EuroTimes Vol. 22 - Issue 9

SPECIAL FOCUS

RETINA

CORNEA

HOW NEW ENHANCEMENTS IN CXL CAN IMPROVE CURRENT STANDARDS

GLAUCOMA

OPTIC DISC PHOTOGRAPHY – IS THIS OBSOLETE OR STILL ESSENTIAL? September 2017 | Vol 22 Issue 9

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS RETINA 4 Robots can add a new dimension to retinal surgery

Colour and Print W&G Baird Printers

6 Major opportunities

Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org

8 Screening programmes

Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

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ISSN 1393-8983

can arise from magnifying surgery are effective in detecting diabetic retinopathy

11 Opthalmologica Update

FEATURES CATARACT & REFRACTIVE 12 Everything you ever wanted to know about brown cataract phacoemulsifaction – Part 2

19 Older patients may be

at risk of cataracts with certain lenses

20 Accommodating IOLs and contacts may be next in presbyopia treatment

www.eurotimes.org

26 JCRS highlights

P.42

27 New corneal inlay

technology shows promise

CORNEA 29 3D heads-up system

can help endothelial keratoplasty procedures

30 Corneal crosslinking may work best in tandem with other approaches

32 Options exist for treating astigmatism without the need for subsequent re-grafting

35 Scheimpflug device

40 The doctor’s dilemma:

provides solid measurements in dry eye patients

Dr Conor Lyons’s shortlisted essay for the John Henahen writing prize

36 Corneal refractive surgery does not raise the risk of progressive cell loss

GLAUCOMA 38 Is optic disc photography obsolete or does it remain essential?

41 Shifted perspective: Dr Rahil Chaudhary’s shortlisted essay for the John Henahen writing prize

REGULARS 42 Hospital diary

23 New techniques for

43 Industry news

measuring lens density can provide clearer images

45 ESCRS news 47 Book reviews

24 Why safety is paramount

48 Exploring Lisbon

in refractive surgery

25 Fluid-accommodating 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.

YOUNG OPHTHALMOLOGISTS

49 Random thoughts

lens provides high satisfaction after three years

50 From the archive 51 Calendar

P.36 EUROTIMES | SEPTEMBER 2017

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EDITORIAL A WORD FROM JAN VAN MEURS MD

INCREASED INTEREST EURETINA is an educational society and this continues to be its main focus

I

am delighted to write this editorial for the September issues and concerns of our trainees are heard. It must never issue of EuroTimes, which has a special focus on Retina. be forgotten that young ophthalmologists are the future of This issue coincides with the 17th EURETINA our society, and I very much welcome the YOURS initiative.

Congress in Barcelona, which convenes at the CCIB We also continue our Observership scheme to enhance the Barcelona from September 7–10. I will not say training experience of trainee too much about the Congress as many of you ophthalmologists.

While the annual Congress may receive the magazine after it has concluded, The 8th EURETINA Winter is the highlight of our year, but it is remarkable that, over years of continuing Meeting will take place in particularly because it growth, our annual Congress has become the largest Budapest on February 16 and offers the opportunity to retina congress worldwide.

17, 2018. We are pleased to While the annual Congress is the highlight of our announce a new format for our see and meet each other year, particularly because it offers the opportunity to winter meeting as the focus shifts in person, it should be see and meet each other in person, it should be pointed from research to updates on pointed out that EURETINA out that EURETINA has many other activities outside clinical topics. has many other activities of the Congress.

There are a lot of other activities outside of the Congress that I could mention, but pressure of space prevents me from doing EDUCATION AND RESEARCH so.

For all the latest news on EURETINA, I recommend that In recent years there has been an increased interest among you visit our website at www.euretina.org. You should also visit comprehensive ophthalmologists in the retinal field, with more www.eurotimes.org, which will feature reports from this year’s treatments available for diseases such as age-related macular Congress in Barcelona and other new initiatives. degeneration and branch retinal vein occlusion.

Finally, this Congress marks the end of my tenure as There are also some very exciting new developments in the President of EURETINA. It has been a huge honour to serve retinal subspecialty that are generating a lot of interest, such as our society and I am confident that Sebastian Wolf, our gene therapy, stem cell transplants and retinal prosthesis.

President Elect, will do an excellent job over the next two years.

EURETINA is an educational society and this continues I wish to thank all of my colleagues for their unstinting support to be our major focus. Let me take this opportunity to look and look forward to continuing to work with them in the future. at some of our major initiatives in the field of education and research. We are publishing EURETINA treatment guidelines for the major medical retina disorders, through our peerreviewed journal Ophthalmologica. We have already started a registry, in collaboration with the British and Eire Association of Vitreoretinal Surgeons (BEAVRS), to monitor vitreoretinal surgery, particularly retinal detachment surgery.

We have also launched a Young Retina Specialists initiative (YOURS), which allows young ophthalmologists under 40 to avail of free membership of EURETINA for three years.

YOURS will also provide a focus point to ensure that the

Jan van Meurs, President, EURETINA

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)

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SPECIAL FOCUS: RETINA

RISE OF THE MACHINES creating Robots add an extra dimension to retinal surgery, new possibilities. Roibeard Ó hÉineacháin reports

C

ontinuing refinements in engineering and the increasing capabilities of computers have given rise to robotic devices designed to manipulate surgical instruments within the eye. These new robotic systems offer the promise of allowing the performance of previously almost impossible procedures, while also EUROTIMES | SEPTEMBER 2017

adding a degree of safety and simplicity to the more common procedures.

Several teams around the world have been developing these new surgical systems, which range from more or less mechanical devices to computer-controlled systems with precision in the micron range. The system that is furthest advanced in terms of clinical use is the R2D2, short for robotic retinal dissection device, which

was developed by Preceyes BV, a medical robotics company based at the University of Eindhoven, The Netherlands.

Using the new robotic system, Robert E MacLaren MD, PhD, Professor of Ophthalmology at the University of Oxford, UK, performed the first ever robot-assisted operation inside the eye in September 2016. The procedure involved the removal of an epiretinal membrane

SPECIAL FOCUS: RETINA

INCREASED SAFETY Following the groundbreaking surgery, Dr MacLaren and his associates carried out a randomised controlled trial in which they performed epiretinal membrane removal in six patients with standard surgery and six patients with the R2D2 unit. They found that there was no statistically significant difference between the two approaches in terms of safety.

However, five of the patients in the conventional surgery group had microhaemorrhages, compared to only two patients in the robotic surgery group. There were also two instances of retinal touch in the conventional surgery group but only one such instance in the robotic group.

“The trial wasn’t really powered to show efficacy but there were clearly fewer instances of trauma and touching the retina in the robot group. The surgery in the robot group took longer to do, particularly in the first cases, because obviously we were going very carefully.

Things went more quickly in our last patients,” Dr MacLaren said.

The controller of the robotic system is essentially a pen suspended from a frame in such a way that, as the surgeon moves it, the motion is translated in a scalable

Images courtesy of Robert E MacLaren MD PhD

from the eye of a 70-year-old man with a macular hole. In an interview with EuroTimes, Dr MacLaren noted that the surgical robot added a new dimension to retinal surgery.

“The ability to limit the forward movement vertically – in the ‘z axis’ – provides a unique aspect to vitreoretinal surgery that we have not seen before with the manual approach. We can see the ‘x-y’ movements quite easily with conventional surgery, but we are still dependent on seeing retinal touch to know how deep we are. This is a critical factor that has only now become important for subretinal approaches, such as with retinal gene therapy. The robot has a huge advantage in this regard,” he said.

5

Robot training in Oxford preparing for the first surgery. From left to right, Dr Kanmin Xue MD PhD (Oxford surgeon), Dr Maarten Beelen PhD (Preceyes engineer), Dr Robert E MacLaren MD PhD (Oxford surgeon), Dr Tom Edwards MD PhD (Oxford surgeon) & Dr Gerrit Naus (Preceyes COO)

We can theoretically adapt it to virtually any kind of existing instrument for retinal surgery Marc de Smet MD, PhD fashion to the movement of the surgical instrument inside the eye, with a precision of 10 microns. Unlike manual surgery it is unaffected by any tremor of the surgeon’s hand, Preceyes’ Chief Medical Officer Marc de Smet MD, PhD told EuroTimes.

“We can theoretically adapt it to virtually any kind of existing instrument for retinal surgery. We are in the process of developing the software for a range of procedures, which would essentially simplify the vitreoretinal surgeon’s life by taking away some of the tedious and boring aspects of the surgery, and also take over those which require very high precision in surgery,” said Dr de Smet, MIOS, Lausanne Switzerland.

He added that unlike manual surgery, if the surgeon pauses to consider his or her next move, the instrument will remain in place until the procedure is resumed.

Similarly, because of the computerised navigation the system provides, when exchanging surgical instruments, it can return to almost the exact same location as it was before.

“Most of the surgeons that try our system will tell you that one of its advantages is that it removes stress, because you don't have to concentrate as much on avoiding steps that could potentially lead to complications,” Dr de Smet said.

Another aspect of robotic and information technology that has made significant advances in recent years is artificial intelligence. Artificial intelligence enables machines to learn through training and experience. That raises the question of whether some day robots like the Preceyes device will be able to perform entire procedures autonomously. However, Dr MacLaren says he thinks that there would always be a role for human surgeons.

“It may become technically possible, but I think we will always need someone to monitor what the robot does. We named our study the ‘robotic retinal dissection device’ (R2D2) trial, but even R2D2 was always under the watchful eye of a Jedi master,” he added.

Robert E MacLaren MD, PhD: enquiries@eye.ox.ac.uk

The R2D2 study team: Dr Marc de Smet (wearing name badge) is standing to the right of Dr Robert E MacLaren (arms folded)

Marc de Smet MD, PhD: marcdesmet@preceyes.nl EUROTIMES | SEPTEMBER 2017

SPECIAL FOCUS: RETINA

MAGNIFYING LENS High-add sectorial bifocal IOL provides improved vision and quality of life for patients with advanced AMD. Roibeard O’hEineachain reports

A

new, magnifying high-add intraocular lens (Lentis MAX LS-313 MF80, Oculentis, Germany) can enhance quality of life and improve the independence in performing daily activities for patients with progressed age-related macular degeneration (AMD), according to a study presented by Andreas F. Borkenstein MD at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“We can report very high levels of satisfaction with this new IOL. All patients ranked their quality of life better than before,” said Dr Borkenstein, who is cataract surgeon in private practice in Graz, Austria.

The case series study included 11 patients ranging in age from 74.5 to 86.1 years. All had clinically significant cataracts and progressed dry AMD. Their best corrected distance visual acuity (BCDVA) ranged from 0.9 to 0.5 logMAR and a best corrected near visual acuity (BCNVA) of 1.3 to 0.5 logMAR, he noted.

All had stable OCT findings for three months preoperatively. No patients in the study had wet AMD with active neovascularisation or cystic oedema. Other exclusion criteria were glaucoma, astigmatism greater than 1.0D and high ametropia.

All patients underwent phacoemulsification and implantation of the new magnifying IOL in their better eye, Dr Borkenstein said. The foldable one-piece lens is composed of copolymer acrylic consisting of hydrophilic acrylates with a hydrophobic surface.

The UV absorbing lens has a 360° square edge technology (optic and haptic) for PCO prevention and can be implanted through 2.2mm clear cornea incisions.

The sectorial bifocal acrylic lens has an aspheric bi-convex design with an add power of 8.0D, equating to 6.0D on the spectacle plane. That, in turn, corresponds to a 1.5 times magnification at a distance of 25cm to 30cm and a three times magnification at 12cm to 15cm, Dr Borkenstein explained.

IMPROVEMENT IN UNCORRECTED VISION All patients had an immediate improvement in their uncorrected visual acuity (VA) after surgery. At the threemonth control exam VA ranged from 0.48 logMAR to 0.2 logMAR, compared to a range of BCDVA 0.9 logMAR to 0.5 logMAR preoperatively.

Uncorrected near visual acuity (UCNVA) also improved significantly but required more time to take effect, because of the training and neuroadaptation patients required to become accustomed to the IOL’s bifocal optics.

At three months followup, UCNVA ranged from

We believe major opportunities arise from a new subcategory in cataract surgery, let’s call it ‘MAGS – magnifying surgery’ as cataract surgeons love acronyms

EUROTIMES | SEPTEMBER 2017

Andreas F. Borkenstein MD

Courtesy of Borkenstein & Borkenstein

6

0.98 logMAR to 0.6 logMAR compared to the preoperative range of 1.0 to 0.8 logMAR. By six months follow-up, their mean UCNVA ranged from 0.9 to 0.4. Furthermore, continued improvements in UCNVA were also evident from the patients’ increasing ability to perform many tasks that they were unable to perform previously, as they reported in their responses to a questionnaire.

Prior to surgery and at six months follow-up Dr Borkenstein and his associates presented a list of 10 everyday activities to the patients, who indicated which they were capable of performing independently. They included normal activities such as reading, eating and cooking, attending to personal hygiene and using a phone.

He noted that on a scale of zero to 10, with 10 indicative of best autonomy and zero indicative of the worst, the patients had a mean score of 4.3 (range 2-6) prior to surgery, compared to a mean score of 8.0 (range 3-9) three months after surgery.

By six months after surgery their score improved still further, to 8.8 (range 5-10).

Moreover, at six months follow-up all 11 patients rated their subjective well-being as better than before. Seven patients felt it was “very clearly better”, three felt it was “clearly better” and one said it was “highly better”.

Dr Borkenstein noted that one of the goals of the study was to change conventional thinking with regard to patients with advanced AMD. He pointed out that AMD affects 35 million people worldwide and is the most common cause of central vision loss in people older than 65. However, practising ophthalmologists commonly tell their patients with advanced disease that there is nothing they can do for them and cataract surgery is a contraindication. What an absurd thought!

“There are thousands who have to wait for death for a release. In our opinion, it is time for the antiquated mindset regarding these hopeless cases to change. We believe major opportunities arise from a new subcategory in cataract surgery, let’s call it ‘MAGS – magnifying surgery’ as cataract surgeons love acronyms,” he smiled. “We can’t look away any more. We have to realize that people with advanced AMD live longer nowadays and deserve closer attention,” he emphasised.

