EuroTimes Vol. 23 - Issue 10

SPECIAL FOCUS CATARACT & REFRACTIVE INNOVATIONS

October 2018 | Vol 23 Issue 10

INNOVATIONS

IN CATARACT SURGERY

CATARACT & REFRACTIVE | CORNEA | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY | OCULAR

Making the difference in eYe SUrgerY Oertli makes the difference. With surgical platforms and instruments of impressive quality that make cataract, glaucoma and vitrectomy surgery even safer, easier and more efficient. With lasting innovations and new technologies that have long term impact on ophthalmology. With superb service and real added value for surgeons and OR personnel.

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

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

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

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

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

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

ISSN 1393-8983

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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

RETINA

CATARACT & REFRACTIVE INNOVATIONS

19 Research suggests

04 Examining the technology

that has evolved to solve the remaining challenges

06 No one will teach you how to fight for the attention of the technology-focused student

08 The eye is among the front runners when it comes to new advances

CATARACT & REFRACTIVE 10 Study follows late dislocations of in-the-bag IOLs

11 New implant leaves space

for subsequent placement of piggyback IOLs

13 JCRS highlights

nAMD can be treated with eye drops

20 Breaking down the

options for managing retinal detachment

21 Ophthalmologica update

GLAUCOMA 22 Glymphatic system of the optic nerve may represent a new target for treatment

24 Altering diagnostic

techniques can reveal macular damage

PAEDIATRIC OPHTHALMOLOGY

15 Phakic IOLs can be safe

28 Deciphering unusual

16 Modified hybrid DMEK

30 Burnout affects doctors

17 Big bubble DALK offers

31 Novel method

good results in some keratoconous patients

REGULARS 32 Travel 35 ESCRS News 37 My mentor 39 Calendar

safe in treatment of vernal keratoconjunctivitis

OCULAR

technique shows promise for challenging cases

P.31

27 Topical ointment appears

CORNEA where laser surgery is not viable

www.eurotimes.org

visual symptoms can be a challenge and patients across the globe

proves effective for lower-lid ectropion

Included with this issue...

2017

Results

Clinical Survey supplement EUROTIMES | OCTOBER 2018

2

EDITORIAL A WORD FROM BEKIR SITKI ASLAN MD

GUEST EDITORIAL

Rapid evolution Cataract surgery has moved from high risk to safety, writes Dr Bekir Sıtkı Aslan

Bekir Sıtkı Aslan

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), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

F

ollowing the unmatched contributions of Harold Ridley and Charles Kelman, today we witness a rapid and striking technological evolution with aims that are refractive rather than simply focused on removal of the cataract.

During the last few years, IOLs have come to allow the correction of presbyopia, astigmatism and spherical and chromatic aberrations, prevent posterior capsule opacification, block wavelengths that are potentially dangerous for the macula and also maintain accommodation. We have been witnessing an ever-increasing dissemination of all advanced technology lenses in general, but especially toric lenses.

Advancements in IOL technology improve visual functionality by creating customised IOLs or modifying optical power postoperatively.

Physicians now have access to advanced diagnostics that can better quantify conditions such as dry eye, light scatter and posterior corneal astigmatism, to enhance refractive measurements and help with selecting the appropriate IOL. The innovative Zepto and the Capsulaser We have been devices provide pristine capsulotomies though they witnessing an work differently. ever-increasing The active fluidics of dissemination the CENTURION Vision System yield reduced of all advanced CDE output compared technology lenses to gravity-based systems, which, in turn, creates a safer, more stable surgery and quicker visual recovery.

The ultrasound phacoemulsification represents the gold standard for cataract extraction, but a new femtolaser energy source seems to be about to prevail. However, we do not know if the new generation of femtosecond lasers for cataract surgery is one of the most important innovations of the beginning of the century; but we are sure it is the most exciting for the future.

The MiLoop is to dissect the cataract into multiple pieces, while it is still in the capsular bag to reduce ultrasonic energy A well-dilated pupil is critical for good outcomes, and Omidria (an injection of phenylephrine and ketorolac) might fit in the practices. However, pupil expansion devices may be needed in up to 10% of cases.

Alcon will launch the first image-guided aberrometer called ORA with VerifEye Lynk, as well as the next-generation Verion.

With Verion, image-guided surgery will be streamlined to connect pre-op diagnostics, case planning and surgical guidance.

In summary, in a relatively short time, cataract surgery was transformed from a procedure with significant morbidities and high risk of vision loss to one of the safest and functional procedures in modern medicine.

Bekir Sıtkı Aslan is Head of Eye Department, Ankara Memorial Hospital, Turkey EUROTIMES | OCTOBER 2018

23rd ESCRS Winter Meeting

ath ens

In conjunction with the 33rd HSIOIRS International Congress

15 – 17 February 2019 Megaron Conference Centre, Athens, Greece

Abstract Submission Deadline: 31 October 2018

www.escrs.org

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SPECIAL FOCUS: CATARACT & REFRACTIVE INNOVATIONS

INNOVATIONS

IN CATARACT SURGERY Technology evolves to solve remaining challenges.

Sean Henahan reports

EUROTIMES | OCTOBER 2018

SPECIAL FOCUS: CATARACT & REFRACTIVE INNOVATIONS

CAPSULORHEXIS PAST AND FUTURE

The capsulorhexis is the starting point for the cataract surgery. Early methods used various instruments and tearing patterns.

This finally gave way to the familiar continuous curvilinear capsulorhexis, co-credited to innovators Dr Neuhann and Dr Howard Gimbel.

Since that time the femtosecond laser entered the arena promising a wellcentred perfect capsulotomy for every procedure. However, femtosecond lasers are quite expensive.

“The femto-lasers are getting better at producing continuous edges – but are not quite there yet – they really still produce ‘micro-can-openers’. Yes, they are obviously 100% circular – but ‘it is really not about circularity – it’s about continuity’, as Howard Gimbel so truly stated. At this time and stage of development, I cannot find it yet an improvement that has relevant advantages over a manual rhexis, not least also under a cost-benefit aspect. But we’ll see what the future brings,” said Dr Neuhann.

The search for cost-sensitive options has prompted the development of a number of interesting alternatives. One of these, the CAPSULaser (Excel-Lens), received the CE mark in 2017. It is a thermal laser that attaches to a standard operating microscope.

Another option, the Zepto precision pulse capsulotomy system (Mynosys), has received the CE mark and US FDA 510K approval. That system uses a disposable handpiece, microsecond electric pulses and suction to create circular capsulotomies.

“I find every new development interesting, worth trying out. Both of these show interesting promises in their principles – we’ll have to see how they perform in large series, in complicated

cases and in comparison with the manual rhexis,” commented Dr Neuhann.

INNOVATIVE IOLS

IOL developers are responding to the remaining challenges of cataract surgery with an unprecedented array of new ideas.

The search for better multifocal IOLs is driven by the desire to reduce the nagging problems with glare, halo and patient dissatisfaction associated with the first generation of this class of lens.

Trifocal IOLs now gaining ground include the FineVision (PhysIOL), the AcrySof IQ PanOptix and the Zeiss AT LISA. Recent clinical results suggest that the lenses provide good visual acuity at near, intermediate and far distances, with fewer adverse optical effects. Other trifocals include the Alsafit (Alsanza) and Acriva Reviol (VSY Biotech).

Extended depth of focus (EDOF) lenses are another interesting development in the multifocal IOL field. The first to market was the Tecnis Symfony (J&J Vision), reportedly producing good vision at a range of distances, particularly for near vision. The AT LARA (Zeiss) also arrived on the market recently. In clinical trials that lens provided a good range of vision, particularly in the intermediate range.

More recently, monofocal IOLs based on the pinhole principle to increase depth of focus have come on the market. This includes the IC-8 IOL (AcuFocus), a singlepiece hydrophobic monofocal IOL, and the XtraFocus pinhole implant (Morcher), an acrylic, small-aperture sulcus IOL.

OPERATE LOCAL, THINK GLOBAL Innovation need not be expensive or involve sophisticated engineering. It is estimated that healthcare systems in the developed world produce 5% to 10% of all greenhouse gas emissions. A recent study (C. Thiel, JCRS, Volume 43, Issue 11, 1391–1398) looking at protocols in place at the Aravind Eye Clinics in India suggests simple ways to reduce the waste generation and environmental pollution associated with cataract surgery. The study found that Aravind generates 250 grams of waste per phacoemulsification and nearly 6 kilograms of carbon dioxide-equivalents in greenhouse gases. This is merely 5% of the levels seen in the UK per phaco procedure.

The Aravind clinics achieved this considerable savings through a system of high-volume patient throughput, reducing overhead costs, while minimising electricity and energy use. They also reduced environmental impacts and costs by way of a careful sterilisation program and reusing surgical gowns, blankets and instruments while reducing the use of disposable instruments.

ACCOMMODATING IOLS

The dream of a truly accommodating IOL is getting closer to reality thanks to several innovative products now in clinical trials.

The FluidVision (PowerVision) changes accommodative power by increasing and decreasing the quantity of fluid within the optic. The Juvene (LensGen) is a twolens modular IOL made of a monofocal base lens into which a fluid-optic accommodating component that changes curvature is placed. Another novel lens in development is the Sapphire IOL (Elenza), an electronically controlled, remotely programmable, customisable IOL. Sulcus-implanted accommodative IOLs are also in development. One of these is the Lumina lens (Akkolens/Oculentis), which produces accommodation via two optical elements shifting in a plane perpendicular to the optical axis. Another is the Dynacurve IOL (NuLens), which uses the movement of the ciliary muscles to change the curvature of the optic. Both are in the early clinical stages.

FINALISING THE FINAL RESULT

Even with perfect surgical technique and the best IOL available, the final result of cataract surgery doesn’t always match the intended result. Now it seems the final result may not be final at all, but could

The waste generation from just one cataract surgery in the United States (above) compared to the waste generation from 93 cataract surgeries in India (below)

Courtesy of Cassandra Thiel, PhD

T

he evolution of modern cataract surgery can be seen as a long history of creative, sometimes iconoclastic innovation. In many cases this innovative process meets resistance from established authorities until the worth of a new idea can be proven to improve on existing procedures.

With 50 years of experience since the debut of phacoemulsification and smallincision IOLs, cataract surgery could be said to have reached maturity. Or is it entering another new era?

