Et22 11 press

SPECIAL FOCUS PAEDIATRIC OPHTHALMOLOGY CATARACT & REFRACTIVE

DEALING WITH COMMON COMPLICATIONS IN CATARACT SURGERY

RETINA

INTENSIVE EDUCATION SYSTEMS ARE DRIVING AN EPIDEMIC OF MYOPIA November 2017 | Vol 22 Issue 11

Eye Care for Children

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VIENNA 2018 36 Congress of the ESCRS TH

22–26 September Reed Messe, Vienna, Austria

www.escrs.org

I/A

P.40

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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS PAEDIATRIC OPHTHALMOLOGY 4 Why paediatric

ophthalmology is important to all surgeons, regardless of specialty

6 Paediatric ophthalmology is at the forefront of genetic therapy

7 A new technique for Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor.

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

ESCRS EuroTimes is not responsible for statements made by any contributor.

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

ISSN 1393-8983

generating a new crystalline lens is showing promising results

FEATURES CATARACT & REFRACTIVE 8 Everything you ever

wanted to know about manual small incision cataract surgery – Part 2

9 Dealing with common complications in cataract surgery

10 Preventing postoperative endophthalmitis

13 Preventing and addressing

suction loss during SMILE

14 JCRS highlights

RETINA 16 EVICR.NET is tackling some of the biggest problems in retinal vascular disease

17 Intensive education As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2016 and 31 December 2016 is 43,593.

systems are driving an epidemic of myopia

18 EURETINA has published a Whitebook on retinal diseases in Europe

www.eurotimes.org

19 A major artificial

P.31

intelligence project for disease diagnosis may help to reinvent the eye exam

20 Ophthalmologica update

CONGRESS REPORTS 21 All the key news from

the ESCRS and EuCornea Congresses in Lisbon, and the EURETINA Congress in Barcelona

CORNEA 30 New strategies

in the treatment of neurotrophic keratopathy

31 Study shows emergency

YOUNG OPHTHALMOLOGISTS 39 We hear from a young doctor about how a mentor helped shape their career

REGULARS

33 Multi-centre trial shows

40 Hospital diary 41 Book reviews 43 Industry news 44 Random thoughts 46 ESASO update 47 Calendar

GLAUCOMA

Clarification

corneal grafting can be a successful procedure good results with DMEK but a high rate of reoperations

34 Keeping up to date with

the latest developments in glaucoma research

36 Alternatives to standard automatic perimetry have their uses and limitations

In our September 2017 issue Vol 22 Issue 9 page 19 the headline on our story stated "Phakic IOLs pose a risk". Dr Gré PM Luyten, on whose research the article was based, has said that while the text in the article was correct, the headline was misleading.

Dr Luyten has asked us to clarify that the conclusion of his research was that the Artisan Lens is a safe procedure with low risk for cataract.

ESCRS 2016 Clinical Survey

GLOBAL OPHTHALMOLOGY 37 News from the ESCRS Academy in Durban, South Africa

2016 Results

1

Included with this issue...

Clinical Survey supplement EUROTIMES | NOVEMBER 2017

2

EDITORIAL A WORD FROM KEN NISCHAL MD

WORLDWIDE EXPERTISE The future of paediatric eye care lies in individuals who are enthused and energetic and committed to the specialty

W

e have just returned from Lisbon, Portugal, Keynote Strabismus Lecture will be presented by Professor where we convened our 4th WSPOS Paediatric Richard Hertle and will discuss “How and What We Learned from Subspecialty Day, which preceded the XXXV Studying Nystagmus in Infancy and Childhood”. The Keynote Congress of the ESCRS. The subspecialty day was Non-Strabismus Lecture presented by Professor Lea Hyvarinen a big success and I would like to thank everyone will focus on “The Important First Year.” For the full programme, who attended the meeting. please visit www.wspos.org.

Now our focus turns to the IV World Congress of Paediatric We also hope to see many young ophthalmologists attending Ophthalmology and Strabismus, which takes our meeting. WSPOS is a global organisation place in Hyderabad, India, from 1-3 December. that reaches out to ophthalmologists of all This meeting, the first WCPOS to be age groups, and the future of paediatric eye At our meeting we will offer held outside Europe, and the first to be held care lies in individuals who are enthused an opportunity for people independently from an adult focus meeting, and energetic and committed to paediatric who are not sure if they will send out the message that expertise resides ophthalmology and strabismus. all over the world. At our first WCPOS in At our meeting we will offer an opportunity are interested in paediatric Barcelona in 2009, people who ordinarily did for people who are not sure if they are interested ophthalmology to come not get the chance to present on the world in paediatric ophthalmology to come and learn and learn about a broad stage were given the opportunity to speak to about a broad spectrum of subjects that we their colleagues. hope will instil enthusiasm in them to take up spectrum of subjects One of the major objectives of WSPOS is to the challenges that we are going to discuss. change the perceptions of some of the paediatric Finally, I would like to thank EuroTimes, ophthalmologists in the developed world, and the official magazine of ESCRS, for giving our meeting in Hyderabad will reinforce this collegial ethos.

WSPOS the opportunity to speak to its 43,000 readers. I am The majority of eye care delivered to children in the world is by delighted that this issue of EuroTimes has a special focus on adult ophthalmic surgeons who see children, as well as dedicated paediatric ophthalmologists and I urge you to read the excellent paediatric ophthalmologists. For this reason we have a dedicated articles that have been written to publicise our meeting and also ‘Adult-Paediatric Interface’ day on Saturday 2 December. to give the wider ophthalmic opportunity a new insight into As Dr Soosan Jacob points out in the Cover Story in this issue, paediatric ophthalmology. it is important that adult ophthalmic surgeons who are taking Thank you, and see you in Hyderabad! the time to look after children are able to discuss their expertise and their problems with paediatric ophthalmologists. It is also important that paediatric ophthalmologists can learn from their adult counterparts about techniques that they are not aware of.

WSPOS currently has 1,969 Members in addition to 18 Chapters and 47 Member Societies, and we look forward to meeting many of you in Hyderabad.

We are proud to present a very exciting scientific programme.

Professor Harminder Dua will present the Keynote Kanski Medal Ken Nischal is the founding co-director Lecture on the topic “Posterior Corneal Anatomy – Context, of World Society of Paediatric Controversy, Corroboration and Clinical Considerations”. The Ophthalmology and Strabismus

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | NOVEMBER 2017

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SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

PAEDIATRIC

OPHTHALMOLOGY Why cataract specialists need a good knowledge of paediatric ophthalmology, even if they do not specialise in paediatrics and strabismus.

Dr Soosan Jacob, MS, FRCS, DNB reports

ith the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) Congress just around the corner, a very relevant question that needs to be asked is: “Do cataract specialists need a good knowledge of paediatric ophthalmology even if they do not specialise in paediatrics and strabismus?� Would it be a waste of time and resources to gain a working knowledge of this sub-speciality? The only way to know this effectively is to look at the

W

EUROTIMES | NOVEMBER 2017

possible advantages of having this knowledge.

According to a Google search, children form 27-35% of the world population, even rising up to 40% in areas like India, Africa etc. Since most cataract surgeons are also general ophthalmologists, we frequently see children, form the first point of contact, and therefore automatically become charged with the responsibility of keeping these young eyes healthy as well as treating them, or at least directing them towards appropriate treatment, if required. It is therefore important to be aware enough to clearly differentiate what needs and what does not need to be referred to a sub-specialist. This

knowledge may be even more important in health systems where it is either difficult or expensive to meet a specialist, let alone a super/sub-specialist. With the strained health setups in most countries, smaller departments often have doctors multitasking, and it is not infrequent to have to examine, diagnose and treat children.

Plain non-availability of a paediatric ophthalmologist can put the onus of treating children on general ophthalmologists.

According to an Indian study, only 28.7% of institutions provided paediatric eye care, and out of these it was only the advanced eye care hospitals that attended

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY to larger numbers of paediatric patients and performed more paediatric surgeries, as compared to even secondary and tertiary eye care hospitals. Even in health setups with highly specialised separate paediatric ophthalmological departments, often the same set of adult sub-specialist doctors work together, but at a time or in a space meant exclusively for children. Thus, manpower shortage, high workload and shortage of dedicated facilities all contribute to the general ophthalmologist necessarily having to take up some of the responsibility.

It is therefore very important for every ophthalmologist to be knowledgeable about childhood diseases. There are many conditions where the non-specialist can easily start treatment, such as initiating massage for congenital nasolacrimal duct obstruction, prescribing glasses for refractive errors, convergence exercises, amblyopia therapy etc. Genetic conditions may be advised counselling and family screening by the cataract specialist. Diseases that children are prone to – both the rare, such as retinoblastoma, and the common, such as a simple refractive error – should be identifiable by every ophthalmologist, as consequences of delayed treatment of these can be grave. Every ophthalmologist also needs adequate training in the management of emergency conditions, accidents and injuries such as chemical burns, pencil stick injury, greenstick fracture of the orbit etc, which children may be prone to get.

Even specialists who limit themselves only to adult patients may come across patients who had childhood onset of a disease that has progressed into adulthood, eg refractive error, juvenile glaucoma, aniridia, keratoconus etc. Many of these conditions need treatment well into adulthood and can present at multiple points during the spectrum of progression.

Knowledge of various stages in the disease gives the specialist a wider perspective regarding different possibilities and various diagnostic and treatment modalities.

Dr Kuheli Bhattacharya, Paediatric Ophthalmologist, Spectrum Clinic, Goa, says: “Squint – congenital or acquired – can point to dominance and is of importance in deciding which eye to operate on first.

In addition, in patients with unilateral high uncorrected refractive error, part of visual loss may be secondary to amblyopia and the patient needs to be counselled accordingly to avoid postoperative disappointment.”

Dr Manjula Jayakumar, Paediatric Ophthalmologist, Dr Agarwal’s Eye Hospital, Chennai, goes on to add: “Patients with intermittent strabismus and good fusional control may decompensate with onset of cataract and present with frequent intermittent diplopia. They would benefit with a simultaneous surgical approach to both cataract and squint. Some patients with manifest strabismus undergoing combined cataract and squint surgery may complain postoperatively of diplopia for a few weeks following alignment if the patient had anomalous retinal correspondence.

Preoperative diagnosis with a red filter after neutralisation of squint with prisms is important, as is counselling.”

Many times, ophthalmic sub-specialists are called to operate upon children with diseases in their fields of specialisations. It is therefore not infrequent for the cornea specialist to perform paediatric deep anterior lamellar keratoplasty, or the glaucoma specialist to implant a tube shunt. And for paediatric cataracts, who better than a cataract specialist to perform surgery, provided the nuances of paediatric cataract surgery and IOL power calculation are known!

For successful outcomes, surgical differences between paediatric and adult eyes must be understood, and therefore a knowledge of paediatric ophthalmology is important. Smaller size, lesser space, lower scleral rigidity, thicker Tenon’s tissue, greater elasticity of anterior capsule, greater chance of a peripheral capsular run-out, need for primary posterior capsulotomy and vitrectomy, greater proclivity to inflammation etc, are some differences that the ophthalmologist should be aware of to modify surgical steps accordingly.

Even if the primary care/surgery has been carried out by a paediatric ophthalmologist, post-surgical care often comes back to the primary or secondary care ophthalmologist practising near the patient’s native place.

Postoperative care of children differs significantly from adults in terms of medication, dosage, difficulties involved in examining and investigating, special examination techniques required, greater need for examinations under anaesthesia, higher chances of emotionally labile attenders and so on, and the general ophthalmologist needs to be aware of these. Synergy between various levels of paediatric care as well as sound basic knowledge is therefore a must.

Taking all the above contexts into consideration, it is evident that all ophthalmologists do need a good knowledge of paediatric ophthalmology, and it is up to us to educate ourselves adequately!

Dr Soosan Jacob is Director and Chief of Dr Agarwal's Refractive and Cornea Foundation and Senior Consultant, Cataract and Glaucoma services at Dr Agarwal's Eye Hospital, Chennai, India. She can be reached at dr_soosanj@hotmail.com.

KEN NISCHAL, DIRECTOR OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS AT CHILDREN’S HOSPITAL OF PITTSBURGH AND FOUNDING CO-DIRECTOR, WSPOS: "The importance of understanding that the child’s eye is part of a developing neural system is crucial when dealing with paediatric cataract surgery. Not only will that child survive many, many years more than the average adult undergoing surgery, but the effect of improving visual function and not just visual acuity will have a global developmental effect. This is more true the younger the child. This means that the surgeon dealing with the child’s cataract must understand the unique anatomical differences (capsular bag diameter changes with age from 8mm at birth to 10.5-11mm at adulthood, elastic tissues, effect of end tidal CO2 on positive vitreous pressure when under GA), but also understand the effect of removing the crystalline lens on the accommodation of the eye. A child under the age of four years is rarely interested in things far away so must be corrected for near only.

If corrected for far under four years, they develop amblyopia because their preferred distance is near, which is blurred. Emmetropisation is disrupted and so having capsular phimosis may cause marked axial myopia due to reduced contrast sensitivity of the peripheral retina. Good surgery is essential but excellent visual rehabilitation and amblyopia management is mandatory and priceless."

RAMESH KEKUNNAYA, DIRECTOR OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS, CHILD SIGHT INSTITUTE, LV PRASAD EYE INSTITUTE, HYDERABAD AND NON-EXECUTIVE DIRECTOR, WSPOS: “Comprehensive or general ophthalmologists perform a significant number of paediatric cataract surgeries. It is very important that everyone who performs paediatric cataract surgeries must know the ‘basic work-up’ of a child with paediatric cataract. Usually the cataract is familial, post-rubella or idiopathic. Occasionally the child may have a serious underlying systemic disease, which should not be missed. A clear understanding of vision development and amblyopia is important as well. More importantly, the follow-up must be ‘REAL’ at every visit: R= Refraction & Vision; E= Eye Pressure; A= Amblyopia & Alignment; L= Lens-related issues (PCO, deposits, tilts).”

