EuroTimes Vol. 22 - Issue 7/8

SPECIAL FOCUS YOUNG OPHTHALMOLOGISTS CORNEA

DMEK: ADVANCES IN SURGICAL TECHNIQUE OVER THE LAST DECADE

RETINA

ROBOTIC ASSISTANCE BRINGING INCREASED PRECISION TO VR SURGERY Jul/Aug 2017 | Vol 22 Issue 7/8

TEACHING MOMENTS

// PRECISION

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Belong to something unique. Join us.

P.23

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

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.

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS YOUNG OPHTHALMOLOGISTS 4 How to get the

maximum benefit out of your training 6 A bright future: Dr Meena Arunakirinathan’s shortlisted essay for the John Henahan Writing Prize 8 Putting your skills to work – some helpful advice on finding a job 10 Serving patients: Dr Clare Quigley’s shortlisted essay for the John Henahan Writing Prize 11 Units of love: Dr Pallavi Singh’s shortlisted essay for the John Henahan Writing Prize

FEATURES CATARACT & REFRACTIVE 17 Binkhorst Medal Lecture:

Lessons learned from performing cataract surgery in high-risk eyes 18 Everything you ever wanted to know about brown cataract phacoemulsification – Part 1 20 ‘Ophthalmology stands on the brink of exciting innovation’ 21 Presbyopia eye drops – drug may restore natural accommodation 22 Clinical trial comparing two single-piece, aspheric, acrylic IOLs

23 ‘Toric trifocal IOLs provide lasting emmetropia and good near vision in many patients’ 24 Meta-analysis shows safety and efficacy advantages of FLACS compared to conventional cataract surgery 25 ‘New lens is a novel concept for an accommodating IOL’ 26 Contralateral eye comparison measures SMILE against topography-guided LASIK 28 Ask the experts: Phacoemulsification in high hyperopes 29 JCRS Highlights

CORNEA 30 ‘FS-DSEK provides better

refractive outcomes than PK but yields poorer visual outcomes’ 32 Corneal thickness – Scheimpflug and OCT measures not interchangeable after accelerated CXL 33 DMEK: Advances in surgical technique over the last decade

www.eurotimes.org

GLAUCOMA 41 PACG – identifying and

taking care of patients at an earlier stage 42 Combining multiple procedures that reduce IOP in patients with POAG

PAEDIATRIC OPHTHALMOLOGY 44 Myopic anisometropia: SMILE yields positive initial outcomes

GLOBAL OPHTHALMOLOGY 46 Cataract train reaching

patients in remote areas

REGULARS 50 EBO Diploma Update 52 Book Reviews 55 Industry News 56 ESCRS News 57 Exploring Barcelona 59 Calendar

RETINA 34 Robotic assistance

bringing increased precision to vitreoretinal surgery 39 Reliable production of photoreceptors for transplantation

Included with this issue...

MedEdicus supplement Cover illustration courtesy of Eoin Coveney

EUROTIMES | JULY/AUGUST 2017

2

EDITORIAL A WORD FROM OLIVER FINDL MD

RIGHT ENVIRONMENT The ESCRS is dedicated to creating a supportive environment for young ophthalmologists in training

A

s Chairperson of the Young Ophthalmologists ESCRS EDUCATION Committee, I am delighted that EuroTimes has Until relatively recently, all of our teaching and learning was done decided to dedicate this edition to doctors in training. in lecture halls, in wetlabs, in operating theatres and through The ESCRS has made major strides in the last textbooks. Now, thanks to the phenomenal development of the 10 years in supporting YOs and has dedicated Internet, we have so many new learning tools at our disposal. significant resources to helping them. One thing The new ESCRS Player now has a special that I have learned from working with the section featuring videos from previous YO Committee is that it is important that YO Programmes. The best videos have We can train them and mentor we talk to our trainee members about their been selected and tagged with keywords them to the best of our individual needs. which makes them easy to navigate. These It is not our function to tell them how abilities, but... as trainers we videos can be viewed at: player.escrs.org/ they can become good or even great category/young-ophthalmologists also need to create the best ophthalmologists. We can train them and YOs will also benefit from studying the environment for trainees who mentor them to the best of our abilities, but Video of the Month and the EuroTimes Eye as my colleague Sorcha Ni Dhubhghaill points want to learn surgery Contact video interviews with key opinion out in this edition, as trainers we also need to leaders, which are also available on the create the best environment for trainees who ESCRS Player. want to learn surgery.

I would also direct trainees to our excellent ESCRS Education Personal interaction is very important and we must also see the Portal which is a free online learning platform for ESCRS person behind the doctor. For that reason, I would urge all our YO members at: education.escrs.org readers of EuroTimes to attend the XXXV Congress of the ESCRS Hopefully, I will see many of our YOs in Lisbon when we can in Lisbon, Portugal in October. discuss these exciting initiatives in more detail. In the meantime, I realise that financial pressures may make it difficult for happy learning! trainees to attend our annual congresses, and for that reason we are awarding a number of bursaries to ESCRS trainee members who have a free paper or poster accepted for presentation at the congress. Recipients will receive complimentary meeting registration and €1,000 to cover their travel and hotel expenses.

Bursary recipients will be selected from among the highest scoring accepted free papers and posters.

We are also awarding a special €1,000 bursary for the winner of this year’s John Henahan Writing Prize.

The topic for the essay is ‘How does commercial interest affect Dr Oliver Findl is Secretary of the ESCRS, my career?’, a subject which generated a lot of interest from our Chairperson of the ESCRS Young Ophthalmologists trainees. We have shortlisted five of the outstanding essays and Committee, Chief of the Department of Ophthalmology in Hanusch these are being published in this issue of EuroTimes and also in Hospital, and Founder of the Vienna Institute for Research in our September issue. The winner of the prize will be announced Ocular Surgery (VIROS), both in Vienna, Austria during the Video Awards ceremony in Lisbon.

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 | JULY/AUGUST 2017

ar FREE 3 ye ip sh member ees for train

Reach the peak.

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Belong to something impressive. Join us.

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

Illustration by Eoin Coveney

4

TEACHING MOMENTS How can you get the most out of your training?

Dr Sorcha Ni Dhubhghaill reports

‘W

e’re pretty much just treading water here’ you can hear yourself think, as your eyes dart over a surgical list that’s more overbooked

EUROTIMES | JULY/AUGUST 2017

than the bathroom stalls at a music festival.

Patients are trickling through at a glacial pace, and the day ward is a nightmare.

You were behind schedule pretty much from the start, and it’s only been getting worse ever since. While it’s not spoken about, you can feel the pressure mounting

in the operating theatre. Nobody wants to run into overtime.

People have other appointments, things to do, or perhaps even plans for tonight.

Your phone tells you it’s nice and sunny out, but you’ll have to take its word for it.

You feel an inkling to ask a question,

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS but you quickly dismiss it as a bad plan.

The message to you as a trainee in ophthalmology is clear: ‘Keep the list moving, write the notes, finish the discharge letters, and let’s all get home on time.’

This is not a ‘teaching moment’, and to ask the whole team to grind to a halt just so that you can learn some steps does not seem like a reasonable request.

The best days for surgical training are when all cases are straightforward, there's been absolutely no overbooking and no urgent meetings for your supervisor to get to on time. In other words, days that are in the best of cases exceedingly rare, and for many of us completely fictional.

ASSERTIVENESS So what do you do? Do you beat yourself up for not pressing the matter? Perhaps you should pass by the bookstore for the latest tome on assertiveness? Perhaps I’m projecting, but I've had my fair share of days like these. They were some of my worst days as a surgical trainee and I would often blame myself for not stepping up.

The point is that your relationship with your teacher is more valuable than any question you might have in that moment Now, I’m glad I didn’t. Yes, we all want to get from here to there in as little time as possible. But making a stand and demanding to be taught is not the way to do that.

Your supervisor has not forgotten that you want to be a surgeon. Like you, they are scrambling to make the clinic run as smoothly as possible. And even when it does run smoothly, there may be genuine reasons why this is not the ideal moment for teaching.

The point is that your relationship with your teacher is more valuable than any question you might have in that moment. Trying to force the issue can create a negative atmosphere in the operating room.

When pressure rises, keeping your

It’s a competitive environment from the very start. Sure, you have the degree and the grades and you really want to become a surgeon. But so does everybody else head down and soldiering on is always going to be your best bet.

COMMITMENT So, how can I show my trainer that I am committed to surgery?

In most of the basic ophthalmology training schemes in Europe, real hands-on surgical training is more of a ‘privilege’ than a ‘right’. Consequently, you can’t always expect to get loads of it. In many schemes, the number of candidates for surgical training outnumber the available trainee positions, and surgeons can be very selective in whom they wish to train.

It’s a competitive environment from the very start. Sure, you have the degree and the grades and you really want to become a surgeon. But so does everybody else. The chances are that a surgeon looking for new trainees will be looking elsewhere for things that set you apart from the other candidates. So take courses and attend wetlabs. In other words, invest in yourself.

Wetlab training is the first concrete step to surgery. Attending the wetlabs at national and international conferences can be quite expensive, but not only will it kick-start your manual skills, it can also bulk up your CV and provide certifications to show your commitment.

Use your own time to read up on as many aspects of surgery as you can. The ESCRS provides online didactic courses that you can take from your own home.

I have mine running in the background when I cook and that works well for me.

TAKING THE NEXT STEP How can I create more ‘teaching moments’?

You have done your preparation, you have followed the courses, and watched the videos. How can you take the next step to actual surgery?

Take the time to talk to your trainer at the beginning of your rotation with them. Be clear about what you want to learn and how you hope to learn it. Be honest about the experience you have and what you can do competently.

See if there is a particular part of the week where you can have time reserved just for you to learn. Small scraps of surgery here and there will never build mastery. The best-case scenario is to organise a weekly moment for training, even if they are only very small steps. This

creates a very relaxed atmosphere and will help ease the natural anxiety and any associated hand tremors.

How do you make the most of your operating theatre time?

Know your microscope, instruments and phaco machine backwards and forwards and have everything set up before you scrub in.

Set your chair up to a comfortable height.

A mentor of mine once told me that they could tell a bad trainee by the amount of fidgeting and manipulation of the microscope they needed after scrubbing in.

SKILL LEVEL When you are given your chance, prepare a case that matches your skill level. Select a calm and co-operative patient with normal eyelids who dilates well. Think about what type of anaesthesia would be best. It can be stressful to jump straight into topical anaesthesia, so consider a block with a longer-acting agent.

Prepare a mental checklist of all of the steps of the surgery you are going to do.

Most trainers teach the last steps of the surgery first and then build on that. It’s worth focusing on a single manoeuvre and repeat it over and over rather than trying to attack a full case.

Every trainee should keep records of their cases, refractive results and complications. Recording videos of your complications as well as your successes can be invaluable feedback.

Surgical training is not a commitment that should be taken lightly. As a trainer, I not only offer my own time – and time in the surgical theatre – for the benefit of the trainee. There is also an implicit commitment that makes me responsible for the complications of the people I train, even after they have completed their training.

On the other hand, seeing a trainee complete their first case can be one of the more rewarding experiences in hospital medicine.

Sorcha Ni Dhubhghaill is an anterior segment surgeon and guest lecturer at Antwerp University Hospital in Belgium.

Dr Ni Dhubhghaill won the John Henahan Writing Prize at the XXX Congress of the ESCRS in Milan, Italy nidhubhs@gmail.com EUROTIMES | JULY/AUGUST 2017

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

A BRIGHT FUTURE In her shortlisted essay for the 2017 John Henahan Writing Prize, Dr Meena Arunakirinathan looks at the relationship between industry, clinical practice and academics

T

hree years as a young ophthalmologist in training, five years having sworn the Hippocratic Oath during my medical graduation, and only of late have I fully considered how commercial interest may affect my career.

As medical students we relished sponsored lunches, eyes glazed over listening to sales pitches. As a freshly graduated doctor, I watched slideshows emblazoned with names of industry greats, and attended continuing medical education seminars and lavish dinners hosted by industry representatives who always picked up the hefty bill.

I began to view these few interactions with them as the secret perks of being a medic – no one in the public seemed to know and no one seemed to judge.

Whilst organising a course for doctors I struggled to remain cost neutral. Having extended an invitation to a well-known company, I secured sponsorship. To my relief, the attendees were spoiled with lunch and stalls laden with goodies. I struggled to comprehend why they sponsored us. We had no power of influence, no professional opinion to solicit and no authority over the formulary. Was there simply a surplus of cash to throw around or were my colleagues and I a vehicle for something bigger? This was the day commercial interests began to affect my career.

What other doors could commercial interests open? I discovered a myriad of industry-funded fellowships, grants and wetlab courses, their credibility affirmed by involving prominent ophthalmologists whom I had admired from afar in conferences, videos and textbooks.

PROPHECIES Industry-funded bursaries facilitated my training, as I would otherwise struggle bearing the financial brunt of many other courses. I practised scleral flaps and releasable sutures in specimens and grooved endlessly in model eyes spilling egg yolk vitreous under the watchful eye of the attendings. Contrary to my preconceptions, I was not bombarded with merchandise and prophecies of emerging therapeutics and miracle devices. Instead, I was provided with models to practise my surgical skills. Representative of the instruments I used in the operating theatre, EUROTIMES | JULY/AUGUST 2017

As medical students we relished sponsored lunches, eyes glazed over listening to sales pitches handling these devices allowed me to build muscle memory and develop dexterity.

My research moved from basic sciences to minimally invasive glaucoma surgical devices, for which I won a prize. The awarding body, a leading academic institution, funded me to present my research on an international platform.

Funds were derived from a company, albeit one with no interest in my research.

I fretted about affiliating myself with their company, and paying lip service to their sales pitch. However, I was wrong - there was no expectation of my involvement in promotional aspects, only the caveat that I should declare this.

I stopped viewing commercial interests through rose-tinted glasses when my proposal for an educational article in a leading medical journal was refused due to my supervisor’s competing interests.

Despite our best appeals, highlighting that ties to industry were not driven by financial gain nor malign motives, we were rejected.

My colleagues trivialised the need for declarations and even regarded this as a form of McCarthyism. I myself felt dejected. This response felt like prohibition. I wanted to cut my own ties with industry at this stage of my career as I needed to publish not perish. I reviewed the mounting evidence in high-impact journals of the influence of competing interests on the conclusions reported.

I began to notice negative results published in lesser journals and author declarations written in the finest of print as if their admission could somehow be overlooked. Bias, like a subtle veil, clouds judgement. So are clinicians truly immune?

My primary interests were the best interests of my patients. At this point in my career I had no care for secondary interests and shunned any further collaboration industry. I could not be tempted by what I now regarded as forbidden fruit.

Through professional networks I was granted an interview with an industry physician. He shed light on strengthening ties with industry that helped bring plans for new drugs and devices to fruition in

‘innovation hubs’ and investigator-initiated studies. He reminded me of the bias working with certain academic institutions conferred irrespective of industry affiliations, and highlighted how frequently industry could be misconstrued as ‘big bad pharma’ by society and the media.

Delving into the world of an industry physician helped me understand my own: generous donations from industry topped up our drug supplies, provided samples for the indigent and funded training for doctors and nurses – vital resources that would otherwise have been a struggle to finance within the budget of the National Health Service.

Brexit’s aftermath poses a risk of delayed access to novel therapeutics due to changes in licensing regimes. A strengthened union with industry can surely be one option to fend these challenges off? Day in, day out we work with industry perhaps more than any other specialty, as evidenced by the novel therapeutics and devices in use around us.

The real conflict of interest rests within my own my mind. Can I recognise the risk of influence and instead harness the opportunities industry provides for the greater good of my patients? Only time will tell as I gain experience.

At the brink of a career in ophthalmology, I hope to see a future where industry, academic and clinical practice work synergistically, with a mutual understanding of their respective motivations maintaining transparency at its heart. Where once there were muddied waters they begin to run clear, and as aspiring leaders, clinicians and researchers, we can forge stronger collaborative partnerships.

Dr Meena Arunakirinathan is a Resident in her third year of ophthalmic training at Moorfields Eye Hospital, London, UK

JOHN HENAHAN

PRIZE 2017

LISBON2017 7–11 OCTOBER

XXXV Congress of the ESCRS Young Ophthalmologists Programme Starting Phaco (inc. YO videos)

SATURDAY 08:30–16:00

Refractive Surgery Didactic Course SATURDAY 08:30–17:30

Instructional Course 01 Basic microsurgical suturing techniques

SATURDAY 08:30–09:30

Instructional Course 09

Instructional Course 05

Toric IOLs: planning for success & dealing with failure SATURDAY 10:30–12:30

How to improve your refractive & cataract surgery outcome by skilful interpretation of corneal imaging SATURDAY 10:30–12:30

Instructional Course 10

Instructional Course 11

Big bubble, no trouble: a step-by-step approach to successful DALK with the big bubble technique SATURDAY 10:30–12:30

Therapeutic refractive surgery...live!

SATURDAY 14:30–16:30

Workshop on Visual Optics SUNDAY 08:00–17:45

YO Session

Instructional Course 16 LASIK: update with surgical tips in primary & secondary cases – basic comparison with surface ablation technique

SATURDAY 14:30–16:30

The mistakes we make in cataract surgery SUNDAY 16:00–18:00

Instructional Course 105 Hit the target: basic concepts and guidance for proper IOL selection MONDAY 17:00–18:00

Instructional Course 107 Acanthamoeba keratitis: a case-based approach MONDAY 17:00–18:00

Instructional Course 113 Techniques & devices for surgical reconstruction of traumatic & developmental iris defects TUESDAY 08:00–10:00

8

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

FINDING A JOB Considering several options might increase the likelihood that you’ll find a good fit. Dr Leigh Spielberg reports

S

o, you’ve completed the first half of your residency training and you’re starting to think about the next step in your career: finding a job as an ophthalmologist so you can put your new skills to work after graduation. But where to begin?

As someone who recently navigated these waters, my advice would be to start broad. Try to consider as many options as possible before deciding that you’ll only accept offers from, for example, small private practices in a large city. After all, there are at least a dozen practice models, ranging from a large, well-established, university-based tertiary referral centre to your own new solo practice. So considering several options might increase the likelihood that you’ll find a good fit.