“Currently, I do not see THE thundering miracle innovation – but I see a number of developments that I find interesting: refractive index manipulation, exchange of only an anterior part of an IOL for later adjustment, rhexis-fixated optics for precise and stable positioning of toric lenses – and, of course, the yet unfulfilled dream of an accommodating IOL. Progress happens incrementally. A big step in hindsight always is composed of many little steps,” Thomas Neuhann MD, Medical Director of the Laser Eye Centre, Munich, told EuroTimes.

5

be adjusted after the surgery has been completed. A small company in California has developed a femtosecond machine it calls the Perfector2 (Perfect Lens), which it says can be used to increase or decrease the dioptres of an implanted lens, change a multifocal into a monofocal or create a multifocal from a monofocal. The product is now in the animal testing stages.

Thomas Neuhann: prof@neuhann.de EUROTIMES | OCTOBER 2018

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SPECIAL FOCUS: CATARACT & REFRACTIVE INNOVATIONS

Innovations in training The distractions of technology in the classroom are nothing new, writes Sorcha Ní Dhubhghaill

O

ur colleagues in psychology describe a dual processing theory where we have two paths to reach an answer. A blazing-fast almost intuitive path, and a slower approach that requires more processing. I am reminded of this duality every time I think about how long ago 1980 was. The year I was born.

Twenty-something years ago? That sounds about right.

What I’m saying is; I don’t feel so different from the students that I teach. Sure, I am a few years older and a bit further along the road. But at the end of the day, we are in a very similar boat.

Until that boat becomes a classroom, and all of a sudden I’m like, who are these people? And would it kill them to look at me for a moment, rather than at their screens?

Nowhere do I feel the generation gap as I do when teaching young(er) students. It is something I struggle with. Not because it makes me feel old – 38 is not old and don’t you dare tell me otherwise – but because I assumed I knew a thing or two about being a student.

But I find my personal experience to be increasingly meaningless.

More often than not, while lecturing, I find myself looking into a crowd of students staring into their laptops. There is no eye contact, no tangible feedback to confirm that I’m making sense.

Just a sea of glowing apples. I know they are feverishly tapping away taking notes. But part of me wonders; Are they playing Fortnite right now?

I get it. The laptop is an essential piece of kit – replacing not just a pen and paper, but doubling as a storage device and a library of all published medical knowledge. No wonder every student clings to it. I would have too, had it been around.

But it can be difficult as a teacher to connect with students when all you can see is their collection of laptop stickers.

In my days, I came to my lessons armed with binders and at least three colours of pens. If only I could scribble down every word uttered by the lecturer I could perhaps understand it later. My notes were a laborious affair, multi-coloured, sorted in many folders. Yet if you were to ask me what any of them actually said, I would be at a loss to tell you. I think I may have been convinced that note-taking was a valid alternative to processing and thinking. Come to think of it, I wasn’t exactly living in the moment either. And I doubt that my lecturers got a great deal of feedback out of me, hunched over my stack of paper, taking notes as if my life depended on it.

I think the bigger change technology has brought to the classroom is the abundance of available information. The internet

EUROTIMES | OCTOBER 2018

is full of YouTube presentations of eye examinations. And anyone who has ever studied for the MRCOphth knows well the Chua Eye Page with hundreds of MCQ self-test questions.

Against this backdrop, the idea of learning off lists of differential diagnoses becomes ever less relevant when all of them are available online. Rote learning is just not that useful any more. We are now more focused on teaching the WHY as opposed to just teaching the WHAT. Most medical schools have transitioned to an integrated curriculum with a problem-based approach. Problem-solving is a critical skill of a doctor and it is best to get them started young. It’s possible to over-correct however. Recent educational theory suggests that focusing only on problem-solving without building a permanent store of memory can hinder creativity by reducing the potential number of links that a student can make. So how can we get this balance right?

Personally, I strive to convey concepts rather than focus on the fine detail. Questions are not only welcome but encouraged.

Students are free to find their own footing, and every teacher should be armed with a list of online resources to cater to different learning styles. And every now and then, I simply ask them to actively listen: “Close your laptops, I need you to pay attention to what I’m about to say.” There are other ways to teach of course; perhaps I just like an audience.

Another side-effect of all that available information is the “I read online that…” scenario. Back in the good (?) old days of education there was a joke the anatomy lecturers shared: You only need to be one page ahead of the class.

It’s funny because it was true. Lecturers pontificating from the front of the room often had a de-facto monopoly on information.

Students paid better attention, because this was the only source capable of sating their appetite for knowledge.

Today, information is an all-you-can-eat 24/7 buffet, and students aren’t exactly starving. Fighting for their undivided attention is going to be a losing battle. As technology changes, teaching changes with it, and we all have to adapt. That being said, I’m still going to tell them to look away from their screens from time to time.

Sorcha Ní Dhubhghaill MB PhD MRCSI(Ophth) FEBO is an Anterior Segment Ophthalmic Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS) and Antwerp University Hospital. Contact: nidhubhs@gmail.com

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SPECIAL FOCUS: CATARACT & REFRACTIVE INNOVATIONS

R APID EXPLOSION of

ophthalmological innovations

The eye is among the front runners when it comes to new advances in technology, writes Soosan Jacob MD

I

n no field other than ophthalmology must there be such constant and rapid explosion of new innovations and technology holding the potential for dramatic change. The eye being an organ that is easy to evaluate subjectively and providing the access required to assess objectively, its various parts lends to it the enviable position of being among the front runners as far as new innovations and technology is concerned.

INNOVATIONS IN CATARACT SURGERY

Machine driven: Newer fluidics such as Active Fluidics (Alcon Centurion Vision System), Fusion Fluidics (AMO Whitestar Signature System) and Adaptive Fluidics (B&L Stellaris Elite) have all but removed surge and made chamber stability a reality. Together with power modulations, newer probe designs and better foot-pedal controls, these increase the safety, ease and speed of cataract surgery.

Hypersonic vitrectomy (Vitesse, B+L), with a cut rate of 1.7 million cpm, can liquefy and aspirate vitreous. Therefore, in case of a posterior capsular rent, one need not change probes but can continue on with vitrectomy, switching safely and seamlessly between phacoemulsification and vitreous cutting. YAG nanolasers use less energy and cause less endothelial damage than conventional phaco and can also remove the laminin layer from the capsule to prevent capsular opacification.

Lasers: Improvements in femtosecond laser-assisted cataract surgery (FLACS) include more precise cuts, better sealing reverse geometry side cuts, topographic integration, iris registration and capsular nubs for astigmatism management via incisions and toric IOLs as well as wireless integration for better workflow. The EUROTIMES | OCTOBER 2018

Zepto capsulotomy system (Mynosys) and the CapsuLaser (Excel-Lens) are accurate rhexis systems that give a stronger rim because of hardened edges.

Laser capsulotomies prevent asymmetric capsular contraction and IOL tilt secondary to asymmetric rhexis and can even make possible posterior capsule capture through precise posterior capsulorhexis.

Image-guidance systems: Surgical accuracy is further increased by iris registration and intraoperative overlay technologies such as Callisto Eye (Carl Zeiss Meditec AG) or Verion (Alcon), which help rhexis sizing and centration; axis, length and optic zone size of astigmatic cuts; IOL centration with respect to pupil etc.

Intraoperative aberrometry with the ORA (Wavetec Vision) and HOLOS IntraOp (Clarity Medical Systems) help in refining decision-making in complex situations such as post-LASIK eyes, presbyopic IOLs, toric IOL alignment and placement of limbalrelaxing incisions. Integration of various technologies such as ORA and Verion through VerifEye Lynk (Alcon) helps make these user-friendly.

However, these technologies may not be as useful in routine eyes because of measurement variability. TrueVision 3D Surgical allows stereoscopic surgery, helps intraoperative alignment and allows better ergonomics by allowing the surgeon to sit up straight while operating. The intraoperative OCT is another diagnostic tool that has proven helpful.

Newer IOLs: Piggyback IOLs, toric IOLs and presbyopia-correcting IOLs are exciting innovations. The latter includes pseudoaccommodative IOLs such as multifocals, trifocals, extended depth of focus and small-aperture IOLs; partially accommodative IOLs including the single- and dual-optics IOLs as well as accommodative IOLs – both in-the-bag as well as sulcus-implanted IOLs. Adjustable IOLs allow for postoperative

Corneal Allogenic Intrastromal Ring Segment (CAIRS) combined with Contact Lens-Assisted Corneal Cross-Linking (CACXL) for a patient with keratoconus: Slit lamp picture showing intrastromal segments together with excellent improvement in topography and other parameters seen

adjustments in power. These include the Light Adjustable Lens (Calhoun Vision) and multi-component IOLs such as Precisight (IVO) and Harmoni (ClarVista Medical). Refractive indexing utilises femtosecond laser to create patterns in the IOL to correct myopia, hyperopia, astigmatism and higher-order aberrations.

New IOL power-calculating formulae are also equally important.

Techniques: Intrascleral haptic fixation has gained traction via the glued IOL and Yamane techniques. The Jacob paperclip capsule stabilizer (Morcher GmbH) developed by the author is an effective means of achieving sutureless trans-scleral fixation of the capsular bag in subluxated cataracts and IOLs. The B-HEX Pupil Expander (Med Invent Devices), HumanOptics artificial iris

SPECIAL FOCUS: CATARACT & REFRACTIVE INNOVATIONS implant and the various MIGS devices are other useful innovations.

Dropless cataract surgery with intracameral, intra-canalicular or punctal plug-based therapeutic sustained-release drug delivery system is another advance to look forward to.

Preoperative Diagnostics: Newer devices such as the Pentacam AXL provide complete data including axial length and anterior and posterior corneal data and is helpful for toric IOL power calculation with greater accuracy. Angle alpha and kappa measurements are provided, which are useful for both refractive and premium IOL decision-making.

Investigations for the ocular surface such as tear osmolarity, MMP-9 and other inflammatory markers as well as new treatment modalities such as the LipiFlow Thermal Pulsation system are useful.

INNOVATIONS IN REFRACTIVE SURGERY

Small-incision lenticule extraction (SMILE): With lack of a flap, less incidence of flap-related complications, better retention of biomechanical strength, less dry eye, better and faster recovery of corneal sensation as well as proven predictability, efficacy and safety, SMILE® is establishing itself as a superior means of refractive correction, gaining popularity with both surgeons

and patients. Less dependence on external influences such as room temperature and humidity, corneal hydration and other factors together with faster workflow are added advantages over LASIK. Disadvantages at present, however, include lack of cyclotorsional adjustment and hyperopia treatment.