DOMINIQUE BRÉMOND-GIGNAC, HEAD OF OPHTHALMOLOGY, UNIVERSITY HOSPITAL NECKER-ENFANTS MALADES, PARIS AND NON-EXECUTIVE DIRECTOR, WSPOS: “I think all cataract surgeons should have a knowledge of congenital cataract. Why? Because embryology is to be known as it explains why there is an anterior epithelium underlying the anterior capsule and why it is absent at the level of the posterior capsule. This is an essential concept for the comprehension of PCO. In addition, everyone should know that a cataract could be familial and have a genetic origin, and therefore familial history is important. A good knowledge of paediatric cataract surgery can also help in cataract surgery in adults. The inflammatory system and the immune system in children is more reactive and this can help in understanding mechanisms in adults.”

EUROTIMES | NOVEMBER 2017

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SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

GENE THERAPY Choroideremia gene treatment now in clinical trials.

Leigh Spielberg MD reports

P

aediatric ophthalmology is at the forefront of genetic therapy, with clinical trials advancing for the treatment of choroideremia, Miguel Seabra MD, PhD, CEDOC, Lisbon, Portugal, told a session of the WSPOS 2017 Paediatric Subspecialty Day held prior to the XXXV Congress of the ESCRS in Lisbon.

“Choroideremia can be regarded as a systemic disease, due to the presence of the defective protein in all cells. However, the disease manifests itself only in the eye,” said Dr Seabra, who has spent the better part of his career researching this disease.

This X-linked condition characterised by progressive visual loss affects approximately one-in-50,000 males.

Impairment of night vision can occur in early childhood, followed by progressive narrowing of the field of vision and decreased visual acuity. Both the rate of progression and the degree of visual loss are variable.

“Genetically speaking, choroideremia is quite a simple disease caused by a lossof-function mutation in the CHM gene leading to one phenotype,” said Dr Seabra.

This gene encodes the Rab escort protein 1 (REP1), which is involved in lipid modification of Rab proteins.

The mutation in the RPE greatly accelerates photoreceptor death. The lack of a functional REP1 protein in the retina results in cell death and gradual deterioration of choroid, RPE and photoreceptor cells.

The “simplicity” of choroideremia stands in contrast to the complexity of other genetic ocular diseases such as the ciliopathies. These are diseases with many causative gene mutations and phenotypes, and present with both

retinal and extraocular manifestations.

“Yet despite choroideremia’s genetic and phenotypic simplicity, there are several things that we still don’t know. For example, what are the exact mechanisms of RPE and photoreceptor cell death? And why is the disease restricted to the retina?” he noted.

This is possibly due to the presence of a compensatory protein, REP2, which prevents lethality. The disease itself is a result of dysfunction of the substrates, Rab GTPases. In many inherited retinal diseases, the defective protein is directly involved in the light-sensing function of the eye. This is not, however, the case in choroideremia.

But what about treatment? Although there is currently no treatment available, strides have been made in the development of gene therapy for choroideremia. Dr Seabra has played a lead role in the treatment’s development, guiding clinical trials.

“The eye is an ideal organ for gene therapy. The eye, and particularly the retina, is small, meaning that only a small volume of cells need to be treated.

Compare that with the trillions of cells in the liver or the central nervous system, and the retina is ideal.”

Furthermore, the eye is accessible, it enjoys immune privilege and it is not a vital organ, despite its great importance to quality of life.

“The primary problem in gene therapy is the introduction of genetic material into the cell. For obvious reasons, cells are resistant to this invasion,” he said.

Gene therapy trials for choroideremia have used adeno-associated viruses (AAV) with healthy REP1 DNA (AAV.REP1) as a vector to bind to the cell membrane and inject the healthy gene into the cell’s nucleus. This allows the cell to make

protein using the healthy gene rather than the mutated one.

“The AAV infects both RPE cells and photoreceptors, resulting in efficient gene expression,” explained Dr Seabra. This method was used in human gene therapy trials for Leber’s congenital amaurosis.

Researchers have spent more than 25 years getting to this point. The first 15 years, from 1990 to 2005, were spent doing fundamental research, such as developing animal models for choroideremia. The next five years saw the translational research, while clinical research has been ongoing since 2011.

The first choroideremia clinical trial was started in October of 2011. In the study, two doses of the AAV.REP1 vector were injected into the subretinal space in 12 patients with choroideremia. The study demonstrated initial improved rod and cone function. Dr Seabra summarised the results.

“The two patients with the most advanced disease had substantial gains in visual acuity. There was improvement of maximal retinal sensitivity in treated eyes, and five patients enjoyed improved mean retinal sensitivity,” he said. Dr Seabra added that the most advanced patients exhibited changes in variable fixation.

Several questions remain, such as when the ideal moment might be to administer the injection in terms of disease progression; and how much of the retina should be treated, as doing so induces a temporary detachment of the retina.

More recently, the positive results seen in the 32 choroideremia patients treated are thought to be long-lasting. The biopharmaceutical company Nightstar has since received both FDA and EMA orphan drug designation to treat choroideremia.

Miguel Seabra: m.seabra@imperial.ac.uk

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS EUROTIMES | NOVEMBER 2017

www.eurotimesindia.org

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

GENERATING A NEW LENS New technique uses lens epithelial cells in paediatric patients.

Roibeard Ó hÉineacháin reports

A

n innovative technique for generating a new transparent, functional and accommodating crystalline lens following cataract removal is already producing promising results in paediatric patients, reported Thomas Kohnen MD, PhD, FEBO, University of Frankfurt, Germany, at the XXXV Congress of the ESCRS in Lisbon.

The technique involves removing the cataract through a tiny 1.5mm capsulorhexis in the periphery of the anterior capsule and leaving the lens epithelial cells on the inside of the capsular bag intact in order to regenerate the lens, explained Prof Dr Kohnen.

In a series of experiments, the researchers showed that the procedure resulted in the regeneration of functional lenses in rabbits, macaques and finally in a series of paediatric patients (H Lin et al., Nature 2016;531(7594):323-338), he reported.

The research was conducted by investigators at the University of California in San Diego and colleagues in China. The clinical study involved 24 eyes of 12 paediatric cataract patients who underwent the minimally invasive surgery to promote lens regeneration, and another group of 50 eyes of 25 paediatric cataract patients, serving as a control group, that underwent the current standard-of-care treatment that left them aphakic, Prof Dr Kohnen said.

The researchers found that in the new treatment group, the capsule healed within one month after surgery, and by three months a regenerated transparent biconvex lens structure had formed, which by eight months was comparable to a native lens, he noted.

In addition, there was no significant difference in visual acuity between eyes that received minimally invasive surgery (n=24) and those that received the current surgical technique (n=50), except at three months, when the control group had capsular opacities prior to undergoing laser capsulotomy.

Furthermore, evaluation at eight months with an open-field autorefractor showed that in eyes with regenerated lenses the mean accommodative response increased to 2.5 dioptres, compared to virtually no accommodation (0.10D) in the aphakic controls (P<0.001).

Moreover, retinoscopy and slit-lamp microscopy showed that the visual axis was clear in all but one patient. In fact, compared to the current standard of care for cataract surgery, the new technique decreased visual axis opacification by more than 20-fold (84% versus 4.2%).

In addition, the authors note that eyes that underwent the novel treatment had a significantly lower complication rate by almost every measurement, including corneal oedema (p=0.04), anterior chamber inflammation p<0.001), ocular hypertension and visual axis opacities.

Furthermore, while 84% of eyes undergoing standardof-care surgery required capsulotomy and 16% required anterior vitrectomy, none of the eyes undergoing the new technique required either intervention.

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Thomas Kohnen: kohnen@em.uni-frankfurt.de EUROTIMES | NOVEMBER 2017

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CATARACT & REFRACTIVE

NUCLEUS MANAGEMENT FOR

MSICS

Everything you ever wanted to know about manual small incision cataract surgery (MSICS) â&#x20AC;&#x201C; Part 2.

Dr Soosan Jacob reports This column is in continuation of my last column, which dealt with wound construction in MSICS.

R

HEXIS:

Superior rectus bridle suture taken while constructing the tunnel is released to allow the globe to move to primary position. Prior to creating the internal tunnel incision, a side port is constructed in the horizontal meridian on the right side for right-handed surgeons to allow a rhexis to be created under closedchamber conditions. Though can-opener capsulotomy can also be done and the nucleus extracted safely in MSICS, a rhexis is preferred as it allows in-thebag IOL placement. Unless the nucleus is small, a rhexis larger (6-7mm) than that conventionally created for phaco is required. The larger the nucleus, the larger the rhexis required to allow easy expression from the bag. Hard brunescent and black cataracts require relaxing incisions on the superior rhexis margin to safely prolapse the pole into the anterior chamber (AC).

The prolapsed pole of the nucleus is dialled out

EUROTIMES | NOVEMBER 2017

After completing rhexis, the tunnel is opened and extended to either side.

Internal incision of the tunnel is longer than the external incision.

HYDRODISSECTION AND HYDRODELINEATION: Hydrodissection and hydrodelineation are done under the rhexis margin to help delineate the nucleus to a smaller size and to aid in later cortex aspiration. The nucleus is then hydroprolapsed out by injecting multiple gentle fluid waves under the epinuclear shell while gently depressing on one side. Increased pressure behind the nucleus causes one pole to tilt out of the rhexis rim. If a can-opener capsulotomy was used, the nucleus is prolapsed by inserting a Sinskey hook carefully under the capsular margin to engage one pole of the nucleus and bring it out of the capsular bag.

NUCLEUS PROLAPSE INTO AC: Once one pole is out, viscoelastic is injected under the prolapsed pole to help tilt it further up. Viscoelastic is also injected to depress and contour the iris

The nucleus lies completely within the anterior chamber

around the prolapsed pole to make it easier to dial it out above the iris. It also coats and protects the cornea during the subsequent nuclear manoeuvres. A Sinskey hook is then used to engage the pole of the nucleus and dial the nucleus completely out of the bag and into the AC.

NUCLEUS EXPRESSION: The classical Blumenthal Mininuc technique uses fluid pressure from an anterior chamber maintainer and a Sheets glide for guiding and expressing the nucleus out of the tunnel. An irrigating vectis may also be used to engage and express the nucleus. Care should be taken not to accidentally entrap the inferior iris between the vectis and the nucleus, which can result in an iridodialysis.

Viscoexpression using HPMC 2% is the authorâ&#x20AC;&#x2122;s preferred technique. Once the nucleus is entirely within the anterior chamber, both anterior and posterior surfaces of the nucleus and cornea are coated liberally with viscoelastic. The superior rectus bridle suture is then tugged gently and a 23-gauge viscoelastic cannula is inserted under the nucleus beyond its centre. Viscoelastic is then injected under the nucleus with the cannula gently depressing the posterior scleral lip. The increased intra-cameral pressure together with the open corneo-scleral tunnel allows the nucleus to be expressed out. It engages the larger internal scleral lip, moulds to the tunnel and comes out through the smaller sized external lip. The cannula should be brought out together with the nucleus to avoid a posterior capsular rent when the chamber suddenly shallows after nucleus expression. Hard brown nuclei that cannot mould require a larger external incision. If the nucleus appears stuck in the tunnel at its widest, a cystitome can be used to rotate it out gently. However, if the nucleus appears

CATARACT & REFRACTIVE foldable IOL into the bag through the paracentesis after extending it with a keratome.

WOUND CLOSURE:

Viscoexpression of the nucleus

First postoperative day shows a clear cornea and round pupil

too large for the incision, forcible attempts should not be made to avoid endothelial loss, posterior capsular blow-out and nucleus drop. In case of difficulty, either the nucleus can be broken into smaller pieces that are extracted individually or the incision should be extended. If part of the nucleus is seen outside the wound, it can be debulked, pushed back into the AC, rotated to engage along the narrower diameter and then expressed.

CORTEX ASPIRATION:

NUCLEUS SECTION: Phacofracture with the bisector, trisector or a second instrument is possible.

However, these require two instruments within the AC and skill in performing the fracture. Uncontrolled movements of the hard nucleus or instruments against the endothelium and inadvertent damage to surrounding structures should be avoided.

A stainless steel snare can also be used effectively to divide a large nucleus.

With viscoexpression of the nucleus, the epinucleus and some cortex also generally express out through the incision. Attempting cortex aspiration through the tunnel can lead to shallowing of the AC and possible posterior capsular rent.

Cortex should instead be removed with the Simcoe cannula passed through the side port. This allows cortex aspiration in a closed chamber and also gives easy access to sub-tunnel cortex.

Viscoelastic is removed with the Simcoe cannula passed through the side port. The integrity of the incision is then checked.

Adequate pressurisation of the AC with air or BSS helps seal the internal valve more effectively. Length, depth, shape and distance of tunnel from the limbus all affect the amount of astigmatism. Sutures may be applied if the tunnel leaks or to decrease against the rule astigmatism.

Conjunctival cut ends can generally be apposed well by lightly applying cautery to the edges held together by a forceps. Doing this at either end allows good conjunctival closure. Alternately, injecting the antibiotic steroid injection into the cut conjunctiva balloons it up such that it covers the exposed sclera beneath. Sutures or fibrin glue may also be used to close conjunctiva.

Dr Soosan Jacob is Director and Chief of Dr Agarwal's Refractive and Cornea Foundation at Dr Agarwal's Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

IOL IMPLANTATION: Under cover of viscoelastic, the leading haptic of a rigid IOL can be implanted into the bag through the main port and the trailing haptic dialled in with the Sinskey hook passed through the side port.

Alternatively, the trailing haptic can be flexed into the bag.

Another alternative here is to inject a

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EUROTIMES | NOVEMBER 2017

9

10

CATARACT & REFRACTIVE

COMPLICATED SURGERIES How to handle your first complications in the operating room. Leigh Spielberg MD reports

E

See into the future of eye surgery and patient care.