Most national ophthalmology associations have a section of their website dedicated to matching available positions with people who can fill them. This is probably the best place to start, as it’s likely to be the most comprehensive source of information.

However, I’ve noticed that many local hospitals and smaller practices do not participate in this very convenient system.

The next step might be to speak with your current mentor(s). Training centres EUROTIMES | JULY/AUGUST 2017

like to see their ex-trainees well placed after graduation, as it reflects well upon them. Directors of residency and fellowship programmes are usually well-connected people who know the landscape well. They receive phone calls and emails from doctors in the area who are looking for new young ophthalmologists to join them in practice.

Speak with them as early as possible.

I found it useful to speak with recent graduates. They were recently in the same position as you are now, so they understand what you’re going through.

Furthermore, because most graduates interview at several practices, they are likely to know what is on offer regarding organisation, salary and surgical possibilities. My experience was that most early-career ophthalmologists are happy to speak at length to give advice. This can be done at conferences or via phone or email.

An often-overlooked source of information are the medical company representatives. These 'reps' visit all the regional hospitals and practices, giving them incredible inside information. They know which doctors might retire early, which practices are considering expansion and even which ones might be struggling, financially or otherwise. Many are willing to serve as a liaison for potential matches.

Feel free to contact these reps to ask

whether they have useful information.

Many will even be happy to introduce you to practices looking for new colleagues.

A last option is to check the websites of hospitals themselves. These usually list available positions in ophthalmology, but often seem to lack crucial information, as they might be written by a human resource specialist rather than by an ophthalmologist.

WHICH SETTING? Once you’ve seen and heard what is available in your selected region, it’s time to consider the various settings. Each type has its pros and cons, and some might have a lasting effect on your career. A university department can offer young graduates visibility and a certain degree of prestige, but may be less attractive for someone uninterested in doing research or working within a rather hierarchical structure.

A large group in a community hospital will allow for subspecialisation as well as the opportunity to refer patients to colleagues within the group rather than referring them elsewhere.

Joining a private practice might offer a great deal of autonomy, but might also come with a lot of administrative responsibility. The same can be said of taking over the practice of a retiring solo

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS practitioner. The ultimate test of nerves (and business acumen) is starting one’s own new practice, and this is not for the faint of heart.

An interesting option for those who remain undecided is to spend a year or so filling in for ophthalmologists who are absent due to, for example, pregnancy.

These positions usually last for several months and are usually offered with no strings attached.

CONTINUING EDUCATION A very important factor to consider is whether you will be given an opportunity to continue your development as a physician and especially as a surgeon. This need is particularly acute for those who were fellowship-trained. A year or two of fellowship is simply the first phase of development, but the most challenging situation has yet to follow.

For your own growth, it’s worthwhile to consider working with a more experienced subspecialist. If this possibility is not available, is there someone working nearby to whom you can refer more difficult cases or at least call for advice?

I personally sought, and found, a situation in which I could be assured of frequent interaction with an experienced surgeon on whom I could count to continue my training, and who I could assist (or could assist me) with more complicated cases.

It is also good to know whether surgery will be a possibility. Beware: many practices would love to have a young graduate to run the office hours while the senior partners are in the operating room.

This is fine for some graduates but not for those with surgical ambitions.

Most national ophthalmology associations have a section of their website dedicated to matching available positions with people who can fill them BENEFITS AND RESPONSIBILITIES Ophthalmologists tend to earn reasonably well in most countries. Nevertheless, expectations vary, and when the reality does not match up with expectations, frustration can ensue. Don’t be afraid to ask for detailed information early in the process.

The same can be said of vacation time.

Time allowed for vacation is a factor that some early-career doctors find very important, while others tend to ignore it.

How much is standard in your country?

How much is enough for you to not miss out on all that life has to offer?

Vacation allowances vary to an almost unbelievable degree. Some groups are hesitant to allow more than just a few weeks per year. These are often rapidly growing partnerships with long patient waiting lists or pressure from hospital administrators to deliver financially. On the other hand, some groups might mandate a large amount of ‘off time’ due to financial constraints from insurance companies, which effectively cap the revenue stream, meaning that any ‘extra’ work done above this constraint effectively goes unpaid.

Try to predict your situation a few years down the road: if you (will) have schoolaged children, your vacation times will be dictated by school vacations rather than

by your own preferences. Either way, it’s important to sort out the expectations prior to signing the contract, so that later misunderstandings can be avoided.

A crucial bit of information is how the on-call schedule is organised.

Ophthalmology doesn’t have many serious emergencies, but it’s important to know whether you’ll be on call every other day or just a few times per month. Is the call schedule organised within the group? Is there a local network? Can an operating room be accessed on short notice in case of trauma?

KEEPING AN OPEN MIND It’s important to keep an open mind regarding the setting in which you want to work. It’s advisable to try to interview widely, so you have a good grasp of what’s available and what the ‘norms’ are in your area. Furthermore, the act of interviewing, even in places you’re not likely to work, gives you some practice, even just to calm your nerves in preparation for that one practice you absolutely want to join.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium leigh.spielberg@gmail.com

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

PROGRAMME OUTLINE 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 go to

www.euretina.org/yours

YOURS Case Discussion with Audience Organiser: M. Singh USA 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

EUROTIMES | JULY/AUGUST 2017

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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

SERVING PATIENTS

I

In her shortlisted essay for the 2017 John Henahan Writing Prize, Dr Clare Quigley says the best interests of patients must be an ophthalmologist’s first priority

have some things to disclose.

On a cold wet November morning, when my rain gear was not sufficient to prevent me from getting saturated on my cycle to work, I arrived to the ophthalmology department shortly before morning teaching was due to start.

After peeling off my dripping outerwear, I trudged to the orthoptist's room, where the consultant-delivered lecture would soon begin. Entering the room, the smell of freshly roasted coffee beans banished my disgruntlement at the wintry morning.

Coffee, tea, orange juice, and a tray of fresh pastries, granola, fruit and yogurt were arranged on display. Less immediately drawing my gaze, next to the lavish breakfast there were product information booklets for glaucoma drops and a bouquet of pharmaceutical company pens on offer.

I was greeted by a smiling industry representative, who invited me to help myself to whatever took my fancy. Filling a cardboard plate, I settled down for teaching with coffee in hand. Colleagues arriving each helped themselves to the generous spread. Following this hearty breakfast, we were happily awake and alert for teaching, and afterwards in clinic we were likely friendlier and more attentive to our patients than our unfed selves would have been.

APPROACHED My second disclosure: I recently arrived to theatre for my usual afternoon session.

I had picked out the cataract patient from the list who would be suitable for me, the most junior team member. As I was waiting expectantly for them to be portered in, a friendly surgical devices company representative approached me. She asked me my name, where I had worked previously, and spoke about a recently developed innovative intraocular lens they were newly offering, explaining some advantages of the lens. Would I like to try a sample? I was flattered by the attention and I duly chose one of her lenses. I found it injected nicely, just as she had set it would.

Disclosures aside, it is an intriguing question – how does commercial interest affect my career? ‘Career’ is a particular term, which does not bring to mind patient care specifically, but rather calls up ideas of personal goals of success, financial and otherwise. One’s career is an individual EUROTIMES | JULY/AUGUST 2017

Shifting emphasis away from career and towards patient beneficence has a significant effect journey, which is planned for, with particular trajectories aimed at.

For our career dreams we pour endless hours of toil into research, writing papers and preparing presentations. We travel to conferences, we pay for surgical courses, we limit our annual leave, we sacrifice time that could be spent with loved ones, family, friends. Commercial interests I imagine to have a positive impact on any given career in ophthalmology.

A commercial interest may lead to sponsorship to travel for an important meeting, or to attend an otherwise prohibitively expensive training course.

Industry may sponsor a study, allowing for a greater sample size, a superior standard of research, and a higher impact factor target journal, than what would be possible under a teaching hospital's standard budget.

SHIFTING EMPHASIS But what if the question was slightly altered? What if a more vocational term was used? ‘How does commercial interest affect my patient care?’ Shifting emphasis away from career and towards patient beneficence has a significant effect.

As medical professionals, we have ready access to best practice guidelines, derived from systematic reviews of highgrade evidence. We can map out our patients’ care, the best drop, the most appropriate implant to choose, based on this knowledge at our fingertips, and also on our patients’ individual characteristics and preferences.

However, if we have been generously looked after by a particular company, be that wined and dined, given a research grant, or sponsorship for an education course to run in our hospital, or perhaps funding to attend a particularly interesting meeting, then accompanying our gratitude and good feeling towards this company, bias surely creeps in.

Pharmaceutical companies and surgical device manufacturers contribute positively

to outcomes for patients, as they support research which ultimately improves eye care. We must, however, recall that the primary objective for these businesses is not the best interest of patients, but rather to generate profits for their shareholders.

Consider then, as ophthalmologists, our bottom line – we have a duty to do what is in our patients’ best interests.

This duty should not be affected by our relationship with industry, and any commercial interests we develop. We must also be cautious of zealous rejection of any association with industry.

Separation of clinicians from the cutting edge industry developments, where advances in the field of ophthalmology are driven forward, would be to the detriment of patient care overall.

Commercial interest will affect my career, I will be exposed to different industry forces, products will be marketed for prescription or implantation. As an ophthalmologist, I have a solid grounding point to return to for guidance – my duties as a professional.

Epstein and Hundert define professional behaviour as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.

I will therefore undertake to declare all my disclosures, and remember that my first priority must always be the best interests of my patients.

Dr Clare Quiqley is a Second-year Resident at Mater Misericordiae University Hospital in Dublin, Ireland

JOHN HENAHAN

PRIZE 2017

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

UNITS OF LOVE In her shortlisted essay for the 2017 John Henahan Writing Prize, Dr Pallavi Singh says commercial gain must be balanced with the joy of helping others

T

here are some things money can’t buy. For everything else, there is a bevy of credit cards to choose from!

Growing up in a middle class family in a developing country, like India, I can safely say that Indian children are taught to work hard, earn a degree and get a job at their earliest opportunity. Survival of the fittest plays out in its most severe form. And medicine is no exception.

The medical profession exacts its sacrifice in the form of the youth of budding doctors. So at the age of 25, while most of our peers are already working with enviable salaries, we still have a long way to go before the promised land of prosperity arrives. The average management professional earns more than the average doctor in India (http:// indianexpress.com/article/jobs/top-tenhighest-paying-jobs-in-india-4567207).

Not the best of incentives I’d say, definitely not at the cost of the sheer number of years and toil demanded.

When I started out as a resident at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, the apex institute of ophthalmology in India, I was on cloud nine. I knew I could serve needy people. It was, at the same time, a bonus to receive training that would enable me to succeed commercially.

During my first year of residency though, two things happened. The first was getting enamoured with the natural glamour that came with ophthalmology.

The prospect of high-end refractive surgeries and oculoplastic procedures, coupled with the promise of a lavish lifestyle, was lucrative enough. And why not, I reasoned with myself. After years of hard work and devotion, I summarily deserved to want the best for myself.

The second thing, also the sinister one, to happen to me was a gradual disenchantment with the emotion involved in treating patients. In the past few years, incidents of violence against doctors had risen in India. Almost every week, there was news about doctors being harassed and assaulted while performing their duty.

This, coupled with an ordinary income for the Indian doctor, paved way for my growing discontent. Hence, slowly but steadily, I felt that commercial interest was of paramount importance to me. Having

almost been burnt out, I continued my training, with a cold detachment.

Months passed by, and one day, in my second year of residency, an old man walked into my outpatient clinic with a little girl. He had no slippers on and his clothes were visibly old and torn. The little girl, about six or seven years old, was bilaterally blind, one eye was phthisical and the other had a choroidal coloboma with a fresh retinal detachment. On further enquiry, the man told me that they had come from more than 700 miles away.

SADDENED I was both awed and saddened at his persistence for his granddaughter’s treatment. Awed, quite obviously, saddened, because her prognosis was poor, and moreover, it was nearly impossible to get an early date for surgery due to the long waiting period.

Nevertheless, with some running around and help from our social worker, and a most solid stroke of luck, the little girl got admitted the very same day.

The next day, I assisted the surgery, which went off well, and just prayed for a good outcome. To my utter delight, when I went to the ward the following day, the child walked up to the examination room without any help.

She had gained some functional vision.

What was more heartening to see was the delight on the old man’s face. His eyes were brimming with tears of gratitude.

I was relieved, and even filled with a fleeting sense of purpose!

More months passed, and the memory faded, when one day in a hot and muggy summer, the same man with the little girl walked into my clinic again. At first, I could not recognise the pair, but the man pointed at me from a distance, and the child ran towards me, squealing ‘Didi!’ (sister) and hugged me. She handed me a beautiful handmade greeting card. I was taken aback for a second, but soon recollected who she was.

Her grandfather then walked up to me, a broad grin lighting up the wrinkles on his face, and satisfaction in his eyes. The girl was now completely self-reliant and was even attending school. I felt a surge of happiness and warmth that I had not felt in a long, long time and though I hate to admit it, in that moment I did have my epiphany.

...at the age of 25, while most of our peers are already working with enviable salaries, we still have a long way to go before the promised land of prosperity arrives GIVING JOY I realised that even though the hours were long, the work back-breaking, and the emoluments oft meagre, we as physicians were capable of giving joy at a very primal level, to both patients and ourselves, when things fell into place. And this joy was irreplaceable, and most definitely could not be bought.

Our profession, by its inherent nature, demands service above self, but also promises contentment and actualisation like no other profession or job can. So even though it is a necessity to secure oneself financially, it should not be done at the cost of helping others and being compassionate.

Hence, when it comes to making a call on the importance of commercial interest in our lives, I would just like to quote one of my favourite singers, Zoë Johnston.

“Treasure is measured in units of love.”

Dr Pallavi Singh is a Junior Resident at the Dr. R P Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

JOHN HENAHAN

PRIZE 2017 EUROTIMES | JULY/AUGUST 2017

11

LISBON2017 Main Symposia n

The Irregular Cornea

n

Changing Pharmaceutical Treatment Patterns in Cataract Surgery

n

Building a New Eye

n

Intrastromal Lenticule Extraction: To smile or to Cry?

n

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

Scientific Programme, Registration & Hotel Bookings

www.escrs.org

XXXV Congress of the ESCRS

7–11 OCTOBER

FIL – Feira Internacional de Lisboa, Portugal

Clinical Research Symposia n

When Surgery is Not Enough: New Drug Delivery Methods

n

The Pupil in Cataract and Refractive Surgery

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What Can We Learn from Patient-Reported Outcome Measures

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Corneal Measurements and Their Effect on Toric IOL Power Calculations

Highlights n

‘Best of the Best’ Review Session

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Poster Village

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Young Ophthalmologists Programme

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125 Instructional Courses

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64 Surgical Skills Courses

XXXV Congress of the ESCRS

7–11 October 2017

Saturday 7 October

Saturday 7 October

Saturday 7 October

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

The Oculentis Toolbox for Lens Surgery: LENTIS Mplus, LENTIS Comfort, FEMTIS & LENTIS Max

Pentacam® AXL and Corvis® ST: New Approaches for Combining Tomography with Biometry and Corneal Biomechanics

Ziemer Satellite Meeting

Boxed Lunch Included

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

Enhancing Outcomes in Cataract Surgery: The Future of Biometry & Premium IOLs Sponsored by

Boxed Lunch Included

Moderator: R. Ambrósio BRAZIL C. Roberts USA T. Kohnen GERMANY First study results and experiences with the Pentacam® AXL F. Hengerer GERMANY Pentacam® AXL for IOL power calculation – first results & impact of possible ocular surface diseases to quality of vision: pre-op vs post-op R. Ambrósio BRAZIL Integration of Scheimpflugbased corneal tomography and biomechanical assessments for enhancing ectasia detection P. Vinciguerra ITALY Detection of keratoconus and subclinical keratoconus with a new Corvis Biomechanical Index

Boxed Lunch Included

Moderator: T. Seiler SWITZERLAND Speakers: T. Seiler SWITZERLAND B. Malyugin RUSSIA J. Mehta SINGAPORE R. Menapace AUSTRIA T.G. Seiler USA B. Pajic SWITZERLAND Sponsored by

The Premium Ophthalmology Practice: Insights from PC-IOL Technologies and Business Management Moderator: F. Carones ITALY Supported by

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Avedro Satellite Meeting

New Strategies in the Treatment of Dry Eye Disease and Blepharitis

Sponsored by

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Iridex Satellite Meeting Sponsored by

Sunday 8 October

Sunday 8 October

Sunday 8 October

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

360 Degrees of Glaucoma Management: Novel Automated Gonioscopy and OCT/OCT Angiography

Simplified Management of the Cataract Patient

Topcon Satellite Meeting

Moderator: C. Traverso ITALY

Heidelberg Engineering Satellite Meeting

Boxed Lunch Included

Speakers: C. Traverso ITALY L. Pinto PORTUGAL F. Gomez COLOMBIA Sponsored by

Visionary Cataract & Refractive Techniques: Explore With Us Moderator: B. Malyugin RUSSIA

Boxed Lunch Included

Sponsored by

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HAAG - STREIT Satellite Meeting

Quality of Vision with MINI WELL Extended Depth of Focus IOL: What’s New? Moderator: G. Auffarth GERMANY

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Ellex Satellite Meeting Sponsored by

Alcon Satellite Meeting

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Optovue Satellite Meeting

Boxed Lunch Included

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Taking Vision Further with Innovative Refractive Solutions Sponsored by

Sunday 8 October

Evening Symposium 18.30

Alcon Satellite Meeting Sponsored by

Monday 9 October

Monday 9 October

Monday 9 October

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

Boxed Lunch Included

Interactive Session: Tips and Tricks to Improve Outcomes in Trifocal IOL Implantation Sponsored by

Alcon Satellite Meeting Sponsored by

Ellex Satellite Meeting Sponsored by

iolAMD Satellite Meeting Sponsored by

Boxed Lunch Included

CoEnzyme Q10: New Approach in the Treatment of Ocular Surface Damage and Glaucoma Moderator: L. Schmetterer AUSTRIA S. Ahmad UK CoEnzyme Q10 and mitochondrial function: role in ocular diseases P. Aragona ITALY Therapeutic benefits of CoQ10 and Cross-linked HA in the management of chronic dry eye & ulcers B. de Castillo SPAIN Preventive and therapeutic benefits of CoQ10 in surgery to restore the ocular surface health F. Cordeiro UK CoEnzyme Q10 in glaucoma: converging/emerging evidence for neuroprotective benefits Sponsored by the eye health company

Clinical Frontiers in Ocular Surface Disease and Glaucoma Moderator: B. Cochener FRANCE Inflammation in ocular surface disease: from diagnosis to treatment Optimizing control of intraocular pressure in glaucoma: what are the pitfalls?

