EuroTimes Vol. 22 - Issue 6 by EUROTIMES

SPECIAL FOCUS GLAUCOMA CORNEA

DSAEK STILL HAS A PLACE IN CORNEAL TRANSPLANTATION SURGERY

RETINA

INTRAOPERATIVE OCT SET TO BECOME AN INDISPENSABLE TOOL FOR VR SURGERY

HOSPITAL DIARY

June 2017 | Vol 22 Issue 6

OPERATING AT NIGHT CREATES CHALLENGES, BUT ALSO OPPORTUNITIES

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P.6

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Lara Fitzgibbon

CONTENTS

Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Soosan Jacob

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS GLAUCOMA 4 Cover Story: MIGS

increasingly adopted but still finding its place

Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org

8 Changes in variation

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

of ocular pulsation amplitude detected with contact lens sensor

‘Different kinds of imaging techniques yield different results in diagnosis’

10 Sustained IOP reductions

achieved with trabecular bypass stent and MICS

11 ‘MIGS playing a growing and earlier role in glaucoma treatment’

FEATURES CATARACT & REFRACTIVE 16 Everything you ever

wanted to know about white cataract phacoemulsification – Part 2

18 Careful screening of

at-risk patients to help reduce the incidence of retinal detachment

19 New toric IOL 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.

alignment system provides easier workflow

www.eurotimes.org

22 ASCRS annual meeting:

Incoming President backs education and research

23 LASIK outcomes:

Wavefront-guided may offer gains over wavefront-optimised procedures

25 JCRS Highlights

CORNEA 27 DSAEK still has a place in corneal transplantation surgery

28 Advances in tear film

testing open new vista in dry eye diagnosis and treatment

29 CXL is cost-effective

in treating patients with progressive keratoconus, study suggests

31 DALK: Viscoelastic device can reduce the risk of Descemet’s membrane perforation

RETINA

P.44

REGULARS 42 Clinical Questions 43 Industry News 44 Hospital Diary 45 ESCRS News 47 Book Reviews 48 Calendar

32 Intraoperative OCT

set to become an indispensable tool for VR surgery

36 OCT-A extends its reach 37 Ophthalmologica Update

20 The benefits of

capsulotomy-centred IOLs

P.21 EUROTIMES | JUNE 2017

EDITORIAL A WORD FROM FOTIS TOPOUZIS MD; AND INGEBORG STALMANS MD, PhD

GLAUCOMA DAY

ESCRS Glaucoma Day 2017 will be held in Lisbon, Portugal on Friday, 6 October, and will cover a comprehensive selection of current hot topics

s the Chair and Co-Chair of the European Glaucoma and minimally invasive glaucoma surgery (MIGS). This is sure Society (EGS) Programme Planning Committee, we are to be one of the hot topics during Glaucoma Day and we look honoured to be invited to write the editorial for this issue forward to a lively and informative debate on the subject. of EuroTimes which has a special focus on glaucoma. We are always looking at new ways of promoting debate in These are very exciting times for the EGS as we glaucoma and we are also very pleased to see that EuroTimes is prepare for the 7th ESCRS Glaucoma Day on Friday, helping to drive this debate through its Eye Contact video interview 6 October in Lisbon, Portugal, immediately preceding series. The latest Eye Contact the XXXV Congress of the ESCRS. Glaucoma Day is interview (which can be accessed on Glaucoma Day is now co-organised by the EGS and the ESCRS. the ESCRS Player at player.escrs.org) For those of you not familiar with the EGS, let us give discusses individualised glaucoma firmly established you a brief history. In 1978, Erik Greve sent a letter to management. in the international Wolfgang Leydhecker proposing to set up a glaucoma Comprehensive management society. Leydhecker contacted Jules Francois, then the of the glaucoma patient requires ophthalmological calendar president of the European Society of Ophthalmology consideration not only of the and we look forward to a (SOE). Representatives from many European countries intraocular pressure and visual very exciting programme were invited to come to Ghent, Belgium (where Francois fields, but also the patient’s age, risk lived and worked) and at that historical meeting in 1979 factors and concomitant conditions when we meet this year the EGS was finally founded. The first congress of the that might affect decision-making. in Lisbon society took place in Brighton, UK in 1980. Ultimately, this means carefully Our vision is that individuals with glaucoma tailoring care to the needs of each should have the best possible well-being and minimal individual patient. In his Eye glaucoma-induced visual disability within an affordable Contact interview Dr Keith Barton discusses current thinking in healthcare system, and it is our aim to pave the way to better this important area. glaucoma care in Europe. In the EGS, we are very fortunate to have access to some of the key international opinion leaders. See you in Lisbon!

EXCELLENT RELATIONS

The EGS has always enjoyed excellent relations with the ESCRS and in September 2011 the EGS hosted the inaugural Glaucoma Day, immediately preceding the XXIX Congress of the ESCRS in Vienna, Austria. Glaucoma Day is now firmly established in the international ophthalmological calendar and we look forward to a very exciting programme when we meet this year in Lisbon. Our programme for Glaucoma Day is still in preparation but you can be assured that it will cover a comprehensive selection of the current hot topics in our field. Among various topics, the Glaucoma Day programme will focus on surgical management, highlighting the strengths and weaknesses of alternative options including trabeculectomy, tubes

Prof Fotis Topouzis is Chair of the EGS Programme Planning Committee

Prof Ingeborg Stalmans is Treasurer of the EGS and Co-Chair of the EGS Programme Planning Committee

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 | JUNE 2017

ESCRS

Glaucoma Day 2017 Friday 6 October FIL â&#x20AC;&#x201C; International Fair of Lisbon, Portugal Registration Open glaucomaday.escrs.org

Scientific Programme organised by

COVER STORY: GLAUCOMA

REACHING A CONSENSUS MIGS a rising star still finding its place in the glaucoma treatment firmament. Roibeard Ó hÉineacháin reports EUROTIMES | JUNE 2017

COVER STORY: GLAUCOMA

inimally invasive surgical techniques that leave the sclera and conjunctiva intact, collectively known as minimally invasive glaucoma surgery (MIGS), have been increasingly adopted by eye surgeons in Europe and North America, but their place in current glaucoma practice is still being fine-tuned. “I think people are still evaluating the role of MIGS and where it stands and where it fits in glaucoma therapy. It is still a relatively new idea and is still relatively uncharted territory in terms of which patients may benefit in the long-term in terms of cost-effectiveness,” Ike Ahmed MD, University of Toronto, Ontario, Canada told EuroTimes in an interview. The MIGS techniques include a range of ab interno implants, and an electric microcautery device. They are designed to provide an outlet for aqueous into the venous system without dissection of the conjunctiva or sclera, and include devices introduced by way of Schlemm’s canal and the collector channels, through the suprachoroidal space, or through a subconjunctival bleb. The procedures are performed through small incisions generally in combination with cataract surgery.

BETWEEN TRABECULECTOMY AND MEDICATION At present, the reduction of intraocular pressure (IOP) remains the only effective treatment for glaucoma, and trabeculectomy remains the most effective means for lowering IOP. The popularity of the procedure rose steadily from the

I think people are still evaluating the role of MIGS and where it stands and where it fits in glaucoma therapy. It is still a relatively new idea and is still relatively uncharted territory in terms of which patients may benefit in the long-term in terms of cost-effectiveness Ike Ahmed MD

MIGS is predicated on the idea of speedy recovery, less impact to the structure of the eye, and less refractive and visual changes. What we’re saying is that it works well in early disease Ike Ahmed MD

time of its introduction in the mid1960s up to the mid-1990s, but declined steeply following the introduction of prostaglandin eye drops.

MAJOR ADVANCE The new medications were therefore hailed as a major advance in the treatment of glaucoma, because they appeared to delay the need for surgery and its accompanying side effects on vision, and its sightthreatening postoperative complications, such as hypotony maculopathy, and endophthalmitis. However, the new medications also present problems. They are costly, and many patients find the daily routine of instilling the drops irksome and uncomfortable. They can also cause changes in eye colour and eyelid skin, as well as stinging, blurred vision, eye redness, itching, and burning. Moreover, they must often be combined with other older IOP-lowering medications, which have their own range of local and systemic side effects. Many patients have difficulty adhering to their prescribed regimens, thereby partly negating their potential benefit. Meanwhile, various implants have been devised as a means of providing a safer and less traumatic alternative to trabeculectomy. They include the Molteno tube and the Ahmed Valve and provide an IOP reduction only slightly less than that provided by trabeculectomy, but with significantly fewer reoperations. More recently, the MIGS devices have become available as a means of reducing the medical burden in patients with well-controlled but not far advanced glaucoma.

SPEEDY RECOVERY “Traditionally, surgery has been reserved for patients with very advanced disease and these new procedures are not really designed for that kind of patient. They are instead designed as an alternative to medication, something that can be used earlier and in place of traditional surgery. MIGS is predicated on the idea of speedy recovery, less impact to the structure of the eye, and less refractive and visual changes. What we’re saying is that it works well in early disease,” Dr Ahmed said. Argon laser trabeculoplasty (ALT), and

later, selective laser trabeculoplasty (SLT) had already provided an almost completely non-invasive means of reducing the need for medication in glaucoma patients. Like MIGS, the treatment provides IOP reductions approximately equivalent to topical medications. However, the effect of a single SLT procedure diminishes over time. Although SLT can be repeated without reduced effect, each treatment entails the risk of anterior chamber reaction/uveitis, which occur in approximately one third to one half of patients, depending on the circumferential extent of the laser treatment. Furthermore, although current European Glaucoma Society Guidelines recommend SLT as a potential second-line treatment, the laser procedure appears to be most effective when used as a firstline treatment. Prior use of prostaglandin analogues diminishes its efficacy and when SLT is used as a second-line treatment, the subsequent use of prostaglandins has little additional effect.

SUPERIOR OPTION The advent of MIGS technology may provide a superior option to SLT. Dr Ahmed and colleagues published a study comparing SLT and the intracanalicular Hydrus™ Microstent (Ivantis). At 12 months there was a significant decrease in both IOP and medications among 31 primary open-angle glaucoma (POAG) patients who underwent a stand-alone implantation of the microstent. However, in the SLT group, only the decrease in IOP was significant. There was also a threefold greater reduction in medication use in the Hydrus group compared with SLT (p=0.001). (Fea et al, Clinical and Experimental Ophthalmology 2017; DOI: 10.1111/ceo.12805) “If you look at the data and try to compare SLT with MIGS – which is difficult to do with confidence – I think that with MIGS we do see less medication use postoperatively and pressure drops,” said Dr Ahmed. He added that a study by Glaukos is under way comparing SLT and dual implantation of the newer collar-button designed iStent, the iStent inject, in a cohort of 500 patients. Another of the implants, the XEN® Gel Stent (AqueSys) implant is a EUROTIMES | JUNE 2017

COVER STORY: GLAUCOMA subconjunctival filtration device. However, unlike trabeculectomy and other filtration surgeries, it creates a filtration pathway from inside the eye without dissection of the sclera or conjunctiva. It is composed of a soft pliable collagen-derived gelatin material. It is inserted using a 27-gauge needle and visualising the meshwork with a gonio mirror. The results in 216 open-angle glaucoma patients from the still ongoing APEX study showed that, at 24 months following cataract surgery and implantation of the XEN device, mean IOP was reduced from 21.4mmHg on a mean of 2.6 medications to 13.1mmHg, with a mean use of 0.7 medications. The results were therefore similar to those achieved with trabeculectomy. However, the needling rate was much higher than that seen with trabeculectomy.

Courtesy of Ingeborg Stalmans MD, PhD

A XEN implant in situ with diffuse filtration bleb

LESS INVASIVE “Due to its less invasive nature, XEN may be considered as a surgical step prior to other filtering techniques such as trabeculectomy or seton tubes. After a superonasal XEN implantation, other filtering surgeries can still be performed as a subsequent step if needed,” said Ingeborg Stalmans MD, PhD, University Hospitals UZ Leuven, Belgium, who participated in the study. She added that, although bleb-related complication can occur after any filtering procedure, they are expected to be less frequent in procedures without conjunctival incisions and with lower doses of mitomycin C. Long-term comparative studies will be necessary to prove whether that is true. “The bleb morphology is different between XEN and trabeculectomy, presumably in part due to the fact that the conjunctiva has not been surgically dissected during XEN implantation and the outflow of aqueous is slow. Optical coherence tomography studies by Prof Herbert Reitsamer in Salzburg have shown that the blebs after XEN implantation are often less elevated and more diffuse,” she added. Keith Barton MD, FRCP, FRCS, Moorfields Eye Hospital, London, UK, told EuroTimes that although the XEN implant and trabeculectomy achieve similar IOP reductions, trabeculectomy has a better record in terms of elimination of the need for medications.

“If you do a trabeculectomy you get probably 65% of patients off medications completely; if you do a XEN implant it is more like 30% to 40%. Overall, this means that you get a good chance of good IOP control with or without medications,” he said. He added that this type of procedure may be less appropriate for surgeons whose main focus is on cataract surgery, because of its bleb-management issues.

STAND-ALONE PROCEDURE The majority of studies involving MIGS have involved patients who were also undergoing cataract surgery, which itself lowers IOP to a small extent. However, there are a limited number of studies that describe the use of MIGS devices as a solo, or stand-alone procedure. “The first cases that we've been looking at have been in cataract surgery, because since the surgeon is already in the eye we can also do something for their glaucoma and their IOP control. And that is really where MIGS has made an impact. I will say that that’s just the surface of it - there is a whole other opportunity for patients who have either had cataract surgery or don't need cataract surgery where we can use it as a stand-alone procedure,” said Dr Ahmed.

Due to its less invasive nature, XEN may be considered as a surgical step prior to other filtering techniques such as trabeculectomy or seton tubes Ingeborg Stalmans MD, PhD EUROTIMES | JUNE 2017

Dr Barton concurred, but noted that the bar for efficacy and cost needs to be set higher for stand-alone MIGS than for MIGS combined with cataract surgery. “Combined cataract surgery and MIGS is much more of a no-brainer than standalone MIGS. You get the patients off the medications and the only additional requirement is five more minutes of surgery and the cost of the implant. But I think if we can prove a sustained fiveyear reduction of IOP with MIGS as a stand-alone procedure, that will be a real worthwhile benefit for patients,” he said. At the same time he cautioned against using MIGS in patients with advanced disease. “If you get very advanced glaucoma you really need to fix the problem. Rather than trying something and seeing if that’ll work and then trying something else, I go straight for trab,” he said.