Andreas F. Borkenstein: crustalith@gmx.at

18TH EURETINA

CONGRESS

VIENNA 20-23 SEPTEMBER

2018 www.euretina.org

SPECIAL FOCUS: RETINA

DIABETIC RETINOPATHY Screening programmes are effective in detecting early sight-threatening eye disease. Dermot McGrath reports

N

ew imaging technologies as well as advances in big data processing and increased internet access all have the potential to further improve current methods of screening for diabetic retinopathy, according to Andrzej Grzybowski MD, PhD. “Diabetic retinopathy (DR) screening programmes are effective in detecting early sight-threatening DR. We are seeing a trend towards more telemedicine applications with improved imaging technologies, automatic assessment of fundus photographs, and more individualised risk assessment. When properly implemented, all of this can dramatically lower the cost of DR screening and make it possible to offer treatment to diabetic patients around the world at manageable costs,” he told delegates attending the European Society of Ophthalmology (SOE) 2017 Congress in Barcelona, Spain.

In an overview of current DR screening programmes in Europe, Dr Grzybowski, Professor of Ophthalmology at University of Warmia and Mazury, Olsztyn, Poland, and Head of Department of Ophthalmology at Poznan City Hospital, Poznan, Poland, said that there was considerable disparity in the methods used from one country to another.

While the gold standard for retinal diabetic photography is seven-field stereo colour ETDRS, this type of fundus photography is time-consuming, expensive, and requires an experienced photographer, noted Dr Grzybowski. Digital photography of the eye seems to be the more efficient and costeffective method of screening, he added.

In England, for instance, the DR screening programme started in 2006, and covers all diabetic patients aged 12 years or older with light perception or more in at least one eye. Screening is performed annually at static and mobile screening locations using digital fundus cameras. The protocol consists of two-field colour eye fundus photographs: one of the macula centre and one of the optic disc centre taken after pupil dilation. Retinal photographs are read in a few centralised grading centres.

References on request

In France, the first tele-medical screening for DR started in 2002 in the Paris region.

A fundus camera was used by orthoptists to capture five-colour photographs of 45 degrees of the central and peripheral retina, with the images sent via internet to a grading centre for assessment. This was followed by OPHDIAT, a tele-medical network screening system for DR in the Île-de-France area.

This system used 16 peripheral screening centres equipped with non-mydriatic cameras, where fundus photographs taken by technicians were linked by telemedicine to a reference centre, where ophthalmologists graded the images. During a 28-month evaluation period of OPHDIAT, 15,307 DR screening examinations were performed.

Retinal photographs of at least one eye could not be graded in 1,332 patients (9.7%), and diabetic retinopathy was detected in 3,350 patients (23.4%).

After the screening examination, 3,478 patients (25.2%) were referred to an ophthalmologist for either DR, cataract, and/or non-gradable photographs.

In Spain, Andonegui et al conducted a 24-month DR screening study based on digital retinal images taken and initially graded by trained general practitioners.

When the interpretation of pictures was

We are seeing a trend towards more telemedicine applications with improved imaging technologies...

Andrzej Grzybowski MD, PhD EUROTIMES | SEPTEMBER 2017

uncertain, the GPs sent the patient to the ophthalmologist to assess retinal status. The study authors concluded that proper training for GPs can significantly improve DR screening and help to save patients’ sight.

In Ireland, a community-based initiative was established in 2010 involving GPs, local optometrists and ophthalmologists to screen patients older than 18 years of age with type 1 or 2 diabetes using digital fundus cameras. Two-field photos of the retina (macula and optic disc) were graded by specialist software and the results were sent electronically to GPs who were responsible for referral to ophthalmic specialists.

The study, which was performed from January until June 2011, found 26% of patients with DR and highlighted the need for a national DR screening programme in Ireland, said the authors.

Having studied DR screening programmes around the world, Dr Grzybowski said that clear conclusions could be drawn from the experience of different countries in drawing up more efficient and effective programmes.

“It is clear that single-field non-mydriatic monochromatic digital photography is a sensitive and specific alternative to the traditional reference standard of seven-field stereoscopic colour fundus photography and ophthalmoscopy. Trained graders remotely interpreting non-mydriatic images achieved greater sensitivity than ophthalmoscopy and comparable results with seven-field photography,” he said.

Andrzej Grzybowski: ae.grzybowski@gmail.com

Courtesy of Andrzej Grzybowski MD, PhD

8

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th EURETINA

Winter Meeting

16–17 February 2018 Budapest, Hungary

www.euretina.org

SPECIAL FOCUS: RETINA

OPHTHALMOLOGICA VOL: 238 ISSUE: 1-2

AREDS IN REVIEW The current issue of Ophthalmologica includes the text of the Kreissig lecture delivered by Emily Chew MD at the 16th Congress of EURETINA. In a wide-ranging discussion, she reviewed the evidence from the Age-Related Eye Disease Study (AREDS) and AREDS2 trials, which showed that supplementation with antioxidant vitamins and minerals can significantly slow the progression of the disease age-related macular degeneration (AMD). The AREDS2 data showed that lutein and zeaxanthin are an effective alternative to the betacarotene and, unlike beta-carotene, are safe for smokers and former smokers. The AREDS2 results also showed that omega-3 long-chain polyunsaturated fatty acids had no beneficial effect on AMD. Dr Chew adds that, as yet, genetic testing prior to administering AREDS supplements has not proved clinically useful. E Chew, “Nutrition, Genes, and Age-Related Macular Degeneration: What Have We Learned from the Trials”, Ophthalmologica 2017, Volume 238, Issue 1-2.

DIFFERENT MORPHOLOGY FOR HIGH-RISK CARRIERS Early-stage AMD patients who are homozygous for the CFH gene and/or the ARMS 2 gene appear to have different disease characteristics than those without the genes. Among 85 patients with early AMD, spectral domain optical coherence tomography (SD-OCT) showed lower retinal thickness in patients homozygous for CFH or ARMS2. The reduced thickness was caused by a significantly reduced photoreceptor layer, which corresponded to reduced retinal sensitivity detected with microperimetry. The number and ultrastructure of drusen also differed significantly between the groups. M Oeverhaus et al, “Genetic Polymorphisms and the Phenotypic Characterization of Individuals with Early Age-Related Macular Degeneration”, Ophthalmologica 2017, Volume 238, Issue 1-2.

PORTABLE FUNDUS CAMERA PROVIDES GOOD-QUALITY IMAGES A new study suggests that well trained paraprofessional health care staff can obtain high-quality images with a portable nonmydriatic fundus camera. The study compared the quality of mydriatic and non-mydriatic fundus images taken with a Smartscope camera (Optomed) with that of mydriatic fundus images taken with a Topcon tabletop fundus camera (Topcon).

Two retina specialists graded a total of 2,475 images obtained from 275 eyes of 155 participants. They found that they could reliably grade 76.2% of the Smartscope non-mydriatic images, 90.1% of the Smartscope mydriatic images and 92.0% of the Topcon mydriatic images. Excluding eyes with cataract or vitreous haemorrhage, the proportion of non-mydriatic macular images they could grade improved to 94.6%. J R Davila et al, “Predictors of Photographic Quality with a Handheld Nonmydriatic Fundus Camera Used for Screening of Vision-Threatening Diabetic Retinopathy”, Ophthalmologica 2017 Volume 238, Issue 1-2.

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

EUROTIMES | SEPTEMBER 2017

11

12

CATARACT & REFRACTIVE

CHOP TECHNIQUES FOR

BROWN CATARACTS Everything you ever wanted to know about brown cataract phacoemulsification – Part 2.

Dr Soosan Jacob Reports ard cataracts require various means to chop them, and the final choice is dependent on surgeon skill, experience, comfort level as well hardness of nucleus. This article is the second instalment of a two-part series on brown cataract phacoemulsification, and deals with various chop techniques that can be used for nuclear disassembly.

DIVIDE AND CONQUER: Described by Shepherd and Gimbel, after nuclear rotation, two cross-grooves are created by sculpting using moderate flow, low vacuum, and continuous ultrasound power. Harder nuclei require higher power to avoid zonular stress. Downslope sculpting is followed by upslope sculpting until a clear red reflex is seen. A groove depth of approximately three phaco tips is generally adequate. Once both grooves are created, the nucleus is cracked into four quadrants, either by conventional cracking, when incisions are at an acute angle to each other, or by cross cracking when, incisions are at 90 degrees to each other.

Each quadrant is then emulsified.

Fig: Terminal chop technique: A: The phaco probe embeds at the equator superficially; B: The blunt olive-tip chopper performs a horizontal chop (Images courtesy Rajendra Prasad, MD). Stop and Chop: C: An initial trench is created and chopped; D: The nucleus is rotated and the crack is completed from the other side. Smaller fragments are then directly chopped

CRATER-AND-CHOP: Described by Vanathi M et al for large, hard, leathery brown nuclear cataracts, a large, approximately 6.0mm diameter crater is first created, leaving an outer nuclear rim.

The edge of the crater is held using high vacuum, and small wedge-shaped pieces are created with a chopper. These small pieces are then emulsified in the endocapsular space created by the crater.

NO VACUUM CHOP: Described by Pezzola, similar to the crater and chop technique, a central crater is first created to obtain a peripheral ring of nucleus. Horizontal chop is then done without using vacuum to hold the nucleus.

EUROTIMES | SEPTEMBER 2017

The peripheral rim is impaled between the phaco probe and the horizontal chopper and chopped using mechanical forces. Avoiding vacuum obviates loss of occlusion and surge.

may be introduced to hold the nucleus at the equator, if excessive resistance is felt during insertion of the prechopper, the pre-chop should be abandoned.

PRECHOP:

Described by Nagahara, the phaco tip is embedded into the nucleus in the superior half, and a long chopper is used to score and crack the nucleus by moving it upwards from around the equator at 6 o’clock position towards the phaco tip.

Once it reaches close to the phaco tip, it is moved laterally towards the non-dominant hand to split the nucleus into two halves.

Described by Akahoshi, the prechopper is utilised to split the nucleus in two, thereby decreasing the amount of phaco power used within the eye. However, in hard nuclei, burial and separation can be difficult, and excess stress may be translated by this manoeuvre to the zonules. Though a supporting instrument

NAGAHARA’S HORIZONTAL CHOP:

CATARACT & REFRACTIVE This is repeated to get smaller fragments. A blunt chopper such as the Chang modified microfinger can be used for this.

Though this technique can be performed with hard nuclei, care should be taken as the amount of epinuclear cushion for the chopper is less or absent, depending on the density of the nucleus.

Inadvertent placement of the chopper in the supracapsular plane can damage the capsulo-zonular apparatus, and care should be taken to ascertain that the chopper has been placed below the anterior capsule.

STOP AND CHOP: Described by Douglas Koch, a longitudinal groove is created using settings for sculpting as previously described, and the nucleus is divided into two. This initial sculpting and the crack formed creates space within the capsular bag, making further disassembly of the nucleus easier. The surgeon is then able to get a deep enough grasp of the heminucleus to make subsequent nuclear disassembly by chopping easy.

CHOO CHOO CHOP AND FLIP: Described by Howard Fine, this uses burst mode to impale the endonucleus, thus reducing cavitation around the phaco tip and giving a better hold. The chopper is then used to perform a horizontal chop. After nucleus removal, the remaining epinucleus is flipped out of the bag and removed.

VERTICAL CHOP:

TERMINAL CHOP TECHNIQUE:

Described by Fukasaku and Dillman, the phaco tip embeds and holds the nucleus up while a sharp chopper depresses into the nucleus to cleave it. In dense nuclei, if the crack has not propagated through the other side, the nucleus is rotated 180 degrees and chopped from the opposite side.

Described by Rajendra Prasad, this variant of horizontal chop impales the phaco probe superficially, just within the equator. The equator of the nucleus is then slightly drawn within the capsulotomy edge and a specially designed wedge-shaped blunt olive-tip chopper is used to perform a horizontal chop. It generates tension at the sides of the groove and initiates a full-thickness nuclear crack, which propagates to the equator on the other side, breaking the nucleus in two on laterally separating both instruments.

It has the advantage of bypassing central trenching, drilling and cratering, which require high-intensity phaco forces and stressful manipulation. In hard cataracts, it should be done with care, and capsulozonular damage should be avoided.

WOODCUTTER TECHNIQUE: Described by Vikas Mahatme, the chopper is buried into the nucleus near the rhexis margin at 6 o’clock. With phaco on in continuous mode, the phaco probe is moved towards the stationary chopper. As the phaco tip reaches near the chopper, the nucleus splits in two, similar to a woodcutter hammering the axe towards a chisel that has been wedged in at one end of the log.

STEP-BY-STEP CHOP IN SITU AND LATERAL SEPARATION: Described by Vasavada et al, a trench or crater is created following which a vertical chop manoeuvre is performed after embedding the phaco probe in the depth of the trench at 6 o’clock. The initial partial crack produced is made full thickness by repositioning the chopper deeper, and this is repeated all along the length of the crack to get a complete separation. The phaco probe holds the nucleus all through the chopping manoeuvres.