Concurrent ocular surface disease and glaucoma: lessons from the clinic Sponsored by

Boxed Lunch Included

PhysIOL Satellite Meeting Moderator: F. Ribeiro PORTUGAL A. Abulafia ISRAEL Abulafia-Koch regression formula: how to improve the prediction of postoperative astigmatic patient outcomes?

K. Nistad NORWAY Refractive astigmatism outcomes with the AbulafiaKoch formula on 634 eyes B. Cochener FRANCE What are the technological features behind the new FineVisionHP? Z. Nagy HUNGARY Clinical outcomes and experience with the FineVisionHP Sponsored by

Perform Without Limits: Making Glaucoma Surgery Intuitive with the Kahook Dual Blade Sponsored by

Orbis Satellite Meeting Sponsored by

CATARACT & REFRACTIVE

LESSONS LEARNED Dr Boris Malyugin looks at his experience in performing cataract surgery in high-risk eyes, the theme of his Binkhorst Medal Lecture at the XXXV Congress of the ESCRS in Lisbon

I

am very grateful to the ESCRS for the honour of being invited to deliver the Binkhorst Medal Lecture. It is really a true privilege to be able to share some knowledge and experience in ophthalmic surgery which I have acquired over the years of my clinical practice.

in eyes undergoing cataract surgery.

Thanks to the work of the ESCRS on intracameral antibiotics for endophthalmitis prophylaxis led by the late Peter Barry, we are now moving more towards the use of intracameral medications in our procedures. Intracameral mydriatic agents help with enlarging the pupil and sustaining it at a large diameter throughout the surgery.

In our careers as surgeons That is the pharmacological we can help thousands and approach. However, it does not work sometimes tens of thousands of all the time. Thus, the other path is patients. But if you share your surgical. Dissecting synechiae and knowledge it can multiply the cutting through fibrotic tissue with number of people being helped scissors or other types of cutting even further. instruments release the pupil and The message I am hoping to allow it expand. convey in my lecture is that One can also consider using we definitely need to try to mechanical expansion devices innovate, learn and teach. It's such as iris hooks or pupil rings. good to have the knowledge, Although pupil expansion rings but it is better to also share it were already available when I first because we never stop learning. started in ophthalmology, they were I also think we can take some not so comfortable or easy to work Boris Malyugin, who will deliver the Binkhorst inspiration from Cornelius with and they sometimes caused Medal Lecture at the XXXV Congress of the ESCRS Binkhorst, who was a pioneer complications. I therefore worked in intraocular lenses (IOLs), on creating a new design of pupil suggesting the new principle of pupil fixation. He and my expansion ring, the Malyugin Ring, that is easier to inject and mentor Svyatoslav Fyodorov knew each other well. Actually, position within the eye than the earlier expansion rings and can be Prof Fyodorov further developed the ideas of Binkhorst, gently implanted and removed through micro-incision.

My innovations have provided a platform for further designing the pupil-fixated IOL called ‘Sputnik’ which was innovations with new capabilities. Different groups all over the very popular at a certain point in time, not only in Russia world try to replicate the huge success of the Malyugin Ring and but internationally. create newer ring designs. However, we are not standing still I was in training and I am still working in an institution with the Malyugin Ring either, and now the second generation that bears Prof Fyodorov’s name today. It comprises a system of the device (Malyugin Ring 2.0) is available, which is softer, of clinics throughout Russia employing about 5,000 people, gentler to the iris, and easier to implant and remove. including over 1,000 doctors. We also have manufacturing Over the years we have learned that the newest technology facilities for designing and producing surgical instruments. that is having distinct advantages might in turn have some This combination allows the combination of a high level drawbacks. Femtosecond laser-assisted cataract surgery of practice with extensive educational activities and (FLACS) is a good example of that. It has the advantage of scientific research. high precision in the creation of incisions and capsulorhexes, and lens fragmentation, however as a result of prostaglandins THE PROBLEM OF SMALL PUPILS released in response to the laser, in a certain number of cases there is pupil size reduction, necessitating the use of the pupil The main focus of my lecture will be dealing with the problems expansion devices. associated with small pupils in eyes undergoing cataract I consider that a philosophical issue. In the core of almost each surgery. This is quite a complex problem and it is not a purely and every innovation that drives us forward there are inherent geometrical issue. A small pupil is an indicator of underlying drawbacks and unsolved problems. That in turn becomes the basis pathologies within the eye, and is usually associated with for the new innovation spiral. systemic or local comorbidities including pseudoexfoliative As medical doctors, as surgeons, we have to innovate syndrome and glaucoma. and share in order to bring our best to the patient.

Small pupils can also result from trauma, inflammation, uveitis and so forth. Therefore, the surgeon is dealing with eyes having Boris Malyugin MD, PhD is Deputy Director General a variety of different clinical conditions. That, in turn, brings an (R&D, Edu) at the S. Fyodorov Eye Microsurgery increased risk of not only intraoperative but also postoperative State Institution in Moscow, Russia complications, such as bleeding and inflammation.

Recent advances have improved the situation for small pupils • Interview by Roibeard Ó hÉineacháin EUROTIMES | JULY/AUGUST 2017

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CATARACT & REFRACTIVE

BROWN CATARACT PHACOEMULSIFICATION Everything you ever wanted to know about brown cataract phacoemulsification – Part 1.

Dr Soosan Jacob reports rown cataracts can be associated with other ocular comorbidities in the form of loose zonules, low endothelial count, shallow anterior chamber, pseudoexfoliation and inadequate pupillary dilatation – all of which add on to difficulty in surgery as well as increase the likelihood of less than ideal outcomes.

Preoperative evaluation should therefore look specifically for these conditions. The leathery non-compliant nature of the brown cataract per se also increases difficulty in surgery, and therefore phacoemulsification of the hard brown cataract should be taken up only by experienced surgeons, and even then with clear acceptance of the fact that conversion to either extracapsular cataract extraction (ECCE) or small incision cataract surgery (SICS) may be required.

Patients who are not able to see well through the hard cataract may benefit more with immersion than with optical biometry. Specular microscopy should be done if possible. Surgery may be preferred under peribulbar anaesthesia rather than topical in order to more easily handle a longer surgical time and the possible eventuality of having to convert to ECCE/ SICS or manage a posterior capsular rent or nucleus drop.

INCISION: Incision architecture should be ideal.

Too long incisions cause oar locking, compression of phaco sleeve while manoeuvring and can also cause corneal burns. Too short incisions may lead to repeated iris prolapse and a small pupil, and therefore should be avoided.

RHEXIS: Lack of a good red reflex results in poor visualisation of the tearing edge of the rhexis. Coaxial light from good quality EUROTIMES | JULY/AUGUST 2017

Crater and chop technique of nuclear disassembly: A - A central crater has been created; B - Horizontal chop is performed for the rim of crater; C - The fragments are emulsified within the crater; D - First post-op day shows clear cornea

microscopes often overcomes this and give sufficiently good red reflex. Trypan blue capsular staining can be performed to enhance visualisation. Oblique light from an endoilluminator may also be used to improve the view.

Small rhexis should be avoided to allow free rotation of the nucleus within the bag as well as conversion to SICS or ECCE if required. A large enough rhexis prevents capsular blowout and accidental damage to rhexis margins during chopping manoeuvres.

bag. Gentle multi-quadrant hydrodissection should be attempted.

Further injection should immediately be stopped and the bag decompressed if elevation and contact of the endonucleus against the capsular bag is seen during hydrodissection. Hydrodelineation may not be able to effectively decrease the bulk of the central choppable core of cataract as there is very little epinucleus to separate.

Nucleus rotation should be very gentle.

HYRDO-MANOEUVRES:

The large nucleus needs more phaco power for emulsification. The amount of phaco energy used, fluid turnover in the eye and the chances of endothelial damage are correspondingly more with brown cataracts.

Trying to attain a complete cortical cleaving hydrodissection using a continuous fluid wave can result in a capsular blowout as the bulky hard endonucleus fills the capsular

NUCLEUS EMULSIFICATION:

CATARACT & REFRACTIVE A dispersive ophthalmic viscosurgical device is preferred to coat the endothelium and this may be replenished multiple times during nuclear emulsification.

Divide and conquer, stop and chop, crater and chop or a direct vertical chop may be used for nuclear disassembly.

Sculpting should be performed using high power and low vacuum to avoid nuclear displacement and zonular stress. The phaco tip should be adequately exposed to go deep enough and to get sufficient purchase of the nucleus.

For vertical chop, a sharp and long pointed chopper is preferred. While chopping, posterior pressure should not be applied.

Instead, the dominant hand pulls the embedded phaco tip slightly forwards and the chopper separates laterally to create a vertical split. It is often difficult to get a complete crack through full thickness of the nucleus including the posterior leathery plate.

In this scenario, the nucleus should be released and again embedded at a deeper plane to laterally separate the halves. This is more effective in cracking the posterior plate than extensive lateral separation of the nuclear halves with a superficial hold, which can cause stress to the zonules. The zonules in brown cataracts are loose and extra manipulation is often required. A capsular tension ring may therefore be considered, especially in case of pseudoexfoliation.

Phaco power may be used in burst mode for embedding and chopping followed by

ESCRS

Practice Management

& Development

pulse/hyperpulse mode for emulsifying the nuclear fragments. After chopping into smaller fragments, high vacuum and flow rate are used for faster emulsification.

Bringing the first fragment out after chopping helps break the jigsaw puzzle arrangement of the nuclear pieces and subsequent fragments can be emulsified more easily. The phaco tip should point sideward and adequate distance should be maintained from the endothelium.

Care should be taken not to aspirate the iris accidentally. Because of the lack of protective epinuclear shell, lax zonules and the thin fragile nature of the posterior capsule, the risk of a posterior capsular rent is higher. Using the air pump or pressurised air infusion allows maintenance of a deep anterior chamber and helps to protect both the endothelium and posterior capsule, as well as helping surgery to proceed faster.

Towards the last pieces, phaco parameters should be brought down.

Chatter is more commonly seen with brown cataracts and pulse mode helps to some extent to decrease this. Torsional ultrasound also helps faster and safer emulsification with less chatter. Small chips of the nucleus often break off and lodge themselves in the angle or sulcus, behind the iris or in the wound, and these should be looked for and removed after nuclear emulsification. BSS irrigation helps dislodge these pieces.

CORTEX ASPIRATION AND IOL IMPLANTATION: Residual cortex is less as compared to soft cataracts and it is removed in the conventional manner. This is followed by viscoelastic injection and in-the-bag IOL implantation.

Wound architecture should be carefully evaluated at the end of surgery for possible leakage secondary to mild wound burn or excessive distortion of the wound from the increased manoeuvring. Sutures may be applied if required. Postoperative care needs to be more intense because of a higher incidence of complications.

• Chop techniques for brown cataracts will be discussed in Part 2 of this series 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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CATARACT & REFRACTIVE

INNOVATION AHEAD The late Roger F Steinert delivered the annual Charles D Kelman Lecture at the 2016 AAO Annual Meeting. Howard Larkin reports

O

phthalmology stands on the brink of exciting innovation, and much of it will come in cataract and refractive surgery, Roger F Steinert MD told the 2016 American Academy of Ophthalmology Annual Meeting in Chicago.

A true accommodating intraocular lens (IOL) that can be inserted through a standard cataract incision, and a laser capable of correcting IOL power, spherical aberration, asphericity and multifocality in the eye after surgery are on the horizon, said Dr Steinert in the 12th annual Charles D Kelman Lecture.

Dr Steinert said these technologies could be the next big innovations in cataract surgery technology. The last major developments were the introductions of foldable acrylic lenses and multifocal lenses.

“We’re still behind – there are a lot of interesting innovative things we can do that are lagging behind compared with want we could be doing,” he said.

BIG MARKET, SMALL PENETRATION Cataract surgery innovation has a disproportionate impact because the procedure accounts for more than half of ophthalmology practice and related industry sales, noted Dr Steinert, who was Professor of Ophthalmology and Chair Professor of Bioengineering at the University of California-Irvine, USA, and Director of the Gavin Herbert Eye Institute.

Still, as of 2015, premium IOLs, including toric and presbyopia-correcting lenses, made up just 6.9% of IOLs sold, according to Market Scope data. Their impact on industry was much larger, accounting for 24% of IOL revenues and an estimated 40% of IOL earnings.

“Industry drives innovation,” Dr Steinert observed. He discussed two innovative cataract surgery technologies he has been involved with that have the potential to revolutionise the field.

One is the LensGen® (LensGen, Irvine, California, USA) accommodating IOL. It consists of a base with a fixed optic into which a fluid-filled lens is inserted.

Slight ciliary contractions are amplified by a ring of levers mounted around the fixed optic that press on the fluidfilled lens, deforming the liquid optic.

This amplification allows the very small range of motion available from the ciliary muscles to create a wide range of continuous accommodation similar to EUROTIMES | JULY/AUGUST 2017

Roger F Steinert was recognised with the Charles D Kelman Lecture at the 2016 AAO Annual Meeting, for his service as an educator and innovator. David Chang (left) presented the certificate on behalf of the AAO

that provided by the crystalline lens, Dr Steinert said.

The lens components can be inserted through a standard small cataract incision, and the fixed posterior optic provides a platform for astigmatism correction, he added. “It does move and this is very promising going forward.”

A second innovative technology may help solve the problem of incorrect IOL power, Dr Steinert said. The Perfect Lens Perfector I (Perfect Lens, Irvine, California, USA) is a device that can change the refractive index of IOLs in the eye after surgery. It works by altering the hydrophilicity of acrylic lenses, and can be used with hydrophobic or hydrophilic IOLs. A femtosecond laser creates a phasewrapped lens that can correct IOL power, or add or remove multifocality, Dr Steinert said. The procedure takes 10 to 20 seconds, and has changed lens power by as much as 3.6 dioptres in model, and the changes can be easily reversed. “It can work both ways and all this is done with on visible change in the lens,” he said.

CORNEAL INLAY The unexpected FDA approval of the Raindrop® (ReVision Optics, Lake Forest, California, USA) near vision corneal inlay may revolutionise presbyopia correction for emmetropes, Dr Steinert said. Implanted in the centre of the cornea of the non-dominant eye, the hydrogel device promotes remodelling of the corneal

epithelium, creating a profocal cornea that enhances near vision in the centre and transitions smoothly to intermediate and distance focus at the perimeter. Distance vision is lost monoculalry in the treated eye, but not affected binocularly. Patients have good binocular acuity at all distances, Dr Steinert said.

The Raindrop near vision inlay is inserted under a corneal flap cut with a femtosecond laser that is centred on the light-constricted pupil. It is made of a biocompatible material with a similar refractive index and water content as the stroma, and maintains natural nutrient flow, Dr Steinert said.

In US clinical trials the implant has produced 20/32 or better vision at all distances in 96% of patients, and is removable, Dr Steinert said. “This is just one of many coming innovations,” he added.

The Kelman Lecture is delivered by an individual who has made significant contributions to the advancement of cataract surgery through education, innovation or scientific study.

The AAO recognised Dr Steinert for his long-time commitment to cataract surgery education in academia and professional societies, as well as his work with industry on advanced devices and instruments.

EuroTimes and the ESCRS wish to extend our sincere condolences to the family, friends and colleagues of Dr Steinert, who sadly passed away in June 2017

CATARACT & REFRACTIVE

PRESBYOPIA EYE DROPS Anti-crosslinking drug may restore natural accommodation.

Howard Larkin reports

I

n a proof-of-concept clinical trial, a topical compound designed to increase the flexibility of the natural crystalline lens in presbyopic patients significantly improved near vision in as little as eight days, Richard L Lindstrom MD told the 2017 ASCRS•ASOA Symposium & Congress in Los Angeles, USA. The compound, lipoic acid choline ester 1.5% (EV06, Encore Vision) is the first topical presbyopia treatment shown to restore some of the visual accommodation lost as the natural lens stiffens with age, he said.

Eventually, EV06 or a similar preparation might also help slow or even reverse nuclear cataract formation, which is thought to result from the same chemical process that causes presbyopia, added Dr Lindstrom, who is founder of Minnesota Eye Consultants, Bloomington, Minnesota, USA, and a board member and equity owner of Encore Vision.

EV06 targets disulfide bonds that form among proteins in the crystalline lens in response to oxidative challenge and UV light that both stiffen and cloud the lens. The choline preparation helps the compound penetrate the cornea. Inside the eye, it reduces to lipoic acid and dihydrolipoic acid, which in turn dissolve the disulfide bonds. “We’re basically un-crosslinking the natural lens,” Dr Lindstrom said.

In the clinical trial, involving 75 patients, EV06 worked faster than expected, and the effect increased progressively throughout the trial, Dr Lindstrom said. Mean logMAR distance corrected near visual acuity in the treatment group improved from 0.397 at baseline to 0.206 at day 91, compared with 0.408 at baseline to 0.313 at day 91 in the control group. At day 91, 84% reached 20/40 or better from a baseline of 30% in the treatment group, compared with 48% from 28% among controls.

Overall, 84% of treated patient gained at least one line of near vision, 53% two or more lines and 22% three lines, and 12% four lines at 90 days, with no loss of corrected distance vision. While a few patients reported minor irritation taking EV06 twice daily, comfort scores were similar in the treatment and placebo groups. No significant adverse events were observed and no patients dropped out of the trial.

A post-treatment study found the treated group continued to show better near vision than controls out to 301 days, though the effect declined slightly over time, Dr Lindstrom added.