STRENGHTS AND WEAKNESSES Dr Ahmed noted that it will take time to develop a consensus as to when and in which patients to use MIGS devices. The evidence for that consensus will come as people use it and realise its pros and cons, its strengths and weaknesses. “If you look at the trends around the world, certainly in the US there has been a big uptake of MIGS and it’s continuing to grow. And around the world in different pockets we see an increase. It will take time. But in my opinion, there is no immediate need to rush into anything – it’s a matter of how the technology evolves,” he added. Ike Ahmed: ike.ahmed@utoronto.ca Ingeborg Stalmans: ingeborg.stalmans@mac.com Keith Barton: keith@keithbarton.co.uk

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SPECIAL FOCUS: GLAUCOMA

OCULAR PULSATION Contact lens sensor detects changes after canaloplasty procedures. Roibeard Ó hÉineacháin reports

over 24 hours both diminished after three months significantly and this effect persisted for 12 months. The reductions in amplitude variation appeared to correlate with a 31% change in intraocular pressure (IOP) during the same period, said Dr Byszewska. “The Triggerfish signal is a dynamic examination which can show us novel aspects of canaloplasty efficacy,” she said. She noted that the Triggerfish device consists of a contact lens embedded with a measuring system and a chip. It measures dimensional changes in the eyeball in the clear cornea. Data is transferred to an antenna in the form of a patch around the eye, which is attached to a recorder. The data can then be easily downloaded to a computer for analysis. “The Triggerfish does not measure IOP, it measures the dimensional, volumetric changes of the cornea. It is the pulsation of the eye rather than IOP. Ocular pulsation has a circadian rhythm. It is lower during the day and higher during the night. We know that after penetrating procedures this rhythm goes flat. What we wanted to see is what occurs after non-penetrating procedures, such as canaloplasty,” Dr Byszewska explained. The patients in the study included six women and four men with a mean age of 69 years. Nine of the patients

Courtesy of Anna Byszewska MD

hanges in variation of ocular pulsation amplitude detected with the Triggerfish® Sensor (SENSIMED) appear to correlate with the shortand long-term efficacy of canaloplasty procedures, according to Anna Byszewska MD, Military Institute of Medicine, Warsaw, Poland. The study was designed and conducted under the direction of Prof Marek Rękas, Ophthalmology Department of Military Institute of Medicine, Warsaw, Poland, and thanks to cooperation with Prof D Robert Iskander and Dr Monika Danielewska from the Wrocław University of Science and Technology, Department of Biomedical Engineering, who analysed the data. The results of this study were recently published in IOVS (Assessing Efficacy of Canaloplasty Using Continuous 24-Hour Monitoring of Ocular Dimensional Changes. Rekas M, Danielewska ME, Byszewska A, Petz K, Wierzbowska J, Wierzbowski R, Iskander DR. Invest Ophthalmol Vis Sci. 2016 May 1;57(6):2533–42. DOI: 10.1167/iovs.1619185, PMID: 27159443). In a study involving 10 eyes of 10 patients who underwent canaloplasty, the short-term variance over 30 seconds of Triggerfish signals and long-term variance

Researchers engaged in the study, Anna Byszewska, Monika Danielewska, Marek Rękas and D Robert Iskander

EUROTIMES | JUNE 2017

had primary open-angle glaucoma and one had pseudoexfoliative glaucoma. In addition to standard examinations, the Warsaw investigators fit patients with the Triggerfish device for 24 hours together with continuous electrocardiogram (ECG) holter to investigate the influence of heart activity on the ocular pulse rhythm. They carried out 24-hour examinations at three time points, prior to surgery and after washout of anti-glaucoma medication, and then after three and 12 months. They analysed raw Triggerfish signals to find the best sine-wave fit. Two parameters were considered: the amplitude of the fitted sine-wave and the overall root mean square (RMS). Statistical analysis included standard descriptive statistics and paired t-test. The researchers found statistically significant differences between the preop and three-month post-op for both the amplitude RMS and the sine-wave amplitude, as well as between the pre-op and 12-month post-op results. They also performed a spectral analysis of the signal in both the time domain and frequency domain. They found that there were two repeated peaks of 0.25Hz frequency and 1.0Hz frequency. This could be due to respiratory rate and pulse rate as seen on the Triggerfish signal. However, those peaks were only detectable at night. During the day the signals were too noisy, due to eye blinking and eye movement. Dr Byszewska noted that the mean IOP was reduced to 14.2mmHg at 12 months on a mean of 0.1 anti-glaucoma medications, compared to the mean IOP of 20.6mmHg measured preoperatively following washout. However, the relationship between the changes detected and IOP has yet to be fully elucidated. “Perhaps the reduction in IOP is dampening the ocular pulse some way. But it is not the same as IOP and it is not so simple to explain. Also the circadian rhythm of pulsation over 24 hours is lower after canaloplasty and this change persists at 12 months. Therefore, it is a longterm change and could be a criterion for progression or non-progression, but we still don’t know,” she said. “The results are very interesting. We are continuing our research under the direction of Prof Rękas, so that the analyses can be performed on a much larger population of glaucoma patients.” Anna Byszewska: ania.byszewska@gmail.com

SPECIAL FOCUS: GLAUCOMA

GLAUCOMA DIAGNOSTICS Glaucoma diagnosis varies depending on the test used. Roibeard Ó hÉineacháin reports

ifferent kinds of optic nerve head (ONH) and retinal nerve fibre layer (RNFL) imaging techniques yield different results when evaluating patients for the presence of glaucoma, according to Mika Harju MD, Helsinki University Eye Hospital, Helsinki, Finland. In a study, he compared several imaging technologies as well as standard automated perimetry (SAP). RNFL photographs had the highest specificity and ONH photography had the highest sensitivity in patients referred for glaucoma testing. The study included 202 eyes of 101 patients. The basis for inclusion was at least one criterion suggestive of glaucoma – namely, ONH with cup/disc ratio 0.6 or more, a difference of more than 0.2 in the cup/disc ratio between their eyes, a mean intraocular pressure (IOP) higher than 21mmHg, and an ONH violation of the ‘ISNT-rule’. All eyes underwent examination with Humphrey Visual Field testing, ONH photography, RNFL photography, CIRRUS optical coherence tomography (OCT) ONH and RNFL imaging, and GdX scanning laser polarimetry. Each test results were assessed by three glaucoma specialists who classified them as glaucomatous, healthy or glaucoma suspects. The final determination of the presence or absence of glaucoma was made by five glaucoma experts using all data available from all examination methods. They found that, among the 202 eyes, 23 had glaucoma, 23 were glaucoma suspects, and 156 were healthy. Regarding each test in comparison to the consensus of the experts, GDx yielded 12 false positives and eight false negatives, and had a sensitivity of 62% and a specificity of 93%. OCT yielded eight false positives and 11 false negatives, and had a sensitivity of 52% and specificity of 99%. In addition, RNFL photography yielded only two false positives and nine false negatives, and had a sensitivity of 61% and a specificity of 99%. ONH photography yielded 13 false positives and four false negatives, and had a sensitivity of 83% and a specificity of 84%. Meanwhile, SAP yielded 15 false positives and 11 false negatives, and had a sensitivity of 52% and a specificity of 92%. Dr Harju noted that subjective evaluation by an ophthalmologist performed better than relying on cut-offs of software parameters only. That is, the sensitivity and specificity was only 67% and 82% respectively for Gdx, only 70% and 87% respectively for OCT, and only 57% and 86% for SAP.

...imaging techniques yield different results when evaluating patients for the presence of glaucoma Mika Harju MD

Mika Harju: mika.harju@hus.fi

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SPECIAL FOCUS: GLAUCOMA

MIGS AND MICS Sustained IOP reductions achieved with trabecular bypass stent and micro-incision cataract surgery. Roibeard Ó hÉineacháin reports

he iStent® (Glaukos) trabecular bypass implant can reduce intraocular pressure (IOP) in glaucoma patients for periods now reaching up to nine years and can also reduce the need for IOP-lowering medication over the longterm, according to the results of a study presented by Tobias Neuhann MD. “In our series, through five years after implantation during cataract surgery, the iStent showed long-term, stable reduction in IOP and medications, with no intraoperative or postoperative complications typically seen with conventional glaucoma surgeries,” said Dr Neuhann, Marienplatz Eye Clinic, Munich, Germany. The study involved 65 eyes of 43 patients with cataracts and glaucoma or ocular hypertension who underwent a combined micro-incision cataract surgery (MICS) and iStent implantation procedure. It showed that, among those with five years of follow-up, mean IOP was reduced by 37% from preoperative medicated values and the number medications patients needed was reduced by 78%. In addition, all eyes achieved a best corrected visual acuity of 20/40 or better, and 79% achieved 20/25 or better. The patients in the study had a mean age of 72.7 years and were evenly divided with regard to gender. Preoperatively, they had a mean IOP of 23.7mmHg and were receiving a mean of 2.0 glaucoma medications. All patients had cataracts requiring treatment. Their glaucomatous conditions included primary openangle glaucoma (POAG) in 40 eyes, pseudoexfoliation in 14 eyes, ocular hypertension in 10 eyes, and posttraumatic glaucoma in one eye, Dr Neuhann said. Previous procedures included laser peripheral iridotomy in four eyes, selective laser trabeculoplasty in six eyes and argon laser trabeculoplasty in eight eyes, and trabeculectomy in eight eyes.

In all eyes, Dr Neuhann performed MICS using a temporal clear corneal incision and implanted a single iStent through the same incision. The length of follow-up was 48 months in 41 eyes and 60 months in 34 eyes.

FIVE-YEAR IOP REDUCTIONS Throughout five years of follow-up, mean IOP remained at 16mmHg or below. Furthermore, IOP was 15mmHg or below in 65%, and 18mmHg or below in 92%. By comparison, preoperative medicated IOP was only 15mmHg or below in only 2%, and 18mmHg or below in only 14%, Dr Neuhann said. In addition, the mean number of IOP-lowering medications patients required fell from 2.0 at baseline to 0.1 at three months postoperative and 0.5 at five years. Furthermore, 69% of those with five years of follow-up remained medication-free. Of the remaining patients, 27% were receiving one to two medications and 4% were receiving three to four medications. Preoperatively, 97% of eyes were receiving at least one medication and 28% were receiving three to four medications, he noted. “When you look for the cost of the medication and the freedom the patient has from the drops, it's not so bad to have 70% of patients medication free after five years. We even have some patients who were implanted nine years ago and are still without medication,” Dr Neuhann added. There were, however, eight eyes that required further surgical interventions. They included one POAG patient and one pseudoexfoliative glaucoma patient who were intolerant of topical and systemic medications and underwent shunt surgery at three months. There were also three patients who underwent cyclophotocoagulation at 12 months, including one who also underwent trabeculectomy at 24 months. Two eyes received a XEN® (AqueSys) ab interno fistularising implant, one eye at 24 months and the other at 48 months.

Implantation of a single iStent plus MICS is a sustained, safe and effective treatment for POAG, pseudoexfoliative glaucoma and ocular hypertension TINY IMPLANT

We even have some patients who were implanted nine years ago and are still without medication

Dr Neuhann noted that the iStent devices are designed to bypass the trabeculum and allow drainage of aqueous from the anterior chamber directly into Schlemm’s canal. They are the smallest medical devices ever to have been implanted in the human body. The original snorkel design used in the study has a length of 1.0mm, a height of 0.33mm and weight of 60 micrograms. It is made of surgical grade heparin-coated titanium. “It is quite small, but it really works. More than 200,000 have been implanted worldwide and it has a clinical history of 10 years,” Dr Neuhann said. He added that the technique for implanting the iStent is very easy to learn for those experienced in using a surgical microscope. It involves the placement of a gonioprism on the cornea to visualise the trabecular meshwork and the iridocorneal angle. The iStent applicator slips the long arm of the device into Schlemm’s canal very easily in most cases. Blood coming from the device’s opening into the anterior chamber indicates a successful implantation. The device is also designed in such a way as to keep the snorkel’s opening safely clear of the iris. “Implantation of a single iStent plus MICS is a sustained, safe and effective treatment for POAG, pseudoexfoliative glaucoma and ocular hypertension,” Dr Neuhann added.

Tobias Neuhann MD

Tobias Neuhann: tneuhann@web.de

EUROTIMES | JUNE 2017

SPECIAL FOCUS: GLAUCOMA

DECADES OF PROGRESS MIGS has changed the glaucoma treatment paradigm, but more research and development is needed. Howard Larkin reports

ith three minimally invasive glaucoma surgery (MIGS) implants now FDA approved, and several more nearing market, the surgery is playing an ever-growing and earlier role in glaucoma treatment, Reay H Brown MD told the 2017 ASCRS•ASOA Symposium & Congress in Los Angeles, USA. The total MIGS market now exceeds $3billion and is growing exponentially. However, many studies suggest that in combined phaco-MIGS procedures the bulk of intraocular pressure (IOP) lowering may be due to phaco, with devices such as the iStent® (Glaukos) and CyPass® (Alcon) increasing the effect. While the therapeutic impact is not trivial – MIGS-treated eyes generally require fewer drops for IOP control after surgery, and are more likely to be dropfree than phaco-only eyes – MIGS has not ‘solved’ glaucoma in the same way that phaco solved cataract, said Dr Brown, who

Courtesy of Reay H Brown MD

The EyePass was invented by Drs Brown and Lynch in 1999. It is a bidirectional tube designed to bypass the trabecular meshwork and promote aqueous outflow. The canal has been unroofed and each leg of the device has been passed down Schlemm’s canal. The joined portion is implanted into the anterior chamber. The EyePass was a precursor to the iStent

The EyePass seen within the anterior chamber. The double tube configuration allows the tubes to provide a pathway for aqueous to bypass the meshwork and flow directly to each side of the canal

One of the finest things about MIGS is it gives us hope that we will finally solve glaucoma Reay H Brown MD

delivered this year’s Charles D Kelman Innovator’s Lecture in recognition of his decades of development of glaucoma surgery techniques.

PUMPING ACTION MIGS device performance might be considerably improved by adding pumping action, Dr Brown said. He is currently working with researchers at the Georgia Institute of Technology in Atlanta, USA, to develop cilia pumps driven by rotating magnets. These cilia can be very small, of the order of 100 microns long, and have been shown to generate significant power in early development. “Nature’s pump is cilia and they are everywhere,” he said. Considerable research will be needed to bring such pumps to life, Dr Brown said. He expects the process to take years, as it already has to develop today’s MIGS devices. What MIGS has done is change the glaucoma treatment paradigm. By demonstrating that a viable market exists for glaucoma surgery it is attracting the money, competition and skills needed to further develop it. “One of the finest things about MIGS is it gives us hope that we will finally solve glaucoma,” Dr Brown said.

