, a vitrectomy must be performed, Dr Vasavada noted. A small capsulorhexis may also make it difficult to do the optic capture, he said.

Two eyes in the in-the-bag group required a secondary procedure for significant visual axis opacification (VAO); one at 14 months and one at 16 months after initial surgery. One eye in the optic capture group required a secondary procedure

for VAO at 21 months postoperatively. In the in-the-bag group, one child requiring a secondary procedure was under age one year and another over, while the optic capture child was under one year. Secondary procedures were defined as vitrectomy or membranectomy, Dr Vasavada said.

“Serious long-term complications were the same when you do a vitrectomy or don’t do a vitrectomy. … Optic capture of the IOL whenever possible can avoid vitrectomy and yet reduce visual axis obscuration with similar incidence of glaucoma and inflammation postoperatively,” Dr Vasavada concluded.

Prof Cochener-Lamard began her talk with a timely nod to Harold Ridley, the great IOL innovator, who she said would probably have understood more than most the rich possibilities of embracing new technological tools such as AI and machine learning.

She noted that AI has been frequently misunderstood and misrepresented as a potential threat to the role of the physician in general and the ophthalmologist in particular.

Prof Cochener-Lamard noted digital tools have already made a major impact in transforming healthcare in the wake of the COVID-19 pandemic. She cited the massive upsurge in telemedicine applications that developed in France and elsewhere as a response to the need to see patients without exposing them to the risk of infection.

14 ESCRSToday | 18th SEPTEMBER RIDLEY MEDAL LECTURE

“We are facing key limitations in terms of bioethics, data protection, and also the distrust of the medical community, which is afraid of doctor substitution and of the transfer of competencies to other actors such as optometrists, opticians, or nurses,” she said.

The ophthalmic profession should broadly embrace the new wave of digital tools steadily making their way into clinical practice and which have the potential to greatly assist physicians in day-to-day patient care, said Béatrice CochenerLamard MD, PhD in her Ridley Medal Lecture delivered as part of the opening ceremony of the 40th Congress of the ESCRS.

Digital revolution transforming the face of ophthalmic practice

In terms of AI applications, the technology is currently advancing faster than public health measures and legal approvals, she said.

“We saw a real explosion of interest in telemedicine in France—which went from 1% of teleconsultations before the COVID-19 crisis to over 20% in April 2020,” sheAssaid.well as remote consultations, mobile ophthalmology cabin use can also play an important role in helping screen and monitor the ocular health of populations in remote and rural areas.

“There are some limits that we need to work around. We need to ensure the collection of good quality data that is systematic and accessible. We need to count on the support of national health authorities and academic societies because we need to develop health data hubs and obtain access to electronic medical records worldwide. We also need to define an economic model for AI and guarantee the integrity and cybersecurity of our medical data, as well as ensure access to bioethics for doctors and patients,” she said.

Prof Cochener-Lamard said AI is particularly visible in three key domains in ophthalmology: registries and big data, imaging, and robotization. She detailed how each of these areas are transformed by AI but also highlighted some of the remaining challenges.

“One of the key challenges to overcome is that of human acceptance. That means we need to communicate better on the subject of AI, educate doctors, stop demonizing AI, share data of quality, and let the doctors decide what to ask of AI, because the critical point is AI has been designed to serve medicine and not to supplant the doctor,” she said.

In a wide-ranging lecture entitled “How the digital world is entering our practice”, Prof Cochener-Lamard, Professor and Head of the Ophthalmology Department in Brest University Hospital, France, focused on the diverse ways digital technologies such as telemedicine, machine learning, and artificial intelligence (AI) are profoundly changing the healthcare landscape for the benefit of physicians and their patients.

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“It’s a screening tool, not for making decisions about surgery,” Prof Hafezi said.