Richard L Lindstrom: rllindstrom@ mneye.com

In the clinical trial... EV06 worked faster than expected, and the effect increased progressively throughout the trial

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Richard L Lindstrom MD EUROTIMES | JULY/AUGUST 2017

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CATARACT & REFRACTIVE

CAPSULAR BAG STABILITY Hydrophobic acrylic material enhances excellent outcomes with open-loop haptic platform. Cheryl Guttman Krader reports

F

indings after two years of follow-up in a contralateral eye-controlled clinical trial comparing two single-piece, aspheric, acrylic intraocular lenses (IOLs) differing only in material, demonstrate slight differences in rotational stability and posterior capsule opacification (PCO) favouring an IOL constructed of a glistening-free (G-free) hydrophobic acrylic (PodEye, PhysIOL) over the hydrophilic acrylic IOL comparator (Pod AY, PhysIOL).

Overall, however, the results show that the symmetrical, bifid open-loop haptics design shared by the two implants provides excellent capsular bag stability and is associated with a low amount of PCO, according to Oliver Findl MD. “To my knowledge this is the first clinical trial to isolate the effect of IOL material on capsular bag performance and PCO inhibition,” stated Dr Findl, Chief, Department of Ophthalmology, Hanusch Hospital, Vienna, Austria.

Providing perspective on the findings, he said: “IOL centration, stability within the capsular bag, and the avoidance of PCO are all critical for achieving good visual quality after cataract surgery and especially with aspheric, toric, and multifocal optics. For every 3° of rotational misalignment, the efficacy of toric IOL correction is reduced by 10%. Today, PCO remains the most common longterm ‘adverse event’ after cataract surgery, and it tends to be higher with plate haptics than with an open-loop design.”

CLINICAL COMPARISON Dr Findl conducted the prospective study that included 80 eyes of 40 patients scheduled for bilateral cataract surgery in a singlecentre study. Implantation of the two IOLs was determined by randomisation. Follow-up examinations were conducted at one hour, one week, three months, one year, and two years after surgery and included measurements to determine rotation, decentration, and tilt. PCO was quantified at one and two years

using dedicated software to analyse retroillumination images.

Mean ± standard deviation (SD) rotation between one hour and three months after surgery was minimal with both IOLs, but significantly less with the G-free hydrophobic IOL compared with the hydrophilic lens (1.6 ±1.61° vs 2.4 ±1.85°; P=0.016).

Similarly, there was very little rotation of either IOL between one and two years, and while it was less with the G-free hydrophobic IOL than with the hydrophilic IOL, the difference did not achieve statistical significance (1.8 ±1.0° versus 2.3 ±1.3°; P=0.09).

“Typically, most IOL rotation happens within the first three months after surgery. The 2.4° of rotation with the hydrophilic IOL is similar to what is seen with other lenses on the market, while the amount of rotation of the G-free hydrophobic IOL, both early after surgery and during the second year of follow-up, is within the noise level of the analysis,” Dr Findl said.

“One might expect a tendency for more rotation in very myopic eyes with larger capsular bags. We found no correlation between axial length and amount of rotation for either IOL, although because there were very few myopic eyes, it is not possible to reach any conclusions,” he added.

Analyses of data collected at one year after surgery with a Purkinje meter showed identical, minimal decentration with both IOLs (mean ± SD, 0.30 ±0.16mm). The hydrophilic and G-free hydrophobic IOLs also displayed similarly low amounts of horizontal tilt (2.3 ±1.7° and 2.1 ±1.7°, respectively) and vertical tilt (2.9 ±1.6° and 2.5 ±1.85°, respectively).

PCO scores, graded on a scale of 0 (none) to 10 (maximum), were very low for both the hydrophilic and G-free hydrophobic IOLs at one year (1.2 ±2.1 and 0.8 ±1.9, respectively) and two years (2.5 ±2.6 and 2.2 ±2.1, respectively). Although the results were numerically better for the G-free hydrophobic IOL at both visits, neither difference was statistically significant.

“Obviously, this is still early follow-up for PCO, but the data slightly favour the G-free hydrophobic material,” Dr Findl said.

Oliver Findl: oliver@findl.at

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CATARACT & REFRACTIVE

Courtesy of Matteo Piovella MD

Left: Trifocal IOL one day after surgery Below: Well-centred trifocal IOL one week after surgery

TORIC TRIFOCAL IOLS Surgeon has personal experience to back up study.

Leigh Spielberg MD reports

T

oric trifocal intraocular lenses (IOLs) provide lasting emmetropia and good near vision in many patients at the three-year follow-up mark, according to Matteo Piovella MD, Centro di Microchirurgia Ambulatoriale, Milan, Italy.

For Dr Piovella, the successful implantation of one toric trifocal IOL involves a very personal story. In 2014, a Zeiss AT LISA toric trifocal IOL was implanted in his own left eye. The results were excellent, and Dr Piovella has continued to practice. “And I still get asked to perform live surgery!” he said.

Dr Piovella provided an overview of toric trifocals, with a particular focus on the Zeiss AT LISA toric trifocal IOL. “We currently have 12 years of experience with multifocal IOLs, starting with the ReZoom and TECNIS mix and match from AMO. Trifocal IOLs have now replaced bifocal IOLs in most countries where they are available. Extended-depth-of-focus (EDOF) IOLs are another new development but they are less effective for near vision,” he said.

However, most multifocal bifocal IOLs have several weak points, he noted. These

include a lack of intermediate distance vision and a reduction of contrast sensitivity of up to 25%. Furthermore, near vision is penalised with dim lighting conditions, particularly with diffractive IOLs. The AT LISA is a trifocal IOL with an asymmetrical light distribution. This IOL distributes 50% of the light to far, 20% to intermediate, and 30% to near.

Dr Piovella’s team conducted a study in which they implanted the AT LISA trifocal toric in 82 astigmatic eyes of 50

Well-centred trifocal IOL two months after surgery

...a multifocal toric optic is more sensitive to cylinder misalignment than a monofocal toric optic Matteo Piovella MD

patients, with a mean preoperative corneal astigmatism of 1.46D. Within this group, 84% of eyes were within 0.50D spherical equivalent postoperatively. “Only 9% of patients sometimes have to use glasses,” said Dr Piovella.

He outlined the indications for a smooth transition to presbyopic IOLs. He advised not using these lenses in high myopic or high hyperopic patients or after radial keratotomy.

Patient eyes selection and examination are crucial, and healthy preoperative convergence, stereopsis and near vision are all important, he emphasised.

“And remember, a multifocal toric optic is more sensitive to cylinder misalignment than a monofocal toric optic. Astigmatism axis alignment needs digital technology like the CALLISTO system. Also remember that all diffractive IOLs penalise near vision in dim lighting conditions due to a reduction of contrast sensitivity and depth of focus,” he noted.

This should not be seen as an insurmountable problem, as it can be solved by increasing the ambient light, for example by using a smartphone’s flashlight (torch) function.

“Patients like getting this advice, and they will thank you for having provided them with a simple and efficient solution,” said Dr Piovella.

Matteo Piovella: piovella@piovella.com Dr Piovella is a consultant for Abbott Medical Optics, TearScience and Carl Zeiss Meditec EUROTIMES | JULY/AUGUST 2017

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CATARACT & REFRACTIVE

FEMTO VERSUS PHACO Meta-analysis shows safety and efficacy advantages of FLACS compared to conventional cataract surgery. Roibeard Ó hÉineacháin reports

F

emtosecond laser-assisted cataract surgery (FLACS) appears to provide better uncorrected visual acuity and significantly less endothelial cell loss compared to conventional cataract surgery, according to a meta-analysis of peerreviewed studies comparing the two techniques, said Thomas Kohnen MD, PhD, FEBO, Department of Ophthalmology, Goethe University Frankfurt, Germany.

The analysis also indicated that FLACS poses no additional dangers to the eye apart from a slightly but significantly higher incidence of anterior capsule rupture. The findings contradict those of other authors which have suggested that FLACS may entail a higher risk of posterior capsule rupture than conventional surgery, Prof Kohnen told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“FLACS has a similar complication profile to conventional cataract surgery but seems to be superior in critical areas like loss of endothelial cell density.

Furthermore, in one of the main areas where FLACS is said to be inferior, higher rate of posterior capsular rupture, we could not find any significant difference between the two methods,” he said.

Prof Kohnen and his associates included 42 peer-reviewed prospective and retrospective studies published until September 2016 in their meta-analysis. They identified the studies through a systematic review of Medline, Cochrane Library and Embase according to PRISMA guidelines.

The meta-anlaysis comprised a total of 9,400 eyes that underwent FLACS and a total of 8,779 eyes that underwent

FLACS has a similar complication profile to conventional cataract surgery but seems to be superior in critical areas...

Thomas Kohnen MD, PhD, FEBO conventional cataract surgery with ultrasound phacoemulsification and manual incisions and capsulotomies. All of the studies compared the two cataract surgery approaches, each recording their own set of parameters.

BETTER VISION, BETTER SAFETY The researchers found that, in terms of mean uncorrected visual acuity, FLACS-treated eyes had significantly better outcomes than conventionally treated eyes at last visit (p=0.05), in five trials reporting the outcome parameter, which involved a total of 3,240 eyes. In addition, there was a non-significant trend in favour of FLACS-treated eyes towards better corrected visual acuity in five studies involving 1,472 eyes (p<0.0001).

Furthermore, overall endothelial cell loss after three months was significantly lower in the FLACS-treated patients than in those undergoing conventional cataract surgery (P<0.01) in five trials involving 1,335 eyes. Central corneal thickness was also lower among FLACS-treated eyes at one day (p=0.00010) and one month (p=0.02) after surgery compared to those undergoing conventional surgery.

Prof Kohnen noted that capsulorhexis circularity was achieved to a significantly

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greater extent in the FLACS-treated eyes than in conventionally treated eyes in six studies involving 966 eyes (p=0.0001). On the other hand, anterior capsule rupture occurred in 37 (1.4%) of 2,516 FLACStreated eyes compared to only eight (0.27%) of 2,863 conventionally-treated eyes. With both techniques, most of the anterior ruptures occurred in one study.

However, contrary to the conclusion of some authors, Prof Kohnen and his associates found that FLACS did not raise the risk of posterior capsule rupture compared to conventional surgery. Overall, there were 11 posterior capsule ruptures among 3,451 eyes undergoing FLACS, and 16 among 3,883 eyes undergoing conventional cataract surgery (p=0.27).

He added that, although a recently published meta-analysis (Popovic et al, Ophthalmology 2016;123(10):2113-26) found a significantly greater incidence of posterior capsule ruptures in FLACStreated eyes, he and his associates found no significant differences between the two approaches in terms of the complication when the results of non-comparative studies were eliminated from the analysis.

Thomas Kohnen: kohnen@em.uni-frankfurt.de

CATARACT & REFRACTIVE

NEW IOL: RESULTS New design provides moderate accommodation.

Roibeard Ó hÉineacháin reports

A

new intraocular lens (IOL) with a different style hinged optic-haptic juncture from older accommodative IOLs appears to provide a moderate forward shift in response to pilocarpineinduced ciliary muscle contraction, but at the cost of increased posterior capsule opacification (PCO), according to a study presented at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands, by Nino Hirnschall MD, PhD. The study included eight patients with a mean age of 69 years. All received the new accommodating IOL (ActaLens™, Emmetrope, designed by Andrew Phillips) in one eye and a control IOL, either the Crystalens® (Bausch + Lomb) or the AcrySof® IQ (Alcon) in the fellow eye, said Dr Hirnschall, Vienna Institute for Research in Ocular Surgery (VIROS), Hanusch Hospital, Vienna, Austria.

At 20 months’ follow-up, the researchers measured anterior chamber depth (ACD) with an optical biometry device (Lenstar, Haag-Streit AG, Switzerland) on two measurement days. On the first measurement day they determined ACD prior to instillation of topical pilocarpine and 30 minutes later. On the second measurement day, they followed the same procedure but used 1% cyclopentolate instead of pilocarpine.

8

th EURETINA

Winter Meeting

16–17 February 2018 Budapest, Hungary www.euretina.org

MODERATE ACCOMMODATION They found that pilocarpine reduced ACD by a mean of 0.32mm (p=0.014) in the ActaLens group compared to only 0.04mm in the control group (p=0.854). In addition, cyclopentolate increased ACD by 0.14mm in the ActaLens group (p=0.014), compared to only 0.03mm in the control group (p=0.181).

A disadvantage of the new accommodating IOL was an increased level of PCO. Two independent examiners graded PCO, on a scale of 0 to 3, as 2.4 in the ActaLens group, compared to 1.8 in the Crystalens group and 0.l1 in the AcrySof group (p<0.001). In addition, Nd:YAG rates were higher in the study group, but the difference did not reach Nino Hirnschall statistical significance.

Dr Hirnschall noted that the ActaLens is a forwardvaulted plate silicone IOL with hinges between the haptic and the optic. It has a total length of 11mm and an optic diameter of 5.5mm. During production, the IOL is flattened with a vicryl suture. Patients undergo cycloplaegia during the first four weeks after surgery. Laser suturolysis performed six weeks after surgery allows the optic to move forward to its accommodating non-planar state during ciliary muscle contraction.

“The investigated IOL is a novel concept for an accommodating IOL and results showed a moderate pilocarpine-induced forward shift of the IOL. However, the investigated IOL seems to have a higher PCO rate compared to standard monofocal IOLs,” he concluded.

Nino Hirnschall: nino.hirnschall@gmail.com EUROTIMES | JULY/AUGUST 2017

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CATARACT & REFRACTIVE

MYOPIC LASER VISION CORRECTION Contralateral eye comparison measures SMILE against topography-guided LASIK. Cheryl Guttman Krader reports

A

randomised, contralateral eyecontrolled study of myopic correction with topographyguided femtosecond LASIK and small incision lenticule extraction (SMILE) showed the two procedures provided comparable refractive outcomes, despite better centration with LASIK. LASIK was also associated with better visual performance, but SMILE resulted in less dry eye, inflammation and epithelial remodelling, according to A John Kanellopoulos MD. Providing his conclusions, Dr Kanellopoulos highlighted the future promise of SMILE rather than its current limitations.

“The results underline how effective laser vision correction is today, and the refractive outcomes for both procedures far exceeded the FDA standards,” said Dr Kanellopoulos, Director, LaserVision Clinical and Research Eye Institute, Athens, Greece.

“Considering that the SMILE cohort included cases done in my personal learning curve, the effectiveness of that procedure was outstanding, and I expect that potential future improvements in centration, tissue removal customisation and cyclorotation compensation may make SMILE-like procedures even superior to LASIK for correcting low-to-moderate myopia,” he added The single-surgeon, rigorously designed study enrolled 25 patients undergoing

Courtesy of A John Kanellopoullous MD

26

Predictability graph with red dots showing overcorrection and blue dots showing undercorrection, with green dots within ±0.5 dioptres for the topography-guided LASIK eyes (group A) and the contralateral SMILE eyes (group B)

bilateral eye treatments with -3.0D to -10.0D of myopia (mean -5.5D) and up to -5.0D of astigmatism (mean -1.5D).

Mean distance uncorrected visual acuity (UCVA) was 20/200 preoperatively for both groups, and at six months was 20/20 in SMILE eyes and 20/15 after LASIK. The efficacy analysis comparing postoperative UCVA with preoperative corrected distance visual acuity (CDVA) showed a one-line gain of CDVA vision for 52% of LASIK eyes and 30% of SMILE eyes.

Refractive results for both surgeries showed excellent predictability and good stability. The refractive outcomes were statistically better for the LASIK-

...a comparison between the two procedures is a little unfair considering there is currently no cyclorotation adjustment with SMILE A John Kanellopoulos MD EUROTIMES | JULY/AUGUST 2017

treated eyes, however, and particularly for cylinder correction.

“It is inherent to the topographyguided treatment for it to be better, and a comparison between the two procedures is a little unfair considering there is currently no cyclorotation adjustment with SMILE,” said Dr Kanellopoulos, who is also Clinical Professor of Ophthalmology, New York University Medical School, New York, USA. Additionally, topography-modified refraction (TMR: modification of the amount and axis of astigmatism according to the topography values and angle kappa) was used in the LASIK eyes, potentially enhancing the visual performance recorded.

Contrast sensitivity was improved postoperatively in both groups, although it was better after LASIK than SMILE. Stating that he has advocated judging refractive surgery with assessments other than conventional visual performance and keratometry measures, Dr Kanellopoulos said that the study endpoints also included analyses of corneal symmetry indices and ablation centration.

CATARACT & REFRACTIVE

Courtesy of A John Kanellopoulos MD

He reported that the index of height decentration (IHD) was lower at one, three and six months in the LASIK eyes compared with SMILE, although the difference between groups tended to dissipate as follow-up lengthened.

“Lower IHD means better regularity of the cornea, and the difference favouring LASIK is probably due to its better accuracy for correcting corneal astigmatism in regard to the corneal vertex (line of sight),” Dr Kanellopoulos said.

“We also looked at the Objective Scatter Index as a marker of quality of vision and found the results were better after LASIK, which probably is because of better corneal symmetry,” he added.

Centration was assessed by digital analysis of Scheimpflug sagittal curvature maps to calculate the difference between the achieved (centre of corneal curvature flattening effect on the anterior curvature sagittal map difference between pre- and post-op) and planned centre of the lenticule or ablation (the corneal vertex). The results showed far better centration for LASIK than SMILE (mean decentration of 150μm versus 450μm respectively) and highlighted that centration is still an issue with SMILE, Dr Kanellopoulos noted.

Measurements of epithelial remodelling showed significant changes in the SMILE eyes, more than anticipated. Nevertheless, less remodelling epithelial effect in SMILE eyes and faster recovery as the epithelial

27

Contrast sensitivity for postoperative month 1 (A) and 3 (B). The blue line represents the preoperative average for all, the red line the average small incision lenticule extraction (SMILE) data at 1 month on the left (A) and at 3 months on the right (B), in all special frequencies, and the green line the respective LASIK data at 1 and 3 months

changes, appeared to significantly subside by month 3. Central and mid-peripheral epithelial thickness increased significantly after both procedures, but the changes were more significant in the LASIK eyes.