KELMAN THE INSPIRATION Both MIGS and phaco look obvious in retrospect, but both took decades to take hold, Dr Brown noted. Throughout the 1970s and 1980s, phaco was resisted, especially in academic circles. “Kelman is the inspiration, he really solved cataracts. MIGS is more of a team sport and glaucoma is not yet solved,” he said. Dr Brown recounted his own involvement with MIGS, which dates back to his residency beginning in 1979. During long nights on call at the Wilmer Eye Institute at Johns Hopkins University, Baltimore, Maryland, USA, he found a rich literature showing trabeculotomy

and goniotomy were very popular and successful in controlling IOP in adult open-angle glaucoma in Europe. “I wondered, ‘Why aren’t US surgeons doing this?’ If the resistance is in the trabecular meshwork, angle surgery makes sense to restore outflow.” Dr Brown’s attempts to improve glaucoma surgery include using a trephine developed for vitrectomy to punch holes in the trabecular meshwork into the subconjunctival space from the inside through a 20-gauge incision. However, flow was too fast or too slow, and a device was needed to keep the channel open, but none existed in the 1980s. In 1994, Dr Brown patented the glaucoma tack with Keith Thompson, which drained aqueous directly from the anterior chamber. “The idea was to make glaucoma a microfluidics problem, not a conjunctival wound healing problem,” he said. The two major eye device companies looked at it but passed – though the concept is now in development by MicroOptx and scheduled to begin FDA human trials.

RESTORING OUTFLOW Work with his wife, Mary Lynch MD, led to 360-degree suture trabeculotomy, which achieved a 90% success in one operation. Later, work with Robert Stegmann MD on viscocanalostomy inspired them to invent a T tube insert called the EyePass that restores outflow in both directions. What really spurred current interest in glaucoma surgery was the insight of device development executives to target MIGS as an eye drop replacement for mild to moderate glaucoma rather than a trabeculectomy replacement for refractory patients. In the USA alone, that increased the potential market from 75,000 procedures annually to 800,000, making MIGS commercially viable, Dr Brown said. Reay H Brown: reaymary@comcast.net EUROTIMES | JUNE 2017

LISBON2017 Main Symposia n

The Irregular Cornea

Changing Pharmaceutical Treatment Patterns in Cataract Surgery

Building a New Eye

Intrastromal Lenticule Extraction: To smile or to Cry?

Six Years On: Is FLACS a Better, Safer Operation than Phaco?

Binkhorst Medal Lecture Boris Malyugin RUSSIA Cataract Surgery in High-Risk Eyes: Lessons Learned

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Moderator: P. Versace AUSTRALIA H. Höh GERMANY New objective measurement of Mplus with i-trace B. Heintz BELGIUM LENTIS Comfort – EDOF technology for every patient D. Holland GERMANY FEMTIS IOL – 2 years results with automated rhexis lens A. Borkenstein AUSTRIA LENTIS Max: MAGS - magnifying surgery – arising of a new special field in cataract surgery Sponsored by

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CATARACT & REFRACTIVE

WHITE CATARACT PHACOEMULSIFICATION Everything you ever wanted to know about white cataract phacoemulsification â&#x20AC;&#x201C; Part 2. Dr Soosan Jacob reports

fter rhexis, the next challenging step in white cataract is nucleus removal. The approach to nucleus management depends on the type of white cataract.

MEMBRANOUS (CONGENITAL OR TRAUMATIC) WHITE CATARACT:

A membranous cataract has partial/ complete resorption of cortex, and a flattened membranous capsule consisting of the collapsed capsular leaflets is seen. In cases with partial resorption of cortex, rhexis and other usual steps are done followed by intraocular lens (IOL) implantation within the bag. In congenital cases, a primary posterior capsulorhexis and vitrectomy may also be done. If the cortex is completely resorbed, management aims at opening the visual axis. Depending on the nature

of the membrane, a rhexis is created or a vitrector is used to cut the membrane in as round and regular a manner as possible. The IOL may then be placed in the sulcus with membrane capture of the optic as described by Gimbel. With inadequate/ unstable capsular support, a scleral or iris-fixated IOL may be done depending on surgeon preference. My personal preference here is to perform a glued IOL.

TRAUMATIC WHITE CATARACT: A white cataract may be seen after penetrating or blunt trauma. If surgery is done soon after trauma, depending on the patientâ&#x20AC;&#x2122;s age, the cataract may be composed either of only soft, flocculent lens material or it may have an endonucleus. In the former case, it is sufficient to use an irrigation/ aspiration (I/A) probe to aspirate the soft lens matter.

However, in the presence of an endonucleus, special manoeuvres are adopted for nuclear disassembly. In all cases, the possibility of an associated posterior capsular rupture and weak zonules should be kept in mind. Hydro manoeuvres should not be done or should be done very gently, to prevent a nucleus drop in case of a pre-existing capsular rent. All manoeuvres should be performed gently. Other associated ocular comorbidity such as corneoscleral tear, scarred visual axis, difficult visualisation, soft eye, iris or vitreous loss, subluxation, secondary glaucoma, macular pathology, retinal detachment etc should be kept in mind while planning management. Blunt trauma classically presents as a rosette-shaped cataract with the possibility of coexisting zonulodialysis.

SENILE WHITE CATARACT: These can be seen as mature hard white cataracts or hyper-mature white leaking Morgagnian cataracts.

MATURE HARD WHITE CATARACT:

A small-sized rhexis is initiated

EUROTIMES | JUNE 2017

It is then spiralled out in a controlled manner to achieve the desired size

The entire cortex is opacified and there is very little epinucleus. The nucleus of the white cataract is large, but generally brittle and more amenable to phacoemulsification than hard, brown, leathery cataracts. Care needs to be taken to decrease total phaco time, power and energy used and to keep the corneal endothelium and the posterior capsule safe. Standard nuclear disassembly techniques may be used. Vertical chop works well

CATARACT & REFRACTIVE for these cataracts. If horizontal chop is being used, the chopper should be slid very carefully under the rhexis margin, avoiding damage to the capsulo-zonular complex.

HYPER-MATURE WHITE LEAKING MORGAGNIAN CATARACT: A leaking Morgagnian has liquefied cortex and a small brown nucleus settled downwards in a bag of milky fluid. As described in Part 1 of this two-part series on white cataracts (EuroTimes Volume 22, Issue 5, May 2017), the milky fluid is aspirated before performing rhexis. After rhexis, the nucleus is vertically chopped into multiple small fragments which are then removed one by one at or just below the iris plane. The posterior capsule is thin, fragile and floppy, the zonules may be weak, and these together with lack of sufficient epinucleus significantly increase the risk of inadvertent posterior capsular rupture during a sudden post-occlusion surge. Therefore, once the bag is no more held distended by the bulk of nucleus, phaco settings are decreased and the last fragments emulsified in a more anterior plane. Implanting a capsular tension ring helps stabilise loose zonules and makes the posterior capsule less floppy. Very small nuclei are mobile and more difficult to embed. These may be viscoprolapsed out of the bag and emulsified at iris plane using lower vacuum parameters. Gas forced infusion or an air pump attached to the bottle allows increased irrigation, which helps maintain a well formed anterior chamber, holds the iris and IOL backwards and prevents surge, all of which help emulsify the nucleus at a more posterior plane and also helps surgery proceed faster and safer. For smaller sized nuclei, Om Parkash et al have described a variation of the scaffold technique, wherein the IOL is injected into the bag after bringing the nucleus into the

A horizontal chop technique is used

Last fragments are emulsified in a more anterior plane

anterior chamber. The IOL then acts as a scaffold holding the posterior capsule back while the nucleus is fragmented safely at iris plane. In all cases where more phaco energy is likely to be used in the anterior chamber, the endothelium should be adequately protected with dispersive viscoelastic.

is done with care for any residual cortical wisps using very low vacuum, since the capsular bag is floppy and zonules weak. Capsule polishing mode is generally enough to remove stubborn cortical wisps.

NUCLEUS REMOVAL WITH AN INCOMPLETE/TORN RHEXIS: The capsule is handled as described in Part 1 of this series. This is followed by slowmotion phaco with low bottle height and low machine parameters. Hydrodissection should be avoided. If possible, the nucleus is gently brought out of the capsular bag and emulsified in a supracapsular plane. If the nucleus is too large to be brought out in toto, it is carefully chopped making sure no vertical or horizontal forces are exerted on the capsule to avoid a wraparound tear in the capsular bag. Once the nucleus is removed, gentle irrigation is generally sufficient to remove any liquefied cortex present in the fornices of the bag.

IOL IMPLANTATION: Capsular bag is distended well with viscoelastic and IOL injected, directed towards the capsular fornix to avoid haptics snagging on the floppy posterior capsule. In case of incomplete rhexis, a three-piece IOL may be injected. Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India dr_soosanj@hotmail.com

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IRRIGATION/ASPIRATION (I/A): I/A is generally not required in these mature or hyper-mature cataracts and simple irrigation with a cannula often suffices. I/A

WSPOS

Friday 6 October 2017

World Society of Paediatric Ophthalmology & Strabismus

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SUBSPECIALT Y DAY

Preceding the XXXV Congress of the ESCRS 7–11 October 2017

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EUROTIMES | JUNE 2017

CATARACT & REFRACTIVE

SCREEN CAREFULLY RRD risk should not be a reason for not performing cataract extraction when needed, even with identified risk factors. Leigh Spielberg MD reports

areful screening of at-risk patients can help reduce the incidence of retinal detachment (RD) after cataract surgery, according to José García Arumí MD. “Considering patients’ high expectations for visual improvement after cataract surgery, a surgical complication like a RD is particularly frustrating,” said Dr García Arumí, Instituto de Microcirurgia Ocular, Barcelona, Spain. Rhegmatogenous retinal detachment (RRD) has a fourfold increased incidence in the years after cataract surgery, as compared to the normal population. Pseudophakic RRDs are different to phakic RRDs, as they evolve more quickly and are more likely to develop total detachment. However, they have a similar anatomic and visual prognosis, he noted. Between 10% and 35% of eyes with RRD will have previously undergone cataract surgery. One study suggests that 70% occur within the first postoperative year, while another found a peak around 40 months after cataract extraction. “What is clear, however, is that the increased risk is present up to 20 years after cataract surgery,” he said.

UNCLEAR PATHOPHYSIOLOGY But why do they occur so much more frequently after cataract surgery? The pathophysiology remains unclear, but there are several reasonable hypotheses, he said. The induction of a posterior vitreous detachment (PVD) develops shortly after cataract surgery in 79% of eyes without it, which greatly increases the risk of RRD. This might be the reason why post-phaco RRD is more frequent in younger patients, particularly those under 60 years of age, as these patients have not developed a PVD prior to cataract surgery, he explained. It is also thought that enlargement of the vitreous cavity after the removal of the crystal lens may cause changes in vitreous dynamics and thus increase vitreous traction postoperatively. Changes in vitreous composition after cataract surgery, such as its viscosity and macromolecular distribution, have been implicated. Surgeon-related factors have also been identified, said Dr García Arumí.

“Increased surgical volume is associated with a lower incidence of RRD thereafter, which might be related to decreased surgical manipulation and release of inflammatory mediators over the vitreous base,” he said. This hypothesis is supported by the fact that the risk has steadily decreased in the past few decades due to improved surgical techniques. Eye-related factors are of great significance and, because they are treatable, deserve a lot of attention. “The odds ratio increases significantly in eyes with an axial length above 23mm. This risk increases further in the presence of peripheral degenerative changes such as lattice degeneration and atrophic holes,” warned Dr García Arumí. As such, he recommended pretreating retinal pathologies that could lead to RD, particularly in younger patients who have not yet had a PVD. However, the benefit of doing so has not yet been proven. “Does prior retinal laser photocoagulation reduce the chances of RRD after cataract surgery? We don’t know for sure, as a Level 1 recommendation, in the form of a randomised study, is lacking,” he said. However, some studies have suggested that prior treatment might be not only unnecessary and ineffective, but also harmful. Dr García Arumí, a vitreoretinal surgeon, recommends examining at-risk patients carefully and treating if retinal pathology that could lead to an RRD is detected. At-risk patients include patients with prior RD or retinal tear in either eye, prior ocular trauma and possibly those with diabetes mellitus. Of course, surgical complications such as posterior capsular break or zonular dehiscence with vitreous are also serious risk factors for postoperative RD. These should be avoided at all costs, and those eyes that suffer surgical complications should be followed up closely. “Whether YAG capsulotomy increases the risk remains controversial,” said Dr García Arumí. He reminded surgeons to counsel patients before surgery of the potential risks and complications of cataract surgery. “RRD risk should not be a reason for not performing cataract extraction when needed, even with identified risk factors,” he concluded. José García Arumí: jgarcia.arumi@gmail.com

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CATARACT & REFRACTIVE

TORIC IOL ALIGNMENT New toric IOL alignment system provides easier workflow but same results as manual technique. Roibeard Ó hÉineacháin reports

new toric intraocular lens (IOL) axis alignment the toric IOL, this new technique aims for a better correction of system, IntelliAxis™ (Topcon), that combines corneal astigmatism during FLACS procedures,” Dr Hagen said. shape analysis with automated iris registration In both groups, they measured manifest refraction and evaluated appears to provide only slight advantages in the the reduction of astigmatism using the vector-based Alpins reduction of astigmatism compared to manual method. He noted that the Alpins formula transforms the toric IOL axis alignment in femtosecond astigmatic values into a two-dimensional vector space laser-assisted cataract surgery (FLACS) procedures, with components J0 and J45. In this vector space one according to a study presented by Philipp Hagen can consider preoperative, postoperative and target PhD at the 21st ESCRS Winter Meeting in astigmatism and define all their difference vectors Maastricht, The Netherlands. and relative angles yielding characteristic quantities “There was less scatter in our results with IntelliAxis such as angle of error, correction index and index of than with the manual technique, but the differences success, Dr Hagen explained. between the groups were not significant. However, He noted that the manual method for alignment data transfer, workflow and prevention of read-off errors requires four manual angular matching steps whereas is better with IntelliAxis,” said Dr Hagen, who is a physicist the IntelliAxis system only requires one. Assuming Philipp Hagen working as a study coordinator and research analyst in a Gaussian error propagation, one can predict a narrower private eye surgery in Düsseldorf, Germany. standard deviation in the index of success and the angle of In their retrospective study, Dr Hagen and his associates error with IntelliAxis. compared the results they achieved in two groups of consecutive “Our findings suggest the IntelliAxis system may provide patients who underwent FLACS and implantation of a toric IOL. greater precision. The question that remains is whether this trend In one group of 84 patients they performed axis alignment with will reach significance in larger studies,” Dr Hagen added. the IntelliAxis system, and in another group of 41 patients they Philipp Hagen: p.hagen@augenchirurgie.clinic aligned the axis manually. All eyes underwent implantation of Lentis® Comfort MF15 multifocal toric IOL (Oculentis). The lens has purely refractive optics, with no diffractive ring segments and provides high light transmission. It has a rotationally asymmetric anterior surface with a sector-shaped segment with +1.5D add for improved intermediate visual acuity, Dr Hagen said. In both groups there was an effective reduction of astigmatism. Mean cylinder was reduced to 0.40D from a preoperative value of 3.00D in the IntelliAxis group, and from 2.77D to 0.45D in the manual group, he noted. The mean correction index and index of success were closer to ideal values in the IntelliAxis group, with smaller standard deviations than in the manual group. All these advantages were of the order of 10% but differences did not reach statistical significance, Dr Hagen pointed out.