Belong to something inspiring. Join us. www.escrs.org

very trainee must face the first complication when learning how to perform cataract surgery. Seasoned veterans at a session of the 21st Annual ESCRS Winter Meeting in Maastricht provided suggestions for how young surgeons could handle some of the more common situations.

Angela Panico MD tackled the difficult issue of the capsulorhexis running out.

“The basic reason for this is a capsular bag pressure that is higher than the pressure in the anterior chamber,” explained Dr Panico, Ophthalmic Unit, San Donà di Piave Hospital, Venice, Italy.

She described three “rescue” techniques to bring the rhexis back from the edge. “The pull-back technique” requires the surgeon to grasp the flap near the root of the tear and pull in the direction opposite the tear, which reverses the force applied to the flap,” she said, while showing a video of the manoeuvre.

The second rescue technique, an anterior zonulotomy, is performed if the tear has reached the zonular fibres. Additional traction may cause the tear to extend through the zonule to the posterior capsule.

In this case, cut the bridging zonular fibres using micro scissors, she suggested. This will release the traction on the capsule and allow for completion of the rhexis.

Catarina Pedrosa The “quick-pull technique”, the third manoeuvre described by Dr Panico, is a rapid forward movement reserved for experienced surgeons as a last resort.

Panellist José Güell MD, Barcelona, Spain, advised delegates to consider a femtosecond laser capsulotomy in cases with a significant risk of the rhexis running out. Professor Rudy MMA Nuijts, Maastricht, the Netherlands, suggested making a small initial rhexis, performing the phaco and then creating a larger rhexis at the end of the procedure.

Catarina Pedrosa MD, Lisbon, Portugal, presented next, advising attendees on how to avoid problems when performing cataract surgery in cases of posterior polar cataract, and how to solve them once they occur.

“Traditional hydrodissection should be avoided. Instead, perform hydrodelineation, in which the epinucleus is separated from the nucleus. This forms a cushion between the nucleus and the capsule,” she advised. An alternative is viscodissection, which also forms a cushion and will help avoid vitreous prolapse into the bag in case of posterior rupture.

Dr Nuijts agreed, and said he often takes it a step further, fully luxating the nucleus into the anterior chamber for removal far away from the posterior capsule.

“Treat all posterior polar cataracts as though there is a preexisting hole in the capsule, performing slow-motion surgery to minimise all risk,” concluded Dr Pedrosa.

Angela Panico: angy.panico@gmail.com Catarina Pedrosa: pedrosa.catarina@gmail.com

EUROTIMES | NOVEMBER 2017

CATARACT & REFRACTIVE

ANTIBIOTICS IN SURGERY Working to prevent postoperative endophthalmitis in cataract surgery. Leigh Spielberg MD reports

T

he good news is that endophthalmitis can be prevented.” So said Per Montan MD, starting his presentation on perioperative antibiotic use in cataract surgery at the XXXV ESCRS Congress in Lisbon.

Dr Montan, St Erik Hospital, Stockholm, and the National Cataract Registry, Sweden, first credited the late Dr Peter Barry, past president of the ESCRS, for his important work on endophthalmitis prophylaxis.

Dr Montan addressed the two crucial components in preventing postoperative endophthalmitis: preoperative disinfection with povidone iodine and intracameral antibiotics. The role of topical antibiotics with this regime, however, is unclear.

“Intracameral antibiotics have been proven to decrease the risk of endophthalmitis. A total of 24 studies, comprising six million surgeries, offer compelling evidence for the benefits of intracameral antibiotics,” he said.

This includes the ESCRS endophthalmitis study, which definitively showed that cefuroxime reduced endophthalmitis rates from 0.35% in controls to 0.05% in those treated prophylactically.

“However, there are still some questions that need to be answered. For example, which intracameral antibiotic is the best choice?”

The prime candidates are cefuroxime, a second-generation cephalosporin, and moxifloxacin, a fourth-generation fluoroquinolone. Analysis of observational data from the Swedish National Cataract Registry did not detect a statistically significant difference in endophthalmitis rates between the two antibiotics.

“Cefuroxime is effective against gram-positive strains, but it does not cover enterococci, and it is encountering resistance from methicillin-resistant staphylococci and gram negatives. On the other hand, moxifloxacin is suffering increased resistance among staphylococci and streptococci,” said Dr Montan.

And although both have been shown to be safe when used correctly, with no endothelial cell loss and no increase in postoperative inflammation, there are also potential safety issues related to dosing errors. For example, if accidentally overdosed, cefuroxime can lead to transient macular oedema or even macular infarction if the concentration is sharply increased.

However, a clear pattern has emerged regarding intracameral antibiotic prophylaxis.

“Whatever the local ‘background rate’ of endophthalmitis with the use of topical prophylactic regimens, the rates of infection are significantly reduced upon widespread adoption of intracameral prophylaxis,” he said.

“With the gold standard of preoperative disinfectants and intracameral antibiotics, it appears that a rate of one case per 5,000 surgeries might be the new benchmark for postoperative endophthalmitis. This rate is now seen in the Swedish endophthalmitis registry despite the non-use of topical antibiotics” he concluded.

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Per Montan: Per.montan@sankterik.se EUROTIMES | NOVEMBER 2017

11

22nd ESCRS Winter Meeting In conjunction with the Serbian Society of Cataract and Refractive Surgeons

9 â&#x20AC;&#x201C; 11 February 2018 Sava Centar, Belgrade, Serbia

www.escrs.org

CATARACT & REFRACTIVE

SUCTION LOSS DURING SMILE An uncommon event without major adverse consequences.

Cheryl Guttman Krader reports

T

he incidence of suction loss during SMILE is low, and as further good news, its occurrence does not prevent patients from undergoing refractive surgery or adversely affect the outcome, according to a study presented by Dan Z Reinstein MD at the XXXV Congress of the ESCRS in Lisbon, Portugal.

Professor Reinstein, Medical Director, London Vision Clinic, London, UK, analysed experience with suction loss in a series of 4,000 consecutive eyes treated by SMILE at his centre.

Consistent with incidence data from previously published studies of patients undergoing SMILE post-learning curve, Dr Reinstein found that suction loss occurred in 20 eyes (0.5%).

Among the 20 eyes, suction loss occurred most often during cutting of the lenticule interface (45%), followed by during creation of the cap interface (20%). Suction loss was most often patient-generated (75%) rather than surgeon-initiated or device-related, and due to involuntary movement associated with Bell’s reflex (50%) or because the patient was inappropriately tracking the green light (30%). SMILE was completed in 60% of the eyes with suction loss, and all of the remaining cases were successfully converted to LASIK. Nineteen of the 20 patients underwent SMILE in the fellow eye and served as a control group for an analysis of the results of SMILE in eyes with suction loss. Compared to Dan Z Reinstein the fellow eyes, the eyes with suction loss had similar efficacy, safety, accuracy, stability and refractive cylinder outcomes.

PREVENTING AND ADDRESSING SUCTION LOSS Dr Reinstein emphasised that the surgeon has the major role in preventing suction loss.

“Surgeons should be constantly talking to the patient, giving clear instructions about the fixation light in a calm, reassuring voice, while intensely monitoring for eye movement and having a high sensitivity for aborting the cut,” he said.

The laser software contains a “restart treatment wizard” that provides guidance on whether to continue SMILE or convert to LASIK, but the program only takes into account timing of the suction loss. By applying his own clinical knowledge and experience, Dr Reinstein said he has created a decision pathway that factors in understanding of the bubble pattern and potential strategies for continuing with SMILE rather than converting to LASIK, which will be published in his textbook in 2018: The Surgeon’s Guide to SMILE (Slack Inc).

He illustrated the algorithm by describing a case where there was patient-generated suction loss during cutting of the lenticule interface. Rather than converting to LASIK, which would be the wizard’s recommendation, Dr Reinstein reprogrammed the SMILE cap thickness from 135 to 110 microns. He completed the procedure successfully without complications and with an excellent outcome.

Dan Z Reinstein: dzr@londonvisionclinic.com EUROTIMES | NOVEMBER 2017

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14

CATARACT & REFRACTIVE

JCRS SYMPOSIUM

Controversies

in Anterior

Segment

Surgery Monday April 16, 2018 1:00–2:30 pm

JCRS HIGHLIGHTS VOL: 43 ISSUE: 8 MONTH: AUGUST 2017

GLUED IOL AND ASTIGMATISM Placement of a glued IOL produces less surgically induced astigmatism than seen after placement of a sutured scleral-fixated IOL, a prospective case study suggests. The study evaluated 16 eyes with aphakia and 15 with subluxated lenses over a mean follow-up of 12 months. There was a significant reduction in mean simulated K after surgery. The maximum K decreased significantly, from 44.85 ± 2.83D preoperatively to 44.47 ± 2.75D at six months. Mean surgically induced astigmatism was 1.0 ± 0.7D, ranging from 0.16 to 3.6D. The postoperative astigmatism analysis by the Alpins method was negative (−1.8), showing relative flattening after surgery. Multiple regression analysis found no association between postoperative vision and preoperative maximum K, postoperative simulated K, incision size and number of sutures. There was no correlation between the postoperative simulated K and incision position, sutures, and scleral flap position. The researchers conclude that glued IOLs can be implanted in eyes with preoperative maximum K ranging from 38.8 to 49.5D without significant loss of CDVA. DA Kumar et al., JCRS, “Corneal topography and keratometry changes after glued intraocular lens implantation”, Vol 43, No 8, p1062–1067.

YELLOW FILTERS AND STRAYLIGHT

Moderators:

Nick Mamalis, MD Sathish Srinivasan, MD

Presbyopia-Correcting IOLs Surgical Correction of Aphakia in a 60-Year-Old Treating Inflammation After Intraocular Surgery

During the ASCRS Annual Meeting Washington, DC, USA

How much do yellow filters influence retinal straylight? A prospective study looked at 56 right eyes of healthy volunteers using a colourless lens, followed by four other measurements using different yellow filters of different wavelengths. The use of yellow filters increased retinal straylight by a small but significant amount compared with the use of unfiltered light.

This suggests that the visual comfort often experienced while wearing these filters is not associated with reduced straylight.

This would exclude glare reduction as a reason people might prefer them over spectacles with colourless plano lenses.

A van Os et al., JCRS, “Influence of yellow filters on straylight measurements”, Vol 43, No 8, p1077–1080.

FEMTO-SCULPTING AN IOL Investigators at the John A Moran Eye Center in the US evaluated the uveal and capsular biocompatibility of intraocular lens power adjustment by a femtosecond laser obtained through increased hydrophilicity of targeted areas within the optic, creating the ability to build a refractive-index shaping lens within an existing IOL. Six rabbits had phacoemulsification with bilateral implantation of a commercially available hydrophobic acrylic IOL. The postoperative power adjustment was performed two weeks after implantation in one eye of each rabbit. Follow-up confirmed that consistent and precise power changes could be induced in the optic of commercially available IOLs in vivo by using a femtosecond laser to create a refractive-index shaping lens. The laser treatment of the IOLs was biocompatible. L Werner et al., JCRS, “Biocompatibility of intraocular lens power adjustment using a femtosecond laser in a rabbit model”, Vol 43, No 8, p1100-1106.

THOMAS KOHNEN European editor of JCRS

Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

EUROTIMES | NOVEMBER 2017

18TH EURETINA

CONGRESS

VIENNA 20-23 SEPTEMBER

2018 www.euretina.org

16

RETINA

QUALITY IN RESEARCH EVICR.NET clinical studies tackle some of the biggest problems in retina.

Leigh Spielberg MD reports

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linical studies now being conducted under the auspices of the European Vision Institute Clinical Research Network (EVICR.NET) are addressing some of the most urgent questions concerning the treatment of retinal vascular disease.

Researchers updated delegates on three of these studies during a symposium at the 17th Annual EURETINA Congress in Barcelona, Spain, in September 2017. The studies are known as: MACUSTAR, which is developing novel clinical endpoints for clinical trials in patients with intermediate age-related macular degeneration (AMD); EUROCONDOR, a clinical trial for neuroprotection in non-proliferative diabetic retinopathy (DR); and PROTEUS, which will study the effects of anti-VEGF injections for proliferative DR (PDR).

Robert Finger MD, professor of ophthalmology, University Eye Clinic, Bonn, Germany, shared the details of MACUSTAR. Described by Chairman Professor José Cunha-Vaz, University of Coimbra, Portugal, as a landmark study that will become a point of reference, MACUSTAR seeks to characterise the functional deficit in intermediate AMD. “The goal is to evaluate and validate candidate clinical endpoints for intermediate AMD and for progression from intermediate AMD to late-stage AMD,” said Dr Finger.

Outcome measures can be categorised as functional outcomes, structural outcomes and patient-reported outcomes.

The challenge will be developing testing protocols for functional tests under low luminance, including scotopic microperimetry, dark adaptation and contrast sensitivity. MACUSTAR will also implement a specifically developed, patient-reported outcome measure, the Vision Impairment in Low Luminance (VILL) questionnaire. The ultimate goal is to find composite endpoints representing both structure and function.

The study seeks to enrol 750 patients across seven countries for a three-year follow-up period, and the first results are expected in early 2019.

Cristina Hernández Pascual MD, presenting for Rafael Simó, both of Vall d’Hebron Research Institute, Barcelona, Spain, informed delegates about the European Consortium for the Early Treatment of Diabetic Retinopathy (EUROCONDOR). This consortium EUROTIMES | NOVEMBER 2017

carried out the first clinical trial for retinal neuroprotection for non-proliferative DR. The study showed that topical administration of neuroprotective agents, especially somatostatin, can ameliorate neurodysfunction in DR. There is a growing body of evidence that retinal neurodegeneration precedes retinal microvascular impairment in patients with diabetes mellitus. This has been demonstrated with multifocal ERG (mfERG) and OCT studies.

Somatostatin has been shown to be neuroprotective and anti-angiogenic.

However, its production in the RPE is down-regulated in the diabetic retina, and its concentration has been shown to be significantly lower in the vitreous fluid as compared to controls. Previous studies had shown that topical administration offered retinal neuroprotection in rat models of diabetes.