Presbyopia-correcting alternatives: Other than presbyopia-correcting IOLs, synthetic corneal inlays, multifocal LASIK (presbyLASIK), femtosecond laser-assisted intracorneal ring pattern application (IntraCor) and scleral implants, new entrants include electrostimulation of the ciliary muscle, pharmacological approaches in the form of presbyopia correcting eye drops and PEARL (PrEsbyopic Allogenic Refractive Lenticule) – a SMILE lenticulebased procedure developed by the author.

Refractive correction of keratoconus: This has received plenty of focus recently, with a goal of providing better quality of vision in keratoconic patients. Phakic toric implants in younger and toric IOLs in older patients as well as topography-guided excimer laser smoothening with corneal cross-linking and topography-guided differential cross-linking are some advances.

Two new techniques pioneered by the author – Corneal Allogenic Intrastromal Ring Segments (CAIRS) and Contact Lens-Assisted CXL (CACXL) – provide

good refractive improvement and stabilisation even in thin keratoconic corneas. CAIRS behave like Intacs but avoid all complications associated with implantation of synthetic material within the cornea as it is prepared from donor corneal tissue.

Diagnostics: There has been tremendous improvement in diagnostics with better topographic abilities, posterior corneal evaluation, aberrometry, very highfrequency digital ultrasound or OCT-aided epithelial mapping, laser interferometry, OCT, corneal biomechanical analysis using new machines and new indices as well as the concept of Percentage Tissue Altered (PTA) are exciting new advances and concepts.

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

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10

CATARACT & REFRACTIVE

OPHTEC | Cataract Surgery

Factors in late IOL dislocations Does intracameral cefuroxime reduce time to dislocation of in-the-bag lenses? Howard Larkin reports

I

n what may be the largest study to date of late dislocations of intraocular lenses (IOLs) placed in the capsular bag during primary cataract surgery, use of intracameral cefuroxime was found to shorten the average interval between implantation and dislocation more than three years, or about one-third.

Combining cefuroxime with phenylephrine to dilate pupils shortened the interval more than two additional years, Kari Krootila MD, PhD, told the American Society of Kari Krootila MD, PhD Cataract and Refractive Surgery (ASCRS) 2018 Annual Symposium in Washington DC, USA. The retrospective study examined all patients implanted with in-the-bag IOLs during primary cataract surgery at the Helsinki University Hospital, Helsinki, Finland, who subsequently presented with late IOL dislocation from 1997 to 2017. Due to bilateral dislocations, the ongoing study involved 598 eyes in 534 patients at the time of the ASCRS presentation, Dr Krootila said.

Overall, the average time from initial implant to late dislocation was 9.7 years. The study correlated the time to dislocation with common risk factors as well as substances introduced during the primary cataract procedure, said Dr Krootila, who is adjunct professor of ophthalmology and head of anterior segment surgery at the University of Helsinki and Helsinki University Hospital.

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EUROTIMES | OCTOBER 2018

The retrospective study examined all patients implanted with in-the-bag IOLs during primary cataract surgery

ROLE OF RISK FACTORS Phacodonesis at the primary cataract operation shortened the average time to dislocation by 2.2 years while pseudoexfoliation shortened it by one year, Dr Krootila reported. About half of patients who experienced a late dislocation had pseudoexfoliation, making it the most common risk factor. A few patients each had risk factors including trauma, glaucoma, retinitis pigmentosa and high myopia, while about one-third of patients had no known risk factor. Presence of diabetes or systemic connective tissue disease had no effect on time to dislocation, he added.

For substances introduced at surgery, cefuroxime alone decreased the average interval to dislocation by about 3.2 years, from 10.9 ± 4.7 years to 7.7 ± 3.5 years (p<0.001). Adding lidocaine did not significantly decrease the interval further, while adding lidocaine and phenylephrine reduced the average interval another 2.2 years, to 5.5 ± 1.9 years (p<0.01).

“Our observation is based solely on our clinical study and so far we have only speculations about the mechanism. I have also not seen any other clinical data supporting our finding, perhaps because our [study] is, to our knowledge, the largest so far regarding late dislocation of ‘IOL-in-the bag’,” Dr Krootila told EuroTimes. Further study is needed to understand the findings.

Kari Krootila: kari.krootila@hus.fi

CATARACT & REFRACTIVE

New intraocular implant

PLANS AHEAD

Implant maintains space for in-the-bag placement of piggyback IOLs. Howard Larkin reports

A

new implant combining an IOL optic with a device to maintain space within the capsular bag to receive a piggyback IOL months after cataract surgery has been successfully tested in humans, Gabriel A Quesada MD told the American Society of Cataract and Refractive Surgery 2018 Annual Symposium in Washington DC, USA. The device allows any standard IOL to be implanted within the capsular bag to correct residual refractive error rather than relying on a specialised lens placed in the sulcus.

Inserted through a 2.8mm incision, the four-haptic implant incorporates an optic in its posterior wall and an enclosed space attached anteriorly with a circular opening that lines up with the capsulorhexis. This allows implantation of a piggyback lens inside the bag at a later date.

“Once it is inside the capsular bag it remains very stable,” Dr Quesada reported.

Sophi is here.

In a first-in-human study conducted in Dr Quesada’s surgery centre in San Salvador, El Salvador, the optic-spacer device was implanted in eight eyes of eight patients. Six months after surgery, four of the eight received piggyback lenses to correct residual refractive error and improve unaided visual acuity.

GOOD VISUAL OUTCOMES Visual outcomes were good in all patients after implanting the experimental devices, which were all of the same refractive power, Dr Quesada said. Mean best-corrected distance visual acuity of the eight patients was logMAR +0.1, or 20/25, at one, three and six months after surgery.

Mild anterior iris surface trauma between the pupil and incision was noted in all eight cases. The trauma did not progress and appeared to be related to the initial insertion, Dr Quesada said.

Any standard IOL can be inserted into the device, and the four used in the study were easily implanted, Dr Quesada said.

Uncorrected distance visual acuity in all four patients receiving the piggyback lenses was logMAR +0.13, or about 20/28, at one and three months after surgery.

The device maintained a large volume of space within the capsular bag throughout the duration of the study, Dr Quesada said.

Anterior chambers were of a normal depth and shape in all cases at all postoperative visits including after piggyback IOL implantation.

“It was technically straightforward to implant this IOL/device within the capsular bag and implant a piggyback IOL within this device at six months post-op,” Dr Quesada said.

In clinical practice, Dr Quesada foresees the device being offered in a variety of powers to get as close to target as possible, with the option of dialling in refraction with a second piggyback lens when needed.

Mobility Sophi is the first wireless Phaco-System, which offers the surgical team high flexibility and mobility. This means simple handling in the operating room and increased usability.

Please note: Device is not yet approved. It has been submitted for EU-market (CE) approval but cannot be purchased until approval has been granted.

Explore Sophi‘s features on:

www.sophi.info EUROTIMES | OCTOBER 2018

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CATARACT & REFRACTIVE

CONGRATULATIONS! 2017 OBSTBAUM AWARD FOR BEST ORIGINAL ARTICLE

Functional magnetic resonance imaging to assess neuroadaptation to multifocal intraocular lenses Andreia M. Rosa, Ângela C. Miranda, Miguel M. Patrício, Colm McAlinden, Fátima L. Silva, Miguel Castelo-Branco, and Joaquim N. Murta J Cataract Refract Surg 2017; 43:1287–1296

2017 ROSEN AWARD FOR BEST TECHNICAL ARTICLE

Artificial iris implantation in various iris defects and lens conditions Christian Mayer, Tamer Tandogan, Andrea E. Hoffmann, and Ramin Khoramnia J Cataract Refract Surg 2017; 43:724–731

The JCRS as we know it today was born out of the amalgamation of two peer-reviewed journals, the Journal of Cataract & Refractive Surgery from the ASCRS and the European Journal of Implant and Refractive Surgery from ESCRS. The merged journal, which marked its 20th year in 2016, is the direct outcome of the spirit of friendship and cooperation that developed between the two societies, in particular between the editors at the time of the merger, Stephen A. Obstbaum, MD, in the United States and Emanuel S. Rosen, MD, FRCSEd, in Europe.

In honor of their passion and foresight, the editors are pleased to announce the creation of two annual awards for articles published in the JCRS, the Obstbaum Award for Best Original Article and the Rosen Award for Best Technique Article.

THOMAS KOHNEN European editor of JCRS

JCRS HIGHLIGHTS VOL: 44 ISSUE: 9 MONTH: SEPTEMBER 2018

SMILE VS LASIK Small-incision lenticule extraction (SMILE®) appears to provide the same efficacy and safety as LASIK, but how does it compare in terms the early recovery of the visual function? A prospective case series compared two groups of 23 patients undergoing the procedures.

The postoperative contrast sensitivity was better in the LASIK group at day one and day seven, but not at the one month mark. No significant differences in visual acuity efficacy, or safety were found between the two groups throughout the follow-up. The objective scatter index assessed by double-pass aberrometry was better after LASIK on the first postoperative day but not after. The patientreported quality of vision was significantly worse in the smallincision lenticule extraction group than in the LASIK group on day seven. Global satisfaction did not differ between groups throughout the study. Significant correlations were found between contrast sensitivity and aberrometry in both groups at all examinations.

A Chiche et al., JCRS, “Early recovery of quality of vision and optical performance after refractive surgery: Small-incision lenticule extraction versus laser in situ keratomileusis”, Vol 44, #9, 1073–1079.

PREVALENCE OF OCULAR SURFACE DYSFUNCTION How common is ocular surface dysfunction in cataract surgery candidates? A prospective study of 120 patients (69% women) found abnormal osmolarity in 56.7% and abnormal MMP-9 in 63.3%. Some 39% presented with positive corneal staining on presentation, 7.5% had epithelial basement membrane dystrophy and 1.6% had Salzmann nodules. More than half of 100 survey respondents reported symptoms suggestive of ocular surface dysfunction. In the asymptomatic group of 46 patients, 85% had at least one abnormal tear test and 48% had both tests abnormal.

Overall, 80% of 120 patients had at least one abnormal tear test result suggestive of ocular surface dysfunction, and 40% had two abnormal results. The researchers conclude that preoperative testing and treatment could improve visual outcomes. PK Gupta et al., JCRS, “Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation”, Vol 44, #9,1090–1096.