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FEWER STEPS FOR FEWER ERRORS In the manual axis alignment group, Dr Hagen and his team first determined the steepest axis by aberrometry or with a Scheimpflug camera and created two epithelial markings on the cornea’s horizontal axis with a YAG laser. They then performed lens fragmentation and capsulorhexis with the femtosecond laser and performed phacoemulsification and lens implantation. They then adjusted the steepest axis on Stacy protractor and then aligned the IOL to the steepest axis on that basis. In the IntelliAxis group, they determined the steepest axis in relation to iris structures with the Cassini (i-Optics) topographer. They then transferred the data from the topographer – using a wireless streamline data link – to the LENSAR® femtosecond laser with IntelliAxis axis alignment software. Just prior to performing FLACS and phacoemulsification, they marked the steepest axis with two opposing laser shots. “By using corneal shape analysis combined with iris detection, the preoperatively measured steep corneal axis can be marked during cataract surgery by a femtosecond laser in a way that compensates for cyclorotation. Using these landmarks in aligning

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org The questions we receive will then be sent to our Medical Editors and International Editorial Board. We will publish a selection of their answers in the magazine.

EUROTIMES | JUNE 2017

CATARACT & REFRACTIVE

Left: One year after monofocal BIL implantation showing perfect pupillary centration and LEC proliferation in the peripheral capsular bag only and optimal optic light transmission

Courtesy of Marie-José Tassignon MD, PhD, FEBO

Below: Early postoperative toric BIL stabilised by bean-shaped rings in a patient with PEX and optimal optic light transmission

IOLS BRING BENEFITS Capsulotomy-centred IOLs could improve image quality and reduce complications. Howard Larkin reports

ne capsulotomy-centred intraocular lens (IOL), the bag-in-the-lens (BIL), has been shown to eliminate posterior capsule opacification (PCO), and another may eliminate negative dysphotopsia (ND), leading clinicians told the Ophthalmology Futures European Forum 2016. IOLs with grooves that snap into precisely placed anterior capsulotomies may also improve quality of vision, especially with centration-dependent multifocal and extended-depth-of-focus IOLs, though the evidence is not yet clear. In use for 17 years, the BIL (Morcher) features a groove around the edge that fits into both an anterior and posterior capsulotomy, supporting the lens while collapsing and sealing the capsular bag. The original goal was completely eliminating PCO, which the BIL does, along with ND and fibrotic proliferation, said designer Marie-José Tassignon MD, PhD, FEBO of University Hospital Antwerp, Belgium.

of the capsulotomy. Out of 88 patients implanted with the new lens none reported ND, he noted. Among the series is one case where a traditional IOL was exchanged for the grooved IOL (Morcher 90S) and the patient noted complete relief of symptoms. "ND is an annoying optical complication of present day technology. It is best prevented if possible," said Dr Masket. Dr Masket sees other potential advantages. With the capsulotomy fixed in the groove and supporting the IOL, capsule contraction is eliminated, ELIMINATING DYSPHOTOPSIA as is rotation of toric IOLs. Moreover, Eliminating ND was the reason Boris Malyugin IOL tilt and decentration will not Samuel Masket MD, of the University occur. “Additionally, if we can centre of California – Los Angeles, USA, the lens on the visual axis, we can fully designed a lens with a groove in the optic eliminate induced higher order aberrations that overlaps the anterior capsulotomy with multifocal or aspheric IOLs,” he (Morcher 90S). The idea came from said. All of these facets are best achieved his success eliminating refractory ND, with an automated anterior capsulotomy, which appears as a peripheral shadow, most typically achieved presently with the by implanting conventional three-piece femtosecond laser. lenses with the optic captured in front Long-term stable lens centration is an added benefit. Femtosecond lasers cutting precisely shaped and positioned anterior and posterior capsulotomies could potentially make more effective use of the stability capsule centration provides, Dr Tassignon said. “New capsule-centred IOLs are coming up and I think this is just the beginning of this new age. There are many advantages of capsules centred in the eye,” she added.

UNANSWERED QUESTIONS

New capsule-centred IOLs are coming up and I think this is just the beginning of this new age Marie-José Tassignon MD, PhD, FEBO EUROTIMES | JUNE 2017

However, the extra manipulation and pressure required to implant capsulotomycentred lenses risks damaging the capsulotomy, noted Boris Malyugin MD, PhD, of the S. Fyodorov Eye Microsurgery Complex, Moscow, Russia. While he

CATARACT & REFRACTIVE Courtesy of Marie-José Tassignon MD, PhD, FEBO

I think most surgeons don’t feel comfortable, even if they have a femtosecond laser, putting the lens through two capsulotomies with the vitreous just behind Oliver Findl MD believes such IOLs could improve stability such as the Masket lens, may still be prone and lens position predictability, it is not to axis shift and capsule contraction while clear whether the capsulotomy should be the BIL probably is not. centred on the limbus, the capsule itself or The BIL has another issue, Dr Findl the presumed visual axis. added. “I think most surgeons don’t For standard monofocal lenses the feel comfortable, even if they have a extra stability and precision may femtosecond laser, putting the lens not be needed, said Paul Rosen through two capsulotomies with FRCOphth, MBA, Oxford the vitreous just behind.” Eye Hospital, London, UK. This could lead to more “Where it becomes a big complications. However, issue is with multifocal, new intraoperative imaging bifocal and toric IOLs. I technologies can visualise the think that is the direction you posterior capsule and anterior want to go with (capsulotomyvitreous hyaloid, which makes centred) lenses,” he said. posterior capsulotomy safe, Dr Paul Rosen Whether capsulotomy-centred Tassignon noted. lenses are more stable may depend Lens tilt is also not well understood, on their design, said Oliver Findl Dr Findl said. His research shows MD, of Hanusch Hospital, Vienna, some patients have physiologically tilted Austria. Lenses with haptics in the bag, natural lenses before surgery, and end up

ESCRS

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Early postoperative toric BIL implantation showing perfect pupillary centration and optimal optic light transmission

with tilted implants after surgery. “There are still things we do not understand properly. I’m not sure, even if we use these kinds of lenses, that we will take care of all these issues,” he added. Dr Malyugin agreed. “There are so many unanswered questions. We do not have enough data to show which technology will prevail. A lot of research needs to be done.” Marie-José Tassignon: marie-jose.tassignon@uza.be Samuel Masket: avcmasket@aol.com Boris Malyugin: boris.malyugin@gmail.com Paul Rosen: phrosen@rocketmail.com Oliver Findl: oliver@findl.at

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CATARACT & REFRACTIVE

ASCRS BACKS RESEARCH Incoming ASCRS President pledges to promote research. Howard Larkin reports

eld in Los Angeles for the first time in 15 years, attendance at this year’s ASCRS•ASOA Symposium & Congress topped 7,000 delegates from more than 100 countries. The meeting included more than 1,500 papers, posters, courses and symposia. Incoming ASCRS President Bonnie An Henderson MD, Boston, USA, praised the society’s founders for their vision and courage in promoting intraocular lens (IOL) implantation, phacoemulsification and other innovations even when they were suspect in the ophthalmology community at large. She pledged to maintain and strengthen the ASCRS’ leading position in ophthalmic education, and promote research to make ophthalmic surgery even safer, including a prospective study of intracameral antibiotics. Retired astronaut and US Navy Captain Scott Kelly was one of the keynote speakers at the meeting. In a wide-ranging speech looking back on his career, he discussed the ophthalmic effects of long-term spaceflight, including increased cerebral fluid pressure, optic nerve swelling and retinal folds.

THE LARGEST U.S. MEETING DEDICATED EXCLUSIVELY TO THE NEEDS OF THE ANTERIOR SEGMENT SPECIALIST THE LEADING PRACTICE MANAGEMENT PROGRAM IN OPHTHALMOLOGY

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EUROTIMES | JUNE 2017

Captain Kelly lived aboard the International Space Station for 340 days in 2015-2016, and has spent a total of more than 520 days in zero gravity. ESCRS Board member Boris Malyugin MD, PhD, best known for the eponymous Malyugin ring iris expander, delivered the prestigious Binkhorst Lecture at the meeting, on the topic of managing small pupils in cataract surgery. The 50th anniversary of phacoemulsification was celebrated with an extended tribute to Charles D Kelman MD. It featured a panel of his colleagues and residents who helped develop this technology into the safe, effective and efficient procedure that revolutionised cataract surgery worldwide. The first Steinert Refractive Lecture, honouring long-time ASCRS programme director, surgeon and researcher Roger F Steinert MD, was delivered by Douglas Koch MD at the inaugural ASCRS Refractive Day. The topic was challenges in IOL calculation in post-op and ectatic corneas. In another presentation, Thomas Kohnen MD, PhD told the meeting that an accelerated corneal crosslinking (CXL) approach appears to be safe for treating patients with progressive keratoconus, and delivers comparable visual and corneal biomechanical results to the standard Dresden Protocol while reducing treatment time.

CATARACT & REFRACTIVE

LASIK OUTCOMES

New OCULUS Smartfield

Wavefront-guided may offer small gains over wavefront-optimised procedures. Howard Larkin reports

avefront-guided (WFG) LASIK showed small but measurable advantages in efficacy, predictability, self-reported vision quality and low contrast visual acuity compared with wavefrontoptimised (WFO) LASIK, Edward E Manche MD told Refractive Surgery Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago. Safety and clinical outcomes were excellent with both procedures, and no difference in induction of higher order aberrations was observed between the two technologies, said Dr Manche, who conducted a series of studies comparing the technologies with colleagues at Stanford University, California, USA. In a prospective, randomised contralateral eye study involving 55 patients, about 84% of eyes treated with WFG LASIK performed with a VISX STAR S4 IR CustomVue® laser (AMO) were within 0.5D of target 12 months after surgery, compared with about 76% of eyes treated with WFO LASIK performed with an Allegretto Wave® Eye-Q 400Hz laser (Alcon), Dr Manche reported. WFG-treated eyes were more likely to achieve 20/20 or better uncorrected visual acuity, and better contrast visual acuity than WFO-treated eyes. Patients preferred the quality of vision in the WFG-treated eye by two-to-one among those who had a preference. WFG outcomes were especially good among patients with low total aberrations, defined as RMS <0.3 microns, before surgery, with statistically better night and day vision clarity, overall vision excellence, and less fluctuating vision. (He L, Manche EE. Am J Ophthamol. 2014;157(6). Kung J, Manche EE. J Refract Surg. 2016 Apr;32(4):230-6) A second prospective, randomised, contralateral eye study involving 36 patients compared WFG and WFO procedures performed on the Allegretto 400Hz system. At 12 months, 94% of WFG-treated eyes were within 0.5D of target compared, with 88% of WFO-treated eyes. More WFG-treated eyes also achieved 20/20 or better vision and had better contrast visual acuity. Patients preferred the WFGtreated vision two-to-one over WFO-treated vision. (Sales CS, Manche EE. Ophthalmology. Dec 2013;120(12):2396-402) A third prospective, randomised, contralateral eye study involving 50 patients compared WFG LASIK performed with the Allegretto laser with WFG-guided LASIK performed with the VISX STAR S4 IR CustomVue laser. At one year, 96% of patients treated with the Allegretto were within 0.5D of target refraction compared with 89% of CustomVue-treated eyes. Allegretto-treated eyes also had significantly better mean night and day vision clarity, Dr Manche said. (Yu CQ, Manche EE. J Cataract Refrct Surg. 2014 Mar;40(3):412-22. Yu CQ, Manche EE. J Refract Surg 2016 Apr;32(4):224-9) “About half of LASIK procedures done in the USA are WFG and half WFO, so it makes sense to compare the two,” Dr Manche said. Larger, multicentre studies are needed to confirm his results, he added.

Welcome the Youngest Member to the OCULUS Perimeter Family – Smart, Precise, Compact!

New OCULUS Smartfield: Optimized for monitoring functional impairment in glaucoma •

Standard automated perimetry with a new feature: PATH – Predictive function-structure display

•

LCD-screen ensures reliable calibration

•

Closed construction: no dark room required

Visit the OCULUS booth 106 during WGC, Helsinki!

www.oculus.de

Edward E Manche: lasik.manche@stanford.edu Eurotimes Smartfield 93x266 e 4c 04.17 v2.indd 1

EUROTIMES | JUNE 2017

25.04.2017 12:45:15

EPOS 2017 43rd Annual Meeting of the European Paediatric Ophthalmological Society 31 August – 2 September 2017 Institute of Mathematics, Oxford, UK

Main topic this year: Hereditary retinal dystrophies: from genetics to gene therapy

Sessions Including: ROP and other retinal disorders, Oncology, Craniofacial and orbital, Cataract and lens, Neurophthalmology

Local hosts: Darius Hildebrand OXFORD, UK Manoj Parulekar OXFORD/BIRMINGHAM, UK Raymond Lobo OXFORD, UK Speakers: Susie Downes OXFORD, UK John Elston OXFORD, UK Marcus Fruttiger LONDON, UK Göran Darius Hildebrand OXFORD, UK Creig Hoyt SAN FRANCISCO, USA Kristina Irsch BALTIMORE, USA Chris Lloyd LONDON, UK Birgit Lorenz GIESSEN, GERMANY Robert MacLaren OXFORD, UK Boris Malyugin MOSCOW, RUSSIA John Marshall LONDON, UK Cameron Parsa PARIS, FRANCE Manoj Parulekar BIRMINGHAM/OXFORD, UK CK Patel OXFORD , UK Sir Peter J Ratcliffe OXFORD, UK Geoffrey Rose LONDON, UK Mandeep Sagoo LONDON, UK Marie-José Tassignon ANTWERP, BELGIUM David Taylor LONDON, UK Eberhard Zrenner TÜBINGEN, GERMANY

https://www.epos-focus.org/meetings http://www.epos2017.org

Registration, Hotel Bookings & Scientific Programme Available

CATARACT & REFRACTIVE

JCRS HIGHLIGHTS VOL: 43 ISSUE: 3 MONTH: MARCH 2017

OCT VERSUS PCI BIOMETRY How do axial length measurements taken with a swept-source optical coherence tomography (SS-OCT) biometer (IOLMaster 700) and a partial coherence interferometry (PCI) biometer (IOLMaster, Version 5.4) compare? Korean researchers looked at this question in a study of 117 myopic patients. The overall axial length was greater when measured with the SS-OCT biometer than with PCI biometry. The same results were found in the sub-analysis in groups classified based on lens status, fixation status, degree of myopia, and the presence of posterior staphyloma. In eyes with good fixation, the study found statistically significant differences in axial length measurements between the two devices when posterior staphyloma was present. JY Yang et al, JCRS, “Axial length measurements: Comparison of a new swept-source optical coherence tomography-based biometer and partial coherence interferometry in myopia”; Volume 43, Issue 3, 328–332.