The EUROCONDOR study included patients with either no DR or only mild disease, and aimed to prevent its development via a non-invasive method without systemic adverse events.

It used mfERG to quantify retinal neurodysfunction. Dr Cunha-Vaz pointed out that this study also showed that topically administered drops can have therapeutic effects at the back of the eye.

Joao Figueira MD, professor of ophthalmology, Universidade de Coimbra, Portugal, shared the results of the PROTEUS trial. This study compared the efficacy and safety of intravitreal ranibizumab plus panretinal photocoagulation (PRP) versus PRP alone in 87 patients with high-risk PDR over a 12-month treatment period. The main endpoint was regression of the total area of neovascularisation.

The results were clear: PRP associated with ranibizumab was more effective than PRP alone in the regression of neovascularisation in high-risk PDR. Significantly fewer eyes needed rescue

treatment, such as vitrectomy or treatment for diabetic macular oedema.

Another session chair, Professor Francesco Bandello, University Vita-Salute, San Raffaele Scientific Institute, Milan, Italy, brought up a good point.

“This study was conceived when PRP was still the standard of care. What we need to know now is whether PRP + anti-VEGF is better than anti-VEGF alone. I think that anti-VEGF is better in the short term, but what happens in the long term is not yet known, whereas we know what happens in the long term after PRP.” The EVICR.NET network, founded in 2010, comprises 102 clinical sites in 18 European countries. The network, headed by Cecília Martinho, Coimbra, Portugal, helps promote multinational collaboration for large-scale trials in ophthalmology within the European Union.

The Coordinating Centre in Coimbra serves as a single contact point, and thus as a resource for both academia and industry. By certifying clinical sites and coordinating training activities for its member sites, EVICR.NET helps guarantee a high level of quality in the clinical research performed. It also serves as a liaison: EVICR.NET is contacted by industry and clinical research organisations (the sponsors) to identify certified clinical sites to participate in clinical studies. After a feasibility assessment, the sponsor selects the clinical sites with which it would like to work.

Because the European Union is comprised of different countries, each with their own laws, entities and languages, an organisation such as the EVICR.NET serves to assist with the overall management and logistical activities necessary to carry out multinational studies. More information can be found at www.evicr.net.

Robert Finger: Robert.Finger@ukb.uni-bonn.de Cristina Hernández Pascual: cristina.hernandez@vhir.org Joao Figueira: joaofigueira@oftalmologia.co.pt Francesco Bandello: bandello.francesco@hsr.it

RETINA

EDUCATION OR MYOPIA Intensive education systems driving myopia epidemic.

Dermot McGrath reports

T

he intensive educational systems of the developed countries of East and Southeast Asia are a leading factor in the explosion of myopia in these regions in recent years, Professor Ian Morgan PhD told delegates attending the 17th EURETINA Congress in Barcelona.

“There is an epidemic of myopia in the developed countries of East and Southeast Asia, which is linked both to the massive educational demands on children in this region and the limited amount of time that they spend outdoors,” he said.

Prof Morgan, Australian National University, Canberra, said it was vital to keep a careful watch on trends in education and to challenge the drive to put greater pressure on children.

“Every time a major international education survey is released we hear ministers of education say that we must imitate East Asia. The question I ask is in return is: What is it that you want to achieve – better educational outcomes or more myopia?” he asked.

Young people should spend more time outdoors, as this has been shown to be a protective factor against myopia development. “We also need to watch trends towards less time outdoors, induced by use of computers, smartphones or study, so that we have a warning and can anticipate that the prevalence of myopia will be going up in those regions,” he said.

Ian Morgan The Brien Holden Vision Research Institute estimates a worldwide prevalence of myopia of 23%, projected to increase to 50% by 2050. In certain Asian populations, up to 90% of young adults are now myopic, with a prevalence of high myopia of the order of 20%, said Prof Morgan.

In regions that had virtually no education systems some years ago – such as Africa in the 1930s or Eskimo populations – only 1 to 2% of young people had myopia by the age of 17 or 18, said Prof Morgan. Even today, the prevalence of myopia is still low in areas with only limited development of school systems.

“This tells you what the level of genetic myopia really is – that is, myopia that does not appear without environmental exposures. The explosion of myopia in East Asia and Singapore going from 20 to 80% in a few decades correlates with the appearance of intensive education systems,” he said.

Outside of East Asia, there is a trend towards rising myopia, and an epidemic is also seen among Orthodox Jewish males. It has similar characteristics to the epidemic seen in all children in parts of East and Southeast Asia. “It is only the boys who receive an intensive orthodox Jewish education that become myopic. The girls have an education that is much less pressured and they do not become myopic,” he said.

The prevalence of myopia is not well-established in Europe, but is probably in the range of 20 to 30%. “Europe needs to collect more comprehensive, methodologically sound and up-to-date data to ascertain a more accurate picture of the prevalence of myopia and high myopia among European populations,” he concluded. That is the best way to see if and when an epidemic of myopia emerges.

Ian Morgan: ian.morgan@anu.edu.au EUROTIMES | NOVEMBER 2017

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18

RETINA

Sebastian Wolf, Jan van Meurs, Robert Finger and Frank Holz at the launch of the EURETINA whitebook

WHITEBOOK ON DISEASE Whitebook provides reliable figures and bigger picture for development of prevention and intervention strategies. Colin Kerr reports

E

urope is facing intense demographic changes due to population ageing and a subsequent increase in age-related eye diseases. An increase in visual impairment and blindness in older Europeans due to retinal diseases is expected in the years to come.

To date, there has been a lack of comprehensive data on the current situation as well as future projections of retinal diseases in Europe. EURETINA has funded and now published a whitebook on retinal diseases in Europe, which provides reliable figures and the bigger picture for the development of prevention and intervention strategies.

Most common retinal diseases are age-related diseases, which leads to the expectation of increased numbers of affected individuals in Europe in the future. Therefore, there will be major challenges for European ophthalmology facing an ageing population. Two of the main causes for blindness and severe vision loss in Europe are retinal diseases: agerelated macular degeneration (AMD) and diabetic eye disease (DED).

The lack of comprehensive data on the prevalence and incidence of retinal diseases has been the starting point to fund a systematic literature review and metaanalysis of relevant sources and an analysis of implications to come up with the most EUROTIMES | NOVEMBER 2017

up-to-date figures on prevalence and incidence as well as forecasts.

All available data on the main retinal diseases were collated in the European Union (EU) as well as its five largest countries: Germany, the United Kingdom, France, Italy and Spain. The information in the whitebook will inform all stakeholders and identifies current and future challenges that need to be addressed appropriately.

In order to avoid an increasing number of blind and severely visually impaired Europeans in the decades to come, health services and research efforts need to be planned accordingly now.

OBVIOUS IMPLICATIONS The data shows that one-in-four Europeans over the age of 60 is affected

by AMD. The highest prevalence of any AMD was found in Italy, followed by France and Germany. The total number of EU inhabitants affected by AMD was estimated at 34 million. Late AMD occurs newly in 1.4 per 1,000 individuals each year. The prevalence of AMD is about to rise by 20% until 2050. With regard to anti-VEGF therapy, there are obvious implications for logistical challenges in the coverage for this mode of therapy, with repetitive intravitreal injections over a long period of time. Likewise, the numbers of patients affected by DED are on the rise, with an estimate of 3.8 million affected in 2040. In addition, barriers to screening and

management of DEDs must be addressed.

The work presented in the whitebook was conducted over 18 months at the Department of Ophthalmology and the Department of Medical Biometry, Informatics and Epidemiology, University of Bonn, Germany.

“Considerable healthcare resources will be needed to maintain vision in Europeans," said Prof Dr Frank G Holz, chair of the Department of Ophthalmology in Bonn and EURETINA President Elect.

Prof Jan van Meurs, President of EURETINA, said that against the background of an ageing European population and the increasing prevalence of retinal disease improvements are necessary both in current and future service provisions, as well as in research.

“The numbers in the whitebook would demand that research resources need to be identified to develop more efficacious treatment as well as faster translation of evidence into practice when novel diagnostic, preventive or therapeutic intervention has become available, which would also include an acceleration of the regulatory review processes as well as access to funding,” concluded Prof Dr Robert Finger, senior author of the whitebook, epidemiologist and clinician from Bonn.

The whitebook is available online at euretina.org.

Frank Holz: frank.holz@ukb.uni-bonn.de

RETINA

ARTIFICIAL INTELLIGENCE

OPHTEC | Cataract Surgery

A major project is working on creating an algorithm for disease diagnosis. Priscilla Lynch reports

A

major artificial intelligence (AI) project is working on creating a general algorithm for the diagnosis of retinal disease and could eventually reinvent the eye exam, reported Pearse Keane MD, Consultant Ophthalmologist at Moorfields Eye Hospital, UK, at the Irish College of Ophthalmologists 2017 Annual Conference.

Dr Keane gave a fascinating presentation on reinventing the eye exam in the era of big data and AI, through his work on Google’s DeepMind AI project. Mr Keane is working with DeepMind on a wide range of macular diseases, including age-related macular degeneration (AMD), diabetic macular oedema, retinal vein occlusion among many others.

The project aims to investigate how deep learning could help analyse optical coherence tomography (OCT) scans and make the diagnosis of these conditions more efficient and effective, leading to earlier detection and intervention for patients. As part of the research project between Moorfields Eye Hospital and DeepMind, deep learning is being applied to one million anonymous historic eye scans, to look for early signs of eye conditions that humans might miss.

While current OCT imaging is very effective, these images contain a huge amount of complex data, which takes considerable time, training and experience to Pearse Keane analyse correctly, with very large volumes of such scans now taken daily in busy ophthalmology clinics, Mr Keane noted.

The idea of using AI is that it is a technique that the algorithm learns from experience so it can look at a process of thousands, or millions, of scans and become as good as a retina specialist at diagnosing these conditions.

“It is important to emphasise that this is a research collaboration and we are hoping to publish a research publication sometime before the end of 2017 showing a ‘proof of concept’ of the algorithm, though it will be a little bit further in the future before it can be used in practice,” Mr Keane told EuroTimes.

The project has the potential to revolutionise the way eye exams are carried out, which could lead to earlier detection and treatment of common eye diseases, and Mr Keane’s presentation attracted considerable interest at the conference.

Meanwhile, Mr Keane also cautioned against the expansion of OCT, traditionally a hospital- and specialist clinic-based technology, into high-street optometrist chains unless appropriate training is in place for optometrists and/or artificial intelligence systems have been developed, saying that such widespread and casual availability could end up overwhelming ophthalmology clinics with needless patient referrals.

Pearse Keane: pearse.keane@moorfields.nhs.uk

Treat astigmatism with confidence  ASPHERICAL CYLINDER  PUPIL INDEPENDENCE 1) Precizon Toric is part of OPHTEC’s

 ENHANCED TOLERANCE TO MISALIGNMENT 2)  PROVEN STABILITY 3) 1) Bench study Kim MJ, Yoo YS, Joo CK, Yoon G; (J Cataract Refractive Surg. 2015;41(10:2274-2282)) 2) Data on File - study report Dr Erik Mertens, ESCRS 2014 3) Vale C, Menezes C, Firmino-Machado J, Rodrigues P, Lume M, Tenedório P, Menéres P, Brochado MC; (Clinical Ophthalmology 19, January 2016) This product is not available in the US

www.ophtec.com EUROTIMES | NOVEMBER 2017

19

20

RETINA

OPHTHALMOLOGICA VOL: 238 ISSUE: 4

NEW CATHETER PROVIDES SAFE AND EFFECTIVE RETINAL FLUID DRAINAGE External drainage of subretinal fluid (SRF) using a 24-G Optiva IV catheter is safe, efficient and useful in eyes with bullous exudative retinal detachment (RD), new research suggests. In a study involving 13 eyes of 13 patients with bullous exudative RD, SRF drainage was successfully accomplished in all eyes using a transconjunctival scleral incision with the 24-G catheter.

Except for one case of localised subretinal haemorrhage, no complications were noted. J Peng et al, “A Modified Technique for the Transconjunctival and Sutureless External Drainage of Subretinal Fluid in Bullous Exudative Retinal Detachment Using a 24-G i.v. Catheter”, Ophthalmologica 2017, Volume 238, Issue 4.

THREE-INJECTION LOADING DOSE EXTENDS TREATMENT-FREE INTERVAL In a study involving 61 eyes of 56 patients with myopic choroidal neovascularisation, eyes on a pro re nata (PRN) ranibizumab regimen appeared to achieve about the same visual outcomes whether they received a loading dose of three consecutive monthly injections or a loading dose of just one injection (p= 0.824). However, after a mean follow-up of 53 months, eyes that received the three-injection loading dose had a significantly longer treatment-free interval than those that received the oneinjection loading dose (36.9 months vs 19.2 months; p < 0.001).

C Calvo-González et al, “Long-Term Outcomes of Two Different Initial Dosing Regimens of Intravitreal Ranibizumab Used to Treat Myopic Choroidal Neovascularization”, Ophthalmologica 2017, Volume 238, Issue 4.

EARLY DETECTION AND TREATMENT ACHIEVES BETTER LONG-TERM RESULTS IN NEOVASCULAR AMD

Peer Review Open Access Journal For more information go to www.eucornea.org

Eyes with neovascular AMD treated early in the course of their disease appear to remain responsive to anti-VEGF therapy longer than those with more advanced disease at the time treatment is initiated, according to the findings of a retrospective review study.

It showed that among 67 eyes consecutively treated with more than 30 intravitreal anti-VEGF injections between 2007 and 2014, those with good final visual acuity also had better initial VA (p = 0.020) and maintained it. In contrast, patients with moderate-topoor final VA improved significantly after the first three monthly injections, and thereafter deteriorated consistently, mostly during the third (p = 0.019) and fourth (p = 0.006) years. Patients with initially moderate-to-poor vision also had more scarring and intraretinal fluid. O.Sagiv et all, “Different Clinical Courses on LongTerm Follow-Up of Age-Related Macular Degeneration Patients Treated with Intravitreal Anti-Vascular Endothelial Growth Factor Injections”, Ophthalmologica 2017, Volume 238, Issue 4.

SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA

EUROTIMES | NOVEMBER 2017

8

th EURETINA

Winter Meeting

16–17 February 2018 InterContinental Hotel Budapest, Hungary 6 Clinical Sessions including: ∙ AMD ∙ Clinical Cases ∙ Diabetic Retinopathy ∙ Imaging ∙ Uveitis/Inflammation ∙ Vitreoretinal Surgery

Free Paper & Poster Submissions Open Online Exhibition & Sponsorship Opportunities Available

www.euretina.org

22

CONGRESS REPORTS

LISBON2017 Tadahiko Kozawa

ESCRS President Prof David Spalton speaking at the Congress Opening Ceremony

RECORD ATTENDANCE AT ESCRS CONGRESS

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ore than 9,800 delegates from 120 countries attended the XXXV Congress of the ESCRS in Lisbon, Portugal.

ESCRS president Professor David Spalton said the record attendance was a testimony to the Society’s mission of bringing the very best in highquality clinical research and education to its members. Prof Spalton said that this year’s Congress had offered a first-rate scientific programme and a wide range of symposia, courses and wetlabs covering most major fields of ophthalmology.

“With 16 symposia, 492 free papers, 1,257 posters, 125 courses and 64 wetlabs – together with a massive exhibition – I think we will all be able to return home with something that is hopefully going to change our practice, make us better surgeons and improve the care of our patients,” he said.

He said that teaching and training would continue to feature at the heart of ESCRS action in serving the needs of its members and the wider ophthalmological community. The ESCRS already offers many educational opportunities to its EUROTIMES | NOVEMBER 2017

members in the form of annual meetings, the “On Demand” presentation library, Video of the Month, “Eye Contact” interviews, a surgical technique library and the iLearn e-learning platform.

Prof Spalton also cited special measures for trainee ophthalmologists such as free membership of the Society, bursaries to attend the annual congress, the Young Ophthalmologists Programme and an ongoing Observership Programme. The Peter Barry Fellowships, awarded for the first time this year, would further strengthen the Society’s commitment to young ophthalmologists.

Among the highlights of this year’s Congress was the Binkhorst Medal Lecture on the topic of “Cataract Surgery in HighRisk Eyes: Lessons Learned”, delivered by Boris Malyugin.

The Congress also marked the release of the results of the ESCRS PREMED Study.

The study found that a combination of a topical corticosteroid and a nonsteroidal anti-inflammatory drug (NSAID) is more effective than either agent alone in reducing the risk of developing cystoid macular edema (CME) after cataract surgery in non-diabetic patients.

GRAND IDEAS WIN PRIZES AT CONGRESS The overall winner in the 2017 Video Competition of the Michael Blumenthal Award was Tadahiko Kozawa, Japan. His video, “New Propeller Turbo Tip for torsional phacoemulsification and aspiration”, described a new phaco-tip designed to reduce the risk of tissue damage that can result from the scattering of lens tissue that occurs with conventional torsional phacoemulsification.

The winners of this year’s poster competition highlighted research on new techniques and technologies in cataract and refractive surgery, as well as reviews of results achieved and complications associated with well-established procedures.

First prize in the Refractive Category went to Lional Raj Daniel Ponniah, India, for “Femto modified keratoconic eyes and intracorneal lenticular transplantation (stromal augmentation technique): an effective alternative to DALK”.

First prize in the Cataract Category went to Panos Gartaganis, Greece, for “Different reasons or a start-up factor of hydrophilic IOL calcification?”.

The winner of this year’s John Henahan Prize is Dr Clare Quigley. Dr Quigley is a third-year Resident at Mater Misericordiae University Hospital in Dublin, Ireland. The winning entry in the writing competition for young ophthalmologists was on the topic of "How does commercial interest affect my career?"

Three young European ophthalmologists also earned the right to go to an ophthalmic centre of their choice in order to pursue their research, courtesy of the inaugural Peter Barry Fellowship.

Luis Fernández-Vega from Spain, Nino Hirnschall from Austria and Myriam Böhm from Germany each received the fellowship award of €50,000, enabling them to further their training at a centre of excellence anywhere in the world.

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LISBON2017 Rudy MMA Nuijts and Laura Wielders, who presented the results of the ESCRS PREMED European study

LANDMARK STUDY RESULTS UNVEILED

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combination of a topical corticosteroid and a nonsteroidal anti-inflammatory drug (NSAID) is more effective than either agent alone in reducing the risk of developing cystoid macular edema (CME) after cataract surgery in non-diabetic patients, according to the results of the ESCRS PREMED European study presented at the XXXV Congress of the ESCRS in Lisbon, Portugal.

The ESCRS PREvention of Macular EDema after cataract surgery (PREMED) study is the first international multicentre randomised controlled clinical trial specifically designed to answer questions relating to the prevention of CME after cataract surgery in diabetic and nondiabetic patients.

EUROTIMES | NOVEMBER 2017

The study outcomes pave the way for the first evidence-based clinical results to prevent CME after cataract surgery in diabetic and non-diabetic patients.

“CME remains one of the most prevalent postoperative complications in cataract surgery and especially in the diabetic population, where the incidence can be as high as 31%,” said Rudy MMA Nuijts MD, PhD, Professor of Ophthalmology at the University Eye Clinic Maastricht UMC+, The Netherlands, and lead investigator of the PREMED Study.

“This landmark study in over 1,000 patients will give us the foundation to draw up concrete evidence-based recommendations to prevent the occurrence of CME after cataract surgery in patients with and without diabetes,” he said.

Dr Nuijts presented the results of the non-diabetic arm of the study, while his colleague Laura Wielders MD, PhD, focused on the implications for diabetic patients.

Carried out at 12 surgical centres across the European Union, the PREMED Study was carefully designed to evaluate the effect of different preventive strategies on the occurrence of macular edema in 914 non-diabetic and 213 diabetic patients. All patients in the study received standard phacoemulsification for cataract and placement of an intraocular lens. Intraoperative and postoperative antibiotics were administered according to local protocols.

In the non-diabetic population, the 914 patients received either a topical NSAID (bromfenac 0.09%) or a topical corticosteroid (dexamethasone 0.1%), or a combination of both. The primary outcome was the difference in central subfield mean macular thickness (CSMT) at six weeks postoperatively. Important secondary outcome measures included postoperative corrected distance visual acuity (CDVA), as well as the incidence of CME and clinically significant macular edema (CSME) within six and 12 weeks postoperatively.

The incidence of CSME within 12 weeks postoperatively was found to be lower in the combination treatment group (1.5%), compared to 3.6% for bromfenac alone and 5.1% for dexamethasone alone.

The 213 diabetic patients in the study were randomly allocated to receive no additional treatment, a subconjunctival injection with 40mg triamcinolone acetonide (TA), an intravitreal injection with 1.25mg bevacizumab or a combination of both after cataract surgery.

The main outcomes were the difference in CSMT, CDVA, and the incidence of CME and CSME within six and 12 weeks postoperatively.

The macular thickness and volume was found to be significantly lower in patients who received a subconjunctival injection with TA compared to patients who did not.

No patient who received subconjunctival TA developed CME, while intravitreal bevacizumab had no significant effect on macular thickness.

• If you missed the presentation, you can view it online at ESCRS On Demand. See also EuroTimes Eye Contact interview at http://player.escrs.org/

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ECCTR ENTERS SECOND PHASE

Friedrich Kruse addressing delegates at the Opening Ceremony of the 8th EuCornea Congress in Lisbon

uCornea President Professor Friedrich Kruse said that he was heartened to see so many delegates supporting the 8th EuCornea Congress in Lisbon, Portugal, and said it provided a firm platform for the future growth and well-being of EuCornea.

Dr Kruse expressed satisfaction with the momentum that the organisation has built up in a relatively short time, with more than 700 delegates registering for this year's congress Launched in 2009 in Barcelona during the XXVII Congress of the ESCRS, the first EuCornea Congress was held in Venice in 2010, and the event has now firmly established itself as a major point of reference for cornea specialists.

The strength of the scientific programme, with eight focus sessions dedicated to key issues in corneal and ocular surface treatment and a wide range of training courses, underscored the outstanding support that EuCornea has received from its members, said Dr Kruse.

He also saluted the recent initiative of the European Cornea and Cell Transplant Registry, which aims to improve quality in corneal transplant surgery and urged delegates to contribute to making the registry a success.

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As part of the opening ceremony, François Malecaze of France, a former President of the organisation, delivered the EuCornea Medal Lecture on the topic of “Keratoconus: what have we accomplished and what is still left to do?”

While keratoconus remains a mysterious disease with a complex pathophysiology, significant progress has been made in recent years in the diagnosis and management of the condition, Prof Malecaze told the Congress.

“We still have much to learn about how this disease develops, but the good news is that the technological advances of recent years have transformed the decision tree of keratoconus patients and given us more options for effective treatment,” he said.

Dr Kruse presented the prizes for Best Poster award to Rénuka Birbal, with joint second prize going to Alberto Villarrubia and David Cordeiro Sousa and third prize to Jorge Alió del Barrio.

The next annual Cornea Day will take place during the 22nd ESCRS Winter meeting on 9 February 2018 in Belgrade, Serbia, and the 9th EuCornea Congress will be held in Vienna from 21-22 September 2018.

ONE of the highlights of the 8th EuCornea Congress was an instructional course that explained how and why cornea specialists should get involved with the European Cornea and Cell Transplantation Registry (ECCTR), a registry system for corneal surgeons co-funded by the ESCRS. “This course provided a thorough introduction to the ECCTR system and included discussion of the project’s legal and ethical aspects, as well as detailed instructions on how to report and take out data, and how to use your own data in order to improve your practice,” said Dr Mats Lundström, Sweden, who together with Mor Dickman MD, the Netherlands, presented the course.

The ECCTR registry will collect and collate data on availability of corneal tissue, methods of transplantation, and visual outcomes, said Dr Lundström. He and the registry team have so far harmonised three existing national European corneal registries, in the Netherlands, Sweden and the UK, and will soon be recruiting individual surgeons and centres of excellence to participate in the project.

“We are hoping that this registry will be a valuable tool for benchmarking and comparison.

We know that when it comes to a specific type of surgery the best way to perform surgery isn’t always found within your own region or even within your own country. It’s definitely an advantage to have a broader international field of data for comparison,” Dr Lundström said.

ENTERING THE RECRUITMENT PHASE The ECCTR had its official launch at the XXXIV ESCRS Congress in Copenhagen. The project is a three-year programme, with the now completed development of an EU web registry in the first year, followed by recruitment of clinics and eye banks and the collection of data starting in the second year. At the 9th EUCORNEA Congress in 2018, the ECCTR’s leading investigators will present their data and will also use the data for creating European guidelines for corneal transplant surgery.

The instructional course in Lisbon represents the initiation of the second, recruitment stage of the project, said Dr Lundström.

“We have actually built the software and it has been tested by representatives for the three involved national registers and for the steering group. After a number of updates, we are now in the phase that a few clinics will test how it works as a sort of a beta version in a test database.”

The project is co-funded by the ESCRS and by the EU under the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA).

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CONGRESS REPORTS

17th EURETINA Congress

EARLY BIRDS RACE FOR WORTHY CAUSE

EURETINA president Jan Van Meurs addressing delegates at the Opening Ceremony of the 17th EURETINA Congress in Barcelona, Spain

CONGRESS EXCEEDS EXPECTATIONS Gathering of retinal experts builds on high standards of previous congresses

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ore than 4,900 delegates were registered for the 17th EURETINA Congress in Barcelona, Spain.

This year’s Congress surpassed all expectations, both in terms of the attendance and the scope of its activities, said Professor Jan van Meurs, outgoing President of EURETINA. Prof van Meurs said that this year’s gathering of retinal experts had built on the high standards set by previous congresses.

“The 17th EURETINA Congress presented more scientific modules than ever before,” he said. “The programme also saw the return of World Retina Day, now in its third year, with contributions from international retina societies and sub-groups. We were also delighted to launch a new initiative dedicated to Young Retina Specialists (YOURS), which underscores the society’s commitment to the future development of our specialty,” said Prof Van Meurs.

The EURETINA Lecture 2017 was delivered by Francine Behar-Cohen of France, discussing the optimised use of ocular steroids.

Other highlights of the meeting included the Gisbert Richard Lecture on the topic “Selecting the Appropriate Surgical Technique for Retinal Detachment”, which was delivered by Borja Corcóstegui, Institut Microcirurgia Ocular, Barcelona, Spain.

Donald Jackson Coleman MD, FACS, delivered the Kreissig Lecture on the topic “Macular Degeneration and Treatment of the Ischemia of the Choroid”.

In the EURETINA video competition awards, first prize was shared jointly

by Subhendu Kumar Boral of India, for his entry on innovative approaches to deal with difficult retained intraocular foreign bodies, and Laura Sararols Ramsay of Spain, for her video entitled “Posterior Hyaloid Dissection: Let’s make it easy with blue”.

Prof Van Meurs, at the conclusion of his last Congress as EURETINA president, offered his best wishes to incoming EURETINA president Sebastian Wolf, and said that he looked forward to seeing everyone next February in Budapest for the 8th EURETINA Winter Meeting and Vienna in September 2018 for the 18th EURETINA Congress.

An early alarm clock call was the order of the day for the large group of dedicated runners who turned out in the pre-dawn darkness in Barcelona to support the 2017 Retina Race in aid of ORBIS. Organised by EURETINA and sponsored by Novartis, the sixth annual Retina Race took place over a winding five-kilometre course around the congress centre, finishing on the picturesque Barcelona seafront.

Drawn from the assorted ranks of ophthalmologists, scientists and exhibitors in town to attend the 17th EURETINA Congress, almost 100 runners of all ages took part in the race, cheered on by well-wishers, friends and family members.