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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26.07.2017 14:38:342017 EUROTIMES | SEPTEMBER

13

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

n

What Can We Learn from Patient-Reported Outcome Measures

n

Corneal Measurements and Their Effect on Toric IOL Power Calculations

Highlights n

‘Best of the Best’ Review Session

n

Poster Village

n

Young Ophthalmologists Programme

n

125 Instructional Courses

n

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

Boxed Lunch Included

Boxed Lunch Included

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

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

Moderator: P. Versace AUSTRALIA

Moderator: B. Dick GERMANY

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

M. Piovella ITALY Today’s cataract patients: aligning options, expectations & outcomes

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New Strategies in the Treatment of Dry Eye Disease and Blepharitis Moderator: C. Cursiefen GERMANY

B. Dick GERMANY Patient identification & care with a new EDOF IOL E. Fabian GERMANY IOL evolution: clinical experience with next generation EDOF lens H.B. Fam SINGAPORE The influence of posterior corneal surface data on IOL power calculation accuracy O. Findl AUSTRIA Improve outcomes & avoid errors: the importance of biometry for today’s cataract patients Sponsored by

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

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

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FEMTO LDV Z8 – Always by Your Side Moderator: T. Seiler SWITZERLAND Speakers: T. Seiler SWITZERLAND B. Malyugin RUSSIA J. Mehta SINGAPORE R. Menapace AUSTRIA T.G. Seiler SWITZERLAND B. Pajic SWITZERLAND Sponsored by

Saturday 7 October

Evening Symposium 18.00 Next Generation Cross-Linking Applications Moderator: R. Rajpal USA Sponsored by

Sunday 8 October

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00

Sunday 8 October

Sunday 8 October

Lunchtime Symposia

Lunchtime Symposia

13.00 – 14.00

13.00 – 14.00

Boxed Lunch Included

OCT Angiography for First-Time User Moderator: C. Holzhey GERMANY

Boxed Lunch Included

Optovue Satellite Meeting Sponsored by

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MIGS Satellite Symposium Moderator: D. Lubeck USA Sponsored by

Taking Vision Further with Innovative Refractive Solutions Moderator: S. Ganesh INDIA J. Ball UK Corneal refractive surgery – a suitable option for presbyopic patients R. Morris UK PRESBYOND: a personal decision process J. Gertnere LATVIA Five years long-term results with SMILE J. Vukich USA The future of LVC: clinical & practice management considerations S. Ganesh INDIA First experiences with SMILE for treating hyperopia within an international multicenter study Sponsored by

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

New Frontiers in IOL Prediction for Improved Refractive Outcomes Moderator: S. Srinivasan UK Speakers: W. Hill USA A. Abulafia ISRAEL D. Goldblum SWITZERLAND L. Robledo SWITZERLAND Sponsored by

Quality of Vision with MINI WELL Extended Depth of Focus IOL: What’s New? Moderator: G. Auffarth GERMANY V.J. Camps SPAIN Assessment of previous refractive surgery effects for MINI WELL: in vitro simulations D. Tognetto ITALY The international multicenter FOCUS trial: aim and design O. Moraru ROMANIA Visual Performance in cataract patients: study outcomes G. Auffarth GERMANY Patients satisfaction in cataract patients: study outcomes H. Bissen-Miyajima JAPAN Clinical outcomes in Asian eyes: personal experience

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Alcon Satellite Meeting Sponsored by

Simplified Management of the Cataract Patient Moderators: M.J. Tassignon BELGIUM A. Behndig SWEDEN V. Daien FRANCE Big Data: an innovative approach to assess efficacy and safety of intracameral cefuroxime D. Kęcik POLAND Return on experience & surgeon’s satisfaction from the first IC combination of mydriatic & anaesthesic M. Labetoulle FRANCE, M.J. Tassignon BELGIUM, A. Behndig SWEDEN Daily use of Mydrane is a new efficient tool for the surgeons J. Güell SPAIN The advantages of the drop less management in cataract surgery Sponsored by

360 Degrees of Glaucoma Management: Novel Automated Gonioscopy and OCT / OCT-Angiography Moderator: C. Traverso ITALY C. Traverso ITALY Automated gonioscopy: a picture is worth more than words - gonioscopy as a clinical tool L. Pinto PORTUGAL Automated gonioscopy: a picture is worth more than words - pros and cons of goniophotography H.F. Gomez COLOMBIA OCT clinical application in the daily practice Sponsored by

Sunday 8 October

Evening Symposium 18.00

Monday 9 October

Monday 9 October

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13.00 – 14.00

13.00 – 14.00

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Boxed Lunch Included

Alcon Satellite Meeting Sponsored by

Monday 9 October

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Perform Without Limits: Making Glaucoma Surgery Intuitive with the Kahook Dual Blade Moderator: K. Mansouri SWITZERLAND Speakers: M. Kahook USA M. Economou SWEDEN Sponsored by

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

Dry Eye Disease: From the Science to the Clinic Moderator: J. Murta PORTUGAL

Clinical Frontiers in Ocular Surface Disease and Glaucoma

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Moderator: B. Cochener FRANCE

iolAMD Satellite Meeting Sponsored by

Alcon Satellite Meeting Sponsored by

H. Dua UK Inflammation in ocular surface disease: from diagnosis to treatment A. Brezhnev RUSSIA Optimizing control of intraocular pressure in glaucoma: what are the challenges?

Laser Floater Removal Satellite Symposium

C. Baudouin FRANCE Concurrent ocular surface disease and glaucoma: lessons from the clinic

Moderator: D. Lubeck USA

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CoEnzyme Q10: New Approach in the Treatment of Corneal Damage and Glaucoma Moderator: L. Schmetterer AUSTRIA S. Ahmad UK CoQ10 and mitochondrial function: what is their role in ocular diseases?

P. Aragona ITALY Cross-Linked HA and CoQ10: their impact in dry eye disease & ocular surface damage B. de Castillo SPAIN CoQ10 and surgery: its benefits in corneal regeneration F. Cordeiro UK CoQ10 and glaucoma: evidence and effects in the preservation of Retinal Ganglion Cells Sponsored by the eye health company

The ORBIS Symposium 2017: The Global Challenge of Corneal Disease Moderator: R. Walters UK R. Walters UK Introduction S. Holland CANADA Corneal disease: epidemiology, prevention and treatment. Update on corneal transplantation M. Montoya USA Eye banking and future challenges Questions and discussion Sponsored by

CATARACT & REFRACTIVE

PHAKIC IOLS POSE A RISK Iris-fixated IOLs may compromise crystalline lenses in older patients.

Roibeard Ó hÉineacháin reports

O

lder myopic patients who undergo implantation of Artisan/Verisyse (Ophtec/ AMO) phakic intraocular lenses (IOLs) are at a high risk of developing cataract within 10 or 15 years, according to Gré PM Luyten MD, PhD, Leiden University Medical Centre, The Netherlands.

A review of 493 eyes that underwent myopic Artisan implantation at his centre from 1996-2015 showed that within 15 postoperative years, half of the patients who were 55 years or older at the time of their procedure underwent cataract surgery, Dr Luyten told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

By comparison, none of the patients younger than 40 years of age at implantation developed cataracts within the same period, he noted. Overall, the rate of cataract surgery was 3% after five years, 11.6% after 10 years, and 34% after 15 years.

The procedures were necessary in 28 of 222 patients in the 40 to 55 years age group, and 10 of 108 patients in the 55 years and older group, after a mean of 10.9 years.

Among 81 patients with Artisan IOLs who have undergone cataract procedures at his centre, the average age at the time of implantation of the phakic IOL was 45.7 years and age at the time of cataract removal was 54.9 years. The primary indication was cataract in 54 eyes, pigment-synechiae in one eye, retinal detachment in seven eyes and endothelial cell loss in 18 eyes, including three eyes that underwent Descemet’s stripping automated endothelial keratoplasty.

“We see endothelial cell loss in the Artisan patients but it generally doesn’t cause problems. But it is important to check endothelial cell counts every year. Sometimes patients have an unexplained dramatic cell loss. Eye rubbing and/or inflammation may be predisposing factors,” he added.

The incidence of cataract with the Artisan lens was lower than that reported with earlier versions of the Visian ICL (STAAR Surgical) posterior chamber (PC) phakic IOL. In a study involving 2,396 eyes with the PC phakic IOL, the phaco rate was 9% at a follow-up of 19.23 months (Chen et al, JCRS 2008; 34:1181-12000).

In a study involving 133 eyes of 78 patients implanted with the ICL, the rate of lens opacity development was 40.9% and 54.8% at five and 10 years, respectively, and the phacoemulsification rate was 4.9% and 18.3% at five and 10 years, respectively (Guber et al, Jama Opthalmol 2016; 134:487-494).

Gré P M Luyten: g.p.m.luyten@lumc.nl

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Gré PM Luyten MD, PhD EUROTIMES | SEPTEMBER 2017

19

CATARACT & REFRACTIVE

SMART LENSES Electronic accommodating IOLs and contacts may be next in presbyopia treatment. Howard Larkin reports

S

mart accommodative lenses using advanced electronics to enable accommodation may be the future of surgical presbyopia correction, Dimitri T Azar MD, MBA, told Cornea Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago.

In his Castro-Viejo Lecture of the Cornea Society, Dr Azar, who recently joined Verily, the healthcare subsidiary of Alphabet, and remains Dean of the College of Medicine at University of Illinois at Chicago, reviewed the history of surgical presbyopia correction. Each has its advantages and drawbacks, and many of these may be addressed with smart lenses.

CURRENT APPROACHES Smart lenses are just one surgical remedy for presbyopia, Dr Azar noted. Monovision is still an option, and the one currently most often chosen by ophthalmologists for treating their own eyes, he said. It has an 81% success rate in surgically treated myopes, though it significantly reduces binocular contrast sensitivity and task performance.

Bifocal or progressive glasses are still needed in many cases, though monovision reduces dependence on them. Extensive patient counselling to explain what it is and what to expect is often required, he said.

Laser corneal surgery techniques include Presby-LASIK, which may enhance near vision with multifocal transitional profiles,

a peripheral Presby-LASIK zone or a central Presby-LASIK zone. However, it does not work well in many patients and the effect may regress over time, Dr Azar said. Even so, it is viable for some patients.

Corneal inlays are another approach, Dr Azar said. These include the AcuFocus KAMRA inlay based on the aperture effect, the hydrogel Raindrop, which changes the central corneal profile. Other inlays involve refractive approaches, such as the FlexiVue 3.0mm lens and others. These lenses’ effects are dependent on placement, and optimal placement may vary. “As corneal surgeons we love this challenge,” noted Dr Azar.

Multifocal intraocular lenses (IOLs) also remain viable despite glare and halos, Dr Azar said. Asymmetric optic approaches, where only a portion of the lens provides a near add, such as the Lentis Mplus LS-312 IOL, suggest the possibilities of multifocal lenses have not played out completely.

THE FUTURE Dr Azar’s experience with smart lens technology goes back to research he conducted with colleagues at the Massachusetts Eye and Ear Clinic. He holds several patents on accommodating eyeglasses dating from 2008, and believes the same approach can be applied to smaller lenses.

“The idea is very simple. You need a controller and an actuator that drives the change in the power of the lens, and a sensor that can feed the information [for accommodation]. All this can be incorporated into a contact lens, a phakic

Practice Management

ESCRS

20

& Development Competition

IOL, or a corneal inlay,” Dr Azar said.

The accommodative mechanism is also flexible; for example, it may be a movable multi-optic lens, a deforming liquid optic, a variable refractive index lens, or a custom lens based on wavefront and pupil dynamic characteristics, he added.

Dr Azar has been collaborating with Verily and Alcon, a subsidiary of Novartis where he is a board member, on an accommodative contact lens. They are building wireless sensors into a variable refractive index lens using advanced sensors and miniaturised low-power electronics driven by data analytics that learn over time.

Glucose-sensing and accommodative lenses are in pre-clinical phases, as is an IOL, Dr Azar said.

Other smart lenses in development include the Elenza Sapphire AutoFocus IOL, which accommodates by changing refractive index. It initiates near accommodation by sensing pupil constriction and lighting conditions associated with a near vision tasks, but can also avoid accommodation if the changes are related to the environment rather than a near task. Accommodating designs including the PowerVision FluidVision, the NuLens Dynacurve and the FlexOptic IOL also may benefit from smart technology.

“My personal experience and opinion is that accommodating contact lenses and IOLs are the future. These are in preclinical evaluation and early research and development,” Dr Azar concluded.

Dimitri Azar: dazar@uic.edu

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CATARACT & REFRACTIVE

MEASURING LENS DENSITY New evaluation technique can provide clearer images.

Dermot McGrath reports

A

n alternative method of measuring crystalline lens density using swept-source optical coherence tomography (SS-OCT) technology (IOLMaster 700, Zeiss) seems to offer a repeatable, sensitive and objective method of performing such biometric measurements, according to Dr Christophe Panthier of the corneal department headed by Dr Damien Gatinel, at the Foundation Ophtalmologique Adolphe de Rothschild, Paris, France.

“Our pilot study showed the interest of using such a device as an objective means of detecting and grading cataract density. It gives us an objective justification of the need to operate and it also offers a compelling economic argument as there is no need to buy another biometry tool when using this device,” he said.

Addressing delegates at the French Implant and Refractive Surgery Association (SAFIR) annual meeting in Paris, Dr Panthier, said that SS-OCT also offers another advantage over conventional biometry methods.

“The long wavelength of swept-source technology is less subject to light scatter by lens opacities and can provide clearer images in patients with cataracts and those with high myopia compared to Optical Quality Analysis System measurements (OQAS, Visiometrics SL),” he added.

Dr Panthier explained that the swept-source device performs 18 scans of the lens. Anatomic measurements include the biometric parameters required for modern IOL power calculation formulas, including central corneal thickness, lens thickness, axial length, and anterior chamber depth.

See into the future of eye surgery and patient care.

STRESSORS Dr Panthier’s study included two groups of patients: a cataract group of 51 eyes and a control group of 59 healthy eyes. Patients in the cataract group were included based on opacities graded according to the subjective Opacities Classification System III (LOCS III) and a reduction in visual acuity. Exclusion criteria included ocular trauma, congenital or secondary cataract, other ocular pathology or previous eye surgery.

Three separate examinations were used in the study: lens density measurements using images exported from IOLMaster to ImageJ software (NIH Inc) for quantitative analysis; objective scatter index scores using the OQAS; and the Pentacam Nucleus Staging (PNS) mean value and PNS cataract grading score obtained by the Pentacam Scheimpflug System (Oculus GmbH).

Looking at the results, the average lens density (ALD) measurements using the IOLMaster and ImageJ combination proved reproducible and showed good sensitivity and specificity, said Dr Panthier.

“An ALD score greater than 82.9 pixel units (pu) indicated the presence of cataract with a sensitivity of 74% and specificity of 91.2%,” he said.

Furthermore, there was a strong correlation between the ALD measurements and other objective measurements obtained by OQAS and Pentacam.

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

Christophe Panthier: christophepanthier@gmail.com EUROTIMES | SEPTEMBER 2017

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CATARACT & REFRACTIVE

EVOLVING CARE Safety in refractive surgery requires good surgical training and a strong evidence base for procedures used. Roibeard Ó hÉineacháin reports

C

omplications of refractive surgery are rare but can be severe. Care taken in patient selection, treatment choice and surgical technique helps reduce their incidence to a minimum, according to José Güell MD, Autonomous University of Barcelona, Barcelona, Spain.

“I think that it is important to point out that this is an elective versus a therapeutic surgery. Therefore, the main concern of a refractive surgeon should be to consider only the safest surgical approaches and also to improve the efficacy and predictability of the procedures, as well as the patient’s optical quality,” Dr Güell told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

The three most common types of refractive procedures – corneal refractive surgery, phakic intraocular lenses (IOLs) and refractive lensectomy – have very low rates of visually significant complications.

A literature search taking only Cochrane reviews or very large studies showed that nearly all of the complications that occur have an incidence below 1% and most of them are below .01%.

Dr Güell recommended a four-point strategy to reduce the incidence of complications still further. The first point is to avoid newer, less well tested technology with only short follow-up.

The second point is careful patient and treatment selection, based on past experience and treatment guidelines.

The third point is to have an experienced and properly trained surgeon. The fourth point is to have an adequate follow-up with peer-reviewed objective research.

He noted that newer refractive technologies, to be avoided by the regular surgeon and not being included in a closed study group, were specifically those that operated on a new untried principle and with little follow-up, such as femtosecond laser crystalline lens shape change induction or transepithelial corneal remodelling thorough corneal crosslinking (CXL). He added that, ideally, there should be rescue options to help return the eye to its preoperative state.