NEW TORIC IOL CALCULATORS Newer toric calculators aim to help surgeons avoid overcorrection in eyes with with-the-rule astigmatism and undercorrection in those with against-the rule astigmatism. A new study compared several calculation approaches in 86 eyes of 86 patients undergoing toric intraocular lens (IOL) implantation. These included the original Alcon calculator and a newer version, the Holladay toric calculator, and the Barrett calculator, along with the Baylor nomogram, the Abulafia-Koch formula, and the Goggin coefficient of adjustment. The Barrett toric calculator and the new Alcon calculator yielded the lowest astigmatic prediction errors. Of the nomogram methods, application of the Abulafia-Koch formula achieved the best results. TB Ferreira et al, JCRS, “Comparison of astigmatic prediction errors associated with new calculation methods for toric intraocular lenses”; Volume 43, Issue 3, 340–347.

CAPSULORHEXIS WITH IMAGED GUIDANCE Digital image guidance could be the next important step in improving the accuracy of the continuous curvilinear capsulorhexis (CCC), a study suggests. The SG3000 (formerly SMI, SensoMotoric Instruments GmbH, now VERION Image Guided System, Alcon Laboratories, Inc.) is a digital image guidance system consisting of a diagnostic reference unit and a surgery pilot for intraoperative surgical assistance. Making use of eye-tracking technology, a preoperative image is injected into the microscope and superimposed on the patient's eye. The device can be used to align toric IOLs during surgery, as well as support manual creation of a capsulorhexis with a predefined target diameter. The study looked at the capsulorhexis size of 427 eyes, 203 of which included digital image guidance. Overall, intraoperative image guidance facilitated CCC creation significantly during standard phacoemulsification. Y Haeussler-Sinangin et al, JCRS, “Clinical performance in continuous curvilinear capsulorhexis creation supported by a digital image guidance system”; Volume 43, Issue 3, 348–352.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | JUNE 2017

8 EuCornea Congress th

2017

LISBON 6–7 October

FIL – International Fair of Lisbon, Portugal

2 Days. 7 Focus Sessions. 6 Courses. 4 Free Paper Sessions.

Registratio n& Hotel Book ings Available

EuCornea Medal Lecture Friday 6 October

17.30 – 18.30 (At the Opening Ceremony) “Keratoconus: What We Have Accomplished And What Is Still Left To Do” Corn

www.eucornea.org

François Malecaze FRANCE e

C o r n

European Society of Cornea and Ocular Surface Disease Specialists

Friday 6 October

Saturday 7 October

Santen Satellite Meeting

Optimising the Ocular Surface for Surgery

13.00 – 14.00

Sponsored by

13.00 – 14.00

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CORNEA

THE VALUE OF DSAEK There is still a place for DSAEK in corneal transplantation surgery.

lthough more corneal transplant surgeons are switching to Descemet’s membrane endothelial keratoplasty (DMEK) for the reported benefits of quicker healing, better visual outcomes, lower risk of rejection and glaucoma, and lower dependence on long-term corticosteroids, older procedures such as Descemet’s stripping automated endothelial keratoplasty (DSAEK) still have a valuable role to play for certain indications, according to Sadeer B Hannush MD. “Despite the emergence of DMEK or pre-Descemet’s endothelial keratoplasty (PDEK) as some surgeons’ endothelial keratoplasty procedures of choice for the indication of endothelial dysfunction, these procedures may not be ideal in the setting of certain comorbidities,” said Dr Hannush. This is especially true if the surgeon is not experienced in performing DMEK, he noted.

CHALLENGING Dr Hannush, Wills Eye Hospital, Philadelphia, Pennsylvania, USA, himself an experienced DMEK surgeon, said that hypotony, unicameral eyes (with easy communication between the anterior and posterior segments), and conditions preventing adequate tamponade make DMEK cases particularly challenging. DSAEK, on the other hand, may give the surgeon a better chance of bringing these cases to a successful conclusion. Likewise, instances where the surgeon anticipates more difficulty than usual in unscrolling the DMEK graft, such as eyes with deep anterior chambers and those with prior vitrectomies, may also potentially benefit from DSAEK procedures, he said, since in these instances no special technique modifications are necessary to complete DSAEK, which may not be the case in DMEK. There are various circumstances in which the aforementioned conditions may occur, said Dr Hannush, including but

Courtesy of Sadeer B Hannush MD

Dermot McGrath reports

The right and left eyes of the same patient. The patient prefers the quality of vision in the left eye

not limited to the presence of aphakia, iris colobomata or zonular dehiscence, aniridia, eyes with anterior chamber intraocular lenses (IOLs), and eyes with iris- or scleral-fixated IOLs. “In cases where the surgeon anticipates IOL exchange (unicameral eye), or in the presence of a filtering procedure like trabeculectomy or tube shunt, DSAEK may be considered as the endothelial keratoplasty procedure of choice,” he added. Dr Hannush said his preference is to use thin grafts, below 100 microns, for DSAEK. “Size does matter when it comes to graft thickness. A thinner endothelial graft is advantageous, not just because of the properties of the graft itself, but also the reduced likelihood of variability in thickness across the cornea when you use a thinner graft, leading to better optical quality and enhanced visual acuity,” he said. To prepare the grafts, the full-thickness donor corneal tissue is mounted, endothelial side down, on an artificial anterior chamber and approximately two-thirds to four-fifths of the anterior stroma is removed using a microkeratome with 300- or 350-micron cutting heads, and varying the pressure in the anterior

A thinner endothelial graft is advantageous... leading to better optical quality and enhanced visual acuity Sadeer B Hannush MD

DSAEK in monocular patient S/P glaucoma filtering surgery with iris coloboma and zonulysis

chamber and the speed of the pass to achieve a 100-micron or less lamellar graft, said Dr Hannush. He highlighted the utility of DSAEK in difficult cases with the example of a patient with an anterior chamber implant and chronic pseudophakic corneal and macular oedema. “After explanting the anterior chamber IOL, a three-piece acrylic posterior chamber implant is fixated to the sclera by insertion of the haptics into scleral tunnels and the use of fibrin sealant. Once Descemet’s membrane has been stripped from the host, the DSAEK endothelial graft is positioned behind the host stroma and tamponaded into position with an air bubble,” he said. There is little concern in this scenario over the graft migrating posteriorly around the sclerally-fixated IOL, which might have been the case with a DMEK graft. Sadeer B Hannush: sbhannush@gmail.com

EUROTIMES | JUNE 2017

CORNEA

DRY EYE BIOMARKERS Advances in tear film testing open new vista in diagnosis and treatment of dry eye. Roibeard Ó hÉineacháin reports

ear-based biomarkers are bringing a new era in the diagnosis and treatment of diseases of the ocular surface and cornea, according to Rohit Shetty MD, PhD, FRCS, of Narayana Nethralaya Eye Hospital, Bangalore, India. “A Schirmer’s test strip, which we generally discard, can be used to diagnose, prognosticate and even help in developing drugs to treat dry eye and other diseases. That is why we say: ‘Please do not discard what could probably be a gold mine that could give us a completely new understanding of the disease’,” Dr Shetty told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands. He noted that he and his associates are developing a database of their patients tear film components in their laboratory. Using molecular profiling techniques and artificial intelligence technology, they are building biomarker profile and integrating it with clinical status and outcome of the diseases under investigation. He also stated that his team and others have identified tear-derived biomarkers for dry eye, keratoconus, as well as systemic diseases including autoimmune disorders, Alzheimer’s disease, and breast and prostate cancer. Dr Shetty added that he and his associates are in the process of developing a tear sampling device prototype to enable point-of-care testing for biomarker levels

in clinics, rather than in the laboratory. “Over the next decade, tear fluid testing will become as important as blood and urine testing,” he predicted. An in-depth understanding of the eye’s immune status and function is necessary to appreciate the clinical relevance of these biomarkers for dry eye, Dr Shetty said. Inflammation is a key factor in the evolution of dry eye. The tear-derived inflammatory biomarkers for dry eye include TNF-alpha, interleukin 6 (IL-6), IL-8 and IL-17, which are all elevated in eyes with the condition. Once set in motion by tear film instability, inflammation leads to changes in neuronal behaviour, an increase in corneal sensitivity, and reduces goblet cell density and mucin secretion, disrupts the corneal barrier function and impairs epithelial healing. Hence, blocking inflammation can prevent these sequelae, Dr Shetty said. Tearderived biomarkers can also help explain some of the complaints of patients with ocular surface discomfort, in whom none of the clinical signs are apparent, he added. As an example, he presented a case of a patient with ocular pain following LASIK that could not be explained with the usual testing techniques. Tear-based biomarker testing revealed abnormally high levels of nociceptive factors as well as low levels of anti-nociceptive factors. Another finding of the Bangalore team was that haze following photorefractive keratectomy (PRK) correlated with

increased gene expression of IL-6 and chemokine CXCL10, and decreased expression of WNTA and SOX17. They have also completed a tear biomarker based study suggesting that eyes that have undergone small incision lenticule extraction (SMILE) surgery have a more favourable corneal healing response than eyes that have undergone LASIK. Dr Shetty and his associates compared the postoperative tear-derived biomarker profile of eyes in a series of patients undergoing either LASIK or SMILE. They found that those undergoing LASIK had increased levels of molecular factors that are associated with inflammation and corneal tissue remodelling. In contrast, those who underwent SMILE had relatively lower levels of those molecular factors in their tears. Tear-derived biomarkers can also provide an indication of the likelihood and extent of disease progression in eyes with keratoconus. For example, Dr Shetty and his associates have demonstrated that tears from eyes with keratoconus had high levels of interleukin-6 (IL-6) and matrix metalloproteinase 9 (MMP9), and the levels corresponded with the severity of disease. They have also shown that the treatment of keratoconus patients with topical eye drops containing cyclosporine A reduced both tear MMP9 levels and progressive steeping of the affected corneas. Rohit Shetty: drrohitshetty@yahoo.com

Young Retina Specialists Day 17th EURETINA Congress, Barcelona Friday 8th September 2017

PROGRAMME OUTLINE YOURS Case Discussion with Audience Organiser: M. Singh USA

EURETINA is delighted to launch YOURS, a new initiative for Young Retina Specialists. As part of this initiative, ophthalmologists under 40 can avail of free membership of EURETINA for three years. YOURS provides a platform to ensure that issues and focus points of this demographic are heard.

For more information and to register go to

www.euretina.org/about-us/yours EUROTIMES | JUNE 2017

YOURS Symposium Organiser: D. Fischer GERMANY ‘The Young Offensive’ Organiser: C. Boon THE NETHERLANDS YOURS Science Slam Organiser: M. Fleckenstein GERMANY Ophthalmologica Lecture 2017 Keynote Speaker: S. Mrejen FRANCE

CORNEA

COST-BENEFIT STUDY OF CXL A 10-year treatment effect justifies CXL in progressive keratoconus. Roibeard Ó hÉineacháin reports

orneal crosslinking (CXL) is cost-effective in the treatment of patients with progressive keratoconus, suggests a comparison study presented at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands. Using a probabilistic-type stochastic Markov-type model, the study compared two identical cohorts, each including 1,000 virtual patients with progressive bilateral keratoconus. One cohort received CXL and the other cohort received no initial intervention, said Daniel A Godefrooij MD, University Medical Center Utrecht, The Netherlands. He noted that the study modelled the patients and their virtual annual evaluations based on data from published trials and cohort studies over a lifetime. They took into account disease progression, and the probability of corneal transplantation and/or graft failure. The analysis showed that, assuming a 10-year duration of effect, CXL is cost-effective for progressive keratoconus at a willingness-to-pay threshold of €115,518, which is three times the current gross domestic product (GDP) per capita. Moreover, assuming a longer stabilising effect of CXL would increase the cost-effectiveness, Dr Godefrooij noted. “We assumed that the longest duration of crosslinking effectiveness will be 10 years, which is the longest follow-up published, but we did not see a degeneration of the crosslinking effect, so it's plausible that the effect is longer than 10 years,” he said. He noted that assuming a 10-year effect of CXL, the incremental cost-effectiveness ratio (ICER) – the difference in cost between two possible interventions divided by the difference in their effect – was €54,384 per quality-adjusted life year (QALY). However, when they adjusted the stabilising effect of CXL to have a lifelong duration, the ICER decreased to €10,149/QALY. “That means the cost of one QALY is under the per capita GDP threshold and thus very costeffective,” he said. Dr Godefrooij noted that the ability to maximise cost-effectiveness of CXL is limited by the difficulty in determining who will benefit most from CXL and who will benefit least. Not all keratoconus patients will require keratoplasty in their lifetime, and contact lenses may be all they will ever require. “A better defined indication for crosslinking would also improve costeffectiveness,” he added. Daniel A Godefrooij: d.a.godefrooij@ umcutrecht.nl

We assumed that the longest duration of crosslinking effectiveness will be 10 years, which is the longest followup published... Daniel A Godefrooij MD

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EUROTIMES | JUNE 2017

WCPOS IV

4th World Congress of Paediatric Ophthalmology and Strabismus

See You in Hyderabad, India 1-3 December 2017 Registration and Hotel Booking Available Online

r e p x

Re s e s i t

ides ALL Around th

www.wspos.org

e Wo

rld

CORNEA

PERFORATION PREVENTION Viscoelastic on the bubble protects against DM perforation during DALK. Roibeard Ó hÉineacháin reports

lacing a viscoelastic device on the top of the big bubble created during a deep anterior lamellar keratoplasty (DALK) procedure can reduce the risk of Descemet’s membrane perforation during subsequent stages of the operation, according to Yusuf Koçluk MD, of Adana Numune Training and Research Hospital, Adana, Turkey. Speaking at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands, Dr Koçluk noted that perforation of Descemet’s membrane is the most common complication of DALK surgery among surgeons learning the technique. To evaluate the protective effect of viscoelastic on Descemet’s membrane during DALK surgery, he and his associates reviewed the medical records and videos of surgeries of their first 40 DALK patients in whom bigbubble formation could be achieved during the stromal dissection phase of a DALK procedures between January 2014 and July 2015.

EXCLUSION CRITERIA The indications for surgery included keratoconus and other corneal stromal dystrophies. The study’s main exclusion criteria were healed corneal hydrops and Descemet’s membrane scarring. The surgeries were performed by the same surgeon using a big-bubble technique. Dr Koçluk and his associates divided the patients into two treatment groups. The first group included 20 eyes in which perforation of stromal bubble was performed in the standard way. The second group included 20 eyes in which they performed the perforation after first applying a viscoelastic device (1.4% sodium hyaluronate) on the stromal wall. Their analysis showed that that perforation of the Descemet’s membrane occurred in only three (15%) of those in eyes in which the viscoelastic was used, compared to 12 (60%) of those in whom it was not. Dr Koçluk noted that their surgical technique involved first achieving a big bubble, confirming it by pushing the previously injected small anterior chamber bubble into the periphery. After the anterior part of the stroma was removed they stained a point on the bubble’s stromal surface.