Maximilian Pfau of Germany was first past the post in a blistering time of 17 minutes and 16 seconds. The first female competitor to cross the finishing line was Elin Holm, who finished the race in 22 minutes.

While the emphasis of the Retina Race is firmly on the fun aspect of participating and raising money for charity, the runners were still keen to improve on personal best times and perhaps earn a place on the winner’s podium.

Speaking on behalf of EURETINA, Anat Loewenstein, co-founder of the race along with Stephane Wolf of Novartis, said that the participants could be proud of their achievement in running for the noble goal of saving vision.

Key race organiser Stephane Wolf thanked everyone who took part in the race and said he hoped to see even more people taking part next year, when the 18th EURETINA Congress will be held in Vienna, Austria.

LIST OF WINNERS 2017 Women over 50 category: (1) Maud Righini, (2) Anat Loewenstein, (3) Claudia Richard Men over 50: (1) Knut Sturmhoefel, (2) Eli Zangvil, (3) Francesc Diaz Plata Women 40-50: (1) Elin Holm, (2) Maja Gran Erke, (3) Nina Angelsen Men 40-50: (1) Huw Jenkins, (2) Paris Tranos, (3) Stephane Wolf Women 30-40: (1) Chantal Dysli, (2) Joke Debruyn, (3) Alexandra Miere Men 30-40: (1) Julien Bullet, (2) Jonathan Smith, (3) Martin Vantomme Women Under 30: (1) Ajla Nebi Men’s Under 30: (1) Maximilian Pfau, (2) Elon Van Dijk, (3) Jayzer Jen Caerlang

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NEW WAYS TO TREAT NK New nerve growth factor agent promising in early trials.

Leigh Spielberg MD reports

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trategies for the treatment of neurotrophic keratopathy (NK) range from basic prophylaxis to surgery.

Now a new agent, recombinant nerve growth factor, offers new hope to these patients, reported Paolo Rama MD at the 8th EuCornea Congress in Lisbon, Portugal.

NK is related to alterations in corneal nerves leading to impairment in sensory and trophic function, with consequent breakdown of the corneal epithelium. This affects the health and integrity of both the epithelium and stroma. It is well known that the permanent, non-healing epithelial defects in NK can be extremely difficult to manage, explained Dr Rama, San Raffaele Scientific Institute, Milan, Italy.

He outlined several different stages of treatment, starting with prophylaxis.

He advised avoiding unnecessary topical drugs; prescribing only preservative-free artificial tears; using scleral or therapeutic soft contact lenses in patients at risk; and making sure the ocular surface is protected at night, either via ointment or occlusion.

Once mild NK has developed, autologous serum or platelet-rich plasma can be prescribed. However, the current treatment paradigm of more advanced NK is primarily surgical.

Besides treating the NK itself, the underlying cause of the loss of nerve function must also be addressed. This is most commonly herpetic eye disease, but a very wide range of aetiologies have been identified, including severe chemical burns, systemic diseases such as diabetes, and any cause of fifth cranial nerve palsy.

“Medical treatment is insufficient, and surgical treatments, like lateral tarsorrhaphy and amnion membrane grafting, are not primarily aimed at improving vision, but at preserving ocular integrity,” said Dr Rama.

In effect, the current treatments, both medical and surgical, simply treat the corneal damage secondary to NK without

Dr Paolo Rama speaking at the 8th EuCornea Congress in Lisbon, Portugal

addressing the underlying neuronal deficit.

The chronic problem of loss of corneal sensory innervation leads to decreased corneal epithelial renewal rate, reduced tear formation and a situation that is ultimately untreatable without resorting to surgery.

Dr Rama introduced delegates to the possibilities of using nerve growth factor (NGF) to treat difficult cases of NK. “NGF is a molecule critically involved in differentiation, growth and survival of neurons. It also has known proliferative effects on epithelial cells,” he said.

Discovered in the 1950s and isolated from mice or produced via genetic engineering, NGF may dramatically alter the treatment of NK. It is, however, a molecule with a complex folding pattern that is difficult to manufacture.

As far back as 1998, Dr Rama and his team published an article in the New England Journal of Medicine to report that topically applied murine NGF restored corneal integrity in 12 patients with neurotrophic ulcers. These included patients who had developed corneal anaesthesia after neurosurgery, herpetic keratitis, topical anaesthetic drug abuse and even simple PRK.

In many cases, seven days of topical murine NGF was sufficient for closure of the epithelial defects Paolo Rama MD EUROTIMES | NOVEMBER 2017

“In many cases, seven days of topical murine NGF was sufficient for closure of the epithelial defects,” he said. Dr Rama showed pictures of beautifully clear corneas that had previously looked hopeless.

More than 100 severe patients have thus far been treated, and 100% have demonstrated complete healing, he said. Side-effects are mild, and include conjunctival hyperaemia, photophobia and periocular pain. Of the 11 patients tested for anti-NGF antibodies, none tested positive. All patients who relapsed suffered from NK due to fifth cranial nerve resection.

In 2011, the Dompé Group of Italy acquired the worldwide rights for the development and commercialisation of NGF. Despite the difficulty of producing NGF, the Dompé Group has succeeded in producing a recombinant molecule that is 10 times more potent in vitro than murine NGF. A phase I study proved the safety of topical recombinant NGF. A phase I-II study, the REPARO study, enrolled 174 patients in 39 centres and was successfully completed. Marketing authorisation was granted in Europe in 2017, and recombinant human NGF, referred to as cenergemin, will be marketed as Oxervate.

“NGF may represent a future therapeutic approach to treat neurotrophic persistent epithelial defects, stromal ulcers and melting, as well as to promote reinnervation, prevent recurrence and improve the prognosis of keratoplasties in neurotrophic cases,” he concluded.

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EMERGENCY GRAFTING Extensive research study finds favourable outcomes.

Cheryl Guttman Krader reports

Courtesy of Parwez Hossain MD

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esults of a retrospective analysis of data from the UK Transplant Registry study provide strong evidence that emergency corneal grafting can be a successful sight-saving procedure.

“There is a common perception among corneal surgeons that corneal grafting for severe corneal disease associated with infection and perforation carries unacceptable risks of rejection and failure.

Consequently, many such patients are offered evisceration or enucleation. Our study, which we believe is the largest to investigate outcomes of emergency corneal grafts, should raise awareness that emergency corneal grafting is worthwhile,” said Parwez Hossain MD, speaking to EuroTimes.

“We found that although there are risks that corneas may fail or reject, over a five-year period even in the worst high-risk case scenarios, the chance of graft survival is at least 40%. Most interestingly, if we look at the outcome over a shorter time period of just one year, the chance of graft survival rate is much higher. And, even if graft failure occurs, vision in many cases is still better than when the eye was in the acute stage pre-grafting. From a patient’s perspective, these odds make grafting a much better option than having the eye removed.”

The favourable outcomes also speak to the importance of having eye banking

Patient with fungal keratitis with corneal perforation

Immediate post-penetrating keratoplasty of same patient (patient continues to keep graft and is rejection free two years after surgery)

facilities that are able to supply corneal tissue immediately for emergency grafting, said Dr Hossain, Associate Professor and Consultant Ophthalmologist, University of Southampton, UK, and lead author of the published article reporting on the study (Br J Ophthalmol. 2017 May 11, epub ahead of print).

“This is important considering that in many parts of the world, eye banking facilities are rudimentary or non-existent for allowing corneal transplant material to be available in a few hours.”

The study reviewed outcomes from 1,330 emergency corneal graft procedures performed between April 1999 and March 2005. The operations included 433 (33%) regrafts, were performed by 244 surgeons from 147 centres, and involved full thickness penetrating keratoplasty in 1,132 (85%) cases. About two-thirds of the procedures were in eyes with perforation,

while threatened perforation and severe infection were each present in about 30% of eyes. Infection (39%) and non-infectious ulcerative keratitis (32%) were the most common diagnoses.

Considering eyes undergoing a first emergency corneal graft, the graft survival rates at one, two and five years were 78%, 66% and 47%, respectively. As a reference, the investigators noted that the one-year survival rate for elective cornea graft operations is 90%. Median BCVA prior to grafting was hand movements. At one year, BCVA was improved in 81% of eyes and 6/12 or better in 30%.

Previous studies providing information on outcomes of emergency corneal grafting have either focused on a subtype of emergency corneal grafts or included a low number of cases.

Parwez Hossain: P.N.Hossain@soton.ac.uk

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REGISTER AND BOOK HOUSING TODAY AnnualMeeting.ascrs.org Programming will be held in the Walter E. Washington Convention Center.

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ADDITIONAL PROGRAMS ASOA WORKSHOPS • APRIL 13 ASCRS REFRACTIVE DAY • APRIL 13 ASCRS GLAUCOMA DAY • APRIL 13 CORNEA DAY • APRIL 13 T&N TECH TALKS • APRIL 13 TECHNICIANS & NURSES PROGRAM • APRIL 14–16

CORNEA

DMEK OUTCOMES DMEK trial shows good results but high rate of reoperations.

Roibeard Ó hÉineacháin reports

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escemet’s membrane endothelial keratoplasty (DMEK) results in good visual outcomes in the majority of eyes that undergo the procedure, although starting DMEK surgeons may experience higher complication rates than experienced DMEK surgeons, according to the results of a large retrospective study presented at the 8th EuCornea Congress in Lisbon, Portugal.

“Our multi-centre study shows that standardised ‘no-touch’ DMEK is feasible for surgeons in various settings, with good clinical outcomes in terms of visual acuity and ECD decrease,” said Silke Oellerich PhD, Netherlands Institute for Innovative Ocular Surgery, Rotterdam, the Netherlands.

The retrospective, interventional cohort study involved 2,485 eyes undergoing DMEK in 55 centres in 23 countries.

The indications for surgery were Fuchs endothelial corneal dystrophy in 74%, bullous keratopathy in 17%, transplant failure in 8% or other indications in 1%, Dr Oellerich noted.

At six months follow-up, BCVA had improved in 90.5% of eyes, remained unchanged in 4.6% and deteriorated in 4.9%. In addition, BCVA was 20/40 or better in 75.4%, 20/25 or better in 45.4% and 20/20 or better in 25.8% for the entire group, with no eyes excluded because of low visual potential.

Dr Oellerich noted endothelial cell density (ECD) decreased by a mean of 40%. Intraoperative complications, such as Silke Oellerich difficulties inserting and manipulating the graft tissue, were reported for 9.4% of eyes. Graft detachment was the main postoperative complication and occurred in 27.4% of eyes, of which 14.9% had only a small detachment (<1/3 of the graft surface area).

BETTER RESULTS AS SURGEONS GAIN EXPERIENCE To assess the impact of experience with the technique on outcomes, they divided the surgeries into the surgeons’ first 24 or fewer DMEKs (group I), their 25th to 99th DMEKs (group II) and DMEK case numbers 100 or higher (group III).

BCVA and ECD outcomes did not differ between beginning and experienced DMEK surgeons (P=.07 and P=.53, respectively). However, group III surgeons had lower intraoperative complications (16% vs 5%) and graft detachment rates (34% vs 22%) than those in group I (P<0.05).

For example, re-bubbling was performed in 20% of eyes overall, but in only 18% of eyes in group III compared to 24% in group I. Likewise, repeat transplantations were necessary within six months in 18% group I eyes versus 9% in group II. “Virtually all transplant-related complications declined with experience. Notably, surgeons with a higher annual caseload may pass faster through their learning curve than surgeons performing their first surgeries over an extended period,” Dr Oellerich said.

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Silke Oellerich: oellerich@niios.com EUROTIMES | NOVEMBER 2017

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NEW FINDINGS IN GLAUCOMA

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New developments in diagnosis, treatment and prevention highlighted. Priscilla Lynch reports

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laucoma remains under-recognised, despite being a major cause of irreversible blindness worldwide, leading international experts on the disease told the 2017 Irish College of Ophthalmologists Annual Conference.

Glaucoma affects 2% of the population over the age of 40 and 3.5% over the age of 80, but remains difficult to diagnose in time, as it is essentially symptomless in the early stages and damages peripheral vision. While glaucoma is an increasing issue due to the rising ageing population, there have been a number of promising new developments in diagnosing, treating and preventing it, the conference heard.

Prof Augusto Azuara-Blanco MD, Professor of Ophthalmology at Queen’s University Belfast, highlighted the recent key findings of the EAGLE trial, of which he is Chief Investigator, and published in The Lancet in October 2016.

This data supports the superiority of clear-lens extraction (CLE) in terms of patient, clinical and economic outcomes for treating primary angle-closure glaucoma compared with laser iridotomy (up to now the currently preferred treatment).

“One-in-five glaucoma cases is angle closure so it is important to recognise the disease. The other issue is that CLE works very well, better compared to the standard laser treatment, and it is an option that should be offered to patients,” he told EuroTimes.

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Meanwhile, also speaking during the glaucoma session, Mr Leon Au MD, Glaucoma specialist Ophthalmic Consultant from Manchester Royal Eye Hospital, UK, argued the importance of perfecting existing surgical techniques and increasing detection of glaucoma over the myriad of new “wonder treatments” and dependence on technology.

He noted that while some of the latest technologies have assisted in making glaucoma surgery less invasive, and some new procedures are quick with little risk, they do not lower pressure as effectively as traditional surgeries such as trabeculectomy, and their longevity remains uncertain.

There is little doubt that given the appropriate patients these new procedures work well, but a complete replacement for tradition filtration surgery they are not, he said.

However, the “competition” in glaucoma treatment has highlighted the need to “do better” and refine, shorten and make existing established surgery more patient-friendly, Mr Au acknowledged.

“In glaucoma, the amount of investment interest and the expansion of technology is so vast. It is not like the odd one or two ‘wonder treatments’ appearing; it is one after another.

There is a huge amount of patient and commercial interest in this field. It comes with a good side, but also a downside.