The length of follow-up before the procedure can be considered safe is debatable – 20 years is a good definition but it is impractical, because by the time there is sufficient follow-up new techniques have evolved. On the other hand, less than five years is probably not enough.

EUROTIMES | SEPTEMBER 2017

José Güell speaking at XXXIV Congress of the ESCRS in Copenhagen

...the main concern of a refractive surgeon should be to consider only the safest surgical approaches and also to improve the efficacy and predictability of the procedures...

José Güell MD Regarding patient and technique selection, consideration is required not only of the visual outcome desired by the patient, but also the patient’s specific orbital anatomy and their likelihood of experiencing complications based on their ethnic profile, for example.

Preoperative examinations for refractive surgery should include topographic measurements, slit-lamp meticulous evaluation, endothelial cell count, optical coherence tomography etc. That will help to achieve the targeted refractive outcome and also detect whether the patient might be prone to ectasia in the case of laser refractive surgery, or corneal endothelial cell loss or cataract in the case of phakic IOLs. In the case of multifocal IOLs, another measure that can help prevent an undesired visual outcome is to provide patients with preoperative simulation of the vision they are likely to achieve in proposed intervention, whether through contact lenses or adaptive optics.

CONTINUE TO EVOLVE Patients also need to understand the temporary nature of refractive corrections, Dr Güell said. For example,

corrections of myopia are unlikely to remain stable forever, since the underlying condition will continue to evolve and some myopic error will likely return over the years.

In addition, the anterior segment changes throughout life. Therefore, the distance between the crystalline lens and a phakic IOL will shrink over time. Similarly, the angle narrows with age, which could have implications for patients with phakic lenses both in the anterior and the posterior chamber.

He added that having an experienced and properly trained surgeon is probably more important in refractive surgery than in therapeutic surgeries, because of the higher expectations and the generally healthier eyes of patients requesting the treatment. Therefore, surgeons should have specific training for each type of refractive procedure.

Finally, the determination of the safety of refractive procedures requires peerreviewed long-term controlled studies, both independent and industry-driven with follow-up lasting decades, providing professional, objective, realistic and independent information, Dr Güell said.

José Güell: guell@imo.es

CATARACT & REFRACTIVE

HYDRAULIC INSERTION

OPHTEC | Cataract Surgery

High satisfaction three years on with fluid-filled accommodating lens. Roibeard O’hEineachain reports

T

Courtesy of Frik Potgieter MD, FRCS

he FluidVision (PowerVision, Inc) accommodating intraocular lens (IOL) demonstrates excellent and stable monocular and binocular visual acuity at distance, intermediate for periods now reaching three years, according to Paul Roux MD, Pretoria, South Africa.

A study including 34 eyes from 26 patients who underwent implantation of the FluidVision lens was performed by two surgeons. Eight patients underwent implantation in their fellow eye 15 to 21 months after the first surgery, Dr Roux said.

In 36 months of follow-up, the patients’ mean distance visual acuity remained stable at 6/6. Furthermore, distance-corrected intermediate and near vision were 6/7.5 and 6/9, respectively.

Oblique view demonstrating the hydraulic accommodating mechanism in situ

The mean amplitude of accommodation as measured by defocus curves in those implanted monocularly was about 3.0D throughout follow-up, he added. In those with the implant in both eyes it was around 4.0D. Binocularly implanted patients reported little or no difficulty in performing intermediate/near activities without spectacles, and those with 12 months’ follow-up said they were satisfied.

He noted that the IOL has 6.0mm optic and an overall diameter of 10mm. The haptics of the hydrophobic lens are filled with a small volume of silicone fluid with the same refractive index as that of the optic. Its accommodative effect is achieved through the pressure exerted on the fluid-filled haptics in response to constriction of the ciliary muscles and relaxation of the zonular fibres in response to a near stimulus. That in turn pushes fluid from the haptic into the optic, causing an increase in its anteroposterior diameter resulting in an improved near focus.

The team implanted the lens using a hydraulic injector device in order to deliver the large lens into the capsular bag. They used a 4.0mm clear corneal incision, which they closed with a suture.

The latest FluidVision lens can be implanted through a 3.5mm incision that does not require sutures. It is also designed to achieve twice the accommodative power as the lens used in the study.

Paul Roux, C/O Frik Potgieter MD, FRCS, Pretoria, South Africa: fjp@lasik.co.za

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www.ophtec.com EUROTIMES | SEPTEMBER 2017

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CATARACT & REFRACTIVE

JCRS HIGHLIGHTS VOL: 43 ISSUE: 6 MONTH: JUNE 2017

IOL CALCULATIONS – PROGRESS NEEDED

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

Percentage 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 lenses (pIOLs)?

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 Optimized traditional approaches

15.35

W. Hill USA Pattern recognition

15.50

Discussion

16.00

End of session

Fifty years after Fyodorov published the first paper on theoretical IOL calculation, achieving an ideal outcome remains a challenge. While biometric tools, a variety of calculation formulas and improvements in surgical techniques have increased the percentage of patients within 0.5 dioptre of predicted outcome postoperatively, the number of patients not achieving this result ranges from 10 to 20%, and worse for difficult eyes. With the goal of stimulating progress, the JCRS commissioned four editorials by experts from around the world.

The first of the series covers reclassifying IOL calculation formulas.

Douglas D Koch MD suggests doing away with the generational classification system in favour of classifying formulas by their method of calculating IOL power and the data used for these calculations.

Future editorials will discuss measurement foibles; analysing astigmatic change; and criteria for analysing outcomes. D Koch et al., “Pursuing perfection in intraocular lens calculations: I. Logical approach for classifying IOL calculation formulas,” Volume 43, Issue 6, 717–718.

CHANGING REASONS FOR IOL EXCHANGE The original indications for IOL exchange were IOL decentration or displacement for posterior chamber lenses, and corneal decompensation and inflammation for anterior chamber lenses.

However, in recent years the indications for IOL exchange have expanded to include refractive concerns driven by increased patient and physician expectations for refractive targets and the desire for spectacle independence, a population-based retrospective data analysis indicates. The study showed that while the absolute number of secondary IOL procedures increased from 2000 to 2013, the five-year risk for surgery decreased.

Repositionings and exchanges were performed most commonly by retinal surgeons (39.3%), followed by glaucoma surgeons (25.5%), general ophthalmologists (22.4%) and corneal surgeons (12.9%). Szigiato et al., “Population-based analysis of intraocular lens exchange and repositioning,” Volume 43, Issue 6, 754–760.

MIOL EXCHANGE OUTCOMES Although most complications following multifocal IOL (MIOL) implantation can be managed conservatively with the use of spectacle correction, keratorefractive surgery or neodymium:YAG (Nd:YAG) laser capsulotomy, up to 7% of these patients ultimately require multifocal IOL explantation. How well do patients do after MIOL exchange?

Researchers reviewed the 29 cases (35 eyes) that underwent exchange surgery for indications including blurred vision photic phenomena, photophobia and diminished contrast sensitivity. The types of IOLs implanted after multifocal IOL explantation included in-the-bag IOLs (74%), iris-sutured IOLs (6%), sulcus-fixated IOLs with optic capture (9%), sulcus-fixated IOLs without optic capture (9%) and anterior chamber IOLs (3%). The CDVA was 20/40 or better in 94% of eyes before the exchange and 100% of eyes after the exchange. EJ Kim et al., “Refractive outcomes after multifocal intraocular lens exchange,” Volume 43, Issue 6, 761–766.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | SEPTEMBER 2017

CATARACT & REFRACTIVE

INLAY LIFESPAN New corneal inlay technology seems promising, but long-term results should be carefully monitored.

Roibeard Ó hÉineacháin reports

T

here is as yet no clear answer regarding the longevity of new corneal inlays for presbyopia, as past experience has shown that visually significant complications can take years to occur, according to Béatrice Cochener MD, PhD, University of Brest, France.

“The current limitations with inlays are the short follow-ups. It is too soon to assume perfect bio-tolerance of the materials,” she told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

She pointed out that some serious complications with the first hydrogel corneal implants for hyperopia did not occur until six years after surgery. With these first-generation inlays, late haze and deposits occurred in more than 80% of eyes and around half of patients required explantation of the implants within the first five years.

The haze deposits and corneal necrosis that occurred with the implants appeared to be related to postoperative inflammation around the implant. And although the complications can be modulated through the use of a tapered topical steroid regimen, the scars may be irreversible, but most often they do not result in long-term visual acuity disturbances.

The current intracorneal inlays which are indicated for presbyopia include the KAMRA Inlay (AcuFocus, Irvine, California, USA) which uses the pinhole effect, the Flexivue Microlens (Presbia, Irvine, California, USA) bifocal corneal inlay, and the Raindrop Near Vision Inlay (ReVision Optics, Lake Forest, California, USA), which reshapes the cornea.

They are composed of a soft material in order to easily conform to the cornea.

Long-term studies out to five years have shown promising safety and efficacy outcomes, with no severe corneal complications; however, patients were monitored closely in these controlled trials.

When a patient was explanted in these studies, the patient returned within one line of best-corrected distance vision from their preoperative measurements.

Depth of implantation appears to be a factor in the development of late haze. There is some evidence that the complication is less likely for the Raindrop inlay when implanted at 30% or greater central corneal depth. The KAMRA and Flexivue inlays fare best when implanted at about 200 microns or deeper in the cornea.

Dr Cochener noted that the age-group receiving the implants are at an increased risk of ocular surface dryness. Changes in corneal shape and the transection of corneal nerves during surgery can exacerbate the condition. Therefore, dry eyes should be carefully screened preoperatively and aggressively treated after surgery.

Decentration of the implants should be treated at an early stage. In the case of the Flexivue and Raindrop inlays, this is less of a problem than for the KAMRA inlay, which depends on perfect centration for optimal effect. When replacing an inlay, an interval between explantation and implantation of a new inlay can diminish the imprint of the initial inlay, she advised.

The new implants have an explantation rate of around 10%. Refraction following implant removal is generally within 1.0D of preoperative values. Reasons for implant removal include lack of effect, loss of effect, or most commonly progressive treatmentresistant haze.

Unlike other refractive procedures, inlays are foreign bodies implanted into the cornea. Implanted patients should be closely monitored every six to 12 months so that complications are diagnosed and addressed early. Drastic changes in vision, refraction, topography, patient satisfaction, or inlay appearance (slit lamp, optical imaging) are clinical red flags that require treatment. In treatment-resistant cases, explantation should always be considered.

“Corneal inlays are another technology we can offer our presbyopic patients, but vigilance should be practised to monitor for long-term complications,” added Dr Cochener.

Launching at the ESCRS 2017

Béatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr

...current limitations with inlays are the short follow-ups. It is too soon to assume perfect bio-tolerance of the materials Béatrice Cochener MD, PhD EUROTIMES | SEPTEMBER 2017

27

VIENNA 2018 36 Congress of the ESCRS TH

22–26 September Reed Messe, Vienna, Austria

www.escrs.org

Instructional Course Submission Deadline: 31 October 2017

CORNEA

HEADS-UP FOR DSAEK 3D system can help in endothelial keratoplasty procedures.

Roibeard Ó hÉineacháin reports

A

new three-dimensional (3D) heads-up system for viewing and recording ophthalmic surgery can be helpful when performing endothelial keratoplasty, Yasser Helmy Mohamed MD, PhD told a Cornea Day session at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“We are extremely impressed by the accuracy and realism of Sony’s 3D viewing and recording system. The system exhibits virtually no time delay and allows for real-time 3D viewing in the operating room,” said Dr Mohamed, Department of Ophthalmology and Visual Sciences, Nagasaki University, Nagasaki, Japan.

In his case report, he described his centre’s first experience of using the heads-up surgery to perform non-Descemet’s stripping automated endothelial keratoplasty (n-DSAEK).

In the heads-up approach, the surgeon performs procedures while viewing the microscopic image on a large 3D display sent from a 3D camera, instead of looking through eyepieces of the microscope, Dr Mohamed explained.

“Recent advances of 3D cameras and 3D display technology have brought increasing reports of heads-up surgery in the field of ophthalmology. However, previous reports about its use in ophthalmology have focused mostly on cataract and vitreoretinal surgery,” he added.

The patient was a 72-year-old male with a history of blunt trauma in the left eye since childhood. In 2004 the patient underwent Yasser Helmy Mohamed phacoemulsification and intraocular lens implantation for post-traumatic cataract.

In February 2016 the patient was referred to University Ophthalmic’s clinic with post-traumatic bullous keratopathy.

The patient presented with uncorrected vision of counting fingers (NC) at 10cm and progressive pain. Slit-lamp examination revealed diffuse stromal and epithelial oedema.

In April 2016 the patient underwent n-DSAEK. Dr Mohamed explained that the heads-up system consists of a RESCAN 700 (Zeiss) optical microscope with real-time intraoperative optical coherence tomography (iOCT), a full high-definition medical-grade camera system (PMW-10MD, Sony) and a dual-channel 3D stereoscopic HD digital video recorder with a 42-inch LMD-4251TD monitor (Sony).

The surgery was uneventful and performed without any complications, Dr Mohamed said. He noted that the heads-up 3D system and its high magnification made preparation of the eye and handling the flap easier. In addition, iOCT enabled the detection of fluid at the graft-host interface.

The only disadvantage of the system was the difficulty in detection of the flap depth within the anterior chamber, which required frequent focus change during the surgery. However, the surgeon did not feel any eye strain or discomfort, Dr Mohamed said.

“The implications of 3D recording and display in an educational institution are immense,” he added.

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Yasser Helmy Mohamed: yasserhelmy@nagasaki-u.ac.jp EUROTIMES | SEPTEMBER 2017

29

30

CORNEA

CXL – WHAT'S NEXT? Corneal crosslinking combined with other surgical modalities shows promise.

Leigh Spielberg MD reports

N

ew enhancements to corneal crosslinking (CXL) techniques could help to overcome the disadvantages of the current standard protocols, according to a series of presenters at the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

“CXL delivers excellent results in terms of halting the progression of keratoconus.

However, we have begun to realise that many of our post-CXL patients do not achieve visual acuity improvement sufficient to provide functional vision, especially when they don’t tolerate contact lenses or spectacles,” said George Kymionis MD, Athens, Greece.

Dr Kymionis described his approach, which he refers to as ‘CXL-plus’, which incorporates adjuvant refractive treatments in combination with CXL in an effort to provide both corneal stability and improved vision.

“Tissue-saving approaches are an option, but we have been unable to achieve satisfactory outcomes. Intrastromal corneal ring segments followed by CXL delivers unpredictable results, while post-CXL toric phakic ICL implants are unable to treat the irregular astigmatism so frequently present in these patients,” he said.