STROMAL BUBBLE In the first group of patients, the stained point was carefully punctured using a 20G MVR blade (Alcon). In the second group, the viscoelastic was applied to the stained point just before perforation of the stromal bubble. In both groups, they removed the stroma in quadrants. Dr Koçluk noted that in 75% of cases overall, Descemet’s membrane perforation occurred during the course of stromal wall puncture. However, no Descemet’s membrane perforation occurred during stromal wall puncture in the viscolelastic group. Yusuf Koçluk: kocluk99@gmail.com EUROTIMES | JUNE 2017

RETINA

PARADIGM SHIFT Intraoperative OCT set to become an indispensable tool for vitreoretinal surgery. Roibeard Ó hÉineacháin reports

vidence continues to accumulate supporting the usefulness of intraoperative optical coherence tomography (iOCT) in the surgical treatment of a range of vitreoretinal pathologies, according to Prof Mathias Maier, Augenklinik, Klinikum rechts der Isar, Technical University of Munich, Germany. “Probably we are just at the time of the paradigm shift, whereas in five years from now iOCT might be standard in vitreoretinal surgery,” he said. He noted that the integration of noncontact indirect ophthalmoscopy into the surgical microscope was an important advance when first introduced 30 years ago. The technology provides wide field viewing at a high magnification. However, it limits the surgeon to an en face view, whereas retinal surgery requires precise 3D manipulation of delicate tissues at a sub-millimetre scale.

AVOIDING DAMAGE Intraoperative OCT with the RESCAN 700 (Zeiss) enables that possibility. It provides real-time simultaneous en face surgical microscopy and spectral-domain OCT (SD-OCT) visualisation of the region of interest through the eyepiece. It therefore allows the surgeon to view intraoperatively the impact of their manoeuvres and manipulations, potentially avoiding damage to the retina. When first introduced, iOCT was met with some scepticism from retinal specialists. For example, at the AAO meeting in 2014, only around half of the retinal surgeons polled believed the new technology would come into standard use. But since that time evidence has accumulated to suggest that iOCT is genuinely helpful in procedures such as epiretinal membrane (ERM) and inner limiting membrane (ILM) peeling and has real potential to improve patients’ outcomes. For example, in a study by Susanne Binder MD and her associates in Vienna,

Courtesy of Prof Mathias Maier

Intraoperative OCT (RESCAN 700): Microscopic view (left) and simultaneous ‘real-time’ SD-OCT colour image (right). Patient with full-thickness macular hole (FTMH) during peeling of the ILM

Austria, iOCT ERM peeling was possible in 28 (40%) of 70 eyes without using dyes, and they found no residual membrane even if they re-stained in 94.3%. It also showed that iOCT facilitated decisionmaking on the need for an intraocular tamponade after membrane peeling and it was comparable to the use of dye in confirming success after membrane peeling and visualisation of flat membranes after staining. (Falkner-Radler et al, Retina 2015;35:2100-2106) Studies by Justis P Ehlers MD and associates have produced similar outcomes. For example, in the PIONEER study, which involved 750 eyes, iOCT altered surgical decisions in 15% of membrane peeling procedures and the recurrence rate for membranes was less than 1%. (Ehlers et al, Invest Opththalmol Vis Sci 2014;56:1141-1146) In addition, in the DISCOVER study, which involved 350 eyes, iOCT revealed the presence of residual membranes requiring additional peeling that were not visible with standard surgical microscopy in 16% of cases. (Ehlers et al, JAMA Opthalmol 2015; 133 :124-1132 ) Prof Maier noted that his own experience with 17 patients treated for full-thickness macular holes using iOCT

supports the findings of the published studies. The technology provided higher magnification of the gap between the ERM and the retina at the initiation of peeling as well as the ILM during and after peeling. In addition, iOCT enables visualisation of retinal deformation during peeling, which in some cases led the surgeons to alter their peeling approach. The intraoperative feedback was also very helpful when using ILM-peeling with the inverted ILM flap technique.

FOVEAL CONTOUR

Probably we are just at the time of the paradigm shift, whereas in five years from now iOCT might be standard in vitreoretinal surgery

Furthermore, the clear visualisation of the foveal contour and cystic roof could help spare the fovea during peeling. Also very helpful is the visualisation of retinal detachment, Prof Maier noted. Moreover, iOCT is extremely useful in dense vitreous haemorrhage, when prior to surgery SD-OCT diagnostic is not feasible. However, iOCT is not without its shortcomings, Prof Maier said. At present it provides no tracking of the region of interest, and the shadow of the metallic instruments can be a problem. In addition, surgery times increased a little (30 seconds approximately) and it is also expensive. Future developments will hopefully address many of these problems. “As time goes on since 2014, iOCT is more frequently used and in future, possibly together with heads-up surgery and probably robotic microsurgery, this trend is going to continue, like computers did starting from the 1980s to today,” he concluded.

Prof Mathias Maier

Mathias Maier: mathias.maier@mri.tum.de

EUROTIMES | JUNE 2017

17th EURETINA Congress 7–10 September 2017 CCIB, Barcelona, Spain

11 EURETINA Updates (Main Sessions) 30 International Society Symposia 25 Free Paper Sessions 40 Instructional Courses 4 Surgical Skills Courses Keynote Lectures EURETINA Lecture

Francine Behar-Cohen SWITZERLAND

Richard Lecture

Borja Corcóstegui SPAIN

Kreissig Lecture

Jackson Coleman USA

Ophthalmologica Lecture Sarah Mrejen FRANCE

III

WORLD RETINA DAY

Saturday 9 September

www.euretina.org

17th EURETINA Congress, Barcelona

17th EURETINA Congress 7 – 10 September 2017

Thursday 7 September

Friday 8 September

Lunchtime Symposia

Morning Symposium

Lunchtime Symposia

Boxed Lunch Included

10.00 – 11.00

Boxed Lunch Included

13.00 – 14.00 Allergan Satellite Meeting Sponsored by

Topcon Satellite Meeting Sponsored by

13.00 – 14.00 Bayer Satellite Meeting

Bayer Satellite Meeting

Sponsored by

Friday 8 September

Novartis Satellite Meeting Sponsored by

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00

Continuous Microdosing with Intravitreal Corticosteroids: A Real-world Perspective in Patients with Chronic DME Moderators: H. Hoerauf GERMANY B. Corcóstegui SPAIN Speakers: H. Hoerauf GERMANY A. Loewenstein ISRAEL F. Goñi SPAIN B. Pessoa PORTUGAL B. Corcóstegui SPAIN Sponsored by

Impact of Geographic Atrophy: Enhancing Our Understanding of the Disease Moderator: J. Monés SPAIN Chair’s introduction Diagnostic paradigms of geographic atrophy Measuring disease-speciﬁc functional outcomes Geographic atrophy: a progressive disease Characterizing disease burden using real world data Q&A Sponsored by

Friday 8 September

Saturday 9 September

Lunchtime Symposia

Morning Symposia

Lunchtime Symposia

Boxed Lunch Included

10.00 – 11.00

Boxed Lunch Included

13.00 – 14.00 Heidelberg Engineering Satellite Meeting

13.00 – 14.00 Alcon Satellite Meeting Sponsored by

Sponsored by

Bausch + Lomb Satellite Meeting Sponsored by

Bayer Satellite Meeting Optos Satellite Meeting Sponsored by Sponsored by

NIDEK Satellite Meeting Sponsored by

Nutrition & AMD: From Diagnosis to Treatment Moderators: A. Garcia Layana SPAIN A.M. Minnella ITALY Sponsored by

Allergan Satellite Meeting Sponsored by

Novartis Satellite Meeting Sponsored by

DORC Satellite Meeting Sponsored by

RETINA

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YEAR-ROUND EDUCATION Annual meetings and the ASCRS Center for Learning (webinars, clinical reports, post-meeting resources, podcasts and CME 24/7)—NEW ascrs.org/learn

CLINICAL SURVEY DATA ASCRS is the only professional organization in ophthalmology offering access to the detailed clinical survey data provided by over 2,000 of its members

TOOLS Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer and more online tools

PUBLICATIONS Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine and EyeWorld news magazine

COMMUNITY Daily online discussions in EyeConnect and the EyeConnect 365 app

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RETINAL IMAGING Optical coherence tomographyangiography extends its reach. Leigh Spielberg MD reports

lessandro Papayannis MD, PhD, of the Manchester Vision Regeneration Lab, UK (Director: Prof P. E. Stanga), presented the results of his evaluation of the Topcon ultra wide-field swept-source optical coherence tomography-angiography (UWF SS OCT-A) in 86 eyes with diabetic retinopathy (DR) at the 16th EURETINA Congress in Copenhagen, Denmark. These images were then compared with those made using Optos California ultra wide-field colour fundus photography (UWF CFPh). Where clinically necessary, fundus fluorescein angiography (FFA) was performed. The purpose of the study was to describe the UWF SS OCT-A features of DR, using the CFPh or the FFA as a reference. Multiple SS OCT-A images were montaged to create an UWF SS OCT-A image. Two independent reviewers then compared Alessandro Papayannis the images as follows: 45-degree colour photography versus UWF SS OCT-A; UWF colour photography versus UWF SS OCT-A; and UWF FFA versus UWF SS OCT-A. “Across the 86 examined eyes, typical signs of DR, including macular oedema, retinal non-perfusion, neovascularisation of the disc and neovascularisation elsewhere were identified on UWF SS OCT-A with 100% reviewer agreement,” said Dr Papayannis. Of the 86 eyes examined, 36 underwent FFA. In 36 of 36 eyes, an enlarged foveal avascular zone and peripheral ischaemia were identified on both UWF FFA and UWF SS OCT-A, he said. Furthermore, 12 patients received the diagnosis of proliferative DR based on the FFA images. “Within the central 100 degrees, there was good correlation between sensitivity of UWF SS OCT-A and UWF FFA in detecting neovascularisation of the disc in 5/5 eyes, and neovascularisation elsewhere in 9/10 eyes,” said Dr Papayannis. He concluded that UWF SS OCT-A already has the ability to detect neovascularisation elsewhere up to the limits of an Optos California UWF FFA when acquired in the primary position. “In fact, UWF SS OCT-A allows us to visualise ischaemic alterations above areas treated with panretinal laser photocoagulation,” said Dr Papayannis. He showed images in which ischaemia was visible in the superficial and deep OCT-A images, depths that are masked on FFA imaging. Ischaemic changes in the choriocapillaris were clearly visible. “UWF SS OCT-A is a sensitive, non-invasive imaging technique that can offer additional topographic information with a layer-by-layer analysis regarding the localisation and the morphology of the vascular lesions in DR, from the retinal vascular plexuses to the vitreous cavity and from the posterior pole up to the mid-periphery,” he concluded. Detection of neovascular and ischaemic abnormalities seems to be as accurate as FFA. Alessandro Papayannis: alexandrospapayannis@yahoo.it

EUROTIMES | JUNE 2017

RETINA

OPHTHALMOLOGICA VOL: 237 ISSUE: 4

NEW EURETINA GUIDELINES FOR DME This issue of Ophthalmologica features the European Society of Retina Specialists’ (EURETINA) new Guidelines for the Management of Diabetic Macular Edema (DME). Among their chief recommendations is that anti-vascular endothelial growth factor (anti-VEGF) therapy should be considered as the first-line therapy for DME, rather than laser photocoagulation, which is now obsolete for the condition. The guidelines' authors note that the advent of optical coherence tomography-angiography (OCT-A) has raised the question of whether fluorescein angiography (FA) is also obsolete. They point out that FA allows a more comprehensive assessment of the extent of the morphological damage to the macular microcirculation. U Schmidt-Erfurth et al, “Guidelines for the Management of Diabetic Macular Edema by the European Society of Retina Specialists (EURETINA)”; Ophthalmologica 2017, Volume 237, Issue 4.

SD-OCT FINDINGS REVEAL EARLY SIGNS OF RETINAL NEURODEGENERATION IN DIABETIC PATIENTS Patients with diabetes mellitus type 1 (DM1), but with no signs or only early signs of diabetic retinopathy, nonetheless have detectable retinal changes that may correlate with initial neurodegeneration, a new study suggests. The authors of the study obtained nine individual retinal layer thickness measurements in 76 eyes of 38 DM1 patients and 26 control eyes using a spectral domain-optical coherence tomography (SD-OCT) automated segmentation algorithm. They found that the inner nuclear layer (INL) thickness was thicker in all DM1 eyes than in the control eyes in all quadrants (p<0.050). They also found that the retinal ganglion cell layer was about 3.5% thinner in DM1 patients than in controls (p<0.050). F Scarinci et al, "Single Retinal Layer Evaluation in Patients with Type 1 Diabetes with No or Early Signs of Diabetic Retinopathy: The First Hint of Neurovascular Crosstalk Damage between Neurons and Capillaries"; Ophthalmologica 2017, Volume 237, Issue 4.

GOOD REPEATABILITY AND INTER-DEVICE AGREEMENT WITH ANGIOGRAPHIC OCT Two new OCT-A devices, the AngioVue (Optovue) and AngioPlex (Zeiss), have demonstrated a low intra-device variability and a high inter-device correlation in the measurement of choriocapillaris (CC) perfusion. A study involving 36 eyes of 36 volunteers showed that the mean CC decorrelation signal index, a measure of the differences in backscattered light between sequential scans, was 104.3 with the AngioVue and 81.3 with the AngioPlex in a 3×3mm2 field, and 95.6 and 81.1, respectively, in a 6x6mm2 field. There was also a high correlation between both devices (3x3mm2: p=0.0053; 6x6mm2: p=0.0139). JL Lauermann et al, “Comparison of Choriocapillaris Flow Measurements between Two Optical Coherence Tomography Angiography Devices”; Ophthalmologica 2017, Volume 237, Issue 4.

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

EUROTIMES | JUNE 2017

Are you ready for the next step?

www.escrs.org

Belong to something energetic. Join us.

ESCRS

BOARD ELECTION 2017

ESCRS Board elections are held every two years. Board members serve for a term of four years and can be re-elected for one additional four year term. Board members must have been a full member of the ESCRS for at least the last three consecutive years and in order to stand for election candidates must be nominated by five other full members of the Society. There are five positions open on the Board in this election. Ten full members of the ESCRS have been nominated for election to the Board and they are profiled on the following pages. Voting opens on 12 June and closes on 1 September. Members entitled to vote will receive a ballot paper in the post by 12 June. The names of the new Board members will be announced at the Annual General Meeting of the ESCRS which will take place during the Annual Congress in Lisbon in October. Please note that only European full members of the ESCRS are entitled to vote in the Board election.