Farhad Hafezi MD, PhD, FARVO, Consultant Ophthalmic Surgeon in Dietikon, Switzerland, suggested the development of Smart Mobile Affordable Reliable Technology (SMART) for use in low- and middle-income countries (LMICs) will change care for patients. He used keratoconus as an example of where the technology could be applied.

WHAT ARE COMMON MYTHS IN AI?

Sunny Virmani, Google Product Manager at Mountain View, United States, explored important misconceptions in health applications of AI. One is that more data is all you need for a better model. Not so straightforward.

Did you know what can be revealed by a photo of your eye? Not a fundus photo, an external photograph? Virmani presented exciting data from an article published by Babenko (et al.) in a 2022 issue of Nature Biomedical Engineering.

only 60% of ophthalmologists had direct access to a topographer for their patients

60%

“You need not just quantity, but quality,” Virmani said. “Another myth: an accurate model is all you need for a useful product. A product must be useable in real-world settings.”

CLARE QUIGLEY

What are unmet needs in ophthalmic care that AI can address? How can research in AI be democratised? What are common myths about AI? These were some of the questions asked in the Digital Medicine session on Saturday, 17 September, in Milan.

ESCRSToday | 18th SEPTEMBER16 ARTIFICIAL INTELLIGENCE

Digital Medicine—6 steps for a better future

“Now that we have a treatment modality to stop the disease— first comes detection,” Prof Hafezi said. Prof Hafezi investigated his home country, high-income Switzerland, asking how many ophthalmologists had access to the most basic placido type topographer. He found only 60% of ophthalmologists had direct access to a topographer for their patients. And in other countries, one can assume that access is likely only worse. This lack of access risks later diagnosis of keratoconus, a potentially blinding corneal ectasia that early screening can detect and allow for treatment with Keratoconuscross-linking.screening can be carried out without a topographer using a smartphonebased keratographer (SBK), which is currently at prototype stage. The device, featuring a lens and a forehead mount attached to a smartphone, will be more affordable than available topographers, with an estimated future cost of $1,500. It can be operated freehand or mounted on a slit lamp and gives a readout similar to a conventional topography machine.

If ophthalmologists want to research in the AI space, will they need to learn how to code? Short answer, no. Pearse Keane, Consultant Ophthalmologist in London, United Kingdom, showed alternative, democratic approaches.

You need not just quantity, but quality. Another myth: an accurate model is all you need for a useful product. A product must be useable in real-world settings.

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“External eye photos for detecting disease,” were investigated in the study. It included a large sample: a training set of more than 140,000 patients with diabetes and a validation sample of more than 40,000 patients with diabetes. A fundus camera took the external photographs to train a deep-learning model that went on to accurately predict diabetic retinopathy, diabetic macular oedema, and poor glucose control. The prediction had a better performance than logistic regression models using demographic and medical history data. It is unknown whether other cameras will replicate the results, Virmani said.

“What I’m excited about, though, is code-free machine learning,” Keane continued. There are cloud-based platforms that allow clinicians to upload photos, which can train an AI model. He suggests using these platforms to get to a proofof-concept stage and that a subset of models may progress to clinical application. While in the past, there was concern among some clinicians about AI replacing doctors, currently, AI is becoming more and more accessible to clinicians to advance their own research ideas and potential clinical applications.

Optical Biometer

“Clinicians will play an important role in the next phase,” Keane said. He believes upcoming developments in AI will be led by those who have the best ideas for clinical applications. And there is a need to make ophthalmology services as throughput and lean as possible. “Nearly 10% of all clinical appointments in the NHS are for eyes. We have standing room only a lot of the time in our clinics,” Keane said. “AI can play at least some role in mitigating these challenges.

OA-2000

Micro-monovision with non-diffractive EDOF IOL yields spectacle independence for some

ESCRSToday | 18th SEPTEMBER18

GOOD DISTANCE VISION

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INTERMEDIATE AND NEAR VISION

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“We certainly have achieved an extended range of focus. A lot of our patients are spectacle independent,” Dr Law said. She disclosed that she is doing a longer-term study of the same lens, sponsored by Rayner.