“Still, SMILE does not seem to leave the ocular surface minimally affected. It is speculated that there is less denervation after SMILE since the side cut transversing the subepithelial nerve plexus of the cornea is just 50 degrees, compared to 310 degrees in LASIK. Our findings argue with this theory and potentially support that corneal

epithelial remodelling is more curvature change-related, and not just transient dry eye-related,” said Dr Kanellopoulos.

Some minor complaints of dry eye symptoms were more common after LASIK than SMILE and persisted longer. At six months, dry eye symptoms had significantly subsided in both groups and were reported for the SMILE eye by six patients (24%) and for the LASIK eye by 12 patients (48%).

A John Kanellopoulos: ajk@brilliantvision.com

22nd ESCRS Winter Meeting

9 – 11 February 2018 Sava Centar Belgrade, Serbia

www.escrs.org

EUROTIMES | JULY/AUGUST 2017

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CATARACT & REFRACTIVE

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

Lampros Lamprogiannis

Fellow in Ophthalmology, Epsom and St Helier University Hospitals, London, UK Q. Can you describe your step-by-step approach to phacoemulsification in high hyperopes?

Cyres K Mehta Surgical Director and Chief, International Eye Centre, Mumbai, India A. Phacoemulsification in small eyes, with short axial lengths less than 22mm and accompanying hyperopia of 3.00D or more, present a unique set of challenges.

The anterior chamber (AC) can be quite shallow. Here, cataract formation can cause the lens to swell and further occlude the angles. Intraocular lens (IOL) power calculation is performed on the IOLMaster® 700 (Zeiss), using both the Haigis suite and the Hoffer Q formulas which are more accurate in short eyes.

Make sure to measure intraocular pressure (IOP) on the table, as dilation of the pupil frequently leads to elevated IOP. Here we can pretreat with 100cc 20% Mannitol, fast IV in five minutes, wait for 30 minutes and then start the case when IOP is controlled.

Make sure your tunnels are long enough to prevent iris prolapse. Use high molecular weight dispersive viscoelastic e.g Viscoat, to give you adequate space in the AC, remembering that in a shallower AC the phaco tip is likely to be closer to the endothelium.

If you cannot get enough space in the AC, a simple technique is to do a small 25/27G transconjunctival vitrectomy at a high cut rate for just a few seconds, which will lead to the chamber deepening substantially.

Once adequate AC depth is achieved, we proceed with regular phaco using the ‘lens salute’ technique and torsional phaco in ultrashort pulses.

Noel Alpins AM Melbourne, Australia A. The risk of small incision cataract surgery and phacoemulsification in high hyperopia is mainly related to the small size of the eye and reduced space in the AC for the safe removal of the lens.

In the planning of the lens power, whatever formula is normally applied, additional weight should be given to the value obtained with the Hoffer formula, which has greater accuracy in shorter axial lengths.

Also preoperatively, to obtain a soft eye and greater compliance of the AC to ‘expand’ with fluid irrigation, then 350-500ml of Mannitol 20% should be administered IV starting 60 minutes prior to the procedure.

Also, a Honan balloon should be applied at 35mm for six minutes to reduce intraocular volume and avoid the complication of high IOP occurring with shallow or flat AC during surgery.

With this preparation, normal phaco parameters can be applied, which for sculpting is a 50% torsional power 55mm, IOP and vacuum 85mmHg, flow 22cm/ minute with an effective bottle height of 75cm, which may be increased by 5-10cm if needed.

A 2.2mm diamond blade incision is made in clear corneas, but sometimes this may need to be enlarged at the time of implant insertion because of the thickness of the foldable lens. Care is taken with the hydrodissection to avoid forward prolapse of the nucleus or over-hydration.

Using a technique of mini-chop after a central gutter, ultrasound time would average at a CDE time of seven seconds.

Removal of viscoelastic should be complete.

The incision is sealed by insufflation and seal confirmed with fluorescein.

Roberto Bellucci Consultant Ophthalmologist, Vista Vision Centre, Verona, Italy A. 1. Preoperative evaluation is the most important step for success.

Anterior chamber depth (ACD) is particularly important. If less than 2mm, the eye probably is affected by angle-closure glaucoma, while if it is more than 2mm, there is usually no risk for glaucoma and mydriasis will be wider and safe.

Shallow chambers are an indication for femtosecond laser capsulotomy, as forceps capsulorhexis requires some additional room and heavy viscoelastic injection.

ACD will also affect IOL power calculation, and IOL powers in excess of 50D may be expected in high hyperopes with deep AC. In addition, the risk for choroidal thickening/haemorrhage suggests general anaesthesia in older patients. I avoid local anaesthesia in these eyes, because of the possible induction of positive posterior pressure.

2. IOP during lens removal should be strictly controlled.

High hyperopes benefit from forced infusion, both with fluid and with vacuum pumps. However, an excessive pressure might force some fluid into the vitreous cavity through the zonules, eventually causing AC shallowing with impossible IOL insertion. For this reason a feedback system like that implemented in recent machines is particularly helpful.

3. IOL selection.

The selected IOL should be easy to implant through small pupils/capsulotomies. Rigid hydrophobic lenses may not be the best option. Multifocal IOLs in the presence of a large angle Kappa should be avoided.

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org EUROTIMES | JULY/AUGUST 2017

CATARACT & REFRACTIVE

JCRS HIGHLIGHTS VOL: 43 ISSUE: 5 MONTH: MAY 2017

KETOROLAC AND PHENYLEPHRINE BETTER TOGETHER A novel drug that combines phenylephrine and ketorolac (OMS302) for intracameral administration proved safe and efficacious in maintaining mydriasis and reducing postoperative ocular pain in a multicentre randomised clinical trial. Moreover, the combination proved superior to either agent alone in maintaining an intraoperative pupil diameter of 6.0mm or larger. The study included 223 patients from 23 centres who were randomised to receive vehicle, phenylephrine, ketorolac, or the study drug containing phenylephrine and ketorolac administered intracamerally during cataract surgery. Significantly fewer patients treated with the study drug (6.1%) had an intraoperative pupil diameter smaller than 6.0mm compared with those treated with the vehicle (47.2%; P<.0001), ketorolac (34.6%; P=.0004), or phenylephrine (22.4%; P=.0216). ED Donnenfeld et al, JCRS, "Intracameral ketorolac and phenylephrine effect on intraoperative pupil diameter and postoperative pain in cataract surgery"; Volume 43, Issue 5, 597–605.

LONG-TERM ASTIGMATIC CHANGES Corneal astigmatism continues to change towards againstthe-rule astigmatism over a period of decades, a new study reveals. Researchers measured corneal astigmatism prior to phacoemulsification cataract surgery in 74 eyes, and in another 68 that did not undergo surgery. This change was similar in eyes that did not have surgery. They were able to take follow-up measurements using power vector analysis 10 and 20 years after baseline measurements. The mean vertical/horizontal change in corneal astigmatism (J0) between baseline and 20 years was -0.64D in the surgery group and -0.49D in the no-surgery group.

K Hayashi et al, JCRS, "Changes in corneal astigmatism during 20 years after cataract surgery"; Volume 43, Issue 5, 615–621.

ASYMMETRIC MULTIFOCAL IOLS SHOW PROMISE Rotationally asymmetric multifocal intraocular lenses (IOLs) appear to offer a promising alternative for the treatment of presbyopia. These IOLs have two distinct zones – that is, a distance zone and a near zone.

In contrast, traditional rotationally symmetrical multifocal IOLs consist of concentric rings to provide multifocality. Investigators enrolled 50 refractive lens exchange patients in a prospective study of the SBL-3 IOL and evaluated vision at the three- and 12-month marks. The asymmetric multifocal IOL provided excellent unaided vision with no significant difference in near, intermediate, and distance vision three months and 12 months postoperatively. A quality-of-vision survey indicated a significant improvement in subjective outcomes at the second postoperative assessment, during which patients reported significantly better quality of vision scores and less blurred vision.

RN McNeely et al, JCRS, "Visual outcomes and patient satisfaction 3 and 12 months after implantation of a refractive rotationally asymmetric multifocal intraocular lens"; Volume 43, Issue 5, 633–638.

JCRS SYMPOSIUM Controversies in Cataract and Refractive Surgery XXXV Congress of the ESCRS, Lisbon, Portugal Sunday 8 October, 14.00 – 16.00 Chairpersons: T. Kohnen GERMANY (EUROPEAN EDITOR) W.J. Dupps USA (US ASSOCIATE EDITOR)

Percent tissue altered (PTA) for predicting post-LASIK ectasia risk 14.00

M. Santhiago BRAZIL Pro

14.15

A. Saad FRANCE Contra

14.30

Discussion

What is the right place for phakic intraocular lens (PIOL)?

14.40

R. Nuijts THE NETHERLANDS In the anterior chamber

14.55

R. Zaldivar ARGENTINA In the posterior chamber

15.10

Discussion

IOL calculations 15.20

T. Olsen DENMARK Optimised traditional approaches

15.35

W. Hill USA Pattern recognition

15.50

Discussion

16.00

End of session

THOMAS KOHNEN European editor of JCRS

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CORNEA

FS-DSEK VERSUS PK FS-DSEK provides good refractive results but disappointing visual outcomes. Roibeard Ó hÉineacháin reports

F

emtosecond laser-assisted Descemet’s stripping endothelial keratoplasty (FS-DSEK) provides better refractive outcomes with less postoperative astigmatism than penetrating keratoplasty (PK) but yields poorer visual outcomes, according to Yanny Cheng MD, PhD, of Leiden University Medical Centre, Leiden, The Netherlands.

In a keynote lecture at a Cornea Day session during the 21st ESCRS Winter Meeting in Maastricht, The Netherlands, she noted that the last decade has seen a revolution in corneal transplantation, with endothelial keratoplasty increasingly replacing PK as the treatment of choice for eyes with endothelial dysfunction.

She pointed out, for example, that in the USA in 2006 PK accounted for 85% of keratoplasty procedures and endothelial keratoplasty only accounted for 12%. By contrast, in 2016 endothelial keratoplasty accounted for 52% of keratoplasty procedures and PK only accounted for 40%.

That experience was mirrored in The Netherlands. The proportion of keratoplasty accounted for by PK fell from around two-thirds in 2006 to only one-third in 2016. Conversely, the proportion accounted for by endothelial keratoplasty rose from less than 10% in 2006 to 60 % in 2016, Dr Cheng said.

The reason for endothelial keratoplasty’s increasing popularity is that it overcomes many of the limitations of PK, she noted.

Those limitations include postoperative astigmatism of more than 5.0D, affecting over a third of patients, suture events, including infection, long-term tectonic instability, and ocular surface disease.

However, posterior lamellar keratoplasty also has limitations, including low proportions of patients achieving a best corrected visual acuity (BCVA) of 20/20 and high early endothelial cell loss, she pointed out.

TESTING THE FEMTOSECOND LASER Dr Cheng noted that, compared to conventional microkeratome dissection, femtosecond laser graft dissection has several potential advantages over mechanical microkeratomes, including better cut safety and creation of planar grafts.

To examine whether these advantages carry over into clinical experience, Dr Cheng and her associates carried out a prospective randomised multicentre study, the Dutch Lamellar Corneal Transplantation Study, comparing 12-month outcomes in 36 eyes undergoing FS-DSEK and 40 eyes undergoing PK. The patients had a mean age of 69 years.

Their main indication for surgery was Fuchs’ endothelial keratopathy, accounting for 21 patients in each group, followed by pseudophakic bullous Yanny Cheng MD, PhD keratopathy, which

In the USA in 2006 PK accounted for 85% of keratoplasty procedures and endothelial keratoplasty only accounted for 12%

EUROTIMES | JULY/AUGUST 2017

accounted for 14 and 18 in the FS-DSEK and PK groups, respectively. One eye in each group had aphakic bullous keratopathy. The FS-DSEK group had a higher proportion of patients with vision limiting retinal macular diseases - 39% versus 20%.

To prepare the lamellar discs, Dr Cheng and her associates used whole donor globes. They began by removing the epithelium. Then they created a horizontal lamellar cut using a flat applanation lens and an Intralase 30KHz femtosecond laser set to a depth of 400 microns and a diameter of 9.5mm, and using a mean energy level of 1.07mJ and a raster pattern.

Following the femtosecond laser dissection, the globe was returned to the eye bank for endothelial evaluation and microbiological and serological examination. The corneoscleral button was then stored in organ culture and the surgeon performed trephination and transplantation.

VISUAL OUTCOMES Throughout the 12 months follow-up, mean BCVA was significantly better after PK than after FS-DSEK (0.5 logMAR versus 0.28 logMAR). The difference was statistically significant even after accounting for pre-existing vision-limiting comorbidities, she said.

However, among patients followed for up to three years, those undergoing FS-DSEK continued to improve for up to two years. The continuing improvement may result from corneal remodelling.

In terms of refraction, FS-DSEK performed significantly better than PK. At 12-months follow-up the mean spherical equivalent was +0.78D in the FS-DSEK group and -1.23D in the PK group (p<0.001).

In addition, refractive astigmatism was -1.22D in the FS-DSEK group compared to -2.98D in the PK group. Furthermore, topographic astigmatism was only +1.58D in the FS-DSEK group, compared to +3.67D in the PK group (p<0.001).

HIGHER ENDOTHELIAL CELL LOSS Corneal endothelial cell loss was much higher in the FS-DSEK group. At one year, endothelial cell density fell by a mean of 65% to 1,067 cells/mm2 in the FS-DSEK group, compared to a 22% reduction to 2,064 cells/mm2 in the PK group.

However, in both groups endothelial cell density remained stable thereafter. The poor endothelial cell density results might be partly attributable to the learning curve involved in this new surgical procedure, she noted.

Complications of FS-DSEK included donor tissue location in 10 eyes, primary graft failure in three eyes, folds in the posterior lamellar discs in one eye and elevated intraocular pressure in two eyes.

Dr Cheng noted that there are several factors that limited visual acuity for FS-DSEK in the study. They include the use of a thick lamellar graft, which could explain the high incidence of graft folds visible by confocal microscopy.

Other factors include applanation strain during the lamellar dissection and poor matching of the host donor interface leading to high-order posterior cornea aberrations. In addition, keratocyte activation in the donor and host corneal tissue resulted in fibrosis and corneal haze, she added.

Yanny Cheng: y.y.cheng@lumc.nl

8 EuCornea Congress th

2017

LISBON 6–7 October

FIL – Feira Internacional de Lisboa, 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

e

Eu

www.eucornea.org

a

a

Eu

François Malecaze FRANCE e

C o r n

European Society of Cornea and Ocular Surface Disease Specialists

Friday 6 October

Saturday 7 October

Ocular Surface Disease and Severe Keratitis: Challenges and Clinical Perspectives

Optimising the Ocular Surface for Surgery

13.00 – 14.00

Moderator: F. Kruse GERMANY Sponsored by

13.00 – 14.00

Sponsored by

32

CORNEA

CORNEAL THICKNESS Scheimpflug and OCT measures not interchangeable after accelerated CXL. Howard Larkin reports

T

he type of imaging device used to measure corneal 12 months. Overall, mean Optovue measurements varied much less, thickness in keratoconus patients after accelerated ranging from 471.16 microns at baseline to 475.38 microns at one corneal crosslinking (CXL) matters, according to Woo month and 476.66 microns at 12 months’ follow-up.

Jyh Haur MBBS, MMed(Ophth), FRCOphth, FRCSE. The consistent differences in corneal thickness readings between Readings are not interchangeable between devices using the Scheimpflug and OCT devices likely come down to differences in Scheimpflug cameras and spectral-domain optical how the technologies capture images and their processing algorithms, coherence tomography (OCT) – and the CXL procedure itself Dr Woo said. The Scheimpflug device uses a rotating camera which may affect the accuracy of some measurements, he said. captures 50 slit images in two seconds, directly measuring With colleagues at the Singapore National Eye elevation at more than 5,000 data points. The OCT device Centre, Dr Woo obtained central and thinnest corneal calculates elevation from 26,000 radial A-scans per second. measurements using the Pentacam® (OCULUS) Using OCT, the anterior corneal boundary may be Scheimpflug camera and Optovue spectral-domain delineated slightly below the anterior corneal surface, OCT devices from 47 eyes in 47 patients before and which may account for its usually thinner readings, Dr after undergoing an accelerated CXL procedure.

Woo suggested. Faster image acquisition and better edge The procedure involved removal of the corneal detection with OCT may also influence OCT readings, epithelium followed by application of a 0.1% riboflavin possibly accounting for their greater consistency. solution, and UVA illumination at 30mW/cm2 for four minutes Woo Jyh Haur These technical differences may also explain why the Scheimpflug for a total energy of 7.2 J/cm2. Postoperative topical antibiotics, device appeared to underestimate corneal measurements one 0.5% moxifloxacin, and corticosteroids, 0.12% prednisolone, were month after surgery, Dr Woo said. Postoperative stromal haze along tapered at one month after complete epithelial healing. with changes in corneal microstructure and reflectivity may have Patients were at least 18 years old and displayed axial topography interfered with measurements. An inverse relationship between consistent with keratoconus as measured with the Pentacam. central corneal thickness measured by dual Scheimpflug tomography All patients’ steepest K values were 47.0 dioptres or more, and and density of stromal haze has previously been reported, he noted were progressing as determined by topography, visual acuity or (Antonios R et al. Am J Ophthalmol. 2016 Jul; 167:38-47). refractive changes.

Limitations of Dr Woo’s study included the small sample size, Patients with thinnest pachymetry less than 400 microns, those and the fact that reproducibility of measurements and possible with gaze disorders or other ocular conditions, or pregnancy, were intra-observer bias were not controlled for, he noted. excluded. The study group included 37 males and 10 females with a mean age of 28 ±7 years, ranging from 19 to 52. Baseline mean K CONSIDER THE SOURCE was 49.78 ±5.00 dioptres, maximum K 59.45 ±8.49 dioptres, and Noting that accurate corneal thickness measurements are essential in mean spherical equivalent -4.30 ±3.00 dioptres. the assessment and follow-up of patients with keratoconus, Dr Woo cautioned against directly comparing readings from Scheimpflug UNEVEN RESULTS and OCT devices. “Systematic differences exist between these In general, measurements from the two devices were highly modalities and measurements are not interchangeable,” he said. correlated, Dr Woo reported. Mean Pentacam estimates of central Post-crosslinking stromal changes may further increase corneal thickness ran about seven microns to 22 microns thicker discrepancies in corneal thickness measurements, with the than Optovue readings at baseline, and three, six and 12 months Pentacam possibly underestimating measurements one month after the procedure. after surgery, Dr Woo said. With this in mind, clinicians should However, at one month post-CXL, the Pentacam estimates dipped interpret corneal thickness measurements in the context of the sharply and were nearly identical with the Optovue measurements. imaging modality used.