ESCRS Board Election 2017

G Gerd Auffarth GERMANY

erd U. Auffarth, MD, FEBO is professor and chairman of the Dept. of Ophthalmology, University of Heidelberg, head of The International Vision Correction Centre (IVCRC), and director of the David J. Apple International Laboratory for Ocular Pathology in Heidelberg, Germany, which is devoted to research on intraocular ophthalmic devices especially IOLs, relocated in 2012 from South Carolina. He is a high volume surgeon in cataract and refractive surgery and operates glaucoma and corneal transplants as well. His research focuses include cataract surgery, IOLs, refractive laser technology, diagnostics, cornea. He has published more than 230 peer reviewed articles and he and

A Massimo Busin ITALY

fter training in Italy and in the USA, where I was fellow with Herbert E. Kaufman, I joined the Faculty of the Friedrich-Wilhelm University in Bonn (Germany), where I am still apl. (ausserplanmaessiger) Professor of Ophthalmology. Since 1996 I have been the chairman of the Department of Ophthalmology at “Villa Serena-Villa Igea” hospitals in Forlì (Italy). My academic career, my research activity (157 peer reviewed articles, 34 chapters in books, 1 book) and my clinical work have focused on the anterior segment of the eye, with a particular interest in corneal transplantation. I frequently meet with colleagues from many European and other foreign countries both at international meetings

Dan Epstein SWITZERLAND

an Epstein has been active within the ESCRS for the past 18 years. He has been a member of key committees, an initiator and faculty member of the Refractive Surgery Didactic Course, lecturer at the Young Ophthalmologists Programme, faculty at various ESCRS instructional courses, senior wetlab instructor, and the Programme Committee member responsible for the main ESCRS symposia. He has actively contributed to the creation of ESCRS’s iLearn platform, which provides free interactive teaching for members. In the past 4 years he was able to intensify his commitment by serving on the ESCRS Board. He has been consultant ophthalmologist for refractive surgery at the Department of Ophthalmology, University

I Jesper Hjortdal DENMARK

am Clinical Professor and Consultant, Medical Director for The Danish Cornea Bank and head of corneal and refractive surgery at Aarhus University Hospital, Denmark. I graduated from Aarhus University in 1988 and have been trained clinically in Denmark and at Moorfields Eye Hospital. My research focus has mainly been in corneal optics, biomechanics, transplantation and refractive surgery, and I have published more than 170 papers/book-chapters. I am immediate past-president of the Danish Ophthalmological Society and the European Eye Bank Association, currently board member of EuCornea and co-editor of Acta Ophthalmologica. In 2013,

I Simonetta Morselli ITALY

graduated from the University of Verona as a General Medical Doctor in 1991 and as an Ophthalmologist in 1995. Since my residency I have been dedicated to anterior segment surgery, specialising in cataract, refractive and cornea, at the University Hospital of Verona, Italy. In 2008 I became Chief of the Ophthalmic Department in Bassano, Italy. I have performed more than 12,000 surgical procedures, performed live surgery at many meetings, and published in international journals and books. A Board Member of the Italian Cataract & Refractive Surgery Society, I am deeply involved in the organisation of national and regional meetings.

his team are extremely active at congresses with lectures and courses. He has served on the board of the German Society of Cataract and Refractive Surgeons (DGII) (currently as VicePresident) and the German Ophthalmological Society (DOG). He was involved in committee work and previously served on the ESCRS Board from 2005–2009. He is involved in cutting edge research and development studies. Fellows from across Europe work in his research facilities and the training of young researchers and residents would be a main focus when serving on the ESCRS Board. Independence of research and education is a very important issue for him.

and at my institution, hosting them for observerships and/ or courses. All these occasions have reinforced my belief that communication and interaction are the keys for improvement at all levels of our ethics, professional skills and legal competence. In pursuit of contributing to the further development of ESCRS as a reference institution for European ophthalmologists, if elected, my priority would be to stand for creating concrete, “ESCRS supported” opportunities for members willing to upgrade their theoretical and practical knowledge with selected tutors.

Hospital, Zurich for 15 years, after holding an appointment at Uppsala University Hospital, Sweden. Earlier he had received a PhD from the Karolinska Institute, Stockholm. In addition to collaborating with several universities and clinics in Europe and running a private practice, he is also active in research/publications, and has recently completed a 15-year appointment as an editor of the Journal of Refractive Surgery. If re-elected to the Board, he plans to continue building on his teaching and organisational experience to expand the ESCRS’s role in providing superior educational programmes for Europe and beyond.

I received the Waring Medal for Editorial Excellence for a paper on SMILE surgery. For more than 10 years, I have attended and contributed to the annual ESCRS meetings as invited main symposium speaker, session moderator, speaker at the Refractive Surgery Didactic Course and several other courses. I have recently become a member of the ESCRS Research Committee, review free papers for the sessions, and take part in organisation of symposia. I hope to be able to strengthen my backing of ESCRS to further support the Society to be a major global contributor to the scientific development of cataract and refractive surgery.

My surgical activity has always been connected with clinical research trials and especially with teaching and training young surgeons. I joined ESCRS years ago as a teacher in the Young Ophthalmologists Programme, more recently becoming a member of the Programme Committee. If elected I would like to serve the Society by increasing educational activities while maintaining the high profile and scientific value of the most advanced aspects of our meetings. Science, education and clinical research are fundamentals of the ESCRS and their evolution is the very life of our Society, a Society of which we are all proud to be members.

Nominated Candidates

I Filomena Ribeiro PORTUGAL

am the current Coordinator of the Portuguese Society of Cataract and Refractive Surgery, Professor at the University of Lisbon, Board Member of the Portuguese College of Ophthalmology and Head of the Ophthalmology Department at Hospital da Luz. In Europe I represent Portugal in the European Union of Medical Specialists and have been an Examiner for the European Board of Ophthalmology Exam. Holding a PhD in Biomedical Engineering, my research interests focus on computational human eye models, biometry and IOL power calculation, presbyopia and astigmatism correction. I have participated actively in the ESCRS scientific programme committee and had the opportunity to organise

I Sathish Srinivasan UK

am joint Clinical Director at University Hospital Ayr and Honorary Clinical Associate Professor, University of Glasgow, UK. I have been a Board member of UK and Ireland Society of Cataract and Refractive Surgeons since 2009. My interests are in lamellar corneal transplants, laser refractive and cataract surgery. I have published over 95 scientific papers. I have been awarded the Achievement and International Scholar awards from the American Academy of Ophthalmology. I have been an active member since 2009 and my current involvement with the ESCRS includes: 1. Associate Editor - Journal of Cataract and Refractive Surgery 2. Member - Publications Committee (EuroTimes)

I Pavel Stodulka CZECH REPUBLIC

am a high volume cataract and refractive surgeon who also performs DMEK and vitreoretinal surgery. I like to innovate and I was the first in my country to perform LASIK, FemtoLASIK, MICS, FLACS, DMEK, Boston KPRO, Avastin injection and several other surgeries. I was the first in Europe to use Victus FS laser for FLACS. I was the first in the world to implant presbyopic phakic IOL and perform CapsuLaser capsulotomy, of which I am a co-inventor. My current research is focused on collagen disc implant for keratoconus. I am founder and chief eye surgeon of Gemini Eye Clinics in the Czech Republic and Austria.

P Paolo Vinciguerra ITALY

aolo Vinciguerra is Director of the Ophthalmology Department Humanitas (Milan, Italy) and Associate Professor in Ophthalmology at Humanitas University. He is internationally renowned for pioneer work in refractive surgery, corneal topography. Winner of many Italian and international awards, he has been the recipient of the Achievement Award from the AAO in 2003 and of the “Lans Lecture” at ISRS-AAO 2005. Prof. Vinciguerra has been an Honorary Member of the Italian Society of Ophthalmology (SOI) since 1995 and an Honorary Member of the Italian Society for Corneal Transplants (SITRAC) since 2004. He is currently member of the Board of Directors of SITRAC and of the Italian Cataract

A Jerome Vryghem BELGIUM

s the candidate nominated by the Belgian Society of Cataract and Refractive Surgery I want to continue the tradition of Belgian ophthalmologists being member of the ESCRS Board, like Prof. Galand, Dr Budo and Prof. Tassignon. I have written many peer and non-peer reviewed articles, organized several scientific sessions and live surgeries (ESCRS Brussels 2000, MICS-Masters) and have regularly been invited to demonstrate my surgical technique during live surgeries abroad (Berlin, Moscow, Alicante, etc.). I very much enjoyed attending several ESCRS Academy meetings abroad in the last four years. I have organized an instructional course on the prevention

the Luso-Hispanic-Brazilian symposium for ESCRS Lisbon 2017, which I invite everyone to attend. As a candidate for the Board of the European Society of Cataract and Refractive Surgeons, I would like to emphasize that I will play an active role both at Board and Committee level, being particularly focused on education and research as leverages for the ESCRS. I also intend to explore the excellent opportunity to reinforce the Iberian representation in this project and expand it to the involvement of the Ibero-American community. Thank you for your support in this electoral process.

3. Evaluation panel member - ESCRS Clinical Research Awards 4. Examiner - European Board of Ophthalmology ESCRS Exam 5. Faculty of ESCRS Academy at international meetings I am committed to the ESCRS to enhance positive promotion and practice of ophthalmology among its member states. My experience and current roles provide me with a detailed insight into the work and dedication required to be active, collaborative and to harvest results. It would be a great honour and privilege to serve as a Board member.

I gave over 800 presentations in Europe and beyond and I have been teaching young residents phaco courses at ESCRS and SOE meetings for several years. I would like to contribute to the ESCRS Board according to the needs of this Society. I would like to create an ESCRS programme to organize virtual cataract surgery courses for young surgeons at European clinics equipped with virtual surgical simulators. We run such a programme for our residents in the Czech Republic and it is extremely successful. I would also like to support intraocular Avastin legalization throughout EU.

and Refractive Surgery Society, Chairman of the Italian Association of Private Hospitals (OPI) and a member of the “CME” Committee of SOI. He has been a member of the International Council of the ISRS-AAO since 2004. Prof. Vinciguerra has filed numerous international patents: excimer ablation profile, masking fluids for therapeutic ablation, an artificial test eye for excimer calibration, fractal calculation in confocal microscopy, corneal curvature gradient calculations to predict corneal healing response. If elected, Prof. Vinciguerra would serve the Society to his best, promoting benchmarks between new technology and clinical innovations and existing ones.

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

CLINICAL QUESTIONS

ASK THE EXPERTS Our Medical Editors answer readers’ questions about current issues in ophthalmology

Dr Clare Quigley

Second-year Resident at Mater Misericordiae University Hospital, Dublin, Ireland Q. I have trained with surgeons who use coaxial phacoemulsification, and others who use bimanual, and I am similarly proficient at both now. Which is the superior technique, or is there only personal preference in the difference? Marie-José Tassignon MD, PhD, FEBO Chief and Head of the Department of Ophthalmology, University Hospital Antwerp, Belgium A. The choice between coaxial or bimanual is triggered by different parameters: 1. Type of cataract: In the case of very soft cataract, a bimanual approach is preferred. In children and certainly in babies, this is the best approach in order to maintain the anterior chamber (AC) deep and avoid iris prolapse. When following the technique of micro-incision cataract surgery (MICS), a bimanual approach presents the advantage to better stabilise the eye. The tighter the incision to introduce the instruments, the more the eye will present pressure spikes. This should be kept in mind when operating terminal glaucoma patients. MICS should be avoided in these cases. 2. Type of intraocular lens (IOL): If the type of IOL needs a 2.2mm or larger incision, then a coaxial gets the preference but with only one incision, so without sideport incision. The idea is to reduce the total incision size. Even if working coaxial, both instruments of right (phaco probe) and left (lens manipulator) hand, are glided through the same single main incision. This allows you to operate with wound sizes of 2.2mm, not augmented by a 1mm side-port. 3. Degree of difficulty: In the case of loose zonules, a coaxial incision will be used but with the help of one or four additional side-port incisions, depending on the degree of severity of the zonular lysis. If four side-ports are needed for the capsule suspension, no additional side-port will be performed for the phacoemulsification. We will then follow the technique as described in point 2. 4. The preferred position of the surgeon: In a case of temporal position, a bimanual coaxial single incision is my preferred option (except for babies). In a case of superior incision, a bimanual double incision might be preferable. EUROTIMES | JUNE 2017

Bekir Sıtkı Aslan MD Head of Eye Department, Ankara Memorial Hospital, Turkey

Oliver Findl MD Chief, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria

A. Bimanual and coaxial MICS are not two conflicting surgical techniques. The common goal is to control surgery better and reduce induced astigmatism during cataract surgery. A balance between irrigation and aspiration is the key element to avoid complications in phacoemulsification in micro-incision. The inflow of the fluid inside the anterior chamber is as important as the outflow. With bimanual surgery, the amount of infusion is compromised and the leakage is significantly more when compared to coaxial phacoemulsification. It is nearly impossible to obtain an adequate seal when you put a rigid instrument through corneal incisions. Phaco tip with a sleeve leads to better seal. Incisions around 2.2mm are almost astigmatically neutral. Coaxial phacoemulsification is feasible through this incision and you don’t need to enlarge the wound for any IOL implantation, whereas you need to enlarge one of the bimanual wounds for IOL implantation. Anterior chamber maintenance, and of zonular stability, can be achieved far more superiorly with coaxial technique due to better fluidics and wound seal, especially in harder cataracts. Though the literature revealed no significant differences in outcome parameters including topographic corneal and ocular abberrometric variables between each surgical technique, the bimanual technique may work for some moderate uncomplicated cataracts but coaxial is for all circumstances. So I advocate coaxial phacoemulsification.

A. As far as I can see from my colleagues, many tried bimanual phaco when it was first proposed, but stopped using it soon thereafter. Promoting bimanual phaco is like beating a dead horse – the reason being that the only real advantage of bimanual over coaxial, namely smaller incisions and more delicate (thinner) instruments, has been made obsolete with the introduction of axial tips with silicone sleeves that pass through 1.8mm and smaller incisions. The sleeve ensures better stability of the AC during surgery and better sealing after surgery due to less strain on the wound. The IOLs need incisions of 1.8mm and larger anyhow, so it does not make much sense to enlarge a paracentesis for IOL implantation at the end of surgery. Even with small floppy iris pupils, the coaxial phase works sufficiently well.