I think some of these devices will come and go, some of the concepts will stay but the concept of minimally invasive eye surgery is something we should embrace. It is what our patients want,” Mr Au told EuroTimes.

Augusto Azuara-Blanco: aazblanco@aol.com Leon Au: info@corneaglaucoma.com

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ALTERNATIVE PERIMETERS The uses and limitations of standard automatic perimetry.

Roibeard Ó hÉineacháin reports

A Keep learning.

Stay relevant.

lternative perimetry techniques may be used as a complementary test in glaucoma diagnosis, but not at the expense of standard automated perimetry (SAP), unless the patient cannot reliably perform the standard test and objective methods are available, suggests Gustavo De Moraes MD, MPH, Columbia University, New York, USA. “There are a lot of alternatives to SAP, but you have to keep in mind that they have their limitations and, above all, these methods are not interchangeable. You also have to be specific about whether you are looking for detection of conversion to glaucoma or for detecting progression,” Dr De Moraes told the 7th World Glaucoma Congress in Helsinki Finland He noted that 30-2 or 24-2 SAP – or its equivalent to other types of perimeters – remains the gold standard for assessing functional status in glaucoma and for monitoring functional changes. Research shows that monocular and binocular threshold sensitivities detected by SAP are significantly correlated with quality of life. However, these do not always equate with the ease with which patients can live their daily life.

Frequency doubling technology (FDT) has some advantages over SAP in that it appears to detect glaucomatous changes earlier and has less variable testing results in patients with more advanced disease. Although previous work suggested a similar application for short-wave automated perimetry (SWAP), more recent research showed it was not any better than SAP for detecting early functional damage.

Moreover, it has high test-retest variability, which limits its usefulness for the diagnosis of early glaucoma and its ability to monitor the progression of the disease.

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Electroretinography has also shown promise and has the advantage of being objective. It performs as well as SAP and FDT, and better than SWAP, in detecting early glaucoma and mapping regions of visual loss, but it has been largely abandoned because tests did not find favour with patients.

However, Felipe Medeiros MD and his associates have developed a more patient-friendly device that can be used with a smartphone. “This portable brain-computer interface makes electrophysiology a lot easier and gives you a good estimate of function in a more objective way than SAP,” said Dr De Moraes.

The device, called the NGoggle, consists of a wearable, wireless, dry electroencephalogram and electro-oculogram system and a head-mounted cell-phone-based display. It allows detection of multifocal steady state visual-evoked potentials associated with visual field stimulation.

Dr De Moraes noted that in a study by Dr Medeiros’ team, the device was able to distinguish between patients with and without glaucoma with equal specificity and greater sensitivity than SAP. The regions of the retina where the NGoggle device showed diminished sensitivity also corresponded to the pattern deviation plots obtained with SAP. Gustavo De Moraes: Gustavo.demoraes@columbia.edu

GLOBAL OPHTHALMOLOGY

ESCRS IN DURBAN ESCRS participates in meeting of Southern African Society of Cataract & Refractive Surgery. ESCRS president Professor David Spalton reports

T

his year we had a first for the ESCRS when we were invited to run two sessions at the meeting of the Southern African Society of Cataract & Refractive Surgery in Durban by Frik Potgieter (the current President). The meeting started on Wednesday with satellite meetings, going on to a full programme on Thursday, Friday and Saturday.

The SASCRS runs a thriving meeting keenly attended by their 400 members, with their membership extending up into the adjacent southern African states with a widely spread international contribution.

South Africa is a country not without problems. Personal security seems to be not far from anyone’s mind, corruption is rife and they suffer the increasing financial and regulatory constraints on practice just as we do in Europe, but the local surgeons are highly motivated and have an unrivalled experience of anterior segment surgery.

Their practices deal with gross trauma and pathology we very rarely see in the West with the advantage of First-World surgical facilities, a combination probably unique to South Africa. PowerVision are conducting the trials of the FluidVision accommodating IOL there, and I recall a case shown by Dr Potgieter of pellucid marginal degeneration that was so gross the patient could not close their lids over the cornea, a surgical challenge few of us will see.

SASCRS President Frik Potgieter (centre) with Boris Malyugin, Rudy MMA Nuijts, David Spalton and Roberto Bellucci of the ESCRS

On Saturday morning, the ESCRS presented a session on toric IOLs, with myself speaking on patient selection, formulas and surgically induced astigmatism, Roberto Bellucci on topography and postoperative adjustment, Rudy MMA Nuijts on surgical alignment, Vicky Katsanevaki on phakic toric IOLs and Boris Malyugin on irregular astigmatism. This was supplemented by each of us giving presentations in other sessions during the meeting.

The first ESCRS session was followed by a new format of ‘Dilemmas in Cataract Surgery’, in which we were joined by local

surgeons Bill Nortje and Robert Stegmann, and we all presented a mixture of problem cases with a lively discussion on ‘what should/would you/I do next’. This was very enjoyable and constructive, but upstaged

by Robert Stegmann’s following Kritzinger Lecture on a lifetime of virtuoso surgery in a bush hospital, amply illustrated with superb video, each case more exotic than the last.

South African friendliness and hospitality is legendary, and after the meeting many of us took the opportunity (self-financed of course) to go up to Phinda, a game reserve four hours north of Durban, which was a life-enhancing experience for me and everyone else.

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EUROTIMES | NOVEMBER 2017

37

YOUNG OPHTHALMOLOGISTS

THE HOLY GRAIL Dr Andrei Solomatin talks about his mentor, his father Igor, who guided

him silently from childhood to a career in ophthalmology

Courtesy of Andrei Solomatin MD

M

entor is the name of the character from Odyssey, written by Homer in the 8th Century. Mentor served as an adviser or teacher to Odysseus’s son, Telemachus.

As for me, I grew up in the medical family and followed the footsteps of my father Professor Igor Solomatin, who is an ophthalmologist. I remember myself in ophthalmology from the 6th grade. I’ve spent hours and hours in the surgery room, watching my father doing his job, and dreaming that someday, someone will teach me how to treat people like my father does.

So, in 2008 I went to a medical school, to find my mentor there, but six years went by and I didn't find that "someone" who would open the holy grail in medicine for me.

But I didn’t give up, because I knew that the residency was up ahead and I would definitely find my mentor there. A couple of years went by. I learned a lot in ophthalmology, but I still could not find the person who I could look up to.

But all those years I had been working with my father shoulder to shoulder in the operating theatre. He was not

Dr Andrei Solomatin (left) with his father Dr Igor Solomatin

teaching me but definitely mentoring me, without me realising it. This is what makes a great mentor.

The Brazilian footballer Ronaldinho was a genius during his professional career.

He played football so easy and so fluently.

When he had the ball at his feet, he made his dribbling look so easy, but in reality, what he was doing is hardly even possible for most other professional footballers.

The great musician Prince once performed a guitar solo on the song 'While my guitar gently weeps'. This is the greatest guitar solo I have ever heard, but Prince hardly even looks to the strings while playing this masterpiece.

Again, like Ronaldinho, he was playing so naturally and effortlessly that some musicians might think that what he is doing is easy.

But it isn't. The same attributes apply to a great ophthalmological mentor.

He or she must not only help develop residents' surgical and medical skills but also give advice in all aspects of everyday life.

If your mentor can do this without you even noticing it, if his ideas and advice are so useful in your daily routine that you think that they're your own ideas, then your teacher knows the art of mentoring.

That is what my father did, and I will be forever grateful to him.

CALL JOHN FOR HENAHAN ENTRIES PRIZE 2018

Young ophthalmologists are invited to write an essay on

“Do We Need a Randomised Controlled Clinical Trial in Cataract Surgery?”

First prize is a €1,000 travel bursary to the 36th Congress of the ESCRS in Vienna, Austria.

CLOSING DATE FRIDAY 30 MARCH 2018 Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org

EUROTIMES | NOVEMBER 2017

39

HOSPITAL DIARY

A MOTORCYCLE DIARY

Concentration, know-how, and a small dose of insanity are all you need for a motorbike – or a career in surgery. Leigh Spielberg MD reports

E

ach ophthalmology cases to my senior colleague conference represents and mentor, Fanny Nerinckx, an opportunity I also don’t attempt to take to rent a new sharp turns at high speed. motorcycle abroad.

After all, you have to expect My editor here at the unexpected. Back when I EuroTimes, having heard finished my fellowship and that I was spending my started off on my own, my EURETINA 2017 evenings father, also a physician, told cruising around the city me the following: “Always streets and into the hills assume that the case you’re around Barcelona with a about to start is the one in shiny red Ducati, asked me which a complication is to write a piece comparing bound to occur.” The same riding a motorcycle to thing applies when you go out working in the operating riding. You can never really let room. I eagerly obliged. What your guard down. could be better, I thought, And yet, when cruising down than writing about two of my on a long stretch of highway, it’s favourite activities? easy to let your mind wander.

There are at least a dozen How about during basic different classes of motorcycle, sculpting or cortex removal? It’s from the loud and shiny Harley something we’ve done so many Davidson-style cruisers made times that it happens almost famous in the movie Easy automatically. But therein Rider to the speedy Japanese lies the danger: as easy as it racers; from the beautiful, may seem, maintaining your roaring Italian street bikes to focus during these moments the big, on-road / off-road is crucial. A quick swerve of BMW sport tourers that you a truck into your lane, or a can ride from Paris to Dakar. tiny fold of posterior capsule in Whereas buying a motorcycle the aspiration port – both can is like signing up for a multiturn a smooth experience into a I’m pretty sure, or at least I like to year surgical fellowship, just nasty surprise. renting a motorcycle is like To lower all risks, you make believe, that I’m a better surgeon than doing a short observership in sure all equipment is present, I am motorcycle rider.

This makes sense a foreign city: it allows you to ready and in full working get a sense of what a particular order. For example, I always motorcycle is like, without having to get too involved. test the phaco function before I make my first incision. I want There are several obvious similarities between riding a motorcycle to know of any mechanical problems first. On a motorcycle, and operating. Both are intense. They require a combination of having a problem with your brakes on the way down a concentration, know-how, and a small dose of insanity. mountain road is no joke. Being caught in the rain with wornI’m pretty sure, or at least I like to believe, that I’m a better down tyres? Non, merci. surgeon than I am motorcycle rider. This makes sense. Whereas And what if something happens? It’s not only crucial to I’ve only taken a few motorcycle training courses, I have the good avoid complications, but also be able to manage them when they fortune to have done a serious surgical fellowship. Operating is occur. Fortunately for our patients, complications in modern my job, my focus, the reason I go to work in the morning. surgery can almost always be properly treated to avoid chronic On the other hand, my time on a motorcycle is purely a problems. Just as the surgical equipment and techniques leisure-time activity. Although I very occasionally ride my have improved drastically over the past 20 years, so have motorcycle to work, I prefer to save the privilege of riding for motorcycles become safer. Anti-lock braking systems and sunny evenings and relaxed weekends. I prefer not to associate traction control on a motorcycle are comparable to phaco’s work and riding with each other. I also don’t want to be stuck in active fluidics and vitrectomy’s advanced IOP management. traffic, rushing to get to the operating room on time. That’s when Problems have become rarer with the introduction accidents happen. of all these advances. Nevertheless, quick reflexes Both on a motorcycle and in the operating room, it’s are needed to correct a rear wheel that has lost traction important to recognise – and respect – your own restraints on some sand or oil on the road, regardless of a in terms of skill and experience. Nothing is more dangerous motorcycle’s technology. than disregarding one’s surgical limitations and adopting a On a lighter note, the funniest piece of motorcycle clothing cowboy attitude. That’s how complications happen. But if these I’ve ever seen has absolutely no comparison in the operating limitations are respected, and risks managed, things generally room. It’s a T-shirt, and on the back, it tells other drivers: “If You seem to work out fine. Just as I refer paediatric retinal surgery Can Read This T-Shirt, My Girlfriend Fell Off.” Illustration by Eoin Coveney

40

EUROTIMES | NOVEMBER 2017

BOOK REVIEWS

SHARPEN YOUR SKILLS Curbside consultations in Neuro-Ophthalmology: 49 Clinical Questions (Slack), edited by Andrew G. Lee is the ideal refresher course for those of us who have noticed our grasp of neuro-ophthalmologic knowledge slip away since the end of our training. Diagnosing neurologic disorders, PUBLICATION ophthalmology’s ultimate CURBSIDE CONSULTATION IN diagnostic puzzles, requires a NEURO-OPHTHALMOLOGY certain understanding of that EDITORS many of us might have lost.

ANDREW G LEE, MD Curbside Consultations encourages us to jump right PUBLISHED BY SLACK BOOKS into clinically relevant case studies that are described with a clarity that allows us to apply the principles in the clinic. For those looking for detailed anatomical diagrams and lengthy descriptions of exotic syndromes, look elsewhere. This book covers the diseases you’ll see on a weekly basis. Let me rephrase that: it covers the diseases you’ll see if you recognise them; and this book should help you do so.

Examples are extremely practical: “A 60-year-old man has binocular horizontal diplopia. He does not abduct OD well and has an incomitant esotropia. Now what?” This question describes the appropriate evaluation in a patient suspected of having a sixth nerve palsy. Beware: they’re not all that easy. “A 65-year-old woman presents with headaches and binocular oblique double vision. Examination reveals limited abduction ODS. Furthermore, OS will not adduct, elevate, or depress, and there is left ptosis. OS pupil is 2mm larger than OD. What should I do now?” This complex question is followed by an easy-to-follow description of the correct procedures for a patient with multiple ocular motor cranial nerve palsies. Ideal.

This 200-page book, illustrated with good clinical pictures and well-made tables, is intended for general ophthalmologists who would like to sharpen their neuro-ophthalmologic diagnostic skills; ophthalmology residents rotating through neuro; and neuro-ophthalmology fellows who absolutely do not want to miss a single standard diagnosis.

BOOK

REVIEWS

INTERDISCIPLINARY APPROACH OCT in Central Nervous System Diseases (Springer), edited

by Andrzej Grzybowski and Piero Barboni, is subtitled The Eye as a Window to the Brain. As such, it “reviews recent important advances in the use of optical coherence tomography in order to analyse neurodegeneration within the retina through the quantification of axonal loss”.