Most patients implanted bilaterally with a non-diffractive extended depth of focus intraocular lens (EDOF IOL) targeting micro-monovision ended up with good distance vision, and many achieved spectacle independence, Elizabeth Law PhD, MSc, MCOptom said at a presented poster session Saturday.

The study allowed patients with up to 1.0 D corneal astigmatism to be implanted, which may explain why mean distance vision improved with correction, Dr Law said. “Perhaps we were not quite stringent enough in treating astigmatism in these patients.”

The binocular defocus curve was also better than monocular performance, yielding a mean uncorrected visual acuity of better than 0.2 from +0.75 D to -1.50 D for the micromonovision approach, Dr Law said. There were no reports of dysphotopsias in the group.

The results came from a retrospective study of the first 30 patients bilaterally implanted with the Rayner EMV EDOF IOL, which uses positive spherical aberration to stretch the focal distance. Patients were assessed 12 to 15 months postoperatively. Mean age was 69.05±8.87.

Law reported. However, “nobody wore spectacles for distance vision even though it was slightly better corrected, and none were unsatisified,” she said.

In the dominant eye, mean uncorrected distance visual acuity was slightly worse than 0.1 logMAR, or about 20/25, while it was a little better than 0.3, or about 20/40, in the non-dominant eye. Binocular uncorrected distance vision was slightly better than 0.1. Mean corrected distance vision was 0.0, or 20/20, in each eye separately and slightly better than 0.0 binocularly, Dr

POSTER HIGHLIGHTS

Not surprisingly, mean uncorrected intermediate vision was significantly better in the non-dominant eye and binocularly than in the dominant eye, coming in at better than 0.2 in the non-dominant eye and binocularly, and a little better than 0.4 in the dominant eye. Near vision was slightly worse, at a mean of about 0.3 in the non-dominant eye and binocularly, and about 0.5 for the dominant eye.

Dominant eyes aimed for emmetropia and non-dominant eyes for -0.75 D to -1.25 D. Patients’ previous experience with monovision determined the targeted myopia in the nondominant eye. Those with no monovision experience targeted closer to -0.75 D, while those with experience targeted closer to -1.25 D, said Dr Law of Southend University Hospital, Mid and South Essex NHS Trust and BMI Southend Private Hospital, both in the United Kingdom.

CTF/TCT optic designed to:

The award winners for best posters at the 40th Congress of the ESCRS have been announced. The posters were judged based on originality, scientific quality, relevance to clinical practice, and presentation.

3  TOLERATE

PRESBYOPIA & ASTIGMATISM CORRECTION REINVENTED

The Refractive poster winner this year was Nanji Lu from China for “Tamoxifen Induces Major Topographical Changes Mimicking Post-Lasik Ectasia”.

The ASI winner was Federica Serino from Italy for “Dupilumab-Associated Ocular Surface Disease: An In Vivo Confocal Microscopy Study.”

Winner in the Glaucoma category was David Lubeck of the United States for his poster, “24-Month Evaluation of Endothelial Cell Density and Loss Following Ab-Interno Canaloplasty.”

In the Cornea category, the 2022 winner was Keshia Duyongco from the Philippines for her poster on the “Prevalence and Risk Factors of Dry Eye Disease Among Office Workers Using Visual Display Terminals.”