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org

INDUSTRY NEWS

INDUSTRY

NEWS

FORGIVING LENS Ophtec BV has received a CE mark for a new aspheric presbyopia correcting intraocular lens (IOL), Precizon Presbyopic, with a patent-pending continuous transitional focus (CTF) optical design. “The new CTF optic seems to offer a safer surgical approach than traditional multifocal technologies available on the market, and addresses the fact that nature is not an optical bench and IOL seating is important for good performance,” said a company spokesman. “The technology offers a full range of vision and, due to the CTF’s transitional zones, a smooth, continuous transition from near vision to infinity is achieved. Consequently, CTF ensures a more 'forgiving' lens that enables surgeons to treat a wider range of presbyopic patients with a higher degree of confidence,” he said. Precizon Presbyopic will be commercially launched in October during the XXXV Congress of the ESCRS in Lisbon, Portugal. The product will initially be available in the European Union and a few selected markets. www.ophtec.com

NEW TECHNOLOGIES Alcon introduced the latest products in its surgical vitreoretinal portfolio during the recent FLOREtina Retina Meeting in Florence, Italy. “The advanced Ultravit® Beveled High Speed Probe is the latest evolution in micro-incision vitrectomy surgery that offers surgical versatility, bevel tip precision and added control,” said a company spokeswoman. “The Vektor® Articulating Illuminated Laser Probe aims to expand the possibilities for reaching and treating the anterior periphery of the retina,” she added. Alcon says these new technologies are designed to help surgeons deliver a higher level of precision and efficiency during vitreoretinal surgery. www.alcon.com

TISSUE MANIPULATORS Vitreq has launched a new generation of tissue manipulators with retractable tip. “The new retractable tissue manipulators can be be used in cases of retinal disorders to manipulate the retina and retinal fold. It features a retractable silicone tip with a special rib structure to manipulate the retinal surface. The specially designed silicone tip is green coloured for clear visual differentiation with the retinal surface,” said a company spokesman. Vitreq says the silicone tip structure does not have any diamond particles to eliminate the risk of losing particles inside the eye. www.vitreq.com

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EUROTIMES | JUNE 2017

HOSPITAL DIARY

NIGHT OWL

Operating at night creates challenges, but also opportunities. Dr Leigh Spielberg reports

ou’re not Caesarean sections happen in only here another building. We have the to assist place to ourselves. me with The OR staff is generally in a this retinal good mood: they have the next detachment morning off, especially if they surgery,” I tell each resident can’t leave before midnight, and when he or she first joins me they are well compensated for in the operating room. “You late-night work. Sometimes I also have a very important can see the moon shining in cheerleading function. By through the windows. Yes, my which I mean you can feel operating room has windows. free to compliment whatever Big ones! Which make for a nice manoeuvres I perform. view of the nighttime sky when Especially if they go well – but the operating room is dark and even if they don’t.” the night is clear. They mostly think I’m On the other hand, joking at first, but I insist, the longer the procedure and they generally get the progresses and the later it hang of it after a while. But gets, the more I start to realise many of them have never what a mess the next 24 hours been in the operating will become. Typically, I’ll get room before, so they can’t home around 1am. Our cat be expected to know when then thinks it’s morning, and something is going well and starts meowing. He wakes up when it isn’t. Raphael, who’s four years old “Nice capsulorrhexis!” and is always looking for an they’ll say, as the tear excuse to get out of bed. But he disappears under the iris. won’t get up while I’m still up. “Thank you,” I reply, as He’ll wait until I’ve sweat starts to roll down descended into my first useful my back. Sometimes they’ll REM sleep before he wakes comment on the equipment me to tell me that he’s hungry, Typically, I’ll get home around 1am. Our or instruments. “Ooh, robot thirsty, and wants to go out for lights!” I hear as I insert the a ride on his bike. OK buddy, cat then thinks it’s morning, and starts twin light chandeliers near back in bed. The whole world meowing. He wakes up Raphael, who’s the superior limbus. is asleep. “Except China! It’s four years old... And finally, “I thought morning in China!” he'll reply. you’d never get that retina But nighttime surgery is reattached!” they'll sometimes say at the end, which makes me when I’m at my most creative, inventive, and adventurous. At look at them over my face mask. “Um, I mean, of course I knew night, necessity is the mother of progress. I did my first direct it would work out, um, eventually, sorry...” they’ll say, not sure decaline-oil exchange in the middle of the night, because I how I’ll interpret it. couldn’t bear the thought of the retina detaching again under an I don’t do it to hear what a great job I’m doing. I do it so that air infusion. This is a tricky procedure, in which the intraocular I know they’re paying attention, focusing on what’s going on in pressure can easily jump above 60mmHg if one is not careful. the eye instead of what’s going on in their mind. OK, maybe I There isn’t much room for error. do it a little bit to hear what a great job I’m doing. Just a little I don’t like the term ‘trial and error’, however. Instead, I would bit. Give me a break, though. Retinal surgery is hard work. I rather borrow a phrase from inventor Thomas Edison: ‘I have not admit we don’t have to spend much time treating blepharitis, failed. I’ve just found 10,000 ways that won’t work.’ and that alone makes it worthwhile. But we do have to I’ve certainly found many ways that won’t work: half a spend hours at a time bringing eyes back from the brink of dozen ways not to try to remove silicone oil from the anterior blindness – at night. chamber; many locations where not to make a retinotomy to I’ve been doing quite a bit of operating at night recently, which drain subretinal fluid; certainly, a dozen ways not to peel the means that whichever ophthalmology resident is on call that night ILM on a detached retina. But this searching always leads me is my assistant. In all honesty, it’s not the most efficient system, to the one or more ways that do work, the ways that will lead but it gets the job done. to an attached retina, the restoration of sight, a happy patient Although neither my wife, my health nor my lower back and a happy me. appreciate me operating after sunset, I tend to enjoy it. I’m Dr Leigh Spielberg is a vitreoretinal and cataract surgeon not in a rush to finish my programme before the staff switches at Ghent University Hospital in Belgium shifts. We’re usually the only ones working in the whole surgical wing, since the orthopaedic trauma and emergency leigh.spielberg@gmail.com Illustration by Eoin Coveney

EUROTIMES | JUNE 2017

ESCRS NEWS

Dr Paul Rosen, chair of the ESCRS Practice Management and Development Committee, with 2016 Marketing Competition winner Dr Rahil Chaudhary and competition judge Kris Morrill

22nd ESCRS Winter Meeting

ESCRS

NEWS

FOURTH MARKETING CONTEST LAUNCHED The ESCRS Practice Management and Development Committee has launched its fourth annual Marketing Competition. The winner will be announced during the Practice Management and Development Programme at the XXXV Congress of the ESCRS in Lisbon, Portugal on Monday, 9 October. “The competition is an opportunity for ESCRS members to make a contribution to the Practice Management and Development Programme,” said Dr Paul Rosen, chair of the Committee. “The competition enables them to demonstrate what they have achieved with their entrepreneurial skills and show colleagues what they may be able to do in their own businesses,” he added. The judges are looking for a marketing campaign which helps to create awareness about the practice/clinic, and results in an increase in enquiries and new patients that translates into additional revenue. Dr Rahil Chaudhary of Eye7 Hospitals in New Delhi, India won the 2016 competition with the marketing campaign ‘Big LASIK Day, in honour of the hospital’s 25th anniversary’.

9 – 11 February 2018 Belgrade, Serbia

www.escrs.org

The deadline for submission is: Monday, 21 August. Full details can be found at: www.escrs.org

ONLINE MUSEUM FEATURES GREAT INNOVATORS The ESCRS has an online museum which shows historic videos from some of the great innovators in ophthalmology. The videos, which are submitted by ophthalmologists, are studied, verified and curated by Dr Richard Packard and Prof Andrzej Grzybowski, and date back to the 1930s. They are featured on the ESCRS Player at: player.escrs.org/category/ online-muesum

By viewing these videos, ophthalmologists can gain an insight into the rich history of the profession, learning from those who have gone before. The museum includes the first LASIK procedure in 1990 by Prof Ioannis Pallikaris and a video of a logbook from 1949 showing a summary of Sir Harold Ridley’s operations. Videos should be submitted to: museum@escrs.org

EUROTIMES | JUNE 2017

BOOK REVIEWS

QUESTIONS AND ANSWERS

BOOK

REVIEWS

HANDBOOK IS SHORT AND SWEET Glaucoma – the title says it all. Short and sweet. Edited by C.E. Traverso, I. Stalmans, F. Topouzis and L. Bagnasco and published by Karger, Glaucoma is the 8th volume in the European School for Advanced Studies PUBLICATION in Ophthalmology GLAUCOMA (ESASO) Course Series. EDITORS The ESASO Course C.E. TRAVERSO Series books are I. STALMANS introductor y-style F. TOPOUZIS texts that are based L. BAGNASCO on interactive lectures PUBLISHED BY KARGER given on each broad topic in ophthalmology. This 125-page handbook is a collection of the most important facts required to diagnose and treat patients with glaucoma. With chapter titles such as 'Visual Field Examination in Glaucoma: Detection and Progression of Disease' and 'Laser Treatment in Glaucoma', one need not expect to read the most arcane details and most recent experimental findings.

Instead, what one can expect after having read this book is to be well-versed in everything one absolutely needs to know. What I found most useful as a nonglaucoma specialist was the very clear tables outlining landmark studies like the the Ocular Hypertension Treatment Study (OHTS); overviews of the precise intraocular pressure decrease that can be expected from each of the available topical medications; and therapeutical algorithms for glaucoma treatment, from first-choice monotherapy to surgical solutions. The information on laser treatments was particularly illuminating. Glaucoma is intended for medical students who are considering a career in ophthalmology and would like to impress their supervisors during an ophthalmology rotation; residents who need to brush up on their knowledge and skills before participating in glaucoma clinics, assisting during glaucoma surgery or taking an exam; and new glaucoma fellows who want to make sure they have solid fundamentals before diving into their training. This book series can be used as a refresher for those who have internalised the AAO series and would like to be reminded of the critical points.

VIDEOS PROVIDE A GREAT LEARNING TOOL Observation is a great way to learn, and since we stay trainees forever, videos are the next best thing. Gonioscopy: A Video-Assisted Skill Transfer Approach (Jaypee) comprises an interactive, 45-minute DVD-ROM containing 137 videos and a slim book which catalogues the videos and describes each one in a short paragraph. Of the 137 videos, 111 are detailed gonioscopic examinations. The remaining 26 are self-assessment video quizzes. The videos are conveniently grouped into five categories: 1. Developmental Anomalies, such as posterior embryotoxic; 2. Open-Angle Glaucoma, including videos of 'normal' examinations in primary open-angle glaucoma and less common occurrences such as pigment clumps in uveitis; 3. Angle Closure Glaucoma, which shows viewers precisely how to open the angle in a primary angle-closure patient; 4. Secondary Glaucoma, with more than 30 videos such as cyclodialysis and hyperoleon; and 5. Intraoperative Techniques, such as goniosynechiolysis. This video set is meant for residents, glaucoma fellows and general ophthalmologists who wish they had paid more attention during their residency.

Curbside Consultation in Glaucoma: Second Edition (Slack Incorporated), edited by Steven J. Gedde, is a highly practical, 230-page review text that reads like a question-and-answer session between a mentor and trainee, or between an examiner and a student. But it also answers the questions that we ask ourselves every day in the clinic. These questions range from the very basic and crucial - ‘How Should I Clinically Examine the Optic Nerve?’ and ‘Which Glaucoma Medications Can Be Safely Used During Pregnancy?’, to the more complex – ‘How Can I Improve Patient Adherence?’, or even philosophical – ‘How Does Glaucoma Affect Quality of Life? Why Does it Matter?’. I personally enjoy this style of review. It reads as though someone is telling me something with the particular goal of making sure I remember it. This is something that lists and tables cannot do. Our minds are wired to read and remember prose. This book is ideal for relaxed exam preparation.

NEW MATERIALS Nano-Biomaterials of Ophthalmic Drug Delivery (Springer), by Y. Pathak, V. Sutariya and A. Hirani is a 600-page tome that covers “the various aspects of nano biomaterials used in ophthalmic drug delivery, including their characterization, interactions with the ophthalmic system and applications in treatments of ophthalmic disorders”. What this means is that the recent growth in polymer sciences has resulted in the development of new materials that might be useful as drug delivery carriers or implantable devices. The book is highly detailed and is not necessarily intended for clinical use. Although some chapters are readable for the general ophthalmologist, most, such as ‘Physiochemical Requirements of Polymers and Polymer-Based Nanomaterial for Ophthalmic Drug Delivery’, are written for the highly-specialised reader. Some of it is beautifully written: “At the interface between nanomaterials and biological systems, the organic and synthetic worlds merge…” This book is intended for researchers, academics and pharmaceutical scientists who have a great deal of patience.

DR LEIGH SPIELBERG Books Editor If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | JUNE 2017

CALENDAR

JULY

MaculArt Meeting

2–4 July Paris, France www.maculart-meeting.com

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AUGUST

ASRS Annual Meeting 2017

LAST CALL

JUNE 2017

30th APACRS Annual Meeting

1–3 June Hangzhou, China www.apacrs2017.org

SOE 2017

10–13 June Barcelona, Spain www.soe2017.org

World Glaucoma Congress 2017

28 June–1 July Helsinki, Finland www.worldglaucoma.org

17th ESASO Retina Academy

29 June–1 July Berlin, Germany www.esaso.org/17th-esaso-retina-academy-2017

11–15 August Boston, USA www.asrs.org/ annual-meeting

EPOS 2017 43rd Annual Meeting of The European Paediatric Ophthalmology Society 31 August–2 September Oxford, UK www.epos-focus.org

SEPTEMBER

17th EURETINA Congress 7–10 September Barcelona, Spain www.euretina.org

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 11–15 September Vienna, Austria www.echography.com

EVER – European Association for Vision and Eye Research Congress 2017 27–30 September Nice, France www.ever.be

DOG 2017

28 September–1 October Berlin, Germany www.dog.org

OCTOBER

8th EuCornea Congress

6–7 October Lisbon, Portugal www.eucornea.org

South East European Congress of Ophthalmology 6–8 October Sarajevo, Bosnia and Herzegovina www.ophthalmologia2017.com

XXXV Congress of the ESCRS 7–11 October Lisbon, Portugal www.escrs.org

3rd European Congress on Ophthalmic Imaging: From Theory to Current Practice 13 October Paris, France http://www.vuexplorer.fr

NOVEMBER

AAO 2017

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

DECEMBER

WCPOS IV 4th World Congress of Paediatric Ophthalmology and Strabismus 1–3 December Hyderabad, India wspos.org/india-2017

Lisbon, host city of the XXXV Congress of the ESCRS and the 8th EuCornea Congress, which will both be held in October

EUROTIMES | JUNE 2017

Serbia’s capital Belgrade, which will host the 22nd ESCRS Winter Meeting in February 2018

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

2018

JANUARY

9th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery 10–12 January Vienna, Austria http://www.ophthalmictrainings.com/ workshops

SEPTEMBER

FEBRUARY

NEW 22nd ESCRS Winter Meeting 9–11 February Belgrade, Serbia www.escrs.org

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DECEMBER

NEW 11th Asia-Pacific Vitreo-Retina Society Congress (APVRS)

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

Frankfurt Retina Meeting 2018

JUNE

WOC 2018

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

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

XXXVI Congress of the ESCRS

MARCH

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

9th EuCornea Congress

SEPTEMBER

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

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