PSEUDOPHAKIC REFRACTIVE ERROR A prospective study compared prediction formulas using a single type of IOL and a single surgeon. The Barrett Universal II formula and Hill-RBF methods predicted more eyes within ±0.25D and ±0.5D of objective refraction at one-week, one-month and three-month followups with PCI biometry. Corneal steepening counteracted hyperopic changes caused by posterior IOL migration in postoperative weeks one to four. Four weeks postoperatively, continued posterior IOL migration caused a mean hyperopic shift. The investigators believe the Hill-RBF formula represents a new generation of data-driven calculators and its self-learning nature will likely drive it to superiority over time. HB Wallace et al. JCRS, “Predicting pseudophakic refractive error: Interplay of biometry prediction error, anterior chamber depth, and changes in corneal curvature”, Vol 44, #9, p1123–1129.

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

EUROTIMES | OCTOBER 2018

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We share his commitment to his calling. What´s your calling? www.zeiss.com/mycalling

CORNEA

Phakic IOL for ectatic corneas Phakic IOLs effective for fine-tuning refraction in keratoconus patients.

Dermot McGrath reports

P

hakic IOLs can provide a safe and effective means of treating residual refractive errors in patients with stable keratoconus and other ectatic dystrophies and corneal pathologies where laser refractive surgery is not a viable option, according to Tamer O. Gamaly FRCS. “Phakic IOLs can provide fast rehabilitation and a wide range of correction of stable refractive error, including myopia and compound myopic astigmatism for these more complicated cases where LASIK is not possible,” Dr Gamaly told delegates attending the World Ophthalmology Congress in Barcelona.

The problem of refractive errors in keratoconic patients is familiar to any surgeon who deals with such patients on a regular basis, said Dr Gamaly.

“These patients often come to us not because they have a weak cornea but rather because of a refractive problem that is bothering them. Phakic IOLs enable us to treat these patients with abnormal corneas since they not suitable for laser refractive surgery, which would weaken the structural stability of the cornea further,” he said.

Phakic lenses may be used in combination with standard keratoconus treatment modalities such as collagen crosslinking (CXL), intracorneal ring implants or after deep anterior lamellar keratoplasty, said Dr Gamaly.

“This is a big advantage as we can treat their cone while also taking care of their refractive errors and giving them better quantity and quality of vision,” he said.

The ideal patient for phakic IOL correction is one with an abnormal or topographically suspect cornea with a residual refractive error whose refraction has been stable for at least two years, said Dr Gamaly.

“Patients should also have stable topography for at least one year, with a clear central cornea, and realistic expectations.

This is important so the patient understands that you will try to give them the best corrected vision possible but that 20/20 might not be attainable,” he said.

Dr Gamaly said he usually considers implanting phakic lenses to correct residual refractive errors for cases of confirmed or suspect keratoconus (forme fruste) or ectatic corneal dystrophies or post-LASIK ectasia.

The contraindications for phakic IOL implantation include unstable refraction, progressive cone, scarred central cornea or unrealistic expectations, added Dr Gamaly.

“The take-home message is that phakic IOLs can be used when no other laser refractive surgery procedure can be performed. In keratoconus cases, we need to be sure of stability both in terms of refraction and topography, to use all available options to get the best visual outcomes, and continue to follow up the patient every three to six months,” he said.

Tamer O. Gamaly: tamergamaly2010 @gmail.com

...Phakic IOLs can be used when no other laser refractive surgery procedure can be performed Tamer O. Gamaly FRCS

EUROTIMES | OCTOBER 2018

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CORNEA

HYBRID DMEK TECHNIQUE

shows promise

T

New approach opens horizon for more challenging cases.

Dermot McGrath reports

he promising early results of a modified Descemet’s membrane endothelial keratoplasty (DMEK) technique may pave the way for the procedure being used in more challenging cases where DMEK would normally be contraindicated, Donald Tan FRCS told delegates attending the World Ophthalmology Congress in Barcelona.

“DMEK remains challenging surgery and it is clear that we need to continue to innovate and modify techniques to make the surgery easier and more predictable. The pull-through hybrid DMEK (H-DMEK) technique, which I have been using over the past few years, is one such promising approach. It provides good control of donor tissue and relatively good anterior chamber control, allowing one to perform DMEK in more challenging scenarios,” Dr Tan said.

The H-DMEK approach draws on the standard Descemet’s stripping automated endothelial keratoplasty (DSAEK) technique, Dr Tan said, but uses the DSAEK stromal tissue only as a carrier. After stripping Descemet’s membrane from the pre-cut tissue, it is replaced loosely on to the stroma and the graft is coiled into an EndoGlide (Network Medical Products) inserter. Dr Tan then pulls only the donor tissue into the anterior chamber, leaving the DSAEK stromal tissue behind in the EndoGlide chamber.

This approach enables better control of the donor tissue and results in reduced endothelial cell loss, enabling more complex cases to be treated using DMEK, said Dr Tan. “Patient selection for conventional DMEK typically meant an intact cornea, iris and anterior chamber. This new approach means that we can now extend

...it is clear that we need to continue to innovate and modify techniques to make the surgery easier and more predictable Donald Tan FRCS DMEK to more complex situations such as aphakia, blebs and valves, anterior chamber IOLS, prior vitrectomy, peripheral anterior synechiae, aniridia and prior failed grafts,” he said.

Dr Tan has now performed H-DMEK in more than 40 challenging cases and the results have been encouraging.

“The main goal is not 20/20 vision, as most of these eyes will never attain such visual acuity. I think that the main aim is the very low rejection rates. A lot of these are previous failed grafts, either penetrating keratoplasty (PK), or DSAEK. The advantage of DMEK over DSAEK in these cases is not having that thick DSAEK donor in the anterior chamber which encounters the iris, the IOL and other structural abnormalities. We are essentially isolating the endothelium from the rest of the anterior chamber structures, and the pullthrough technique allows for better control of the donor during these more challenging procedures,” he said.

Dr Tan said that the benefits of using DMEK are evident in the graft survival rates for the Singapore Corneal Transplant Study, one of the largest such databases in the world.

For Fuchs’ Dystrophy, the five- and 10-year survival rates for both DSAEK and DMEK are significantly better than PK. However, for pseudophakic bullous keratopathy, DMEK is clearly superior to both DSAEK and PK with three or four years’ follow-up, added Dr Tan.

While H-DMEK works well in challenging cases, there is nevertheless scope to further improve the procedure, said Dr Tan. “There were two main problems with it: firstly, it still goes through a 4.5mm scleral tunnel wound, which is much larger than conventional DMEK incisions. There is also the additional cost of using pre-cut DSAEK stromal tissue, which is then discarded,” he said. The solution has been to use a new EndoGlide inserter, which works with a 2.65mm clear corneal tunnel incision and no longer requires pre-cut tissue.

“This works like standard DMEK, we insert the DMEK donor in a tri-folded configuration into the new DMEK EndoGlide chamber, which is narrower than the conventional EndoGlide DSAEK inserter, and which is now able to enter the eye a much smaller 2.65mm clear corneal incision. The anterior chamber maintainer is positioned nasally and the rest of the procedure is very similar – as the donor is pulled in, the cartridge is removed and we tap gently to close the wound. We just wait for the AC to slowly reform, and usually what happens is that the graft will automatically unfold in the right position.

It works very smoothly,” he said.

Preliminary endothelial cell studies after about six cases performed with the latest method shows about 10% endothelial cell loss, concluded Dr Tan.

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS EUROTIMES | OCTOBER 2018

www.eurotimesindia.org

CORNEA

Big bubble DALK and keratoconus Better outcomes in big bubble DALK for keratoconus when sutures remain in place. Dermot McGrath reports

B

ig bubble deep anterior lamellar keratoplasty (DALK) is effective and reproducible and delivers very good refractive and visual outcomes for the surgical treatment of moderate-to-advanced keratoconus, according to Mouamen M. Seleet MD, FRCS. “While the outcomes are good, we do need to bear in mind that the refractive changes after the removal of sutures remains unpredictable. However, based on our experience we can say that in cases of good refractive outcomes it is a safer bet to leave the sutures in than to remove them and that will help to achieve a better final visual acuity,” Dr Seleet told delegates attending the World Ophthalmology Congress in Barcelona.

A procedure such as big bubble DALK provides a smooth interface by cleaving the stroma from Descemet’s membrane, thereby preventing the irregularities of the stromal interface and the stromal scarring that can occur with manual dissection, noted Dr Seleet.

His prospective non-randomised study included 105 consecutive eyes over 18 months and was designed to assess big bubble DALK in terms of efficacy, reproducibility, safety and the effect of removal of sutures on visual acuity and corneal astigmatism. Almost all patients (94%) were available for analysis after 12 months, and 84% were available at 18 months. One-quarter of patients (25%) were suture-in and 59% were suture-out.

All corneas had single running 12-bite sutures with the same size donor and recipient buttons from 8mm to 8.5mm.

“The indications for suture removal at 12 months after DALK was if the refractive cylinder was more than 4.0D, if there was an anisometropia, suture-related complications or planned secondary refractive surgery,” said Dr Seleet.

The uncorrected distance visual acuity (UDVA) was closely matched for suture-in versus suture-out patients at six months, but the picture shifted when the patients were assessed at 12 months.

“Those patients that were destined to have their sutures out started to show a decrease of their UDVA while the suture-in patients showed an improvement at 12 months.

This difference increased after the final removal of the sutures at 18 months,” he said.

Similarly, the corrected distance visual acuity (CDVA) also showed that patients destined to have their sutures in showed better visual acuity than those destined to have sutures out. Refractive cylinder outcomes were also significantly better in the suture-in group, added Dr Seleet.

Adverse events in the study included a failed bubble in 10 eyes (9.5%), microperforation in six (6.7%), near Descemet dissection in five (4.8%), delayed epithelial healing in three (2.9%), steroid-induced glaucoma in 11 (10.5%), traumatic wound rupture in four (3.8%), cataract in three (2.9%) and stromal rejection in six (5.7%). Broken sutures were also seen in two patients, but neither of them had to be converted to penetrating keratoplasty, he said.

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Mouamen M. Seleet: mouamenseleet@gmail.com EUROTIMES | OCTOBER 2018

17

5-8 September 2019 Instructional Course & World Retina Day Abstract Submission Deadline 20 December 2018

Le Palais des Congrès Paris, France

www.euretina.org

RETINA

nAMD treatment shows promise Topical integrin inhibitor shows potential therapeutic results in early trial. Sean Henahan reports

A

novel integrin inhibitor could offer the prospect of treating neovascular age-related macular degeneration (nAMD) with eye drops, reported researchers at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting, in Honolulu, Hawaii.

The drug in question, SF0166 (SciFluor Life Sciences), is a selective small-molecule inhibitor of integrin αvβ3 with physiochemical properties designed to facilitate an ability to reach the retina in high concentrations after topical administration.