Poster winnersawardannounced GLARE & HALOS1 THE KAPPA ANGLE2 DECENTRATION MISALIGNMENT

 TOLERATE

POSTER HIGHLIGHTS 1) Broader Toric meridian designed to be more tolerant of misalignment. White paper: Evaluation of a new toric IOL optic by means of intraoperative wavefront aberrometry (ORA system): the effect of IOL misalignment on cylinder reduction. By Erik L. Mertens, MD Medipolis Eye Center, Antwerp, Belgium 2) The misalignment tolerance and the use of segments instead of concentric rings reduces photic phenomena, helping patients to adapt more naturally to their new vision. 3) The central zone of 1.4 mm in diameter is larger than most available mIOLs and allows a wider tolerance so that the visual axis passes through the wider central segment avoiding visual disturbances. 4) In cases of tilt or misalignment, the patient can still beneﬁt from good near and far vision, as the segmented zones allow a balanced far/near light distribution in a steady optical platform. OPHTEC | Cataract Surgery  REDUCE

 TOLERATE

The Cataract winner was Grzegorz Łabuz from Germany for his poster entitled “OcularBiometry Driven Changes of Add-Power Demand in Normal Eyes: Ray-Tracing Simulations”.

Luca Gualdi, also from Italy, won the top prize in the Others category for “Optimization of Laser Scleral Microporation Therapy Utilizing Real-Time Interstitial Swept Source Oct & Automated Tissue Segmentation.”

ESCRSToday | 18th SEPTEMBER20 VERBAL E YE EXAM Use the circled letters to solve the puzzle with new words. The new ophthalmology clinic was a–“__ __ __ __” __ __ __ __ __ __ __ __ __ __ __ ARSNE TI CRAL OU SNEZ OL U I FXRN O Y ESE

Innovation.Education.Research.

ESCRS’ vision is to educate and help our peers excel in our field. Together, we are driving the field of ophthalmology forward.

27 th ESCRS WINTER MEETING 10–12 MARCH 2023 TIVOLI MARINA, VILAMOURA ALGARVE PORTUGAL 20 23 wintermeeting.escrs.org

“It is critical to realise the risks posed by climate change exceed those of any single disease. It cannot be stressed often enough that the climate crisis is also a health crisis,” said Dr Elferink, who serves as Chair of the newly formed ESCRS Young Ophthalmologists Green Group.

Dr Elferink said the healthcare sector cannot shirk its responsibility in the global effort to tackle the climate crisis.

“We see in the Netherlands, for example, that the healthcare sector accounts for 8% of the total carbon footprint [in the country]. So it basically means that we as a healthcare sector are harming health,” he said.

Global action and collaboration are needed to effect change, said Dr Elferink. Everyone can contribute by taking positive steps to learn more, become aware of sustainability measures, and become advocates for change at local and national levels. He urged delegates to attend the sustainability programme taking place at the Milan Congress as well as dedicated Practice Management sessions devoted to the topic.

ophthalmology must do more to fight climate crisis

18th SEPTEMBER | ESCRSToday 23

That was the stark message delivered to delegates at yesterday’s opening ceremony by Sjoerd Elferink MD, FEBO, who said the healthcare sector and ophthalmology, in particular, can do a lot more to reduce its carbon footprint and lead by example.

to six times more energy consuming than the other parts of hospital. And cataract surgery is unique because it has the highest surgical volume worldwide, which will increase significantly in the coming years. So we can have this significant impact if we change our habits and the way we do things,” he said.

Surgery accounts for a large proportion of this carbon footprint.

Surgeons need to play a more active role in minimising carbon emissions, reducing waste, and putting sustainability at the heart of their professional endeavours.

“We know it produces 30% of the waste in a hospital. It is three

SUSTAINABILITY

“As physicians, we have an important role to play because the climate crisis is a health crisis. And the key to winning the climate debate is not economic—it is health. Climate ranks low in polls of public fears while sickness ranks top. This is where we come in. I have a dream that we as medical doctors will use our position as a trusted messenger to help people understand what is at stake—because if everything is at stake, everything is possible,” he said.

All photography by Andrea Adami

MOMENTS

IN MILAN24

MOMENTS IN MILAN 25

notes ESCRSToday | NOTES26 MISSDON’TJCRSSymposium Sunday 14:00 Silver Practice Management and WorkshopDevelopment 8:30Monday Brown 1

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NOTES | ESCRSToday 27

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