Mean Pentacam central corneal measurements dropped from 492.95 microns at baseline to 474.03 at one month, recovering to 490.61 at Woo Jyh Haur: woo.jyh.haur@snec.com.sg

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS

EUROTIMES | JULY/AUGUST 2017

www.eurotimesindia.org

CORNEA

DMEK: THEN AND NOW The surgical technique has advanced over the last decade.

Roibeard Ó hÉineacháin reports

T

he evolution of the Descemet’s membrane endothelial keratoplasty (DMEK) procedure since it was first introduced and performed by Gerrit Melles MD, PhD in 1998 and 2006, respectively, provides an illustration of how an initially very difficult technique for any surgeon can be transformed into an elegant technique that is safer and easier to learn and perform, said Lamis Baydoun MD, Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands.

At a Cornea Day session at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands, Dr Baydoun presented video clips of Dr Melles performing the procedure on the first DMEK patient in 2006 and contrasted it with another video clip showing the modern standardised iteration of the technique 10 years later.

In his early DMEK procedures, Dr Melles first did a ‘halfdepth’ limbal pre-incision of the main incision and used three side-ports for instrument insertion. Then he filled the anterior chamber with air, performed the descemetorhexis, the scoring and stripping of Descemet’s membrane in the same manner he had previously introduced for Descemet’s stripping endothelial keratoplasty (DSEK).

He would then complete the incision and use a prototype balloon pipette – somewhat analogous to a miniature turkey baster in design – to inject the scrolled Descemet’s membrane into the anterior chamber. Dr Baydoun noted that the pneumatic design of the injector meant that it provided little control during the injection. Once the graft was inside the anterior chamber, Dr Melles would flush it through the main incision (i.e. from inside the eye) to unfold it. As soon as a flange of the graft was unfolded, this part was lifted on to the posterior stroma by injecting an air bubble underneath.

In the current version of the procedure, Dr Melles and his associates do not perform a pre-incision, but only mark the incision at 12 o’clock. The following steps, i.e. creation of three side-ports and Descemetorhexis under air, have not changed. A main incision of 3.0mm x 3.0mm is then created to remove the detached tissue.

The now developed injector, consisting of a curved glass pipette attached to a syringe, similar in design to injectors for foldable intraocular lenses, allows for a very smooth and well-controlled injection of the graft. A main difference to the early DMEK procedures is that nowadays graft manipulation is performed in a ‘no-touch’ (i.e. indirect) fashion using an air bubble as an intraocular tool to manoeuvre and unfold the graft, while applying gentle pressure with a cannula from on top of the cornea (i.e. outside the eye).

As in the original procedure, they use an air bubble to lift the graft to the stroma, however this step is only fulfilled provided that the graft is completely or majorly unfolded.

“You can see how difficult it was to perform DMEK in the early days, compared to today,” Dr Baydoun concluded.

Lamis Baydoun: baydoun@niios.com; research@niios.com

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33

RETINA

34

ROBOTIC ASSISTANCE System offers improved accuracy and other advantages which can advance vitreoretinal surgery. Cheryl Guttman Krader reports

R

Courtesy of Preceyes BV

obotic assistance brings increased precision to vitreoretinal surgery which can enhance the success and safety of existing procedures and provide new interventional opportunities, according to Marc de Smet MD. Dr de Smet, co-founder and Chief Medical Officer of Preceyes BV, Eindhoven, The Netherlands, described a platform that his company has been developing over the last 10 years.

The PRECEYES Surgical System is comprised of a table-mounted instrument manipulator that holds the surgical instrument and copies the movements made by the surgeon using a second component, the motion controller. As designed, the compact system can be easily integrated into current operating room environments, and it can be utilised by surgeons without being intrusive while they are working in their standard position with existing operating microscopes or a heads-up viewing system.

The robotic arm filters out hand tremor and has scalable motion so that it moves faster when in the periphery and then more slowly as the instrument tip approaches the retinal surface. The system has positional precision of about 10 microns, which surpasses the accuracy limits of human physiologic performance by about 10-fold.

The PRECEYES Surgical System

EUROTIMES | JULY/AUGUST 2017

Because the robot can memorise the position of the instrument, the surgeon can transition to perform another task...

Marc de Smet MD

“Surgeons may ask if there is really a need for the better precision provided with robotic assistance. Testing shows that in the X-Y direction, humans are virtually as good as the robot regardless of experience, although younger individuals may perform better than their older colleagues. When moving in the Z direction and entering tissue, however, more experienced surgeons can do better than their less experienced colleagues, but a robot will still do best,” said Dr de Smet.

The system is designed to be ergonomic so that it can be utilised without any anatomic limitations in up to 98% of heads. So far, there is only an arm that allows a temporal approach, but development of a nasal arm will be an easy task, Dr de Smet said.

The robotic arm gives broad access into the eye and helps prevent some motion of the eye itself. The motion controller provides an intuitive working environment for the surgeon because it places the point of motion of the hand at the tip of the instrument located in the eye.

“The rotation point of the controller lies above the surgeon’s hand. It thereby creates the feeling of manipulating the instrument tip inside the eye and eliminates rotational force,” Dr de Smet explained.

The system also allows surgeons to rapidly change instruments while staying focused on the retina. It has positional stability and memory.

“Because the robot can memorise the position of the instrument, the surgeon can transition to perform another task and come back to a previous location,” added Dr de Smet.

CURRENT STATUS In September 2016 at John Radcliffe Hospital, Oxford, UK, Robert MacLaren MD used the PRECEYES Surgical System to perform the world’s first human robotassisted vitreoretinal procedure – an epiretinal membrane peel. Now funding is being sought to enable expansion of clinical testing to involve more patients, more centres, and additional applications, including procedures that are currently part of the vitreoretinal surgery repertoire and novel techniques.

As described in two published articles, the robotic system has been used successfully for retinal vein cannulation and intraluminal injection of ocriplasmin to release experimentally-induced vein occlusions in animal models. (de Smet MD, et al. PLoS One. 2016 Sep 27;11(9):e0162037. de Smet MD, et al. Release of experimental retinal vein occlusions by direct intraluminal injection of ocriplasmin. Br J Ophthalmol.

2016;100(12):1742-1746) Dr de Smet noted that further development of the robotic system includes work on imaging integration that may include visualisation capabilities built into the instruments themselves. He provided an example of a prototype in which movement of the robotic arm is controlled through referencing to landmarks on an optical coherence tomography image.

Marc de Smet: mddesmet1@mac.com

EURETINA Programme FPA

17th EURETINA Congress

TO BE APPROVED 7–10 September 2017

BY DARA

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

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

13.00 – 14.00

T.Y. Wong SINGAPORE

Continuous Microdosing with Intravitreal Corticosteroids: A Real-world Perspective in Patients with Chronic DME

Welcome and introductions

Moderators:

Real-world evidence: a valuable resource

H. Hoerauf GERMANY B. Corcóstegui SPAIN

Real World Evidence: Considerations for the Ophthalmologist Moderator:

Swept Source OCT & Angiography: Clinical Advances and Applications Moderators:

Aflibercept in the real world: the latest evidence from clinical practice

L. Arias SPAIN

Focusing on the patient: what to expect from RWE

Speakers:

Symposium summary

L. Arias SPAIN A. Adan SPAIN G. Anastassiou GERMANY J. Ruiz-Moreno SPAIN Sponsored by

Retinal Imaging – Pushing the Limits AngioPlex OCT-A Widefield and ultrafidefield imaging Multi – modal retinal imaging Sponsored by

Speakers: H. Hoerauf GERMANY A. Loewenstein ISRAEL F. Goñi SPAIN B. Pessoa PORTUGAL B. Corcóstegui SPAIN

Q&A session Sponsored by

Sponsored by

Friday 8 September

Friday 8 September

Friday 8 September

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

Aflibercept: Innovative Data and Emerging Evidence

Heidelberg Engineering Satellite Meeting

Moderator:

Sponsored by

M. Suárez de Figueroa Díez SPAIN

Welcome and introductions Aflibercept and the role of a multi-target approach to retinal disease Innovative imaging and functional outcomes with aflibercept Emerging clinical evidence with aflibercept

Utilising Ultra-Widefield Imaging - Clinical Applications and Practice Efficiency Moderator: P. Stanga UK P. Stanga UK

Symposium summary

Ultra-widefield imaging in the diagnosis and management of paediatric retinal diseases

Q&A session

E. Souied FRANCE

Using true ultra-widefield imaging for evaluating sickle cell retinopathy

Sponsored by

A. Joussen GERMANY

Managing Retinal Diseases with Ranibizumab: New Evidence Moderator: J. Monés SPAIN Speakers: U. Chakravarthy F. Holz GERMANY A. Koh SINGAPORE Sponsored by

UK

Peripheral retinal ischemia S. Sivaprasad UK

Measure of non-perfusion on ultra-widefield imaging S. Sadda USA

Re-engineering the classification & staging of diabetic retinopathy: implications from widefield imaging Sponsored by

New Views on the Retina with Multimodal Imaging: Integration of Correlating Structure, Function and Retinal Sensitivity Moderator: S. Rizzo ITALY Sponsored by

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

Saturday 9 September

Saturday 9 September

Saturday 9 September

Morning Symposia

Lunchtime Symposia

Lunchtime Symposia

10.00 – 11.00

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

Alcon Satellite Meeting Sponsored by

Advances in DME Treatment Moderator: I. Pearce UK Welcome and introductions

Impact of Geographic Atrophy: Enhancing Our Understanding of the Disease Moderator: J. Monés SPAIN Chair’s introduction

A New Chapter in Retina Surgery with Bausch + Lomb Moderator: S. Rizzo ITALY Sponsored by

R. Tadayoni FRANCE

Diagnostic paradigms of geographic atrophy

Challenges and innovations in diabetic retinopathy screening

N. Bressler USA

Measuring disease-specific functional outcomes

Ranibizumab for nAMD: New Evidence to Improve Patient Care

The importance of vision gains: a patient perspective

F. Holz GERMANY

Moderator: M. Figueroa SPAIN

Improving vision for patients: insights from the DRCR.net

U. Chakravarthy UK

Aflibercept: proactive treatment for long-term outcomes

Q&A

Geographic atrophy: a progressive disease Characterizing disease burden using real-world data

Sponsored by

Speakers: A. Loewenstein ISRAEL P. Mitchell AUSTRALIA R. Tadayoni FRANCE Sponsored by

Symposium summary and Q&A session Sponsored by

DORC Satellite Meeting Sponsored by

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RETINA

PHOTORECEPTORS New technology making reliable production of photoreceptors for transplantation a realisable dream. Roibeard Ó hÉineacháin reports

I

n vitro factories for producing replacement photoreceptors in eyes with retinal degenerative disorders are becoming an increasingly realistic possibility as stem cell technology continues to advance, according to presentations at the Retina 2016 meeting held in Dublin, Ireland.

The potential of the new technologies extends to several aspects of retinal disease. Apart from a cell replacement therapy in the more distant future, in the shorter-term stem cells and stem cellderived cultures may serve as a means of testing drugs and gene therapy in vitro, said David Gamm MD, PhD, Director of the McPherson Eye Research Institute at the University of Wisconsin, Madison, Wisconsin, USA. “Ultimately, all the applications of stem cell technology we can conceive of are predicated upon our ability to understand and perhaps even manipulate the developmental processes that occur in a dish. But what must first be ensured is the authenticity of the differentiated cell or tissue products,” he added.

Already retinal pigment epithelium (RPE) stem cell cultures are being used in clinical trials. However, compared to photoreceptors, RPE stem cells may be cultured, purified and manipulated with relative ease. In addition, unlike cultured RPE stem cells, photoreceptors mature in an environment that also contains other neuroretinal cell types, Dr Gamm said.

Originally, many centres used twodimensional plated protocols with either embryonic or human induced pluripotent stem cells (hiPSCs). However, cells cultured in this way failed to form distinct layers and also often contained undesired cell types.

EMBRYONIC CELLS Subsequently, Dr Gamm and others developed three-dimensional (3D) protocols where aggregates of embryonic cells or hiPSCs were started on a culture plate and then transferred to a suspension, or kept suspended throughout. That eliminated many unwanted cells, and research has shown that neuronal tissues grow better in 3D culture medium.

Using this approach, and other additional steps, they found that they could induce hiPSCs to differentiate into neuroretinal cells in a spherical layered configuration, resembling the natural retina. These layered structures are

These structures not only produce all major neuroretinal cell classes, but do so in a conserved spatio-temporal manner with the capacity to generate laminated neuroretinal tissue David Gamm MD, PhD sometimes referred to as optic vesicle structures, or retinal organoids.

“These structures not only produce all major neuroretinal cell classes, but do so in a conserved spatio-temporal manner with the capacity to generate laminated neuroretinal tissue,” Dr Gamm explained.

He noted that the advantages of the 3D hiPSC approach for neural retinal culture include greater neural retinal cell enrichment and the generation of tissue-like structures with advanced cell morphology and function.

However, the 3D approach at present is a cumbersome process requiring significant culture manipulation. In addition, scaling up the process remains a challenge to be met if the technology is to be used on a wide scale in the clinic or clinical laboratory, he said.

CONE IMPLANTATION Daytime vision is highly dependent on cone photoreceptors. Retinal degeneration resulting in their loss is a leading cause of blindness, said Robin Ali PhD, FMedSci, University College London, UK. A potential regenerative strategy for many forms of retinal diseases is the replacement of lost cone receptors by cell transplantation.

He noted that the subretinal space is very conducive to such an approach because it is a natural anatomical space and is accessible to surgery. In addition, the blood-brain barrier provides it with some protection from the host immune system.

Preliminary clinical trials involving transplanted human embryonic stem cell-derived RPE have so far shown safety and limited efficacy. Successful RPE stem cell transplantation requires only the formation of a functional monolayer of cells. Photoreceptor transplantation has the additional requirement of functional connectivity. Research is showing that this is feasible, Dr Ali said.

For several years, Dr Ali and his

associates have been characterising and optimising cone differentiation in cells from mouse and human embryonic stem cells (hESCs). They have been able to culture photoreceptors exhibiting conespecific phototransduction-related proteins. In 2006 they demonstrated that effective photoreceptor transplantation is possible in adult mice, provided the photoreceptor precursors are at a very specific stage of development.

“Although the effect was slight, it was an important proof-of concept. This knowledge might be used to generate appropriate cells for transplantation from stem cells,” he said.

ADDITIONAL DISCOVERY An additional discovery they have made is that much of the improvement in vision reported so far in laboratory animals has not been primarily due to integration of the cone photoreceptors, but instead appears to result from a transfer of RNA and/or protein material between the implanted cells and the remaining host cone photoreceptors.

However, a percentage of transplanted cells did integrate with the surrounding cells and expressed biomarkers for phototransduction. Dr Ali and his associates are investigating whether implantation at later precursor stages of cone cell development might yield a higher rate of integration.

“The exciting thing is that we are now able to do a lot of experiments with a purified population of human cones.

There is still a lot of work before we can go to a clinical trial but we are now defining a protocol to generate clinical grade cell lines and we are starting to work with larger animals. We expect clinical testing to begin in around five years,” Dr Ali added.

David Gamm: dgamm@wisc.edu Robin Ali: r.ali@ucl.ac.uk EUROTIMES | JULY/AUGUST 2017

39

17th EURETINA Congress 7–10 September 2017

EURETINA is delighted to announce the

6th Retina Race at the 17th EURETINA Congress in Barcelona

Date: Saturday 9 September, 6.30am Registration Fee: Ð30 in aid of Orbis Information at www.euretina.org

GLAUCOMA

THE BURDEN OF PACG Diagnosis and treatment earlier in the disease spectrum is important.

Cheryl Guttman Krader reports

A

lthough primary openangle glaucoma (POAG) affects nearly three times more people worldwide compared with primary angle-closure glaucoma (PACG), PACG accounts for half of the total cases of glaucoma-related blindness.

Those statistics about the burden of PACG underscore the importance of understanding that it resides at the far end of a progressive disease spectrum, and of identifying and taking care of patients at an earlier stage, according to John Thygesen MD, who delivered the keynote lecture, ‘Angle-closure: from suspicion to certainty’, at ESCRS Glaucoma Day 2016 in Copenhagen, Denmark.

He reviewed information on the epidemiology of angle-closure, its clinical features, classification, mechanisms, screening, diagnosis, and treatment, but began his lecture with two key messages.

“First, POAG is a diagnosis of exclusion.

That means gonioscopy must be done to exclude chronic angle-closure,” said Dr Thygesen, Clinical Associate Professor of Ophthalmology and Director of Glaucoma Services, Copenhagen University Hospital, Copenhagen, Denmark.

“Second, most cases of angle-closure are asymptomatic. Therefore, blindness develops in the setting of chronic angle-closure.”

DETECTION AND TREATMENT According to a consensus statement from the Global Glaucoma Network, evaluation of limbal anterior chamber depth may be an appropriate screening test for angleclosure. Gonioscopy, however, is essential for diagnosis and treatment. Dr Thygesen

Trabeculectomy is associated with a lot of emphasised that the examination should complications in eyes with ACG, including be performed in a nearly dark room an elevated risk of failure compared with its and using both a Goldmann lens and an use for POAG. indentation lens.