Forty-four patients with active subfoveal choroidal neovascularisation and the presence of retinal or sub-retinal fluid participated in a Phase I/II, randomised, double-masked, multi-centre study. The patients self-administered an eye drop containing either 1.25 or 2.5mg SF0166, twice a day for 28 days. They were then followed for an additional 28 days.

Patients were evaluated and followed with spectral domain optical coherence tomography, visual acuity, slit-lamp biomicroscopy, intraocular pressure measurements, fundus photography and fluorescein angiography.

Forty-two of the 44 patients completed the study. Of these, 15 had not been treated previously with anti-VEGF agents. The researchers noted evidence of biologic activity in the form of mean increase in visual acuity and decreases in central retinal thickness and/or fluid seen with spectral domain optical coherence tomography in the 36% of patients that were treatment naive.

POTENTIAL TO REVOLUTIONISE TREATMENT “This has the potential to revolutionise the treatment of age-related macular degeneration. Topical treatment could increase compliance and possibly prevent vision loss through early intervention. We believe the positive results of this study justify additional clinical study,” Omar Amirana MD, Chief Executive Officer, SciFluor Life Sciences, Inc., Cambridge, US, told EuroTimes.

Treatment responses were seen with both doses. The mean improvement in visual acuity in the treatment-naïve patients was four letters by 28 days. Decreases in central retinal thickness and subretinal fluid of approximately 25 microns were observed.

No serious ocular adverse events were observed. Five patients experienced mild-to-moderate ocular adverse events.

One case of dry-eye was considered to be possibly related to the treatment. The study also saw one unrelated, non-ocular serious adverse event, a brachial artery thrombus, and 10 unrelated non-ocular adverse events.

The one-month follow-up suggested a durable response after treatment was discontinued. Additional studies are planned.

Several other potential eye drop treatments for AMD are in development. One of the first, squalamine (Ohr Pharmaceuticals), failed in clinical trials for AMD and has been abandoned. Another, PAN-90806 (PanOptica), a selective inhibitor of VEGF-R2, is in clinical trials. Another agent, KPI-285 (Kala Pharmaceuticals) is in the clinical trial planning stages.

EUROTIMES | OCTOBER 2018

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RETINA

Surgical options There is a need for more randomised clinical trials to determine the best procedure for particular indications of retinal detachment. Dermot McGrath reports

W

ith technology and repair techniques rapidly evolving in recent years, surgeons now have a range of safe and successful surgical options available for the management of primary retinal detachments (RD), according to José García-Arumí MD. “The three principal techniques – pneumatic retinopexy, scleral buckling and pars plana vitrectomy (PPV) – are all used successfully for the treatment of primary retinal detachments. However, what we do need are more randomised clinical trials to determine the best procedure for particular indications,” Professor García-Arumí told delegates attending the 8th EURETINA Winter Meeting in Budapest.

The key to successful surgery lies in rigorous preoperative evaluation, said Prof García-Arumí.

“It is critical to identify retinal breaks with meticulous planning preoperatively and then employ skilful surgery to remove traction and seal retinal breaks. The choice of the surgical technique and tamponade agent is related with the experience of the surgeon and the severity of the case,” he added.

BROAD OVERVIEW In a broad overview of the various techniques available for RD surgery, Prof García-Arumí said that pneumatic retinopexy offers a lower rate of retinal reattachment with a single operation and with limited indications.

“It is not applicable in many types of retinal detachment and is less effective in aphakic or pseudophakic patients. It is also less employed in Europe and it seems to be less used in the United States as well. An

American Society of Retina Specialists survey in 2017 showed that pneumatic retinopexy as preferred primary procedure for RD has decreased in the last 10 years,” he said.

While several studies have confirmed similar results for scleral buckling and PPV, the indications for both procedures are not identical, said Prof García-Arumí.

“Scleral buckling works well in phakic patients, inferior tears, young patients, myopic patients with posterior hyaloid detachment, superior tears in fresh RD, retinal dialysis cases and proliferative vitreoretinopathy (PVR) degree A or B. It is always important to check the status of the vitreous beforehand,” he said.

SCLERAL BUCKLING The advantages of scleral buckling include the fact that there is no associated lens trauma or iatrogenic breaks, while drawbacks include issues related to increased myopia, image disparity, double vision in myopic patients, red eye, discomfort, possibility of extrusion and problems related with drainage and suture, added Prof García-Arumí.

Advantages of PPV include the fact that it induces no refractive changes, there are no floaters and it less painful than scleral buckling procedures.

While PPV is growing in popularity as a first-line procedure for primary RD, especially in pseudophakic patients, it comes with its own complications, including postoperative cataract formation in patients older than 50-55, long-term IOP increase, retained perfluorocarbon liquids and macular retinal folds, said Prof García-Arumí.

“There is also probably more intraocular inflammation and epiretinal membrane

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formation with PPV and it is more expensive than scleral buckling,” added Prof García-Arumí.

The surgical indications for combined scleral buckle and PPV surgery include retinal detachments with inferior breaks, pseudophakic/aphakic patients, early or established PVR, multiple breaks in three or more quadrants, and extensive detachment cases in which breaks are difficult to detect, or those with giant tears, he said.

For PVR cases, a scleral buckle will sometimes relieve the traction, said Prof García-Arumí, and is particularly indicated in circumferential contraction.

In terms of the choice of retinal tamponade agent, there is no real consensus as to what works best for particular types of RD. “The only clear conclusion we can draw at the moment is that tamponade agent is related with the experience of the surgeon and the severity of proliferative disease present,” he said.

Looking at current trends in RD surgery, Prof García-Arumí said that a recent study by McLaughlin et al. looking at Medicare patients in the United States from 2000 to 2014 confirmed the increase in PPV procedures.

“Scleral buckling declined from 6,502 procedures in 2000 to 1,260 procedures in 2014, while vitrectomy increased from 13,814 surgeries in 2008 to 19,288 surgeries in 2014. The distribution in 2014 was 83% vitrectomy, 5% scleral buckling and 12% pneumatic retinopexy. Cryotherapy declined across all indications,” he added.

José García-Arumí: jgarcia.arumi@gmail.com

RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 240 ISSUE: 3

9th EURETINA Wi n t e r M e e t i n g

Prague 2019

RANIBIZUMAB WORKS BETTER IN CAUCASIANS The findings of a new study suggest that Caucasian patients may have an improved response to intravitreal ranibizumab than nonCaucasians. Prospective data was collected from 434 eyes of 217 patients with wet AMD receiving intravitreal ranibizumab on a treat-and-extend basis. At 24 months follow-up, the percentage of eyes that maintained or improved vision was 91% in Caucasian patients and 83% in non-Caucasian patients. Correspondingly, at 24 months, the percentage of visual loss was 9% for Caucasian patients and 17% for non-Caucasian patients. And although Caucasian patients required fewer overall injections (14.1), they gained an average four letters of logMAR visual acuity.

However, non-Caucasian patients required 14.6 injections to gain only 0.5 letters of logMAR visual acuity. R Mohamed et al, “What Effect Does Ethnicity Have on the Response to Ranibizumab in the Treatment of Wet Age-Related Macular Degeneration?”, Ophthalmologica 2018, Volume 240, Issue 3.

1–2 March 2019 Clarion Congress Hotel Prague, Czech Republic

www.euretina.org MACULAR HOLES IN FELLOW EYES Among patients with macular holes, one in five will develop macular holes (MH) in their fellow eyes within five years and one in three fellow eyes with vitreomacular traction will develop the complication in the same period. The 77 fellow eyes included had a mean follow-up of 34.11 ± 22.3 months (6–78.4). At baseline, 31 eyes had vitreomacular traction (VMT), 35 vitreomacular adhesion and 11 no posterior vitreous detachment. MH occurred in 19.5% of the cases (15/77). The rate of MH was significantly higher among the eyes with VMT than among the eyes without VMT at baseline (35.5 vs. 8.7%; p = 0.009). E Philippakis et al, “Incidence of Macular Holes in the Fellow Eye without Vitreomacular Detachment at Baseline”, Ophthalmologica 2018, Volume 240, Issue 3.

OBSERVATIONAL STUDY OF MYOPIC CNV INITIATED A long-term observational study is now under way to assess the natural disease progression of high myopia in Caucasians considered at risk for the development of myopic choroidal neovascularization (mCNV). Called the HELP study, it involves 150 participants (66% females) recruited in 25 clinical sites between June 2014 and June 2016. All have an axial length of 26 mm, best-corrected decimal equivalent visual acuity 0.05 or better and presence of at least one out of five predefined morphological disease risk criteria. Baseline findings included a reduced incidence of enhanced choroidal curvature length compared with Asian series, and a significantly more common occurrence of patchy atrophy among older patients (p = 0.0012). C Melzer et al, “Design and Baseline Characteristics of the HELP Study: An Extended and Long-Term Observation of Pathological Myopia in Caucasians”. Ophthalmologica 2018, Volume 240, Issue 3.

Ophthalmologica is the peer-reviewed journal of EURETINA

EUROTIMES | OCTOBER 2018

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GLAUCOMA

Glaucoma research Research in neurophysiology suggests new targets for neuroprotection in glaucoma. Roibeard Ó hÉineacháin reports

W

hile the search for glaucoma treatments typically focuses on the ocular tissues involved with the disease, it now appears that dynamic fluids surrounding the tissues may provide new therapeutic targets, reports Neeru Gupta MD, PhD, MBA, Professor of Ophthalmology and Vision Sciences at the University of Toronto, Canada.

“Right now we really have no cure, and until we can cure the disease we have to be satisfied with somehow slowing progression. And ideally we would use disease-modifying treatments that target the underlying pathology,” she told the 13th European Glaucoma Society Congress in Florence, Italy.

The recent discovery of lymphatic vessels in the uvea raises the possibility of another means of IOP reduction, and also points to some potential new targets for protecting the neurological components of the visual system from glaucomatous degeneration.

She noted that the optic nerve is connected to its target in the lateral geniculate nucleus, and that 90% of the retinal ganglion cells axonal connections go on to the lateral geniculate nucleus and the visual cortex.

Many studies, conducted at centres around the world, have shown that the neural degeneration of glaucoma likewise extends well beyond the optic nerve and into the optic tract, lateral geniculate nucleus, optic radiations ad visual cortex.

“Clearly, neural circuits are destroyed and signal processing is upset and there is a loss of vision. Our targets for rescue are therefore all of these, and there are numerous studies going on that are attempting to target these,” Dr Gupta said.