But this is not simply a summary of recent research. The chapters provide a wealth of useful clinical information. For example, Chapter 3 covers the OCT appearance of optic nerve oedema, offering explanations on how to differentiate true oedema from pseudo-subtypes. Later chapters focus on the retinal OCT appearance in patients with neurological disease.

This textbook is intended for those interested in interdisciplinary approaches between ophthalmology and neurology/psychiatry.

LEIGH SPIELBERG MD Books Editor

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41

INDUSTRY NEWS

NEWS IN BRIEF SUB-RETINAL IMPLANT Pixium Vision has announced that its next-generation miniaturised wireless sub-retinal implant, PRIMA, has received authorisation from the French regulatory agency, Agence nationale de sécurité du médicament et des produits de santé (ANSM), to start a feasibility clinical study in patients with advanced dry age-related macular degeneration (dry-AMD).

Khalid Ishaque, Chief Executive Officer of Pixium Vision, a company developing bionic vision systems to enable patients who have lost their sight to lead more independent lives, commented: “PRIMA enters an exciting phase of its development, with a first patient expected to be implanted before year end.” www.pixium-vision.com

INDUSTRY

NEWS

MOBILE PATIENT BED Johnson & Johnson Vision’s CATALYS System Mobile Patient Bed has received FDA clearance for sale in the United States and will be available for sale this month.

“Our goal with this innovation is to enhance patients’ overall surgical experience, so we worked to provide an easy transition as they move from one part of their cataract procedure to the next and premium comfort while they are in the operating room,” said Tom Frinzi, Worldwide President, Surgical Vision, at Johnson & Johnson Vision. “We also designed the mobility and adaptability features of this bed to help simplify the workflow for surgeons between the laser cataract suite and phacoemulsification.” www.jnjvision.com

SIMPLIFIED OPERATION

James V Mazzo

ONE MILLION PROCEDURES ZEISS has reported that doctors performing laser vision correction surgery using its SMILE refractive technology have now surpassed one million procedures worldwide.

“We are thrilled that SMILE, the first major advancement in laser vision correction since the 1990s, has reached this important milestone and that ZEISS has played an integral role in ushering

in a new era in refractive surgery with this proven technology,” said James V Mazzo, Global President Ophthalmic Devices at Carl Zeiss Meditec.

“We are honoured to see SMILE so widely accepted by doctors and their patients, and that SMILE has helped doctors restore and improve the vision for so many people around the world.” www.zeiss.com/med

NIDEK has launched the LM-7P Auto Lensmeter with printer and the LM-7 Auto Lensmeter.

“Both design and user interface have been improved for simplified operation to expand utility of the instrument, while maintaining the highly valued measurement principles, functionality and quality,” said a Nidek spokesman.

“An advanced measurement principle, that incorporates simultaneous measurement of 108 data points within the nosepiece, provides greater accuracy and reliability with easier and faster measurements,” he said. www.nidek.com

ENHANCED CUSTOMER EXPERIENCE OCULUS Optikgeräte GmbH has announced that OCULUS Surgical, Inc has acquired Insight Instruments.

“We feel that the addition of the Insight Instruments product line will enhance the ever-growing portfolio that OCULUS has introduced to the retina surgeons, beginning with the original SDI/BIOM in 1985.” said Christian Kirchhübel, CEO, OCULUS Optikgeräte GmbH, Germany.

“As both organisations are well known and respected in the ophthalmic community, this acquisition will enhance the overall customer experience among ophthalmic surgeons, our distributors and key industry partners around the world.” www.oculus.de

US SUBSIDIARY Rayner has established a dedicated subsidiary for the US market, ‘Rayner Surgical Inc’.

“Based out of New York, Rayner Surgical Inc will provide US-specific marketing, regulatory, commercial and research functions to Rayner. From its offices at 100 Park Avenue, NYC, Rayner Surgical Inc will actively promote and support the growth and development of Rayner’s business in the US,” said a Rayner spokeswoman.

“A new, physical US presence will strengthen Rayner’s relationships with US surgeons, universities and key opinion leaders (KOLs), generating valuable collaborative partnerships and identifying new opportunities in IOL design and innovation,” she said. www.rayner.com

EUROTIMES | NOVEMBER 2017

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44

RANDOM THOUGHTS

RELIEVING STRESS Meditation is not for everybody, but it may help to relieve stress.

Maryalicia Post reports

A

t a party recently, the question of ‘stress’ came up. Who had it, what they do about it. When I was asked if I suffered from stress – my first reaction was to say ‘no’.

After all, I’m not an eye surgeon! The most stressful thing I would normally face is a long queue at airport security or a cancelled flight.

So for a moment I thought I might just say ‘no’, but somehow that seemed pretentious, as if I were implying I was too well organised to experience stress. Or perhaps it would suggest I was a lady of leisure, which I’m not. So I said ‘yes', and then the young man who’d asked the stress question had the chance to ask another.

CLEARING THE MIND “Have you thought about meditation?”

Now I could say ‘no’ without a second thought?

“I’m not sure what religion it’s based on,” I explained, “but it’s not mine.”

“Okay,” said he. "You don’t need any specific spiritual belief. I don’t practice a religion and meditation works for me."

“Well,” I confessed. “‘I can’t imagine sitting still – trying not to think about anything – for any length of time. It would drive me crazy.”

Turns out that’s a common misconception. He assured me it’s not about

stopping your thoughts. It's about becoming more aware of them, but not dwelling on them. You focus on your breath and on your sense perceptions. You let your thoughts pass by like clouds. Label them and let them go.

“It’s a gentle procedure,” he added. “Not sombre at all.”

I asked him what he’d gotten out if it.

“In my case – it varies with the individual – after about a month I noticed my mind was clearer and I had developed a heightened sense of perception. Ultimately, I experienced a feeling of relaxation, of being uplifted.”

“Sounds great,” I stonewalled, “but I wouldn’t have the time.”

Ready when you are.

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“Ten or 15 minutes a day...”

Since that evening I’ve been noticing the posters – taped to trees along the footpath, pinned up in my local supermarket and in the post office – offering ‘meditation’ sessions in my locality. And, at goodreads.com, I came upon a book called Teach Yourself To Meditate by Eric Harrison that got great reviews.

What have I got to lose? A few euro for a book – or a course – and 15 minutes a day. I’m thinking about it.

This article first appeared online at www.eurotimes.org

Reach the peak.

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Belong to something impressive. Join us.

46

ESASO

NEW SKILLS PROGRAMME ESASO teams up with universities to train residents in simulated surgical environments

T ESASO

Training Programme for Residents September 2017 to September 2018

The faculty members that participate in the university specialisation programme are: Francesco Bandello University Vita-Salute, Scientific Institute San Raffaele, Italy Anselm Jünemann University Rostock, Germany Leonardo Mastropasqua University “G. d’Annunzio” Chieti-Pescara, Italy Robert Rejdak University Lublin, Poland Giovanni Staurenghi University Eye Clinic Department of Biomedical and Clinical Science “Luigi Sacco”, Italy

EUROTIMES | NOVEMBER 2017

he European School for Advanced Studies in Ophthalmology (ESASO) is a pioneer in postgraduate education. This September, ESASO extended its educational activities: together with renowned universities, ESASO has developed a new programme for residents to build-up surgical skills necessary to become ophthalmologists.

One year ago, the Swiss-based school inaugurated its ESASO Training Centre (ETC) in Lugano. With its state-ofthe-art facilities the ETC provides a solid base for tailored education, hosting 16 wetlab workstations, four dry lab stations and a classroom for up to 60 participants. Learners train their skills in diagnostics and surgical techniques and can choose from different medical devices. The innovative multimedia equipment captures surgical techniques on an elevated level, and allows faculty members to interact with the participants individually or in the group.

The pilot phase of the newly launched programme has successfully started with residents from three Italian universities.

A second roll-out phase will involve German and Polish universities and will be launched during 2018 and 2019.

TAILORED PROGRAMMES

ESASO aims to support its partners by training residents and preparing them for their future careers. Complementary to the training ESASO will offer tailored programmes for wet and dry lab activities. The participants will learn about surgical steps and processes, become familiar with the OR environment and perform surgical interventions. They will benefit from shared knowledge from senior colleagues guiding them through their individual learning experience.

The benefit for the participant is to gain hands-on experience without pressure, sharing knowledge while assisting colleagues to perform their surgeries, and reflecting on outcomes with experts and other participants.

Depending on the varying university specialisation curricula, ESASO’s tailored programmes can include several days of wet and/or dry labs: vitreoretinal surgery and/or cataract surgery with a virtual simulator; and vitreoretinal and/or cataract in the wet lab.

The dry lab, with its virtual simulators, allows residents a stepwise approach to consecutive surgical attempts without time-consuming preparations; an efficient personal and equally professional experience that would require years of practice in a real-world environment and with real patients.

This newly created residents training programme creates a win-win-situation between ESASO and stakeholders. It will allow partner universities to include an effective preparation for their residents learning current concepts while using sophisticated technologies and medical devices correctly. The participants will benefit from acquired hands-on skills while mastering their knowledge in surgery and required steps for clinicians.

ESASO can offer these benefits to medical department at your university and support your resident training programmes. For more information see www.esaso.org, or contact ESASO’s head office at info@esaso.org.

CALENDAR

↙

LAST CALL

NOVEMBER 2017

AAMC Annual Meeting: LEARN SERVE LEAD

3–7 November Boston, Massachusetts, USA https://www.aamc.org/meetings/annual/

New Orleans Conference for Educators 2017

11 November New Orleans, USA https://ico.formstack.com/forms/ confeds_neworleans2017

AAO 2017

11–14 November New Orleans, USA www.aao.org/annual-meeting

XXXIX Inter-American Course in Clinical Ophthalmology

19–22 November Miami, Florida, USA http://bascompalmer.org/cme/inter-americancourse-in-clinical-ophthalmology

International Conference on Ophthalmology

21–23 November Dubai, United Arab Emirates http://oap-conferences.org/ico-2017

4th International Symposium “Low Vision and the Brain” 24–26 November 2017 Berlin, Germany http://www.4r-vision.com/

The 4th World Congress of Paediatric Ophthalmology and Strabismus will take place in Hyderabad next month

DECEMBER

JANUARY

WCPOS IV: 4th World Congress of Paediatric Ophthalmology and Strabismus

Annual Conference on Ocular Microsurgery

Asia-Pacific Vitreo-Retina Society Congress (APVRS)

22nd ESCRS Winter Meeting

1–3 December Hyderabad, India wspos.org/india-2017

8–10 December Kuala Lumpur, Malaysia http://2017.apvrs.org

2018

JANUARY

Basic Science Course in Ophthalmology

8 January – 2 February New York, USA http://columbiaeye.org/education/ the-basic-science-course

10–13 January 2018 Eilat, Israel www.eyemeetingeilat.com/en/

FEBRUARY

9–11 February Belgrade, Serbia www.escrs.org

2nd International Swept Source OCT & Angiography Conference 16–17 February Paris, France https://www.issoct.com/

8th EURETINA Winter Meeting 16–17 February Budapest, Hungary www.euretina.org

9th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

10–12 January Vienna, Austria http://www.ophthalmictrainings.com/ workshops

VOS Congress 2017

24–26 November 2017 Hanoi, Vietnam http://www.vos2017.org.vn/

Annual Ophthalmologists Meeting

29–30 November Atlanta, Georgia, USA http://ophthalmology.alliedacademies.com

Paris will host the 2nd International Swept Source OCT & Angiography Conference in 2018

EUROTIMES | NOVEMBER 2017

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48

CALENDAR

MARCH

14th ISOPT Clinical: The International Symposium on Ocular Pharmacology & Therapeutics

The 2018 EURETINA, EuCornea and ESCRS Congresses will take place in Vienna

1–3 March Tel Aviv, Israel https://www.isoptclinical.com/

NEW 32nd International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 1–4 March Athens, Greece www.hsioirs.org/index.php/en/

Frankfurt Retina Meeting 2018

24–25 March Mainz, Germany www.eckardt-frankfurt.de

JUNE

APRIL

NEW 2018 ASCRS•ASOA Annual Meeting

13–17 April Washington DC, USA http://annualmeeting.ascrs.org/

NEW 4th ESASO Anterior Segment Academy

26–28 April Milan, Italy www.esasoasa2018.org

NEW 31st International Congress of German Ophthalmic Surgeons

14–16 June Nuremberg, Germany http://www.doc-nuernberg.de/index-e.php

3rd World Eye Bank Symposium

15 June Barcelona, Spain http://www.gaeba.org/events/ 3rd-world-eye-bank-symposium-gaeba/

WOC 2018

16–19 June Barcelona, Spain www.icoph.org

SEPTEMBER

18th EURETINA Congress 20–23 September Vienna, Austria www.euretina.org

9th EuCornea Congress

21–22 September Vienna, Austria www.eucornea.org

2018 WSPOS Subspecialty Day 21 September Vienna, Austria www.wspos.org

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

Eye Contact Interviews

l

Video of the Month

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Video Journal of Cataract & Refractive Surgery

l

Young Ophthalmologists Videos: “My Early Surgeries”

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Online Museum

player.escrs.org EUROTIMES | NOVEMBER 2017

SEPTEMBER

36th Congress of the ESCRS

22–26 September Vienna, Austria www.escrs.org

OCTOBER

AAO Annual Meeting 2018 27–30 October Chicago, USA https://www.aao.org/

SPECIAL FOCUS PAEDIATRIC OPHTHALMOLOGY CATARACT & REFRACTIVE

DEALING WITH COMMON COMPLICATIONS IN CATARACT SURGERY

RETINA

INTENSIVE EDUCATION SYSTEMS ARE DRIVING AN EPIDEMIC OF MYOPIA November 2017 | Vol 22 Issue 11

Eye Care for Children

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