Dr Kymionis quickly moved to his preferred approach, simultaneous topography-guided photorefractive keratectomy (PRK) followed by CXL. He reminded the audience that the most accurate device in ophthalmology is the excimer laser.

“The main advantage of this approach is that laser ablation does not interfere with the crosslinked cornea. This combination results in significant improvement in all parameters: keratometric values, spherical equivalent, defocus, uncorrected visual acuity and best corrected visual acuity,” said Dr Kymionis, adding that postoperative refractive stability has been demonstrated at five years post-surgery.

A published report by Dr Kymionis’ team indicates that the mean steep and flat keratometry readings reduced by 2.35D and 1.18D, respectively. Complications

Tissue-saving approaches are an option, but we have been unable to achieve satisfactory outcomes George Kymionis MD include posterior linear stromal haze and mild grade 1 anterior stromal haze, which gradually becomes less dense over time.

Considering the success of the PRK + CXL procedure in halting the progression of ectasia in keratoconus, Dr Kymionis addressed the use of CXL in refractive patients.

“If we can successfully combine CXL with refractive surgery in keratoconic patients, why not combine the two in refractive patients in order to prevent iatrogenic ectasia?” he asked.

The addition of CXL might compensate the biomechanical destabilisation caused by refractive surgery, particularly in light of our current inability to accurately detect high-risk corneas.

“It sounds great, but we can’t forget that CXL has its own risks, such as corneal scarring, infiltrates, diffuse lamellar keratitis and endothelial cell damage. Further, how could we perform retreatments in these patients, as the ablation rate of a crosslinked cornea is different to that of a ‘virgin’ cornea,” he warned.

When asked what the youngest treatable age is for combined PRK + CXL, Dr Kymionis reminded delegates that patient cooperation was essential, as the excimer laser procedure cannot be combined with general anaesthesia. That suggests 16 years is the minimum age.

Beatrice Frueh MD, Bern, Switzerland, has extensive experience in treating children with CXL for keratoconus. “Standard, epioff CXL is effective in arresting keratoconus progression in children. Progression after CXL in children is rare, although it can occur years after the procedure,” she said.

Dr Frueh presented data of a prospective, five-year follow-up study of epi-off standard CXL in 23 eyes of 19

Further studies are needed to evaluate these novel CXL modalities before they can be incorporated into clinical practice...

Mor Dickman MD EUROTIMES | SEPTEMBER 2017

patients with a mean age of 14 years (4-17), which demonstrated flattened corneas and improved topographic indices.

“There were no cases of scarring or haze.

We had two cases of progression, both of which were retreated. Corrected distance visual acuity was unchanged in 16 patients and improved ≥ 2 lines in seven. However, there was a surprising, continual corneal thinning over these five years.”

Mor Dickman MD, Maastricht, The Netherlands, presented an overview of the new CXL modalities and their potential applications. He shared the results using a novel photosensitising agent photoactivated by near-infrared (NIR) light.

“Although the current standard of riboflavin and UVA light (RF/UVA) provides long-term stability in about 90% of patients with keratoconus, there are still great problems and limitations,” said Dr Dickman. Problems include the postoperative pain and infectious potential of epithelial debridement and toxicity to keratocytes and endothelium.

CXL modalities can be divided into chromophore and pharmacological.

Chromophore modalities include the standard RF/UVA technique; rose bengal stain + green light; and water-soluble taurine with dextran (WST-D) + NIR light. Pharmacological modalities comprise Genipin and Galacorin.

Dr Dickman focused on WST-D/NIR, which was originally developed as an agent for photodynamic therapy for prostate cancer. Both corneal and scleral stiffening with this procedure has been demonstrated in rabbits, offering possibilities for the treatment of both infectious keratitis and progressive myopia.

Further studies are needed to evaluate these novel CXL modalities before they can be incorporated into clinical practice, but their ability to overcome the current disadvantages of the standard RF/UVA protocol might make the effort worthwhile, he said.

George Kymionis: kymionis@med.uoc.gr Beatrice Frueh: beatrice.frueh@insel.ch Mor Dickman: mor.dickman@mumc.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”

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François Malecaze FRANCE

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European Society of Cornea and Ocular Surface Disease Specialists

32

CORNEA

EuCornea 8 Congress th

6 –7 October 2017

Friday 6 October | 13.00 – 14.00 Ocular Burn Treatment: From Acute Phase to Reconstruction Moderators: P. Rama ITALY, J. Hjortdal DENMARK P. Rama ITALY Introduction R. Nuijts THE NETHERLANDS Treatment of acute and sub-acute phase F. Kruse GERMANY Diagnosis and staging of LSCD H. Dua UK Management of dry eyes in LSCD P. Rama ITALY Limbus & cornea reconstruction J. Hjortdal DENMARK Conclusions and future perspectives

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S. Garcia-Delpech SPAIN Preparing the surface for LASIK G. Gazzard UK The influence of ocular surface health in glaucoma management R. Mencucci ITALY Cataract surgery and dry eye G. Garhöfer AUSTRIA How ‘simple’ drops seek to protect the ocular surface

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TREATING ASTIGMATISM Management options available that may prevent re-grafting.

Howard Larkin reports

D

ue to differences in healing and post-transplant stretch, high astigmatism is difficult to prevent in both penetrating and lamellar keratoplasty, and glasses or contact lenses are not always possible.

David S Rootman MD, of the University of Toronto, Canada, offered tips for treating it during Cornea Day at the 2016 American Academy of Ophthalmology Annual Meeting in Chicago.

For patients with 6.0D or less, surface ablation is often an option, Dr Rootman said. For higher astigmatism, astigmatic keratotomy (AK), stitches or reoperation may help bring the patient’s astigmatism down to a treatable level.

ARCUATE KERATOPLASTY In a cognitively challenged young man with about 10.0D astigmatism after deep anterior lamellar keratoplasty (DALK) for keratoconus, Dr Rootman used manual AK because the patient could not cooperate for a femtosecond laser procedure.

“This is often successful in reducing astigmatism David S Rootman down to the level where a patient can wear glasses and function without further treatment,” he said.

A second patient who had undergone penetrating keratoplasty (PK) 25 years earlier for keratoconus presented with cataract and about 15.0D astigmatism. Dr Rootman used femtosecond laser AK to bring the astigmatism down to a treatable range. He typically uses an optical zone of the graft diameter minus 1mm, with incisions of 80-90% over arcs of 45 to 80 degrees.

After two months to allow the results to stabilise, Dr Rootman removed the cataract and inserted a toric intraocular lens (IOL). The patient was 20/100 uncorrected with about 4.0D cylinder one day after surgery.

STITCHING A third patient with severe keratoconus had undergone PK, then AK and photorefractive keratectomy. After 10 years he had a cataract developing and 16.0D cylinder due to stretching of the host cornea. In this case Dr Rootman opted for a wedge resection with stitches left in place for several months to allow complete healing, followed by cataract extraction and implanting a toric IOL. Going back to the second case, the patient later experienced a Descemet’s membrane detachment. After Descemet’s membrane endothelial keratoplasty (DMEK), he returned to 20/80 uncorrected outcome, Dr Rootman said.

Endothelial keratoplasty is usually effective in such cases, Dr Rootman said. However, PK may be required in cases of stromal scarring, or astigmatism cannot be corrected.

“Astigmatism challenges us all. However, there are valuable surgical tools available, and in many of these cases we can obtain good vision without having to repeat the graft,” Dr Rootman concluded.

David S Rootman: d.rootman@utoronto.ca

EUROTIMES | SEPTEMBER 2017

SUBMISSIONS OPEN AUGUST 11–SEPTEMBER 22 ADDITIONAL PROGRAMS ASCRS REFRACTIVE DAY • APRIL 13 ASCRS GLAUCOMA DAY • APRIL 13 CORNEA DAY • APRIL 13 ASOA WORKSHOPS • APRIL 13 T&N TECH TALKS • APRIL 13 TECHNICIANS & NURSES PROGRAM • APRIL 14–16

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

CORNEA

CORNEAL TOPOGRAPHY

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Scheimpflug device provides solid measurements in dry eye patients.

AN D RE I FIL IP MD, P h D Ama Optimex Eye Clinic — Bucharest, Romania

Roibeard O’hEineachain reports

C

orneal topography measurements obtained with the Sirius Scheimpflug device do not appear to be affected by the presence of dry eye, according to the results of a study presented by Aysun Sanal Doğan MD, Department of Ophthalmology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.

“These findings confirm that use of Scheimpflug corneal topographic is reliable for dry eye patients,” Dr Doğan told the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

In the retrospective case review study, Dr Doğan and her associates compared the performance of the Sirius Scheimpflug topographer in 33 patients with diagnosis of dry eye disease with its performance in 40 control patients.

The two groups were similar in terms of age and gender distribution. The dry eye group included four men and 29 women with a mean age of 39 years, ranging from 18 to 65 years, and the control group included eight men and 32 women with a similar age profile.

Dr Doğan noted that, compared to the control group, the dry eye group had significantly higher Meibomian gland drop-out than the control group (21% vs. 15.1%), and significantly lower tear break-up time as measured with noninvasive tear film (6.5 vs 17 seconds).

EXCELLENT REPEATABILITY The researchers used two images with at least 95% acquisition quality to assess the reliability of measurements.

They analysed intra-class coefficients (ICC), a measure of repeatability, for each corneal topography parameter within both groups using SPSS 20.0 software.

They found then that the ICCs were excellent (>0.95) for the comparison of two images in terms of all parameters in both the dry eye group and the control group. In addition, comparison in terms of topographic parameters, including the central corneal thickness, revealed that dry eye patients and controls are not different topographically.

Dr Doğan noted that dry eye leads to unstable tear film, which can affect image quality and reliability. However, the speed with which the Scheimpflug topographer acquires its images may improve the reproducibility of its measurements.

In addition, the selection of high-quality images may have enhanced the repeatability of the measurements.

“Our study showed that repeated Scheimpflug corneal topographic measurements of the same patient in both dry eye group and controls are in agreement to an excellent degree.

Secondly, there is no significant difference between dry eye patients and controls in terms of topographic features.

"Therefore, the device may be useful as a screening, biometric measures and diagnostic tool for various ophthalmic diseases even if dry eye syndrome also coexists.

But further studies are needed to compare the repeatability of measurements in very severe dry eye patients,” she concluded.

Aysun Sanal Doğan: asanaldogan@gmail.com

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EUROTIMES | SEPTEMBER 2017

35

CORNEA

SAFE PROCEDURES Corneal refractive surgery does not raise the risk of progressive endothelial cell loss. Roibeard Ó hÉineacháin reports

C

orneal refractive surgery generally poses little risk to the corneal endothelium, but phakic intraocular lenses (IOLs) currently in use are associated with a minor risk of corneal decompensation, according to Massimo Busin MD, Villa Serena Forlì Hospital, Italy.

“In general, with corneal refractive surgery we have some endothelial cell loss (ECL) but no progression and no corneal decompensation,” Dr Busin said in a keynote lecture at a Cornea Day session during the 21st ESCRS Winter Meeting in Maastricht, The Netherlands.

In the early days of refractive surgery, the delicate nature of the corneal endothelium was poorly understood. In fact, the first type of radial keratotomy (RK) developed in the 1940s involved radial incisions on both the anterior and posterior surface of the cornea.

The treatment often led to corneal oedema and decompensation.

However, the mean time between the procedure and the development of bullous keratopathy was around 27 years, which highlights the follow-up needed to judge a procedure’s safety.

RISK FACTORS With a more familiar type of RK, central ECL was only 3-10% in the 10-year-long PERK study involving patients who underwent the procedure from 1982-1983. Risk factors for ECL included increased number of incisions and smaller optical zones, he said.

Despite some theoretical dangers of corneal photoablative procedures such as photorefractive keratectomy (PRK) and LASIK, overall the evidence suggests that excimer laser refractive surgery

Courtesy of Massimo Busin MD

36

Preoperative slit-lamp appearance (left) of the right cornea of a 31-year-old patient showing endothelial decompensation observed three years after implantation of an iris-supported phakic IOL (iris-claw style). Two years after a procedure (including removal of the phakic IOL, phacoemulsification, implantation of a posterior chamber IOL in the capsular bag, pupilloplasty and DSAEK), the right picture shows a perfectly clear cornea with a perfectly attached DSAEK graft and a round pupil. Vision was 1.0

does not cause progressive loss of corneal endothelial cells.

And although an early study by Prof Ioannis Pallikaris reported an ECL of 9-10% after LASIK or PRK for high myopia, most subsequent studies have not shown a progressive ECL. A more recent study showed that the mean rate of ECL was the same among patients who underwent LASIK or PRK as it was in control eyes, 6.0% at nine years (Patel et al, Arch Ophthalmol.

2009;127:1423-7). Different ablation frequencies also do not appear to differ in their effect upon the endothelium, and femtosecond laser LASIK flap creation appears to have little effect on the endothelium.

He noted that research shows that a residual stromal bed of 200μm or more prevents ECL following excimer laser photoablative procedures. A residual stromal bed of 250μm or more is currently recommended to avoid corneal ectasia.

NO SIGNIFICANT EFFECT

Preoperative slit-lamp appearance (left) of the right cornea of a 44-year-old patient showing endothelial decompensation and extreme pupillary distortion after implantation of an anglesupported phakic IOL (Baikoff style). Two years after a quintuple procedure (removal of the phakic IOL, phacoemulsification, implantation of a posterior chamber IOL in the capsular bag, pupilloplasty and DSAEK), the right picture shows a perfectly clear cornea with a perfectly attached DSAEK graft and a relatively round pupil

Preoperative slit-lamp appearance (left) of the left cornea of a 52-year-old patient with endothelial decompensation occurring 18 months after implantation of an angle-supported phakic IOL (Cachet style). Seven years after a quadruple procedure (removal of the phakic IOL, phacoemulsification, implantation of a posterior chamber IOL in the capsular bag, and DSAEK) the cornea was perfectly transparent (right) with a well-centred DSAEK graft. Vision was 0.8

EUROTIMES | SEPTEMBER 2017

Even PRK plus mitomycin-C has no significant effect on the endothelium, although research has shown it can enter the anterior chamber. Dr Busin noted that, because of its anti-proliferative mode of action, mitomycin-C is unlikely to damage the naturally non-proliferative endothelial cells. Intracorneal inlays and intracorneal ring segments also appear to leave the endothelium without damage, even when explantation is necessary.

Perhaps the best evidence that LASIK and PRK treatment is not unduly harmful to the cornea is that, according to current Eye Bank Association of America (EBAA) guidelines, corneas that have undergone the laser photoablative procedures can be used as donor corneas for posterior lamellar keratoplasty.