She noted that there is also evidence that some neurodegenerative diseases like Alzheimer’s disease develop partly as a result of inadequate removal of metabolic waste products, such as amyloid protein, by the glymphatic system. The glymphatic system is an avascular waste clearance pathway for the central nervous system. First described in 2012, its name is a combination of glial and lymphatic (Iliff et al, Science Translational Medicine 2012, 4; 147; DOI:10.1126/scitranslmed.3003748).

Furthermore, she noted that she and her associates have found evidence for cerebrospinal fluid entry into the optic nerve using a glymphatic pathway. In a study in which fluorescent dextran tracers were injected into the cisterna magna in adult mice, CSF was detected in the subarachnoid space surrounding

the orbital optic nerve and within the optic nerve itself (Mathieu et al, Invest Ophthalmol Vis Sci. 2017;58: 4784–4791).

“When we think of protecting the structure and function of the optic nerve we are always thinking about the tissues, but it is important to remember all of our tissues are surrounded by fluids. These fluids are very dynamic and full of molecules critical to the tissues' maintenance and survival, and are also essential for the removal of waste,” Dr Gupta explained.

She noted that tracers found within the nerve were specifically localised between isolectin-labelled blood vessels and GFAPpositive astrocytes or aquaporin 4-labelled astrocytic endfeet. That suggests CSF enters the optic nerve though a channel lined by the vascular endothelium on one side and aquaporin 4-labelled glial cells on the other.

“Currently, lowering IOP is a way to protect our optic nerve from damage. It is possible that the glymphatic system of the optic nerve helps to remove waste and may represent a new target for glaucomaa,” Dr Gupta concluded.

Neural injury in glaucoma extends from the eye to the brain and involves many cell players

EUROTIMES | OCTOBER 2018

GLAUCOMA

EXPANDING THE RANGE OF TREATMENT OPTIONS

It is possible that the glymphatic system of the optic nerve helps to remove waste and may represent a new target for glaucoma Neeru Gupta MD, PhD, MBA

Artistic work by Luz Paczka Giorgi

There are already several examples of pathology-targeted treatments for different types of glaucomas, such as anti-VEGF treatment for neovascular glaucoma, laser peripheral iridotomy for primary angleclosure glaucoma and cataract removal for phacomorphic glaucoma, she said.

In all types of glaucoma, treatment is based on lowering IOP. And although the treatments do not directly target the neurodegenerative processes that characterise the condition, research shows that they do reduce damage to the optic nerve and also the resulting visual loss.

Research is continuing to expand this line of attack on the disease. The second decade of the current century has seen the introduction of rho-associated protein RHO-kinase inhibitors.

Netarsudil (Aerie Pharmaceuticals), the first in this new class of drug, was recently approved by the US FDA, and reportedly lowers IOP by relaxing the cells of the trabecular meshwork, increasing outflow.

Traditional View: CSF around the optic nerve is confined to the subarachnoid space as shown in blue

New Understanding: CSF in the subarachnoid space is in direct communication with the optic nerve and enters via a glymphatic pathway.

doi:10.1016/j.ophtha.2018.06.017. [Epub ahead of print]).

“For the moment there really is no cure for glaucoma, no neuroprotective drug available to date, and I think in order to protect the optic nerve we have to think about it in relationship to the central visual system and all the other cell players,” Dr Gupta said.

She noted, for example, that new data suggests that gene therapy can be used to decrease the oxidative stress in the optic nerve and thereby make it more resistant to damage by elevated IOP. She cited a study

in which gene therapy with an adenovirusassociated vector carrying a gene for a type of erythropoietin (rAAV.EpoR76E) preserved visually evoked potentials and axon transport in the DBA/2J mouse model of glaucoma. It appeared to achieve this effect at least in part by decreasing infiltration of peripheral immune cells, modulating microglial reactivity and decreasing oxidative stress (Hines-Beard et al., J Neuroinflammation. 2016; 13: 39).

DIRECT NEUROPROTECTION However, actual neuroprotection outside of IOP reduction remains an elusive target. Memantine, an agent used in the treatment of Alzheimer’s disease, showed early considerable promise in a monkey model of glaucoma (Yucel et al., Arch Ophthalmol. 2006 Feb;124(2):217-25; Hare WA, WoldeMussie E, Lai RK, et al., Functional measures. Invest Ophthalmol Vis Sci. 2004;45(8):2625-2639), but failed to reach its endpoint in a randomised prospective controlled clinical trial (Weinreb RN et al., Ophthalmology.

2018 Aug 3. pii: S0161-6420(18)30029-0.

23

Neeru Gupta: guptan@smh.ca

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EUROTIMES | OCTOBER 2018

24

GLAUCOMA

Modern glaucoma diagnostics Closer scrutiny of structural and functional changes can reveal macular damage. Roibeard Ó hÉineacháin reports

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odern diagnostic techniques including 10-2 visual field perimetric testing and optical coherence tomography (OCT) can detect visually important damage to the macula in eyes with glaucoma better than older techniques, reported Don Hood MD at the 13th European Glaucoma Society Congress in Florence, Italy.

“Nearly every glaucoma patient who has undergone the 24-2 or 30-2 testing should undergo the 10-2 test. The 24-2 test can underestimate macular damage, which is very common even in the early stages of glaucoma,” said Dr Hood, Columbia University, New York, New York, USA. He noted that the macula, which he defined as the area within an 8-degree radius from the point of fixation, has less than 2% of the retina’s total area, but contains more than 30% of its retinal ganglion cells. It is vital for reading, driving and facial recognition.

He pointed out that a 24-2 test screen has only four points within the macula and its points are spaced by six degrees, starting at +3 degrees from fixation. By comparison, the points in the 10-2 test are spaced by 2 degrees, starting at +1 degree from fixation. The 24-2 visual field test therefore misses the thickest part of the macula.

Dr Hood added that in eyes with glaucoma the most vulnerable part of the macula is the lower retinal region, called the macular vulnerability zone. His team and others have demonstrated that retinal ganglion cells (RCGs) from this part of the macula send their axons to the most vulnerable part of the optic disc, whereas RGCs from the remaining macula send their axons to less vulnerable parts of the disc.

He emphasised that macular damage should be further scrutinised with an OCT scan that includes the macula.

An OCT disc scan can miss damage that can be seen on a cube scan of the macula. Macular damage is best seen on RGC deviation maps, which are available with most OCT instruments.

He further explained that viewing a large image of a circumpapillary scan will allow assessment of scan quality and detail of local damage, thereby enabling the monitoring of structural changes in eyes with advanced glaucoma. Agreement between perimetry and OCT findings can be confirmed by a topographical comparison of abnormal regions of the OCT with abnormal regions of the visual field, and discrepancies between the two can usually be resolved in the same way.

Don Hood: dch3@columbia.edu

EUROTIMES | OCTOBER 2018

Nearly every glaucoma patient who has undergone the 24-2 or 30-2 testing should undergo the 10-2 test. The 24-2 test can underestimate macular damage Don Hood MD

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PAEDIATRIC OPHTHALMOLOGY

Topical tacrolimus safe and effective for paediatric keratoconjunctivitis.

Dermot McGrath reports

T

opical tacrolimus ointment appears to provide a safe and effective treatment for vernal keratoconjunctivitis (VKC) in paediatric patients, according to a study presented by a Spanish team of researchers.

“Tacrolimus 0.03% ointment was effective at reducing signs and symptoms of VKC with few adverse events. It is a good treatment option to reduce the use of long-term topical steroids in VKC,” the study authors concluded in their poster study presented at the World Ophthalmology Congress in Barcelona.

VKC is a sight-threatening inflammatory disease of conjunctiva and cornea and is frequently observed in young children with the onset usually occurring in the first decade of life, according to co-authors José Espinosa Saldaña MD, FEBO, Rocío Rodríquez MD, Laura Soldevila MD and Alba González MD of the Catalonia Retinal Institute in Barcelona.

While its name suggests a seasonal occurrence, the allergic condition frequently persists throughout the year and usually increases in intensity in warmer weather. Clinical signs to look for include the presence of giant papillae on the upper tarsal conjunctiva, the presence of aggregates of epithelial cells and eosinophils at the limbus and marked conjunctival hyperaemia.

In severe cases, corneal ulcer may occur both from the onset of the disease and the physical trauma caused by intense eye rubbing.

While topical corticosteroids are often required for controlling symptoms and signs in severe VKC, their use can lead to serious ocular complications. Tacrolimus, which is widely used for the treatment of atopic dermatitis, is a strong, non-steroidal immune suppressant that is up to 100 times more potent than cyclosporine.

The retrospective observational study from January 2014 to January 2017 included 35 children with VKC with a mean age of eight years who were treated with tacrolimus 0.03% ointment every 12 hours. Symptoms such as itching, photophobia and red eyes were monitored before and after the application of tacrolimus ointment.

The mean treatment duration with tacrolimus was 3.5 months, with a maximum of 12 months. Of the study participants 88.5% were medicated with other treatment before the use of tacrolimus, with a majority (83%) receiving a topical steroid. Five patients suspended the treatment due to itching and irritation.

Significant improvements in clinical signs and symptoms were achieved in a majority of patients. A total of 21 patients were able to taper or suspend the use of antihistamines or steroids. The mean score for signs and symptoms before and after treatment with tacrolimus was 1.4 and 7.9 respectively.

Further randomised controlled studies are required to evaluate the appropriate concentration and dosage of topical tacrolimus, as well as the longterm safety profile of this medication, the investigators conclude.

José Espinosa Saldaña: jespinosasaldana @gmail.com

It is a good treatment option to reduce the use of longterm topical steroids in VKC

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27

OCULAR

Deciphering unusual visual symptoms Patients may not always be able to explain what’s wrong.

Priscilla Lynch reports

U

nusual, unexplained visual symptoms are sometimes a sign of a serious underlying disease but, on the other hand, can be completely harmless despite appearing alarming, the Irish College of Ophthalmologists 2018 Annual Conference heard.

Prof Patrick Lavin MD, Professor of Neurology and Neurosciences and Vanderbilt Headache Clinic Tennessee, US, presented a number of topics during the conference’s neuro-ophthalmology session.

One of his talks focused on patients who appear to be faking their symptoms but have real problems that may be misinterpreted because of the rarity or subtlety of the disorders. Making the correct diagnosis for these patients can be complicated by behavioural characteristics that might be misconstrued as real disease, or exaggeration of minor problems for financial gain, he noted.