The EAGLE study addressed the need Treatment decisions for eyes with PAC/ for evidence about lens extraction as a PACG should be based on classification treatment for PAC/PACG. It enrolled using the newer classification system from patients with PACG with IOP >21mmHg the International Society for Geographical or PAC with IOP ≥30mmHg. Other and Epidemiological Ophthalmology eligibility criteria required angle(ISGEO). Unlike the previously closure, either appositional or used system that was symptomsynechial in 180° or more, based, the ISGEO system phakic status with absence describes the natural history, of cataract, age 50 years or staging, tissue damage older, and diagnosis within affecting visual function, and six months. mechanisms for angle-closure, The EAGLE study found Dr Thygesen said. that initial treatment with lens He encouraged clinicians to John Thygesen extraction was more effective and follow the European Glaucoma cost-effective than laser iridotomy Society Guidelines flowchart for with medical therapy. Based on treatment, and he reviewed the the outcomes, the investigators concluded indications, effectiveness and drawbacks of that lens extraction may be considered the various surgical treatment options for as an alternative to current practice, Dr PAC/PACG, citing the consensus statement.

Thygesen said.

Iridotomy or iridectomy is the preferred However, they also observed that there initial treatment for PAC and PACG. Argon is an increased risk of posterior capsule laser peripheral iridoplasty is indicated in rupture when performing lens extraction in eyes with plateau iris configuration where eyes with angle-closure, and that the results the angle cannot be opened by indentation, of EAGLE are not applicable to other types but patients must be counselled about its of PACs/PACGs. potential to cause permanent pupil dilation, Dr Thygesen noted that EAGLE had Dr Thygesen said. other limitations, and he cautioned that Anterior chamber paracentesis rapidly one good quality trial may not be enough lowers intraocular pressure (IOP) and to change policy. immediately relieves symptoms, as well “For sure we should still be doing as preventing further optic nerve and primary iridotomy. Cataract surgery alone trabecular meshwork damage secondary to may be considered in some mild cases, acutely elevated IOP. However, it can lead and the results of the EAGLE study say the to choroidal changes due to the sudden same. However, we do not need to do lens IOP decrease. extraction in all cases,” Dr Thygesen said.

Goniosynechialysis is an option for removing peripheral anterior synechiae of John Thygesen: john.thygesen@regionh.dk recent onset and if the cornea is clear.

CHINESE LANGUAGE EDITION NOW ONLINE Visit: www.eurotimes.cn EUROTIMES | JULY/AUGUST 2017

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42

GLAUCOMA

COMBINING PROCEDURES Multiple approaches may help – but patient needs, risks and benefits must be considered. Howard Larkin reports

C

ombining multiple procedures that reduce intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG) may be more beneficial than relying on one procedure alone. However, determining if a second procedure will further reduce IOP, or reduce it too much, can be difficult.

A clear understanding of the mechanisms of action, potential benefits and increased risks of combining glaucoma procedures, and how a specific combination addresses individual patient needs, are essential for success, say glaucoma researchers.

The classic IOP-lowering combined procedure involves adding trabeculectomy to phacoemulsification and intraocular lens implantation for patients with both cataracts and POAG. Phaco alone has been shown to reduce IOP, and trabeculectomy significantly increases the effect, reported Richard A Lewis MD, Sacramento, California, USA, at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago.

However, Dr Lewis no longer does combined phaco-trabeculectomy because the procedure is lengthy and more likely to involve complications than separating the two, and trabeculectomy often compromises the excellent visual acuity anticipated after phaco.

He also does not consider combining two glaucoma procedures, such as a shunt plus endocyclophotocoagulation, as viable combinations because it is impossible to tell if one or the other is working unless they are done separately.

Dr Lewis’s first choice in combined procedures today is phaco plus iStent® (Glaukos) or one of the other new minimally invasive glaucoma surgery (MIGS) options. These procedures are safer and less likely to compromise postoperative vision than phacotrabeculectomy, and are more effective than phaco alone, he said.

Dr Lewis noted that a three-year followup of 62 eyes in 43 patients receiving phaco plus iStent showed a mean IOP reduction of 8.4mmHg, or 36%, from preop medicated mean IOP, with 79% at less than 16mmHg. Glaucoma medications were also reduced by a mean of 1.7, and 74% of eyes were medication free, with a low incidence of complications (Neuhann T. JCRS 2015).

Similarly, FDA Phase III trial data for the CyPass® (Alcon) with phaco saw unmedicated mean diurnal IOP reduced 7.4mmHg compared with 5.4mmHg for phaco alone at 24 months, a 38% additional reduction with CyPass (p<0.001). Only 15% of CyPass eyes required medication compared with 41% of controls. Complications were low, with small increases in hyphaema and hypotony seen in CyPass-phaco eyes, though incidence was less than 3%. “These are minor compared with the IOP reduction benefit,” Dr Lewis said.

Richard K Parrish II MD, of the Bascom Palmer Eye Institute, University of Miami, USA, also cautioned against combining glaucoma procedures without a thorough understanding of the effects. Some combinations just don’t make much sense, he said.

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For example, a trabeculectomy or tube shunt typically have much more IOPlowering effect than an iStent or CyPass, so it probably is not helpful to add a MIGS device to a successful filtration procedure, Dr Parrish said. Combining a tube or trabeculectomy with a cyclodestructive procedure is risky, because it may reduce IOP too much by both increasing aqueous outflow and reducing inflow.

Dr Parrish also questioned combining stents with cyclodestruction. “If substantial IOP-lowering is the goal, then consider that a successful translimbal filtration or trabeculectomy will likely outperform the combination of any other two procedures,” he said.

Both Dr Lewis and Dr Parrish emphasised matching IOP-lowering procedures to patient needs, and considering both short- and long-term benefits and risks.

“Perhaps we should avoid the term ‘combo procedure’ and think of it in terms of doing what is right for the patient,” Dr Lewis added.

Dr Parrish noted that regulators may ultimately define combined procedures, at least as far as reimbursement goes. He noted that CyPass is only indicated in combination with phacoemulsification surgery under its recent FDA approval, and expects that future MIGS device approvals may carry similar limitations.

Richard A Lewis: rlewiseyemd@yahoo.com Richard K Parrish II: rparrish@med.miami.edu

ESCRS

Glaucoma Day 2017 Friday 6 October FIL â&#x20AC;&#x201C; Feira Internacional de Lisboa, Portugal Registration Open glaucomaday.escrs.org

Scientific Programme organised by

44

REGULAR OPHTHALMOLOGY PAEDIATRIC

MYOPIC ANISOMETROPIA SMILE garners interest because of safety advantages and yields positive initial outcomes. Cheryl Guttman Krader reports

E

arly experience indicates that small incision lenticule extraction (SMILE) performed with a proprietary femtosecond laser (VisuMax®, Zeiss) is a promising technique for correcting myopic anisometropia in children in order to facilitate treatment of amblyopia, according to Osama Ibrahim MD. Dr Ibrahim said he has performed 32 cases of SMILE to treat myopic anisometropia in children who were intolerant of glasses or contact lenses. He presented outcomes from follow-up to six months from data collected in 18 eyes that are part of a prospective, non-comparative, interventional case series.

Dr Ibrahim reported good predictability and stability for the refractive outcomes.

SMILE resulted in improvement in visual acuity, with some eyes even achieving full best spectacle-corrected visual acuity (BSCVA) correction, and no eye lost any lines of BSCVA compared with baseline.

POPULARITY “SMILE has demonstrated efficacy and safety for myopic correction in adults, but it has not gained popularity for use in children,” said Dr Ibrahim, Professor of Ophthalmology, Alexandria University, Alexandria, Egypt.

“Now we look forward to collecting more data from a larger series of paediatric eyes with longer follow-up, and also to the future availability of SMILE to correct hyperopia.”

Dr Ibrahim noted that the history of performing keratorefractive surgery in children to minimise amblyopia caused by anisometropia began with radial keratotomy (RK) and subsequently included the use of photorefractive keratectomy (PRK) and LASIK. “Compared with PRK, LASIK could treat higher refractive error, offered better refractive stability, and had less risk of causing haze and scarring. We have accumulated our own large series of LASIK for myopic anisometropia in children, showing that it improves uncorrected visual acuity and best corrected visual acuity,” he said.

He noted that SMILE, however, has advantages relative to LASIK. In addition to being less invasive, causing less dry eye, and offering better biomechanics, SMILE EUROTIMES | JULY/AUGUST 2017

avoids concerns about flap dislocation from eye rubbing or trauma, which is particularly important in children.

There is also less potential for risks when operating on an uncooperative child when performing SMILE, and so the procedure can be done with just sedation rather than general anaesthesia.

The patients in the series Dr Ibrahim presented ranged in age from six to 12 years.

SMILE was performed using local or general anaesthesia and was followed by patching of the dominant eye for a half-day.

MEAN BSCVA Preoperatively, mean cycloplegic sphere was -8.78D (range -6.50 to -14.00D), mean cycloplegic cylinder was -1.26D (range up to -3.00D), and mean BSCVA was 0.32 (range 0.05 to 0.4). At six months after SMILE, mean cycloplegic sphere was -1.28D (range +0.75 to -2.25D) and residual cycloplegic cylinder averaged -0.83D (range up to -1.75D).

Analysis of spherical equivalent outcomes showed a single eye was overcorrected, while 89% were within 0.5D of the attempted target.

“Our refractive outcomes are very good considering this is a population with high myopia. Some cases were left undercorrected, either intentionally

because of the refraction in the other eye or because of the correction limit of our nomogram,” Dr Ibrahim explained.

REFRACTIONS MEASURED The aim of refractive surgery for myopic anisometropia is not to reach emmetropia or eliminate the need for glasses. Rather it is to allow the child who is spectacle or contact lens intolerant to wear proper correction and do occlusion therapy, he explained. Refractions measured on the day after surgery and at six months were almost the same.

“Stability was a main concern because we have seen regression over time in children who underwent RK, PRK, or LASIK for treatment of myopia,” Dr Ibrahim said.

BSCVA at last follow-up averaged 0.74 with a range from 0.5 to 1.0. It was unchanged in 61% of eyes, while 16% gained one line, 16% gained two lines, and 5% gained more than two lines.

All eyes demonstrated topographic stability during the available follow-up, and review of the topography images showed the area of flattening was larger than the diameter of the lenticule. “This feature helps with visual quality and improvement in BSCVA,” Dr Ibrahim said.

Osama Ibrahim: ibrosama@gmail.com

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

E

r e p x

Re s e s i t

ides ALL Around th

www.wspos.org

e Wo

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46

GLOBAL OPHTHALMOLOGY

MOBILE EYE HOSPITAL Cataract train keeps track of hard-to-reach patients.

Leigh Spielberg MD reports

WSPOS A World Society of Paediatric Ophthalmology & Strabismus

SUBSPECIALT Y DAY Friday 6 October 2017

mobile hospital on a train can provide medical services in remote, inaccessible areas, Sunil Jain MD, Indira Gandhi Eye Hospital And Research Centre, Lucknow, India, told delegates at the XXXIV Congress of the ESCRS in Copenhagen, Denmark.

“The Lifeline Express, the world’s first hospital on a train, is helping us reduce the huge backlog of treatable cataract blindness across India,” he told a session dedicated to Orbis.

The train was launched by the Impact India Foundation.

Dr Jain shared the results of his team’s extensive experience on the Lifeline Express, which has performed over 75,000 cataract surgeries since 1991.

RURAL AREAS

Lisbon, Portugal Preceding the XXXV Congress of the ESCRS 7–11 October 2017

Registration Open

“The purpose of the mobile hospital is to provide on-the-spot, curative surgical treatment free of cost to the disabled poor in rural India, by utilising the entire Indian railway network.

As disabled and poor people in rural areas cannot reach a hospital, the hospital should reach them,” he said.

The train consists of five coaches, each of which has a specific function. There is a generator, a steriliser, two operating theatres and an auditorium coach, reserved for conferences and teaching moments.

Patients are screened by a medical officer and intraocular lens (IOL) power is calculated preoperatively by optometrists.

Postoperative steroid, antibiotic and cycloplegic drops are started the next day. “We perform small-incision cataract surgery with IOL implantation, after which the patients are moved to the postoperative ward,” said Dr Jain.

Surgery is performed inside the train itself, with the outpatient department and postoperative ward set up outside the train at scheduled stop locations. Each stop lasts for three to four weeks, during which approximately 600 cataract surgeries are performed.

The train is shared with several other subspecialties, covering orthopaedics, ear nose and throat pathology, plastic surgery, dental services, and health education and women’s health specialists.

COLLABORATIVE EFFORTS

www.wspos.org

EUROTIMES | JULY/AUGUST 2017

Several administrative tasks must be performed prior to the arrival of the train. These include selection and preparation of the local project site, including receiving permission from local authorities, and generating publicity and awareness via the media.

This preparation requires the collaborative efforts of the government, voluntary agencies, voluntary medical and paramedical professionals, sponsorship organisations and the Indian railways.

The ‘mobile hospital on a train’ concept has since been replicated, with four Lifeline Express trains in China, two in South Africa, as well as riverboat hospitals in Bangladesh and Cambodia. It provides a model for the many nations where a similar need for medical care in hard-to-reach places exists.

ASCRS

ESCRS

Practice Management

& Development

8â&#x20AC;&#x201C;9 October 2017 Lisbon, Portugal

Grow Your Practice Manage Your Business

Programme Practice Management Masterclass Sunday 8 October 09.00 – 18.00

Masterclass in Ophthalmic Practice Management with John Pinto and Corinne Wohl The effective management of an ophthalmology practice is nearly as intellectually challenging – and interesting – as the practice of ophthalmology itself. This practical day long course will be taught by two of America’s most active practice management advisors, with a combined 70 years of healthcare experience and hundreds of publications. John Pinto is the founder of J. Pinto & Associates, Inc., a 38-yearold ophthalmic management consulting firm based in San Diego, California. Corinne Wohl MHSA, COE, is President of C. Wohl & Associates, Inc., a practice management consulting firm in San Diego, California.

Practice Management & Development Programme Monday 9 October 08.00 – 18.00 Chairman: Paul Rosen UK Moderators: Kris Morrill FRANCE, Rod Solar

UK,

Ed Toland IRELAND, Paul McGinn IRELAND

Topics Include... 

Search engine optimisation and reviews to grow your practice



All digital practices



Presbyopia: How to increase your share of the market



Social media for ophthalmologists



Need-based marketing



Ambulatory surgeries: Your next step?



Influencer marketing for progressive ophthalmologists



The top 10 most common human resources mistakes

For full programme visit: www.escrs.org

EUROPEAN BOARD OF OPHTHALMOLOGY

EBOD HITS NEW HEIGHTS

Record-breaking number of candidates take part in this year’s examination. Dermot McGrath reports

I

nterest in the European Board of Ophthalmology Diploma (EBOD) examination continues to hit new heights, with a record-breaking 651 candidates from 27 European countries taking part this year.

“It is enormously gratifying to see so many candidates coming from all over Europe to take part in the examination. It shows the relevance and the value of the EBOD and underscores the European spirit that the EBO is so keen to promote,” said Dr Gordana Sunaric Mégevand, President of the European Board of Ophthalmology.

Held every year in Paris, the EBOD examination is designed to assess the knowledge and clinical skills required to deliver a high standard of ophthalmic care, both in hospitals and in independent clinical practices.

Dr Sunaric Mégevand paid special tribute to the 280 examiners from 27 countries who put the candidates through their paces during the examinations.

“The examiners have given so generously of their valuable time to come to Paris to ensure the success of the exam.

It is a very difficult task and the EBO is extremely grateful for your efforts.

Without your contribution, it simply would not be possible to host these exams every year,” she said.

Dr Sunaric Mégevand also thanked the French Society of Ophthalmology (SFO), which hosts the exam every year in conjunction with its annual meeting, as

EUROTIMES | JULY/AUGUST 2017

well as Laboratoires Théa for their active support over many years.

Addressing the assembled audience, Dr Pierre-Jean Pisella, President of the SFO, said that the French society remains deeply committed to the EBO exams and looks forward to hosting many more in the future.

The EBO exams also included the third subspecialty examination in glaucoma (FEBOS-Glaucoma Diploma), organised in collaboration with the European Glaucoma Society (EGS).

“The effort that has been made by the EBO to set a standard level of proficiency in knowledge in ophthalmology is truly laudable. I think this is a very important initiative that will ultimately benefit patients in the long-term,” said Prof Carlo Traverso, a member of the EGS Executive Committee.

The inaugural Peter Watson Medal, awarded for the best score in the FEBOS exam, went to Dr Pedro Faria from Portugal.

The 2017 Peter Eustace Medal, in recognition of service to the cause of European ophthalmic education, was awarded to British ophthalmologist Prof Roger Hitchings.

This year, Katja Matovic from Slovenia received the Alan Ridgway Award for best multiple choice questions (MCQs) result, while the award for Best Overall EBOD outcome was shared by four candidates: Celal Murat Hasanreisoglu from Turkey, Eliane Vogler from Switzerland, Marvin Marti from Switzerland, and Michal Post from Poland.

ROGER HITCHINGS HONOURED IN PARIS The renowned British ophthalmologist Roger Hitchings MD, FEBO was honoured at the European Board of Ophthalmology Diploma (EBOD) Awards Ceremony as the recipient of the Peter Eustace Medal, for his contribution to ophthalmic education in Europe.

“Prof Hitchings has been an inspirational figure for generations of young glaucoma specialists and doctors in Europe and around the world,” said EBO President Gordana Sunaric Mégevand.

She noted that Prof Hitchings, Professor Emeritus of Glaucoma and Allied Sciences at the University of London and honorary consultant ophthalmologist at Moorfields Eye Hospital, London, UK, has published numerous peerreviewed scientific papers in the field of glaucoma and has also served as a highly respected president of the European Glaucoma Society.

“I am particularly honoured to accept this award, because it is in fact the 25th anniversary of the founding of the EBO. This is clearly a landmark,” said Prof Hitchings.

Roger Hitchings receiving the Peter Eustace Medal from Gordana Sunaric Mégevand

Courtesy of Laboratoires Théa

Courtesy of Laboratoires Théa

EBO President Gordana Sunaric Mégevand speaking at the Awards Ceremony in Paris

PETER WATSON MEDAL Dr Pedro Faria from Portugal was the recipient of the first ever Peter Watson Medal for achieving the highest score in the glaucoma subspecialty examination.

The subspecialty exam in glaucoma, organised for the third consecutive year in close collaboration with the European Glaucoma Society (EGS), awards successful candidates with the Fellow of the EBO Subspecialty Glaucoma Diploma (FEBOS-Glaucoma Diploma).