He added that corneas with intracorneal ring segments can be used for Descemet’s membrane endothelial keratoplasty (DMEK), but not for Descemet’s stripping automated endothelial keratoplasty (DSAEK), because of the loss of integrity of the deep stroma. Instead, corneas that have undergone RK have been used successfully for ultra-thin DSAEK. However, the story is different with regard to anterior chamber phakic IOLs, especially some of the now discontinued anglesupported models. Iris-supported IOLs have been involved in a much smaller number of cases of postoperative complications.

Most studies show a slow rate of ECL, although cases of severe ECL occasionally occur with the lenses.

However, good visual recovery is possible for most patients through phakic IOL explantation, phacoemulsification, posterior chamber IOL implantation, and DSAEK. Massimo Busin: mbusin@yahoo.com

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38

GLAUCOMA

DISC PHOTOGRAPHY Baseline optic disc photographs, obsolete or still essential?

Roibeard O’hEineachain reports

M

odern imaging technology can provide an increasingly well defined representation of the optic disc, and the software used in interpreting the images is also gaining in sophistication and the accuracy with which it can distinguish between glaucomatous and normal eyes.

That raises the question of whether glaucoma specialists should still rely on disc photography. That was the topic of a debate held at the 7th World Congress of Glaucoma in Helsinki, Finland.

George Spaeth MD maintained that optic disc photographs do indeed remain an essential tool in the diagnosis and continuing care of patients with glaucoma.

“The ideal diagnostic test should be diagnostically valid and relevant, allow staging the severity of the condition, and provide a permanent baseline against which future tests can be compared. It should be readily available everywhere, it should not require instrumentation that is expensive and difficult to maintain and should be easily learned and easily interpreted,” said Dr Spaeth, Wills Eye Hospital, Philadelphia, Pennsylvania, USA.

IDENTIFYING PATTERNS He noted that identifying glaucoma through ophthalmoscopy is a skill that one can acquire through viewing of optic discs of patients who definitely have glaucoma. He suggested that rather than deconstructing the images and looking for specific features like disc haemorrhages, one should learn to recognise the patterns glaucomatous eyes have in common. He likened it to the way art critics learn to identify the artist who painted a painting without having seen it before.

“There is no reason for you as an ophthalmologist to learn to identify paintings, but there is every need to learn the method of identifying patterns and turn it into something meaningful,” Dr Spaeth said.

He also maintained that data obtained from newer imaging technologies like

optical coherence technology (OCT) and Heidelberg Retinal Tomography (HRT) instruments is not truly diagnostic regarding glaucoma. Opinions vary on the threshold thinness of the retinal nerve fibre layer (RNFL) for glaucomatous damage. Moreover, there are other pathologies, such as myopia, that also cause RNFL thinning.

Another problem with the newer technologies is that companies keep changing their methodology, making it impossible to compare the data over time.

Furthermore, as disc cupping develops, the retinal nerve fibres are pulled towards the disc margin, making registration uncertain. Thus, following patients so as to identify the rate of change is better done with photographs than with OCT. Optic disc photographs do not require expensive equipment that becomes obsolete. Photography is cost-effective.

Ophthalmoscopy for the purpose of examining the optic disc and photography to provide a permanent record are essential aspects of the examination of a patient with, or suspected of having glaucoma, even though the skill is difficult to learn and even though as with every technique the disc appearance will not always provide us with the answer we need.

NEWER TECHNOLOGY MAKING OLDER TECHNIQUES LESS RELEVANT Felipe Medeiros MD said that while he still obtains baseline disc photographs for most of his patients, he questioned whether they are still essential for everyone.

He noted that while his own research has shown that changes detected in disc photographs are highly predictive of visual field progression, those studies involved film photography obtained by simultaneous stereophotography cameras, and highly trained graders for assessing those photographs. Nowadays, most ophthalmologists use digital photography that does not seem to provide the same level of quality for assessing glaucomatous change to the optic disc as conventional

The ideal diagnostic test... should be readily available everywhere, it should not require instrumentation that is expensive and difficult to maintain...

George Spaeth MD EUROTIMES | SEPTEMBER 2017

stereoscopic film photographs, he said.

His statement was based on research from his database of thousands of patients with glaucoma followed for several years, which showed that digital photography could detect only very few subjects that showed progression over time.

He also pointed out that the European optic disc assessment trial showed a large variability in diagnostic accuracy among clinicians when grading optic disc stereophotographs, and that imaging devices actually outperformed those clinicians in distinguishing eyes with glaucoma from those without the disease.

He added that unlike imaging technology, disc photographs do not provide an objective quantification of change. As a result, clinicians limited to stereophotography will have difficulty in determining the rate of progression as well as in detecting small changes in the optic nerve. He emphasised that measuring the rate of progression is a fundamental variable in the longitudinal care of patients with glaucoma.

Dr Medeiros showed recent evidence on the use of imaging devices for detecting progression and measuring rates of change, such as spectral-domain (SD) OCT. “We need to be able to identify those patients who are progressing fast, as they will be those at the highest risk for developing vision impairment from glaucoma.

Imaging devices are ideally suited for quantifying rates of progression and, in general, will do a better job than disc photographs in identifying patients who are progressing fast. This is what really matters”, he said.

Dr Medeiros also maintained that the technological advances in imaging devices is something that ophthalmologists should welcome. “People have criticised imaging tests based on the fact that devices change over time. However, imaging platforms such as SDOCT have been stable for quite some time, and efforts have been made to maintain backwards compatibility even when there are hardware and software improvements.

“This has allowed continuous follow-up of patients for many years, within the time frame that clinical decisions are usually made for most cases," he concluded.

George Spaeth: gspaeth@willseye.org Felipe Medeiros: felipe.medeiros@duke.edu

ESCRS

Re gi O stra pe t n ion

Glaucoma Day 2017 Friday 6 October FIL – Feira Internacional de Lisboa, Portugal glaucomaday.escrs.org

Friday 6 October 13.00 – 14.00 | Room 3.1

Alcon Satellite Meeting Sponsored by

Scientific Programme organised by

40

YOUNG OPHTHALMOLOGISTS

THE DOCTOR’S DILEMMA In his shortlisted essay for the 2017 John Henahan Writing Prize, Dr Conor Lyons says an important covenant exists between the physician and the patient that must remain at the heart of medicine

G

eorge Bernard Shaw in The Doctor’s Dilemma stated: “That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity.”

The dilemma here is that of a doctor who has developed a revolutionary cure for tuberculosis, but due to limited resources and financial interests, must choose which patients are worthiest of the cure and which must continue to suffer. Commercial interest and influence over medicine are not new causes for unease. Long before Shaw first explored this concept, the idea of a conflict between the demands of medicine as a business and as a vocation existed.

While this age-old concern persists in medicine, fresh ethical dilemmas have come to the fore. Since the birth of the pharmaceutical industry there has been an underlying disquiet at the thought of drug companies and doctors as bedfellows.

This is not an unfounded worry; the pharmaceutical industry in the USA spends approximately $24 billion annually on marketing to physicians. (1) Sponsorship from drug companies has been shown to affect prescribing habits. (2) Among the general public there can be suspicion regarding the advice doctors provide, and at times justifiably so. When looking at recent controversies in the pharmaceutical industry ophthalmology unfortunately makes an appearance, and all ophthalmologists are aware of the bevacizumab versus ranibizumab debate.

In the United Kingdom, it is alleged that Novartis representatives actively discouraged doctors from carrying out comparative trials, with the suspicion that some doctors were being offered research grants if they avoided this head-on evaluation. This episode highlights the dangers of becoming too friendly with drug companies.

Ophthalmology faces many of the same problems as other specialties, with drug representatives promoting their pharmaceuticals. Practitioner-business relations are varied, ranging from a free branded pen to a million-euro research endowment. In Ireland, there are sponsored teaching sessions throughout the year at which drug company employees distribute their promotional material, pay for lunch EUROTIMES | SEPTEMBER 2017

Commercial interest and influence over medicine are not new causes for unease... and speak at the start of the session. It would be naive to think that this doesn’t have an effect on prescribing habits.

Taking a superficial view, it could be concluded that doctors and drug companies should be kept apart. Many would argue that drug companies should not fund research into their own medication; however, without this funding medical advancement may stagnate. Similarly, teaching sessions and research meetings are essential, especially for trainee doctors like me. Many of my colleagues are carrying out research with funding from pharmaceutical companies, vital work that could not be carried out without funding. The question is how best to manage conflicts of interest while preserving the collaborations on which medical advances depend?

In recent times, editors of medical journals have made it more difficult to publish journal articles funded by industry, a response to concerns that such documents may be biased. Is this divide between clinicians and industry in patients’ best interests? I believe not — and I am not alone.

Several independent organisations have championed greater interaction between doctors and industry: Institutes of Health, the World Economic Forum, the Gates Foundation, the Wellcome Trust, and the Food and Drug Administration. (3) These organisations realise that for advancements to occur in medicine collaboration rather that division is essential.

I am a first-year resident who has had very little interaction with drug companies; in my own career, so far, I cannot say that the role of industry has directly affected how I treat patients. At present, none of my research has been sponsored by industry and I have a pathological inability to keep any biro (branded or otherwise) long enough to develop loyalty to its manufacturer. However, as I progress in my career it is likely that I will have increased interactions with drug companies and, like all doctors before me, I will be placed in positions where commercial interest will influence my practice. For trainees

and consultant ophthalmologists there are opportunities where patients’ best interests may be overlooked. An important covenant exists between the physician and the patient that must remain at the heart of medicine, unfettered by outside forces.

Forty years after a George Bernard Shaw character developed a fictional cure for tuberculosis, the microbiologist and future Nobel laureate Selman Waksman was working on the first (non-fictional) cure: streptomycin. Waksman understood that if his finding was to be of use to humankind, he required a partner able to manufacture sufficient quantities of the substance. For this reason, he struck a deal with Merck to produce streptomycin for clinical use.

The partnership went on to assuage great level of human suffering. In an ideal world, this is how all partnership should work, where patients’ best interests remain at the centre of the relationship. As with many aspects of life, and medicine, there are no black and white answers. Doctors and drug companies are like early explorers moving through uncharted waters, hoping to find the next medical advancement, in which doctors must use their own moral compass and expert judgement.

1. Data CS. US Pharmaceutical Company Promotion Spending (2013).

2. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift?. Jama. 2000 Jan 19;283(3):373-80.

3. Drazen JM. Revisiting the commercial– academic interface.

Dr Conor Lyons is a first-year resident (ophthalmol) at the Royal Victorian Eye and Ear Hospital, Dublin, Ireland

JOHN HENAHAN

PRIZE 2017

YOUNG OPHTHALMOLOGISTS

SHIFTED PERSPECTIVE In his shortlisted essay for the 2017 John Henahan Writing Prize, Dr Rahil Chaudhary says the primary concerns for any medical professional need to be the patient’s welfare and society’s benefit

T

o become an ophthalmologist, you spend years honing your abilities and deepening your knowledge. When you are finally ready to start a practice of your own, you will have the opportunity to use your skills to serve patients. However, the moment you open your doors to patients, you also attract customers of another kind.

Drug representatives and other device manufacturers will pursue you as well, offering gifts and a sales pitch.

As young ophthalmologists, we need to be especially wary of such advances. The primary concerns for any medical professional need to be the patient’s welfare and society’s benefit. That is why the industry is governed by a code of ethics, which is managed by professional organisations.

In order to protect our integrity and our careers as ophthalmologists, we need to understand the risks of accepting gifts and other indulgences from for-profit companies.

First, we need to understand what these companies are all about. Obviously, pharmaceutical companies and device manufacturers play a critical role in medicine.

They provide products that can and do help patients. If these companies did not exist, there would be limited innovation in the field of ophthalmology, and our ability to provide for patients would be diminished. These companies provide drugs and technology that we can leverage to provide better outcomes for our patients.

However, these companies need to make money. This means that their products may be useful, but that usefulness must be judged by our professional standards and not theirs.

For these companies, it does not matter if the product or drug is actually the best. Instead, the company simply wants to make money.

As ophthalmologists, we are dedicated to our patients. For-profit companies have a duty to their stockholders or owners. If we forget this distinction, we risk being regulated by the government and losing the respect of our patients.

In order to avoid being compromised by the commerciality of manufacturers and drug companies, we have to know what such compromise looks like. Drug and device companies use a variety of techniques. This starts with free gifts. They may offer travel cups, pens, keychains and more. They may

also try to attract your attention with a free meal or a free trip. These venues serve as the backdrop of their sales pitch, which is designed to hit us while we have our guards down. All gifts or other perks need to be understood in context, and we need to acknowledge the risk of compromise when we accept any of them.

When free gifts are offered, most of us do not think they are risky. After all, we are professionals. We can sit through a free lunch without feeling committed to buying.

Unfortunately, that is the mindset forprofit companies use for their gain.

These fun events and attractive venues create a positive association with the product.

In essence, these companies use our good moods to make their products even more attractive.

All they have to do is get us to sit down for the presentation, and they have already made progress in their marketing efforts.

Most of us would argue that we still approach these meetings critically enough to escape the risk. However, research clearly shows that no one is immune to such advances. If we accept gifts or perks, our habits in the office usually begin to change. We tend to recommend those drugs and devices more often, and the more we take free gifts, the more our perspective will shift. This happens without our knowledge, and it compromises our professionalism.

The danger lies in the inherently coercive nature of marketing. No matter how good the product is, marketing is still about persuasion.

Sometimes, this is an overt process, but the effect can also be subtle and cumulative.

When sales representatives present information, they do so in a controlled context. In essence, they provide only one side of the story. They extol the positive attributes of their product without discussing the drawbacks or other comparable techniques. Moreover, these companies do not discuss problematic elements of the product, such as the cost to patients or society.

Even when representatives provide data, we need to be critical. These companies sponsor research to get the results they want. This creates an inherent bias that we cannot allow.

In order to decide if the product is right for our practices, we need to rely on professional research and comprehensive analysis of the cost and risk of the product.

For many ophthalmologists, drug representatives provide excellent access to pharmaceuticals our patients need. However, these sales representatives have a specific goal to make money. Accordingly, drug representatives are almost always personable, and they take the time to get to know us and our practices. This is their way of developing a professional relationship. Over time, this can create a bias in any practice. We will start to favour that company, even if we do not intend to be biased. These representatives may be an inevitable part of the business, but we need to be wary of investing in a relationship with one.