Prof Lavin also highlighted unusual visual symptoms that can be normal but occasionally herald serious disease. These include entopic phenomena such as benign floaters, more serious floaters and migraine aura, which can be present in 25% of migraine attacks and are rarely harmful.

While visual hallucinations can be caused by drug and alcohol abuse, some may be the manifestation of serious health issues such as stroke, brain tumour, seizures (epilepsy) and the like, or certain psychiatric disorders, he noted.

Also, he discussed unusual visual conditions like palinopsia, the persistent recurrence of a visual image after the stimulus has been removed that can occur with certain medications; and synaesthesia, a perceptual phenomenon in which stimulation of one sensory or cognitive pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway, e.g. words and numbers can appear to have certain colours for those with the condition.

Speaking to EuroTimes, Prof Lavin said that the key to determining the cause of unusual visual symptoms is taking a thorough patient history and system review.

“Listen to the patient who is trying to tell you what’s wrong and it is up to EUROTIMES | OCTOBER 2018

Photo by Dylan Vaughan

28

Prof Patrick Lavin, Miss Patricia Logan and Mr Michael Burdon

you to interpret the clues. Examine the patient based on their complaint, and, generally speaking, don’t get side-tracked by other issues, unless they are relevant.

If you don’t know what is wrong, don’t be afraid to ask for help.”

Also speaking during this session was UK neuro-ophthalmology specialist Mr Michael Burdon, Consultant Ophthalmologist, Queen Elizabeth Hospital, Birmingham, who discussed how a small number of patients with unusual visual symptoms referred to his clinic were eventually diagnosed with CreutzfeldtJacob Disease (CJD).

Cortical blindness, dysmetria and hallucinations are among the visual issues that can signal a potential diagnosis of this very rare but devastating disease, he said.

“I also noticed very distinct anxiety in these cases. Patients experiencing visual loss are anxious, or depressed or worried but this acute anxiety of ‘I can’t see, I can’t see’, that repetitive concern on their vision I’ve never seen in any other neurological disease,” Mr Burdon told EuroTimes.

Another unusual visual issue he discussed was night vision blindness caused by vitamin A deficiency, which can often occur in patients who have had bariatric surgery.

During the neuro-ophthalmology symposium there was also an interesting paper study presented on ‘visual snow’, carried out by Emer Doolin MD under the supervision of the session’s chair Miss Patricia Logan MD, Consultant Ophthalmologist, Beaumont Hospital Dublin.

Although seldom recorded in the medical literature, visual snow can be distressing for patients and often lead to multiple unnecessary investigations and inappropriate treatments.

Visual snow is syndromically consistent from one case to the next and this phenomenon is reported by young and healthy individuals, with neither ophthalmic nor neurological disease, said Dr Doolin.

Her study of eight patients confirmed that all had normal ocular examinations, normal neuroimaging, and normal electrophysiological studies.

The study concluded that patients could be reassured that the condition, although sometimes disabling, is benign, i.e., does not lead to visual loss. Special investigations may still be required for patient reassurance but must be made on a clinical basis, the study found.

Patrick Lavin: Patrick.lavin@vumc.org Michael Burdon: mike.burdon@btinternet.com

Overlapping Pattern with Sharp Edges

â&#x20AC;˘ Minimized dysphotopsia due to the reduced scattered light

30

OCULAR

Burnout is a worldwide issue Burnout affects the health of doctors as well as the quality of care provided to patients. Priscilla Lynch reports

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isk of burnout, increasing workloads and the need for more investment in public ophthalmology services were the focus of a lively session on the future of the specialty at the Irish College of Ophthalmologists (ICO) 2018 Annual Conference in Kilkenny.

Dr Cynthia Bradford, Professor of Ophthalmology, Dean McGee Eye Institute, University of Oklahoma Health Sciences Centre, US, discussed the impact of doctor burnout.

Burnout can lead to depression and around 400 doctors a year die by suicide in the US, she said.

Factors leading to medical burnout include lack of control over working conditions and decision-making, excessive workload pressures, chaotic and inefficient work environments and onerous administration tasks, Dr Bradford outlined. The most susceptible doctors are dedicated, conscientious, responsible, motivated and often idealistic with perfectionist qualities, she contended.

Burnout not only impacts doctors, it also impacts patients negatively, in relation to the quality of care they receive, and leads to higher healthcare costs, Dr Bradford said.

She said a major culture change is needed to help better support doctors, which would include returning trust to doctors, less onerous regulation and administrative processes and “letting them concentrate on the work only they can do”.

BUILDING RESILIENCE Some of Dr Bradford’s points were echoed by ICO Dean of Education and Ophthalmic Surgeon Miss Yvonne Delaney during her presentation on educating the doctors of tomorrow and building resilience.

“People (doctors) love their job – they just want to be able to do it,” Miss Delaney said. She highlighted the importance of communication in medicine: Around 50-65% of complaints against doctors are related to communication errors, and 10% of health budgets are spent on error/negligence.

The session also heard that while there have been many positive advances in treating and better diagnosing ocular conditions like age-related macular degeneration and diabetic retinopathy, this has led to increased and unsustainable workloads for ophthalmologists.

Ireland’s Health Service Executive National Director of Quality Improvement Dr Philip Crowley stressed that public health funding is finite so countries like Ireland, who have high ophthalmology waiting lists and inadequate staff numbers, should try and learn from those with less resources but smaller waiting lists about how they maximise services and outcomes.

We need efficient models of outpatient delivery but also adequate Consultant numbers to deliver the service.

Dr Crowley also stressed that it is vital that healthcare staff are involved in health service decision-making and that roles for clinical leaders are developed and supported. “While it is important to learn from our mistakes, we must also learn from excellence,” he commented.

Cynthia Bradford: cynthia-bradford@dmei.org Yvonne Delaney: yvonnedelaney1@gmail.com Philip Crowley: nationalqid@hse.ie

OCULAR

NOVEL METHOD

for lower lid ectropion

Courtesy of Rizwana Khan MD

New approach to lateral canthal tightening and medial retractor plication shows good results and low recurrence. Priscilla Lynch reports

The inferior retractors were identified and sutured to the tarsal plate (left); The prolene suture passed through the grey line in the upper and lower lids was passed through the periosteum of the lateral orbital wall and tied (above)

A

novel surgical method for the treatment of mildto-moderate involutional lower-lid ectropion with medial involvement has good results, low recurrence rates and is a useful new option for this condition, according to new Irish research.

Dr Clare McCloskey, from the Royal Victoria Eye and Ear Hospital, Dublin, presented the results of a case series of patients who underwent lateral canthal tightening and medial retractor plication using a novel surgical method, at the Irish College of Ophthalmologists 2018 Annual Conference in Kilkenny.

Under this method, a 1-2mm shallow incision is created in the grey line laterally in the upper and lower lid at the lateral

canthus extending approximately 6mm medially. A separate deep incision to the periosteum of approximately 10mm is made perpendicular to the orbital rim at an angle of approximately 45 degrees to the horizontal orbital plane in line with the lower lid.

A 5.0 double-ended prolene suture is passed through both medial ends of the grey line incision. This is passed through the periosteum via the orbital rim incision, tied and buried deep to the orbicularis muscle. The skin is closed with interrupted prolene sutures. A medial retractor plication is performed by way of incising the tarsal conjunctiva inferior to the tarsal plate, exposing the inferior retractors and suturing them to the tarsal plate with buried interrupted 6.0 vicryl sutures.

Lateral canthal tightening with lower lid retractor plication has a low recurrence rate Rizwana Khan MD

The results of 42 eyes of 27 patients who underwent the method; lateral canthal tightening with concurrent medial retractor plication, were included in the study.

Nineteen patients were male. The mean patient age was 76 years (range 60-86). The mean length of follow-up was 5.4 years (range 1-8). Only one patient required surgery for recurrent lower lid ectropion.

It was felt this patient was a poor candidate for the surgery in retrospect as his ectropion carried a cicatricial element, the study authors said. He underwent lower lid wedge resection and skin graft and maintains good lid apposition 14 months after surgical repair, they reported.

The study concluded that lateral canthal tightening with lower lid retractor plication has a low recurrence rate and is a useful option for the treatment of mild-tomoderate involutional lower lid ectropion with medial involvement.

As involutional lower lid ectropion is largely an age-related condition it is a growing problem in the Western world as people live longer and the elderly population increases.

Rizwana Khan: rizwana.khan@rveeh.ie EUROTIMES | OCTOBER 2018

31

32

EXPLORING ATHENS

The Acropolis as seen from the pedestrianised Ermou street

ATHENS

3

TO NOTE...

BEAT THE QUEUES WITH THIS HANDY TAXI APP A useful free app for your mobile phone in Athens: 'Taxibeat’, a service dreamed up by a group of friends after problems finding late night-transport. Despite initial resistance from the local taxi company, Taxibeat eventually signed up a number of drivers and meshed with the regular Yellow Taxi system; it charges the standard taxi rates but offers some useful options. You can pre-select an Englishspeaking driver and choose the type of car you prefer. You can book a taxi (although not 24 hours in advance) and there’s no booking fee.

At the booking stage choose to pay by cash or card. Rate your driver after your trip. Download the Beat-Ride app for iOS devices at iTunes.

FIND A VEGGIE OR VEGAN MEAL WHEREVER YOU GO IN THIS MEAT-LOVER’S CITY Finding a meal a vegetarian or a vegan can enjoy – wherever in the world they travel – has been made a lot easier by HappyCow. Click on to this site, choose your country, then your city, to find a listing of suitable establishments near you. In Athens – a notoriously meatfriendly city – there are 60 listings. The site also highlights the city’s top 10 establishments, based on HappyCow community customer reviews. Whether you're vegetarian, vegan, or just searching for plant-based dining options, there’s something here from breakfast to brunch, dinner to late-night snacking, and every meat-free meal in between. www.happycow.net

GIVE YOUR STEAK A PROPER SEND-OFF DURING THE APOKRIES CARNIVAL Carnivores who like nothing better than the sound of a steak sizzling should know that the Apokries (literally good-bye to meat) carnival starts in Athens on 17 February, 2019, the last day of the ESCRS Winter meeting. It continues for the 40 days until Lent. Not as well known as the carnivals of New Orleans or Rio, it is nevertheless a high-spirited festival of food and music leading up to the Greek Orthodox Easter. Street parties under the lights, theatre, dancing and costume parades are part of the mix with each neighbourhood contributing its own original twist. It’s your chance to fill up on barbecue and watch this old city let its hair down. For the schedule of events: www.whyathens.com

EUROTIMES | OCTOBER 2018

Surprising Athens Delegates to the ESCRS Winter Congress in Athens may be surprised by some ‘halycon days’, says Maryalicia Post To see Athens in winter is to see this ancient city in a new light. The crowds have gone, the locals are out enjoying their cafes and wine bars, the first shoots of green can be seen. February may even bring Alkyonides – ‘Halcyon days’ – summer-like days that regularly occur during the winter months.