For the first time this year, in memory and honour of Prof Peter Watson who passed away earlier this year, the EBO and EGS have decided to award the Peter Watson Medal to the candidate with the highest score in the exam.

Prof Watson held clinical appointments at Addenbrooke’s Hospital in Cambridge and Moorfields Eye Hospital in London, UK. His landmark textbook, The Sclera and Systemic Disorders, was first published in 1977.

“Prof Watson was a giant in ophthalmology in many fields and in particular glaucoma,” said EBO President Gordana Sunaric Mégevand.

Pedro Faria receiving the Peter Watson Medal from Gordana Sunaric Mégevand

Courtesy of Laboratoires Théa

50

EUROPEAN BOARD OF OPHTHALMOLOGY

A VERY IMPORTANT ROLE IN MY CAREER A

Katja Matovic, Slovenia, Winner of the Alan Ridgway Award

Katja Matovic

International training and observerships are strongly encouraged by Slovenian ophthalmology authorities, so it was highly recommended to take the EBO examination. Moreover, the EBO exam substitutes for the theoretical part of our national exam.

B

C

A

play a very important role in my ophthalmological career. My plan in the short-term is to secure a fellowship and implement the clinical skills obtained in daily practice.

Education is a lifelong pursuit and my goal is to continue to upgrade my knowledge in B in the years ahead.”

C ophthalmology

Passing the exam is required for further employment as a consultant, A which is often already lined up.

This puts on quite some pressure. The high pass rate may seem reassuring but it is stressful at the same time – nobody wants to be the one to go through the trouble twice.

However, the atmosphere of the exam was very pleasant and all B C of the examiners were extremely friendly and fair. So overall the EBO exam will remain a good memory.

I will be working at the University Hospital Zurich for another year and aspire to attain a fellowship abroad thereafter.”

Both the written and viva voce part of the examination were fair. The written exam was detailed but objective. In the oral examinations, all the examiners were kind and cases and discussions were interesting.

Not only was the exam a positive experience, but I believe the experience could

A VERY PLEASANT ATMOSPHERE Marvin Marti, Switzerland, Joint Overall Winner 2017 In Switzerland, the EBO examination is taken by all candidates after completion of their third year of residency as part of becoming an ophthalmology specialist/consultant.

Marvin Marti

A

B

C

TAKING THE EXAM WAS A SPECIAL EXPERIENCE Eliane Vogler, Switzerland, Joint Overall Winner 2017 The Swiss Board of Ophthalmology has replaced their board certification exams with the EBO examination, so we are obliged to take the EBO exam in order to get our licence.

I went to the exam with some good friends of mine from work and it was a special experience in that we all passed the exam and took our final step to becoming fully-qualified A ophthalmologists together.

For ophthalmologists who don’t need to participate at the exam, it is a great opportunity to train for their

board exams back home and get some experience, especially with the oral exams. Paris is also a lovely city in which to spend a weekend.

In July, I start as a senior physician B in Lucerne, Switzerland, with the C main focus on oculoplastics. For the near future I also intend to pursue a fellowship abroad.”

Eliane Vogler

ask the experts

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 | JULY/AUGUST 2017

51

52

BOOK REVIEWS

A GUIDE TO ARTIFICIAL VISION

BOOK

REVIEWS

IMAGES OF THE RETINA The Retinal Atlas: Second Edition (Elsevier), edited

by K. Bailey Freund, David Sarraf, William F. Mieler and Lawrence A. Yannuzzi, features more than 5,000 images covering the entire spectrum of PUBLICATION vitreoretinal disease, THE RETINAL ATLAS: from the macula SECOND EDITION through to the peripheral retina to EDITORS the vitreous and all its K. BAILEY FREUND pathologies.

DAVID SARRAF WILLIAM F. MIELER This 1,150-page LAWRENCE A. YANNUZZI textbook is a true atlas, a pure visual PUBLISHED BY ELSEVIER representation of the retina in all its states of health and disease. It is not intended to be a diagnostic or treatment manual. No systematic advice is given regarding differential diagnosis, ancillary testing or therapeutic interventions.

Instead, it is the ultimate visual reference guide. Each pathology has at least several clinical photographs, exposing the reader

to several variations possible in a single pathology. When relevant, fluorescein, autofluorescence, near-infrared, red-free, ICG and OCT images are included to provide a complete picture of the disease.

The excellent photographs are preceded by a very concise description of the pathology and are accompanied by short explanations of the salient features. Disease progression is often shown, such as the progressive development of a vascular shunt in ocular ischaemic syndrome.

More common diseases, such as central serous chorioretinopathy and MacTel type 2, are given a great deal more attention and space than rarities like Norrie disease, using the same logic used in an atlas of maps: frequently visited cities such as New York are displayed in more detail than a tiny town of less importance.

Purchase of the text allows access to the digital contents, which are accessible on all platforms on Inkling via Expert Consult.

This book is the ideal gift for (vitreo)retinal fellows who are just getting started and need to have all the visual information in one place for study sessions and rapid reference.

Others who might be interested are highly motivated general ophthalmologists and retinal researchers.

TREATING CYSTOID MACULAR OEDEMA If one would like to read a great deal more detail regarding specific diseases or complications, the Springer series provide a great place to start. Cystoid Macular Edema: Medical and Surgical Management (Springer), edited by Shlomit Schaal and Henry J. Kaplan, is a 230-page textbook entirely devoted to the often terribly frustrating phenomenon of CME. Divided into three parts, the book first outlines the pathophysiology and diagnosis of CME, including the disease mechanisms and the correct use of diagnostic imaging. Part II covers the medical management. This is organised by the primary problem causing the CME, such as uveitis, diabetes, vitreo-maculopathies and retinal vascular occlusions. Part III delves into the surgical management, essentially covering the same topics as Part II, but describing what should be done when medical management fails.

This text-heavy book is intended for those of us charged with treating patients with CME: retinal specialists and general ophthalmologists who would like to treat their patients rather than refer them elsewhere.

EUROTIMES | JULY/AUGUST MONTH YEAR 2017

No large retinal conference is complete these days without a fascinating presentation on retinal implants. Thus, another Springer guide that captured my interest is Artificial Vision: A Clinical Guide, edited by Veit Peter Gabel.

As with the Springer book on CME, reviewed above, this text is divided in to three parts. Part I is an introduction to the principles of functional assessment, outlining which patients are eligible, how prosthetic visual systems work and what patients and physicians can expect.

Part II is the most interesting. It is an extensive review of the retinal approaches to artificial vision. Each of the established implants has its own devoted chapter, including the following subsections: ‘principal idea’ , ‘indication’, ‘technical description’, ‘surgical methods’, and ‘clinical study’, which describes the results of all studies to date.

Part III covers the more exotic orbital and intracranial approaches now being studied.

This book is intended for young researchers, ambitious retina departments, and general ophthalmologists who understand the appeal of staying up-to-date.

KEEPING INFECTION OUTSIDE THE ORBIT I think it’s fair to say that ocular infections are near the top of every ophthalmologist’s list of ‘Please don’t let this happen to my patient’. Ocular Infections: Prophylaxis and Management (Jaypee), by Namrata Sharma, Neelima Aron and Atul Kumar, is a practical guide on how to keep the incidence of ocular infections in one’s practice as close to zero as possible.

This book “provides comprehensive information on operating theatre design and layout”, “highlights the methods of sterilisation and disinfection of… instruments”, “enlists the prophylactic measures to be taken… to prevent postsurgical infections”, and “provides step-bystep management protocols for the timely and proper treatment of postoperative ocular infections”.

This is a highly descriptive and concrete ‘how-to’ manual intended for surgeons or departments who are setting up a new operating theatre, renewing their procedures or reviewing their protocols.

It can also help increase compliance of assisting personnel through education, and thereby improve efforts to eliminate postoperative infections altogether.

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

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

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INDUSTRY NEWS

Membership POWERFUL DATA | CLINICAL TRENDS

INDUSTRY

NEWS

INTEGRATED LASER SYSTEM CLEARANCE OCULUS has announced that the wireless integration of the LENSAR® Laser System with the OCULUS Pentacam® HR and Pentacam® AXL tomographers has received FDA 510(k) clearance.

“The integration is based on the Streamline™ III software provided by LENSAR. The Streamline III’s IntelliAxis™ and astigmatic incisions are guided by Pentacam® parameters, helping to manage patients’ astigmatism,” said a company spokesperson.

This includes integration of complete corneal measurements, including total corneal refractive power and total corneal astigmatism; iris registration with automatic cyclorotation adjustment; IntelliAxis™ steep axis corneal marking; and arcuate incision planning leveraging pre-programmed and updated surgeon data. www.oculus.de

ASCRS Members receive the latest ophthalmic surgical news, research and resources.

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

DRUG DEVELOPMENT

SLT/YAG LASER

Novaliq GmbH has announced the successful application of a first-in-class ocular neuropathic pain and anti-inflammatory cannabinoid-based dry eye disease (DED) treatment approach, in collaboration with the University of Cologne, Germany.

“Based on solid results of our ongoing test series, we expect a significant impact of Novaliq’s first-in class Nov-07 programme, in comparison with existing DED drugs on an established DED mouse model,” said Philipp Steven MD, Principle Investigator, Ocular Surface Group at the Department of Ophthalmology, University of Cologne, Germany.

Ellex Medical Lasers showcased its newlylaunched Tango Reflex™ selective laser trabeculoplasty (SLT)/YAG laser alongside its other laser floater removal (LFR) innovations at the ASCRS•ASOA Symposium & Congress in Los Angeles, USA. “The unique LFR product portfolio includes the Ultra Q Reflex™, the world’s first and only YAG laser optimised for anterior and posterior YAG treatments; and the new Tango Reflex SLT/YAG multi-modality laser, a breakthrough in laser technology that provides surgeons with four treatment modalities (SLT, LFR, capsulotomy and iridotomy) in a single device,” said a company spokesperson.

www.novaliq.com

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

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ESCRS NEWS

ESCRS

NEWS

VIDEO PREVIEW FOR LISBON CONGRESS

REGISTER AND BOOK HOUSING ADDITIONAL PROGRAMS ASCRS REFRACTIVE DAY • APRIL 13 ASCRS GLAUCOMA DAY • APRIL 13 CORNEA DAY • APRIL 13 ASOA WORKSHOPS • APRIL 13 TECHNICIANS & NURSES PROGRAM • APRIL 14–16

AnnualMeeting.ascrs.org

EUROTIMES | JULY/AUGUST 2017

A video previewing the XXXV Congress of the ESCRS is now available on the society’s website.

The video features contributions from key opinion leaders including Richard Packard, Roberto Bellucci, Oliver Findl, Kaarina Vannas, Dan Epstein and Matteo Piovella, who explain why they look forward to the ESCRS Congress every year.

“The ESCRS Congress for me is the most important congress in the year,” said Dr Bellucci, past-president of the ESCRS, speaking in the new video. “Year by year, it took me through ophthalmology. It educated me to surgery, ultimately becoming the most important attraction to me.”

Dr Bellucci added that he was very much looking forward to the Basic Optics Course.

As Dr Vannas points out in the video, new online communication is becoming increasingly important at the annual congress. “Now at ESCRS, we have the possibility to get questions from the audience through an app which you can use in your telephone,” she said.

Dr Packard has run the Video Awards Session at the congress for many years. “I particularly enjoy chairing that session and interviewing the young people who have made these videos and who we give prizes to,” he said.

To view the video go to: www.escrs.org/lisbon2017 In addition, the ESCRS Player features a separate EuroTimes Eye Contact interview with ESCRS past-president Dr Paul Rosen and current ESCRS President Prof David Spalton previewing the forthcoming congress. To view the video go to: player.escrs.org/category/eurotimes-eye-contact

125 INSTRUCTIONAL COURSES SCHEDULED FOR LISBON AND PROGRAMME AVAILABLE ONLINE The programme of instructional courses for the ESCRS Congress in Lisbon is now available on the society’s website at: http://www.escrs.org/ lisbon2017/programme/ instructional-courses.asp Delegates planning to attend the congress can look out for the courses recommended for young ophthalmologists, and

courses which can be prepared for by using ESCRS iLearn at: elearning.escrs.org All instructional courses at the congress will be free of charge. It is not necessary to register for these courses.

EXPLORING BARCELONA

La Boqueria Market

Barcelona

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TO NOTE...

BARCELONA

AVERAGE SEPTEMBER TEMPERATURE: 26°C TIPPING: NOT EXPECTED, LEAVE SMALL CHANGE METRO: €2.15 FOR A SINGLE TICKET The Sagrada Família is Barcelona’s famous temple-in-progress. Begun in 1882, Antoni Gaudí’s extraordinary project is now more than 70% completed. The building was consecrated in 2010, though Mass is not yet regularly celebrated here. Since Gaudí’s accidental death in 1926, work has been carried on by consecutive teams of architects who have dedicated themselves to deducing how Gaudí’s design would have developed. Most of his plans were destroyed in the Spanish Civil War. Completion is expected in around 2026. Admission fees and private benefactors provide the funding. The Sagrada Família is Barcelona’s number one tourist attraction, so expect long queues. Plan ahead by buying a skip-the-line ticket online. For details visit: www.sagradafamilia.org A bustling temple to food, La Boqueria Market is more than just a market, it’s a cornucopia of produce, a hive of restaurants, and a social centre with scheduled events. It even hosts a cooking school. Take a four-hour course (in English) and learn how to prepare Gazpacho, Spanish Tortilla, Seafood Paella, Crema Catalana and Pa amb Tomàquet. You will be guided every step of the way, from choosing products in the market to the preparation. Then enjoy the meal. Book on the Boqueria website at: www.boqueria.info. Or let someone else do the cooking, and find a seat at one of the market’s 14 bars and restaurants.

Entrance at Rambla 91, Monday to Saturday, 08.00-20.30.

The Sardana, Catalunya’s traditional dance, has been an emblem of Catalunya’s national pride and defiance since the 19th Century. Banned

by Franco, the dance survived. Most Saturdays at 18.30 and Sundays at noon, a Sardana band assembles on the steps of Barcelona’s 15th Century cathedral. When the music begins, people in the square form circles by linking hands and then dance the slow and stately Sardana. Picasso called it ‘the communion of souls’. If you’re tempted to try (it looks easier than it is), just leave your coat and bags in the centre of one of the circles and join in.

A BEAUTIFUL CITY

Delegates to the 17th EURETINA Congress can enjoy some great attractions. Maryalicia Post reports TAKE A WALK

ADMIRE THE ARCHITECTURE

You won’t be in Barcelona long before you find yourself on La Rambla, the 1.2km pedestrian avenue that stretches from Plaça de Catalunya to Port Vell near the cruise port terminal. Join a never-ending stream of tourists, students and locals enjoying the human statues, bird stalls, flower shops and magazine kiosks. Stop for coffee at the historic Cafè de l’Òpera: www.cafeoperabcn.com Alternatively, stretch your legs on the Barceloneta promenade. Relax with a beer at the seaside, but if you’re hungry veer inland for something to eat at an authentic Barceloneta institution, La Cova Fumada.

No booking – either squeeze in at the bar or, if you want a table, give your name to the proprietor and wait to be called. Located at Carrer del Baluart 56, Barceloneta.

The incredible craftsmanship and refinement of Palau Güell will transport you to another era.

From the basement stables to the fancifully decorated chimneys, this masterpiece by architect Antoni Gaudí for the family of industrialist Eusebi Güell is one of the outstanding icons of Barcelona’s architecture. It is located just off La Rambla, at Carrer Nou de la Rambla. Tickets online at: www.palauguell.cat or at the office 20 metres from the entrance.

Gaudí wasn’t the only important architect in the Catalan Modernisme movement. The Palau de la Música Catalana is a testament to the artistry of Lluís Domènech i Montaner.

Like Palau Güell, this opulent concert hall has been declared a UNESCO World Heritage Site. Tours are conducted every 30 minutes daily from 10.00 to 15.30. For detail visit: www.palaumusica.cat/ca

VISIT A MUSEUM Pablo Picasso, who was born in Malaga, spent about 10 years of his adolescence and youth in Barcelona. In 1963, the artist oversaw the foundation of Barcelona’s Picasso Museum, a repository of his early works. Established in ancient buildings in the Gothic quarter, the capacity of the galleries is limited. Booking online is advised: www.museupicasso.bcn.cat/en The influential 20th Century artist Joan Miró was born in Barcelona. He also helped form a museum in the city to house his works. In 1975, the Fundació Joan Miró opened high on Montjuïc Hill in a light-filled building designed by the artist’s friend, Josep Lluís Sert.

Pictures, drawings, ceramics and graphics are exhibited, as well as a large tapestry, all made and donated by the artist. For details visit: www.fmirobcn.org

Palau de la Música Catalana

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CALENDAR

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LAST CALL

JULY 2017

MaculArt Meeting

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

AUGUST

ASRS Annual Meeting 2017 11–15 August Boston, USA www.asrs.org/ annual-meeting

EPOS 2017: 43rd Annual Meeting of The European Paediatric Ophthalmological Society 31 August–2 September Oxford, UK www.epos-focus.org/meetings www.epos2017.org

Paris will host the 3rd European Congress on Ophthalmic Imaging in October

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

Barcelona, host city of the 17th EURETINA Congress this September

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

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CALENDAR

DECEMBER

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

Budapest, which will host the 8th EURETINA 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

FEBRUARY

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

MARCH

Frankfurt Retina Meeting 2018 24–25 March Mainz, Germany www.eckardt-frankfurt.de

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

JUNE

WOC 2018

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

SEPTEMBER

SEPTEMBER

18th EURETINA Congress

NEW 2018 WSPOS Subspecialty Day

9th EuCornea Congress

XXXVI Congress of the ESCRS

20–23 September Vienna, Austria www.euretina.org

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

21 September Vienna, Austria www.wspos.org

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

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

Eye Contact Interviews

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Video of the Month

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Video Journal of Cataract & Refractive Surgery

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Young Ophthalmologists Videos: Early Cases with Expert Discussion Online Museum

Go to: player.escrs.org EUROTIMES | JULY/AUGUST 2017