Ultimately, nothing is truly free. If we take a gift or perk, we are creating a relationship with that company or salesperson. With every gift, that relationship strengthens. This will compromise our integrity and create a conflict of interest. Instead of looking out solely for our patients, we will start to think about our loyalty to the company. Moreover, we will stop considering the best practices and look for the easy solution. This conflict of interest will impede our ability to serve our patients faithfully.

This conflict of interest can also shortchange our careers. Many doctors have been wooed away from their practices and universities to work for for-profit companies. There is simply no way for other institutions to match the perks offered by such employers. This means that the best and brightest doctors in ophthalmology are no longer actively practising. This deprives patients of their doctors, and it eliminates the potential for powerful mentoring relationships with upcoming ophthalmologists.

Therefore, we must remember our priorities. If we focus on our practice of ophthalmology and keep commercial interests at bay, we can protect our careers and our patients.

Dr Rahil Chaudhary is Managing Director at the Eye7 Chaudhary Eye Centre in Delhi, India

JOHN HENAHAN

PRIZE 2017 EUROTIMES | SEPTEMBER 2017

41

HOSPITAL DIARY

HEROICS AND MAGIC Grass is always greener when looking from the medical to the surgical and back. Leigh Spielberg MD reports

D

r De Zaeytijd For both of us, I suppose referred me the grass always seems a bit to you, so greener on the other side. We you could both have tremendous respect peel the for what the other does, and membrane this admiration is mixed with from my retina,” said a patient a bit of envy for what the other to me yesterday. "Dr De has achieved, for what the other Zaeytijd has saved my vision can do to treat referred patients. since she started treating me Julie is a bit jealous that most five years ago. But she said that of the problems she’s asked to now is the time for you to help solve take months or even years her help me.” of dedicated follow-up, whereas Julie De Zaeytijd is the a retina can be reattached in medical retina specialist in our an hour or so. On the other department at Ghent University hand, I envy her ability to Hospital, an excellent colleague make a difficult diagnosis, who keeps the medical side of to recognise a single pattern our department running like a among thousands, to be able to high-speed train. tell the difference between two Medical and surgical different subtypes of retinitis retina are distinct, separate pigmentosa with a quick look at subspecialties in Belgium, so a the mid-periphery. symbiotic relationship between It’s a great feeling to know the two is crucial to the success that my own patients will be of both. So, Julie and I have each well taken care of when I refer other’s numbers on speed dial. them to her. “The pucker in your I call her when I need to know right eye is gone and it all looks something. She calls me when very good, but your left eye is she needs something to be done. developing some problems due I must admit, however, that to your diabetes,” I’ll say, “so I’d I call Julie more than she calls like to refer you to the diabetes Medical and surgical retina are distinct, me. I guess this is because there eye specialist for further followseparate subspecialties in Belgium, so a are more patients with macular up and treatment.” degeneration, vascular occlusions I’ve noticed that introducing symbiotic relationship between the two and diabetic retinopathy a colleague by mentioning their is crucial to the success of both... than there are patients with subspecialty field usually draws retinal detachments, macular a blank stare. “Dr De Zaeytijd holes and trauma. is a medical retina specialist” “Look at this OCT with me, will you?” I ask, as we both open means literally nothing to most patients. Instead, I’ll say, “Dr the images on our own computers on opposite sides of the De Zaeytijd is specialised in treating abnormal fluid in the department. We are separated only by the big new glass-enclosed retina, which is exactly what you have.” This works for all kinds atrium and waiting room. “I’m thinking anti-VEGF, followed of disease descriptions. “She’s a specialist in blood clots in the by laser if necessary…” My favourite thing to hear Julie say: retina… a specialist of diabetes in the retina… a specialist for “Absolutely, that’s exactly what I would do.” inherited diseases of the retina.” This kind of introduction distils But she’ll often offer a more nuanced approach, one based on everything down to the information that is most relevant for this the most recent research results in medical retina. I then add this one specific patient. information to my own treatment protocols, so I can avoid asking It’s amazing what someone with seven years of dedicated the same question twice. study, fellowships and full-time attention to medical retina can Although I call her more than she calls me, Julie views what I do realise. She can confidently identify diseases that most of us have in the VR department as a mixture of heroics and magic. She sends simply not heard of since studying for the final exam of our patients blinded by a macula-off retinal detachment or a dense residency training. I’m not sure whether I’ve ever said that to diabetic vitreous haemorrhage. Six weeks later, the patients return her, but maybe I should. And yet I know that she would answer, to medical retina, their vision restored. Hooray! And yet, this skips with her characteristic modesty, something like: “Yes maybe, the drama of the anaesthesia, surgery, postoperative care, daily Leigh, but I don’t think I could peel an inner limiting membrane drops and all the rest. By week six, it all looks just great. And thus, to save my own life.”

Julie has a very vivid imagination regarding my interventions: “And then the VR surgeon appears out of nowhere, takes the Dr Leigh Spielberg is a vitreoretinal and cataract surgeon patient to the operating room and solves everyone’s problems, at Ghent University Hospital in Belgium while we have to spend months or years injecting and lasering for a single line of improvement.” leigh.spielberg@gmail.com Illustration by Eoin Coveney

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EUROTIMES | SEPTEMBER 2017

INDUSTRY NEWS

90° Directional Laser Probes INDUSTRY

NEWS

SLIT LAMP NIDEK has announced the launch of the SL-2000 Slit Lamp.

“NIDEK’s expertise in optical engineering has been used to design the SL-2000 in pursuit of a superior experience for both patient and practitioner during examination,” said a company spokesperson. “The SL-2000 provides a crisp and clear view of ocular tissue in nearly natural colour. The optical design of the SL-2000 optimises resolution and contrast to visualise ocular tissue in exquisite detail. Additionally, the increased depth of focus enables better observation of the peripheral fundus,” said the company spokesperson.

According to Nidek, a long-lasting LED light source provides effective, consistent brightness, and the unique colourtemperature relationship of the illumination system enables observation in nearly natural colour, even for fundus examination.

A proprietary optical lens is incorporated into the SL-2000 to reduce uneven lighting and compensate for aberrations. www.nidek.com

PRODUCT DEVELOPMENT

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Katena Products has announced the purchase of NuPak Medical Ltd. “With this acquisition, we look forward to better serving the ophthalmic community through our enhanced ability to develop innovative products focused on elevating eye care globally,” said Mark Fletcher, CEO of Katena Products.

David Cocke, General Manager at NuPak, said: “We are excited to join Katena and explore new opportunities in ophthalmic manufacturing.

We believe this partnership will open new avenues in contract manufacturing for NuPak while supporting Katena’s efforts to provide innovative solutions to its global customer base.” www.katena.com

IOPtima Ltd has announced the launch of the iLid CO2 laser kit. A spokeswoman said the kit will enable oculoplastic surgeons to perform safe, effective CO2 laserassisted blepharoplasty.

Using the iLid CO2 laser kit instead of a manual surgical scalpel, surgeons employ a CO2 laser beam with adjustable levels of penetration to incise the upper and lower eyelids and remove excess fat.

The CO2 laser beam also vaporises the top layer of skin, restoring its surface and smoothing the lid.

“Dual use of this technology allows clinics to have two applications in one device,” said IOPtima CEO Ronen Castro. www.IOPtima.co.il

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EUROTIMES | SEPTEMBER 2017

43

Membership POWERFUL DATA | CLINICAL TRENDS

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ESCRS NEWS

Paul Rosen and Nino Hirnschall at JSCRS 2017

ESCRS

NEWS

ESCRS IS BIG IN JAPAN The ESCRS took part in a joint symposium at the 32nd Annual Meeting of the Japanese Society of Cataract and Refractive Surgery (JSCRS). The annual meeting was held in Fukuoka from June 23 to 25, and more than 1,800 attendees gathered from all over Japan for the meeting.

The topic for the joint symposium, with speakers from ESCRS, American Society of Cataract and Refractive Surgeons (ASCRS) and JSCRS, was “Controversies in Femtosecond Laser-assisted Cataract Surgery (FLACS)”. Paul Rosen (England) and Hiroko Bissen-Miyajima (Japan) moderated the session. The positive and negative aspects of FLACS were presented by six speakers, with discussions from the ESCRS speakers on ‘Capsulotomy’ by Nino Hirnschall (Austria) and ‘Economics of FLACS’ by Paul Rosen.

Following the symposium, an Open Forum was held in the special theatre built in the Exhibition area.

The differences between Japanese standards and international standards in cataract and refractive surgeries were discussed.

Significant differences were found in intra- and postoperative management of infection, and the usage of toric and multifocal IOLs. The Special Lecture, the main event of the annual meeting, was given by Associate Professor Kazuno Negishi of Keio University on the theme of ‘Quality of Vision and quality of life in cataract and refractive surgery’.

“I am deeply grateful for the valued support and cooperation of JSCRS members and many others in holding this meeting,” said Chikako Suto, chair of JSCRS, Department of Ophthalmology, Tokyo Women's Medical University Medical Center East. “It is my hope that from small beginnings, the meeting will send up green shoots and grow tall until it flowers into a radiant future, and contribute to the development of cataract and refractive surgery through the participation of as many people as possible,” she said.

ESCRS On Demand is an online library of presentations from ESCRS Congresses.

This library offers ESCRS members the opportunity to view the scientific content of all

ESCRS Congresses at their leisure. This includes all presentations, videos and eposters. Access is free for ESCRS members.

Full information is available at http://escrs. conference2web.com

EUROTIMES | SEPTEMBER 2017

45

365 Curriculum

Saturday, November 11 The Astigmatism & Presbyopia Forum: Providing Premium Surgical Results to Patients With Growing Expectations

Register now! meetings.eyeworld.org

Supported by educational grants from Alcon Laboratories Inc., and Johnson & Johnson Vision. Additional grants pending.

Registration and reception: 5:30 PM – 6:00 PM Program: 6:00 PM – 8:00 PM New Orleans Marriott 555 Canal Street Moderator: Bonnie An Henderson, MD

Sunday, November 12 What Next? Customizing Modern OSD Therapies to Individual Patient Needs Supported by educational grants from Allergan, Shire, TearLab, and TearScience. Additional grants pending.

Registration and breakfast: 6:30 AM – 7:00 AM Program: 7:00 AM – 8:00 AM New Orleans Marriott 555 Canal Street Moderator: Terry Kim, MD

Monday, November 13 Laser-Assisted Cataract Surgery: Balancing Incremental Clinical Advantages with Learning Curves Supported by educational grants from Alcon Laboratories Inc., Bausch + Lomb, and Johnson & Johnson Vision. Additional grants pending.

Registration and breakfast: 7:00 AM – 7:30 AM Program: 7:30 AM – 8:30 AM New Orleans Marriott 555 Canal Street Moderator: Richard L. Lindstrom, MD This activity is approved for AMA PRA Category 1 Credits.TM

New Orleans 2017

BOOK REVIEWS

OCULAR TRAUMA Ocular trauma is one of several categories of pathology that every ophthalmologist, including the subspecialists, encounters from time to time. And yet, due to the relative rarity of these cases, staying up to date regarding optimal management remains a challenge. I thus decided to review Mechanical PUBLICATION: Ocular Trauma: Current Consensus MECHANICAL OCULAR TRAUMA and Controversy (Springer), edited by Hua Yan. EDITOR: The preface reminds us that HUA TAN ocular trauma is the leading PUBLISHED BY SPRINGER cause of blindness in young people. It often involves healthy people who are suddenly thrust into a long-term treatment trajectory. This serves to focus our attention on the necessity of optimal treatment, as many disability-adjusted life years can be avoided by good decision-making and prompt treatment.

Simply figuring out what has happened is a big challenge.

Injury classification is thus the focus of Chapter 1, which outlines the ways we can evaluate the pathology and communicate our findings. Chapter 2 deals with anterior segment trauma. Particularly interesting are the descriptions of the ways that iris rupture can be surgically repaired, near the pupillary margin or at the iris base.

Chapter 3: Posterior Segment Trauma describes the complex interventions required when the choroid, retina and / or vitreous base are affected. The crucial aspect of timing of each intervention is discussed at length, making use of illustrative cases.

Chapters 4 and 5 cover intraocular foreign bodies (IOFB) and traumatic endophthalmitis, respectively. The two are often related, as IOFB can lead to endophthalmitis, which dictates the general rule of immediate IOFB removal. Chapter 6 discusses ocular trauma in children, and Chapter 7 provides insight into severely traumatised eyes with no light perception.

This book is intended for ophthalmology residents and fellows and any ophthalmologist who is on call and is likely to be asked to treat ocular trauma.

BOOK

REVIEWS

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QUESTIONS AND ANSWERS There are a million and one ways to study ophthalmology. But once one has mastered the material, there is only so much one can continue to learn from standard textbooks. A next step might be to read question-and-answer books that resemble exams one expects to take. Ophthalmology Clinics for Postgraduates (Jaypee),

by Prafula Kumar Maharana, Namrata Sharma and Atul Kumar, is aimed at those studying for the postgraduate exam in India.

“This book attempts to present the important topics in a format that is exactly the same as required in the practical exams,” the preface reads. This entails “long cases” like thyroidassociated ophthalmopathy and “short cases” such as cherry-red spot. The information is presented in such a way as to facilitate rapid review, with a particular focus on history taking, clinical examination and differential diagnosis.

Ophthalmology Clinics was written for those studying for postgraduate exams, but is useful for anyone looking to sharpen their clinical skills.

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

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EUROTIMES | SEPTEMBER 2017

47

48

EXPLORING LISBON

LISBON

3

TO NOTE...

LISBON

AVERAGE OCTOBER TEMPERATURE: 23°C/73.4°F ELECTRICITY: 220 VOLT/2-PIN SOCKET EMERGENCY: DIAL 112

The Champalimaud Foundation will be familiar to eye surgeons as the sponsor of the annual million-dollar Vision Award, the largest prize in a field supporting the fight against blindness. The foundation’s spectacular research and oncology treatment centre occupies a riverside position near Belém. Its landscaped public area has become a popular attraction. The foundation’s interior garden is reserved for the use of oncology patients treated at the centre, but can be glimpsed through the building’s spectacular windows. The centre’s café, the Darwin, is open to the public so that anyone can enjoy the food and take advantage of the terrace with its view of the mouth of the River Tejo. www.darwincafe.com The project for developing the archaeological site at São Jorge Castle as a museum won the Piranesi Prix de Rome 2010 International Prize for architect João Luís Carrilho da Graça. His ultraelegant structure encloses and exhibits a portion of the dig on the site of Lisbon’s first known human settlement. The excavations on the top of the city’s highest hill began in 1996. Remnants of successive periods of inhabitation – Iron Age settlement, Medieval Muslim occupation and a 15th-Century Palace – were uncovered, and the most significant artefacts are exhibited in the museum. Free tours include entry to the Muslim houses. In October there are six tours a day. No need to book, just wait at the site for a guide.