It’s the ideal time to follow the pedestrian route that links many of Athens’ most iconic monuments.

Constructed as part of the city’s Archaeological Unification Project, it’s a landscaped walkway winding through several neighbourhoods. The roughly twohour pedestrian walk offers views of the Olympieion (or the Temple of Olympian Zeus), Acropolis, Agora and Kerameikos Cemetery. Start at the Acropolis Metro station – and take a look inside the station, which is decorated with casts from the Parthenon.

Wish you had a local friend to walk with you and fill you in as you go? Try My Athens, a free programme inaugurated in Athens in 2010. It pairs visitors with local volunteer guides, providing daily tours of two-to-four hours for up to six participants. As they greet and connect with visitors, these knowledgeable Athenians take pleasure in sharing offthe-beaten-path experiences and tuckedaway corners of the city they love. The website myathens.thisisathens.org profiles the volunteers, answers any questions you may have about the free service and provides a booking tool.

Time for just one museum? Invest an hour or two in the Museum of Cycladic Art. Housed in two interconnected buildings, this museum presents ancient art from across Greece and temporary contemporary

art exhibitions. Located on Douka Neofitou, near Syntagma Square, it presents the largest Collection of Cycladic Art in the world, from Mycenaean and Classical eras to modern times. Four floors of artefacts; the first floor offers an incredible display of Cycladic art – the fourth floor presents the daily life of Athenians in ancient days. The Cycladic Café is an oasis of greenery and a charming place for coffee or a light meal.

There’s an interesting gift shop as well. www.cycladic.gr And if shopping is your thing, it’s good to know the winter sales are on in Athens until the end of February. Check out the famous shops in pedestrianised Ermou Street and the offerings at the Attica department store at Panepistimiou 7.

Boutique fashions are to be found in the upmarket Kolonaki district.

The Temple of Olympian Zeus

10th EuCornea Congress

13 â&#x20AC;&#x201C; 14 September 2019 | Paris Expo Porte de Versailles

www.eucornea.org

ESCRS ACADEMY

ESCRS Academy in Riga The ESCRS Academy convened at the recent Baltic Eye Surgeons Talk Show.

Sorcha Ní Dhubhghaill reports

T

he Baltic Eye Surgeons Talk Show (BEST) is a yearly conference that is earmarked in the agendas of many of our Baltic colleagues. This year’s edition – presided over by Prof Guna Laganovska – took place at the end of August in Jūrmala, a Baltic sea resort close to Riga, capital of Latvia.

I was part of an ESCRS delegation that travelled to the conference. Not merely to listen to and network with our Baltic colleagues, but to share our own experiences and best practices in the ESCRS academy.

The session kicked off with David Spalton, who walked the audience through the ins and outs of preparing a patient for toric lens surgery. Preoperative keratometry, biometry and lens formulae were discussed and there was a clear preference for the Barrett formula.

For my part, I presented surgical alignment techniques and showed that simple marking can still play a role in our toric lens practice.

Paul Rosen discussed an approach to fine-tuning refractive outcomes or surprises. He encouraged us not to jump straight into an IOL exchange.

Florian Kretz ran through a dizzying array of premium EDOF IOL

The ESCRS Academy speakers together with their Baltic colleagues

technologies, underscoring that there is no one size that fits all.

Jonathan Moore presented some on his extensive trifocal IOL experience and gave and overview on the extensive research that he and his team do in this field.

Richard Packard covered the unhappy multifocal patients and told us how a listening ear can often help a patient more than a surgical knife.

The clear standout moment, however, was when Andrea Rosa presented her work on functional MRI confirmation of the neuroadaptation process. Her MRIs showed areas of the brain lighting up as beautifully as the fireworks at the gala dinner that night.

BEST has been a great experience. We all felt truly welcome, and Prof Laganovska did her society and her beautiful country proud with this wonderfully organised conference.

Reach the peak.

Belong to something impressive. Join us.

www.escrs.org EUROTIMES | OCTOBER 2018

35

MY MENTOR

A sudden attack of teaching Joséphine Behaegel, 2018 winner of the John Henahan Writing Prize, describes how her mentor came into her life

I

t was another day in the OR during one of the first months of my residency, when the ophthalmologist I was following that day decided we should take a coffee break. Not even a minute later she spontaneously started to ramble about the differences between intraocular lenses while scribbling on a napkin in the coffee room of the operating theatre.

Surprised by this sudden attack of teaching, I was questioning myself uncomfortably “Does she want anything from me?” “Should I keep this napkin?” I wasn’t used to this approach and felt fairly stupid since I could barely answer to any of the questions. At the same time, however, this random improvised teaching-on-a-napkin moment awakened my curiosity. That evening I cracked open my Kanski and I dove into the Lens chapter.

Triggered by this ophthalmologist, Sorcha Ní Dhubhghaill, and her napkin, I tried to seize more opportunities to work under her supervision. I soon discovered that she had a passion for sharing knowledge with everyone who wants to be taught… and even some who don’t.

She organises weekly teaching sessions for residents on early Friday mornings or during weekend days no matter how hard the week was, while she could easily use this free time pursuing her own career goals or spending it with her husband. She has an impressive knowledge, loves to discuss cases and is accessible to the residents… All ingredients for a great mentor! And on top of that she has a sense of humour and likes dogs!

But mentoring is a two-way street. It needs commitment from both sides. Her deadlines must be honoured, administration must be completed, start times must be adhered to and patients must be handled with the greatest care.

Every trainee who is lucky enough to have a mentor during his or her residency will recognise its value and having a mentor is not a given. While as a resident you must run your own race, mentors can be a coach. They understand where you are in your training programme and are there to infuse you with new energy when you’re slowing down or lacking motivation. (More than once) I have had miserable days, particularly when I’m combining my training with clinical research. Tempers and adrenaline can be high and I start to wonder why I didn’t open a flower shop instead.

In these moments, having a mentor pulls me through and reminds me what I have accomplished so far. So I highly recommend getting a mentor; just don’t take mine, I need her.

...this random improvised teaching-on-anapkin moment awakened my curiosity. That evening I cracked open my Kanski and I dove into the Lens chapter

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

EUROTIMES | OCTOBER 2018

37

CALENDAR

↙

LAST CALL

OCTOBER 2018

6th Egyptian Vitreoretinal Society (EGVRS) Training School 4–6 October Alexandria, Egypt www.egvrs.org

International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 8–11 October Munich, Germany www.echography.com

Ophthalmic Imaging: from Theory to Current Practice 12 October Paris, France www.vuexplorer.com/en/congres

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

The 23rd ESCRS Winter Meeting will take place in Athens, Greece

DECEMBER

MARCH

Arab International Ophthalmology Congress

9th EURETINA Winter Meeting

7–8 December Dubai, UAE www.menaophthalmologycongress.com

2019

FEBRUARY

Cataract Surgery: Telling It Like It Is

6–10 February Florida, USA www.CSTellingItLikeItIs.com

23rd ESCRS Winter Meeting 15–17 February Athens, Greece www.escrs.org

Snowmass Retina & Eye 2019

25 February – 1 March Colorado, USA www.snowmasscme.com

1–2 March Prague, Czech Republic www.euretina.org

Retina World Congress

21–24 March Florida, USA www.RetinaWorldCongress.org

NEW 8th World Glaucoma Congress 27–30 March Melbourne, Australia www.worldglaucomacongress.org

APRIL International Meeting of the Egyptian Vitreoretinal Society (EGVRS) 10–12 April Cairo, Egypt www.egvrs.org

46th EFCLIN Congress Exhibition 25–27 April Brussels, Belgium www.efclin.com

Ophthalmic Imaging: from Theory to Current Practice, which will take place in Paris, France

EUROTIMES | OCTOBER 2018

39

40

CALENDAR

The AAO Annual Meeting 2019 will take place in San Francisco, USA

MAY

JUNE

SEPTEMBER

SEPTEMBER

ASCRS•ASOA Symposium and Congress

SOE Congress 2019

WSPOS Subspecialty Day

37th Congress of the ESCRS

3–7 May San Diego, USA www.ascrs.org

NEW 16th South East European Congress of Ophthalmology

13 September Paris, France www.wspos.org

SEPTEMBER 19th EURETINA Congress 5–8 September Paris, France www.euretina.org

↙

May 31- June 2 Prishtina, Kosovo http://www.shofk.org/shofk/

13–16 June Nice, France www.soevision.org

10th EuCornea Congress 13–14 September Paris, France www.eucornea.org

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

Eye Contact Interviews

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Video of the Month

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Video Journal of Cataract & Refractive Surgery

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Young Ophthalmologists Videos: “My Early Surgeries”

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Online Museum

player.escrs.org EUROTIMES | OCTOBER 2018

14-18 September Paris, France www.escrs.org

OCTOBER AAO Annual Meeting 12–15 October San Francisco, USA www.aao.org

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Instructional Course Submission Deadline: 31 st October 2018

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Workshop 26.10.2018 – AXIS Workshop Advanced 30.11.2018 – AXIS Workshop for Young Ophthalmologists

VENUE: Alcon Experience Center (Barcelona, Spain) COURSE LEADERS:

1. Prof. J. Murta, Portugal 2. Dr. K.G. Gundersen, Norway 3. Dr. H. Carreras, Spain 4. Dr. N. Pesztenlehrer, Hungary 5. Dr. A. Dmitriew, Poland 6. Dr. B. Galan, Romania

DESCRIPTION: From a discussion on general Astigmatism Management and Surgical Planning Pearls, to a thorough review of the new Online Toric Calculator and powerful New Theories in Corneal Astigmatism, join Session One for some of the latest developments in Astigmatism Management.

Session Two features tips and pearls on managing surgical variables, along with insightful clinical cases and post-op assessments showcasing ORA®.

Moving through New Patient and Pre-Op Data, to Post-Op Reviews and powerful reporting features, join Session Three for an insightful discussion on how to maximize the many facets of the AnalyzOR® within the practice.

Get first-hand experience with the latest cataract refractive Alcon technologies at the VerionTM 3.1 and ORA® VLynk® Hands-on Session.

For more information and course registration, contact your local Alcon representative.

© 2018 Novartis 6/18

18-MK-AXIS-001-JAD-EU