Museum website: www.castelodesaojorge.pt If you think the artwork on the tile wall of the Botto Machado Garden looks like graffiti, you’d be right. The 52,738 hand-painted tiles that make up the mural are the work of the PortugueseFrench artist André Saraiva, who won his street cred in the 1990s, in Paris. His work, tagged with a top-hatted stick figure known as ‘Mr. A’, showed up on postboxes, windows and abandoned buildings. Now his work is featured in museums and galleries around the world. Lisbon’s 188-metre-long mural, the initiative of Lisbon City Council and MUDE (Design and Fashion Museum), was inaugurated in October 2016.

The design represents Saraiva’s imaginary Lisbon rendered in bright colours. The mural is near Flea Market Square, Campo de Santa Clara.

EUROTIMES | SEPTEMBER 2017

Champalimaud Centre

FADO IS THE CITY’S SOUL

Unique experiences await congress delegates in Portugal’s capital. Maryalicia Post reports Lisbon has a soul, and its name is ‘fado’.

Fado, or ‘fate’, is the theme of Lisbon’s plaintive songs, born on the streets and elevated to the status of art by fadistas such as Amália Rodrigues. An evening of fado features a singer and two guitarists – and in the most traditional setting, these artists will also have served the dinner (and possibly cooked it too).

When dinner is over, the announcement is made: ‘Silêncio que se vai cantar o fado’ (‘Silence, because fado is about to be sung’). After that you may sip your wine – but not eat, and especially not talk – while the singer pours her heart out.

For an authentic fado evening, a popular recommendation is Sr Fado in the Alfama.

The hosts are Duarte Santos and Ana Marina, who offer homemade ‘rustic Portuguese’ food cooked by Ana. Ana sings, and Duarte, who will probably have been your waiter, is joined by another guitarist as the guests experience an evening to remember. The cosy room seats about 25 people. Reservations are essential. Fado evenings are Wednesdays through Saturdays.

For details, visit: www.sr-fado.com Fado was recognised by UNESCO in 2011 as an ‘intangible cultural heritage’.

You can learn more about fado and its most celebrated exponents at a museum dedicated to the art. The Museum of Fado is a good place to start or finish a walk in the hilly, picturesque streets of the Alfama.

TILTED BOAT It’s safe to say that only in Lisbon can you go to sea in a tiled boat, the Trafaria Praia.

A decommissioned ferry, re-purposed into a floating work of art by Joana Vasconcelos, it was Portugal’s entry in the Venice Biennale in 2013. Hand-painted tiles – a 21st Century panorama of Lisbon

– cover the hull while below deck there’s a surrealistic installation of fairy lights and blue fabric to explore.

If you’d simply like to visit the ferry at its dock at Cais do Sodré, it’s open on Mondays.

To combine a visit with a one-hour river cruise, you can go Tuesday to Sunday, with departures at 10.30, 14.30 and 16.30. Reserve on the website: www.douroazul.com A ride on the vintage No 28 trolley is one of the most popular ways of seeing Lisbon, the Alfama in particular, without the challenge of climbing its steep streets.

In fact, you may find it a touch too popular as it’s often full to bursting.

Consider Tram 12 instead. This route is also served by pre-war Remodelado trolleys and covers a shorter distance – 4km from Baixa to Alfama in 20 minutes – and is significantly less crowded. On either route, be careful of pickpockets. Trams, called ‘eléctricos’ in Portuguese, operate from 08.00 until 20.45.

Sr Fado in the Alfama

RANDOM THOUGHTS

THE REALITY OF BURNOUT Ophthalmologists are as prone to mental exhaustion as any other specialty. Aidan Hanratty reports

A

re you suffering from burnout? It can happen to the best and brightest of us. Tiredness, frustration, a lack of concentration, poor performance at work – these are just some of the signs that you may be in a rut. David Ballard PsyD of the American Psychological Association describes job burnout as “an extended period of time where someone experiences exhaustion and a lack of interest in things, resulting in a decline in their job performance”.

Graham Greene’s A Burnt-Out Case predates the first use of the term in psychology, telling the story of a dissatisfied architect who travels to a leper colony in the Congo to find purpose.

“Leprosy cases whose disease has been arrested and cured only after the loss of fingers or toes are known as burnt-out cases,” wrote Greene in his journal In Search of a Character.

He used this in parallel with the mentally exhausted and disinterested architect, who is fortunate enough to be in a position to drop everything and get away in the hopes of returning afresh. That’s not so easy for doctors, whose patients don’t stop needing help.

STRESSORS Writing in the Huffington Post, Melinda Hakim examines some of the reasons doctors in particular are facing burnout.

Key factors include an inordinate amount of time spent on paperwork (as opposed to treating patients); rising overheads; debt following long years of training; an imbalance between hours worked and money received.

Studies have shown that ophthalmologists are among the most satisfied with their chosen field, but they may also feel forced to hide problems with mental health. Every specialty faces issues with waiting lists, and ophthalmology is no different – this can have a draining effect, leaving physicians with a feeling of helplessness.

Among other things, the Mayo Clinic recommends that anyone suffering from burnout manage their stressors, and adjust their attitude. These are easier said than done, especially if those stressors come from management or general dissatisfaction with the state of the health service.

VALUE There are no simple answers to the dilemma of burnout, and Hakim does not attempt to provide any. Instead she points out how important it is that the field of medicine can continue to attract the brightest minds. “We must all reach out to doctors and do everything in our power to demonstrate that we value our country’s physicians before it’s too late.”

The architect at the centre of Greene’s novel meets an unfortunate end; hopefully the same will not be said of the medical profession.

Aidan Hanratty is Content Editor of EuroTimes. This article was first published on the EuroTimes website in July 2017 EUROTIMES | SEPTEMBER 2017

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BOOK REVIEWS FROM THE ARCHIVE

NITINOL SUTURES An injectable metal clip may reduce time spent constructing intraocular sutures by up to 20 times, greatly simplifying procedures including pupilloplasty, iris fixation of intraocular lenses, encircling band fixation and anchoring EUROTIMES VOLUME 17 glaucoma drainage devices, Michael Erlanger MD told ISSUE 9, PAGE 60 the innovators session of the FIRST PUBLISHED SEPTEMBER 2012 ASCRS annual symposium.

The circular, shapememory titanium-nickel alloy 0.007-inch nitinol (nickel titanium alloy) suture wire is five times stronger than prolene and 38 times stronger than nylon. Proven in neurosurgery and cardiac stent applications, it is highly biocompatible and can be delivered one-handed through needles as small as 30 gauge for intraocular procedures.

And unlike filament sutures, the wire clip can be bent and returned to its original shape, said Dr Erlanger, who is developing the technology at the University of Colorado, Denver, US, and has a patent pending on the injectable Nitinol suture with Jeffrey Olson MD. “This is very useful when you are working in the eye.

You don’t have to use ocular gymnastics to get in a Seipser suture,” Dr Erlanger said.

In animal tests, pupilloplasty was performed 16 times faster with the nitinol suture than with a modified Seipser slip knot, and the need for limbal-to-limbal passes was eliminated, making the procedure less technically challenging. Similarly, IOL iris fixation times were reduced 20-fold.

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When properly prepared, the titanium-nickel nitinol alloy is highly resistant to corrosion, Dr Erlanger noted. The compound has been used extensively in cardiovascular stents as well as orthopaedic and dental devices.

While nitinol can be formed into any shape, for intraocular use a circular double-coiled clip may be most useful. Dr Erlanger has tested it in 0.5mm and 1.0mm suture sizes.

He has developed an injector based on a syringe. Nitinol’s memory characteristics allow the suture to be straightened and injected through a straight or curved needle. It resumes its circular shape as it leaves the injector, allowing it to be anchored in tissue as it comes out. The suture can be manipulated with forceps after injection. Pre-set sutures can be sprung open to grasp haptics, glaucoma shunts, rings or other devices.

In a three-month biocompatibility study involving five Yucatan mini pigs, five eyes receiving nitinol sutures and five receiving modified Seipser knots showed no significant differences in corneal specular cell counts, corneal thickness measured by OCT, corneal histology staining, or retinal histology measured by cell counts of the ganglion cell, inner nuclear and outer nuclear layers, Dr Erlanger reported (Inv Ophthalmol Vis Sci 2011). However, mean surgical time for the nitinol eyes was one minute 18 seconds compared with 19 minutes 38 seconds for the modified Seipser knot eyes (p<0.005).

Other successful tests include anchoring an Ahmed glaucoma drainage shunt, Retisert fixation, installation of encircling bands and IOL fixation, Dr Erlanger said.

He believes this technology will find broad application in ophthalmic surgery.

CALENDAR

Barcelona will host the 17th EURETINA Congress

↙

LAST CALL

SEPTEMBER 2017

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 27–30 September Nice, France www.ever.be

DOG 2017

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

OCTOBER

AAO 2017

South East European Congress of Ophthalmology

NEW Annual Ophthalmologists Meeting

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

6–8 October Sarajevo, Bosnia and Herzegovina www.ophthalmologia2017.com

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

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

NOVEMBER

8th EuCornea Congress

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

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

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

DECEMBER

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

Asia-Pacific Vitreo-Retina Society Congress (APVRS) 8–10 December Kuala Lumpur, Malaysia http://2017.apvrs.org

EUROTIMES | SEPTEMBER 2017

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CALENDAR

2018

Vienna will host the 36th Congress of the ESCRS, the 9th EuCornea Congress and the 18th EURETINA Congress in September 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

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

MARCH

Frankfurt Retina Meeting 2018

JUNE

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

9th EuCornea Congress

WOC 2018

SEPTEMBER

↙

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

SEPTEMBER

18th EURETINA Congress

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

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

World Society of Paediatric Ophthalmology & Strabismus

SUBSPECIALT Y DAY Friday 6 October 2017 Lisbon, Portugal Preceding the XXXV Congress of the ESCRS 7–11 October 2017

www.wspos.org

EUROTIMES | SEPTEMBER 2017

21 September Vienna, Austria www.wspos.org

36th Congress of the ESCRS

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

WSPOS Registration Open

2018 WSPOS Subspecialty Day

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

9 â&#x20AC;&#x201C; 11 February 2018 Sava Centar, Belgrade, Serbia Abstract Submission Deadline: 31 October 2017

www.escrs.org

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Talk to your local Alcon representative to learn more about the AcrySof® IQ PanOptix® Toric IOL and visit us at the ESCRS Congress- Booth#P272. * Enlighthen technology, AcrySof platform and new calculator (1-11). **Studied over a one-year period.

1. Leydolt et al. Posterior Capsule Opacification with the iMics1 NY-60 and AcrySof SN60WF 1-Piece Hydrophobic Acrylic Intraocular Lenses: 3-Year Results of a Randomized Trial. Am J Ophthalmol 2013;156:375–381. 2. Linnola RJ, Sund M, Ylonen R, et al. Adhesion of soluble fibronectin, laminin, collagen type IV to intraocular lens materials. J Cataract Refract Surg. 1999;1486-1491. 3. Boureau C, et al. Incidence of Nd:YAG laser capsulotomies after cataract surgery: comparison of 3 square edge lenses of different composition. Can J Ophthalmol. 2009;44:165-170. 4. Clinical Evaluation Report for: AcrySof® IQ ReSTOR® Multifocal Toric IOLs. TDOC-0016076. Effective date 05 Jul 2013. 5. Mechanical equivalency rationale for AcrySof® Toric Models. TDOC-005078 Effective date 11 Aug 2015. 6. Lane SS, Burgi P, Milios GS, Orchowski MW, Vaughan M, Schwarte E. Comparison of the biomechanical behavior of foldable intraocular lenses. J Cataract Refract Surg. 2004;30:2397-2402. 7. Lane SS, Ernest P, Miller KM, Hileman KS, Harris B, Waycaster CR. Comparison of clinical and patient reported outcomes with bilateral AcrySof® Toric or spherical control intraocular lenses. J Refract Surg. 2009;25(10):899-901. 8. Wirtitsch MG, Findl O, Menapace R, et al. Effect of haptic design on change in axial lens position after cataract surgery. J Cataract Refract Surg. 2004;30(1):45-51. 9. Nejima R, Miyai T, Kataoka Y, et al. Prospective intrapatient comparison of 6.0-millimeter optic single-piece and 3-piece hydrophobic acrylic foldable intraocular lenses. Ophthalmology. 2006;113(4):585-590. 10. Potvin R, Kramer BA, Hardten DR, Berdahl JP. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Ophthalmol 2016;10:1829-1836. 11. Koshy JJ, Nishi Y, Hirnschall N, et al. Rotational stability of a single-piece toric acrylic intraocular lens.

J Cataract Refract Surg. 2010;36(10):1665-1670. 12. Lawless M, et at. Visual and refractive outcomes following implantation of a new trifocal intraocular lens. Eye and vision (2017) 4:10. 13. Garcia-Pérez JL. Short term visual outcomes of a new trifocal intraocular lens.

BMC Ophthalmology (2017) 17:72. 14. Gundersen LG, et al. Trifocal intraocular lenses: a comparison of the visual performance and quality of vision provided by two different designs. Clinical Ophthalmol 2017:11;1081-1087. 15. PanOptix™ Diffractive Optical Design.

Alcon internal technical report: TDOC-0018723. Effective date 19 Dec 2014. 16. Defocus Visual Acuity Estimation of Trifocal IOLs Using Neural Network Algorithm. TDOC-0050480. Effective date June 12, 2015. 17. Hayashi K et al. Effect of astigmatism on visual acuity in eyes with a diffractive multifocal intraocular lens. J Cataract Refract Surg. 2010;36:1323-1329. 18. AcrySof® IQ PanOptix™ IOL Directions for Use. 19. Carson D, Xu Z, Alexander E, Choi M, Zhao Z, Hong X. Optical bench performance of 3 trifocal intraocular lenses. J Cataract Refract Surg.2016;42(9):1361-1367. 20. Lee et al. Optical bench performance of a novel trifocal introacular lens compared with a multifocal intraocular lens. Clin Ophthalmol 2016;10:1031-1038. 21. Charness N, Dijkstra K, Jastrzembski T, et al. Monitor viewing distance for younger and older workers. Proceedings of the Human Factors and Ergonomics Society 52nd Annual Meeting, 2008. http:// www.academia.edu/477435/Monitor_Viewing_Distance_for_Younger_and_Older_Workers. Accessed September 16, 2016.

22. Average of American OSHA, Canadian OSHA and American Optometric Association Recommendations for Computer Monitor Distances. 23. AcrySof® IQ PanOptix® Toric IOL Directions for Use.

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