EuroTimes Vol. 23 - Issue 11

SPECIAL FOCUS

PAEDIATRIC OPHTHALMOLOGY

November 2018 | Vol 23 Issue 11

?

??

TACKLING T HE CHALLENGES OF

PAEDIATR IC

C ATAR AC T SURGER Y CATARACT & REFRACTIVE | CORNEA | RETINA CONGRESS REVIEW | GLAUCOMA

NOW WITH THE OPTION TO

T R E AT & E X TEND

IN YEAR 11

For TREATMENT-NAΪVE patients with wAMD1

WHAT YOU

START TODAY MAKES A DIFFERENCE TOMORROW

UKEYL09180137 © Bayer AG, September 2018.

Reference: 1. EYLEA (aflibercept solution for injection) Summary of Product Characteristics Berlin, Germany: Bayer Pharma AG; July 2018.

Eylea 40 mg/ml solution for injection in a vial (aflibercept) Prescribing Information. (Refer to full Summary of Product Characteristics (SmPC) before prescribing). Presentation: 1 ml solution for injection contains 40 mg aflibercept.

Each vial contains 100 microlitres, equivalent to 4 mg aflibercept. Indication(s): Treatment of neovascular (wet) age-related macular degeneration (wAMD), macular oedema secondary to retinal vein occlusion (branch RVO or central RVO), visual impairment due to diabetic macular oedema (DMO) in adults and visual impairment due to myopic choroidal neovascularisation (myopic CNV). Posology & method of administration: For intravitreal injection only. Must be administered according to medical standards and applicable guidelines by a qualified physician experienced in administering intravitreal injections. Each vial should only be used for the treatment of a single eye. Extraction of multiple doses from a single vial may increase the risk of contamination and subsequent infection. The vial contains more than the recommended dose of 2 mg. The extractable volume of the vial (100 microlitres) is not to be used in total. The excess volume should be expelled before injecting. Refer to SmPC for full details. Adults: The recommended dose is 2 mg aflibercept, equivalent to 50 microlitres. For wAMD treatment is initiated with 1 injection per month for 3 consecutive doses. The treatment interval is then extended to 2 months. Based on the physician’s judgement of visual and/or anatomic outcomes, the treatment interval may be maintained at 2 months or further extended using a treat-and-extend dosing regimen, where injection intervals are increased in 2- or 4-weekly increments to maintain stable visual and/ or anatomic outcomes. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly to a minimum of 2 months during the first 12 months of treatment. There is no requirement for monitoring between injections. Based on the physician’s judgement the schedule of monitoring visits may be more frequent than the injection visits. Treatment intervals greater than 4 months between injections have not been studied. For RVO (branch RVO or central RVO), after the initial injection, treatment is given monthly at intervals not shorter than 1 month. Discontinue if visual and anatomic outcomes indicate that the patient is not benefiting from continued treatment. Treat monthly until maximum visual acuity and/or no signs of disease activity. Three or more consecutive, monthly injections may be needed. Treatment may then be continued with a treat-and-extend regimen with gradually increased treatment intervals to maintain stable visual and/or anatomic outcomes, however there are insufficient data to conclude on the length of these intervals. Shorten treatment intervals if visual and/or anatomic outcomes deteriorate. The monitoring and treatment schedule should be determined by the treating physician based on the individual patient’s response. For DMO, initiate treatment with 1 injection/month for 5 consecutive doses, followed by 1 injection every 2 months. No requirement for monitoring between injections. After the first 12 months of treatment, and based on visual and/or anatomic outcomes, the treatment interval may be extended such as with a treat-and-extend dosing regimen, where the treatment intervals are gradually increased to maintain stable visual and/or anatomic outcomes; however there are insufficient data to conclude on the length of these intervals. If visual and/or anatomic outcomes deteriorate, the treatment interval should be shortened accordingly. The schedule for monitoring should therefore be determined by the treating physician and may be more frequent than the schedule of injections. If visual and anatomic outcomes indicate that the patient is not benefiting from

continued treatment, treatment should be discontinued. For myopic CNV, a single injection is to be administered. Additional doses may be administered if visual and/or anatomic outcomes indicate that the disease persists. Recurrences should be treated as a new manifestation of the disease. The schedule for monitoring should be determined by the treating physician. The interval between 2 doses should not be shorter than 1 month. Hepatic and/or renal impairment: No specific studies have been conducted. Available data do not suggest a need for a dose adjustment. Elderly population: No special considerations are needed. Limited experience in those with DMO over 75 years old. Paediatric population: No data available. Contraindications: Hypersensitivity to active substance or any excipient; active or suspected ocular or periocular infection; active severe intraocular inflammation. Warnings & precautions: As with other intravitreal therapies endophthalmitis, intraocular inflammation, rhegmatogenous retinal detachment, retinal tear and iatrogenic traumatic cataract have been reported. Aseptic injection technique is essential. Patients should be monitored during the week following the injection to permit early treatment if an infection occurs. Patients must report any symptoms of endophthalmitis or any of the above mentioned events without delay.

Increases in intraocular pressure have been seen within 60 minutes of intravitreal injection; special precaution is needed in patients with poorly controlled glaucoma (do not inject while the intraocular pressure is ≥ 30 mmHg). Immediately after injection, monitor intraocular pressure and perfusion of optic nerve head and manage appropriately. There is a potential for immunogenicity as with other therapeutic proteins; patients should report any signs or symptoms of intraocular inflammation e.g pain, photophobia or redness, which may be a clinical sign of hypersensitivity. Systemic adverse events including non-ocular haemorrhages and arterial thromboembolic events have been reported following intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors. Safety and efficacy of concurrent use in both eyes have not been systemically studied. No data is available on concomitant use of Eylea with other anti-VEGF medicinal products (systemic or ocular). Caution in patients with risk factors for development of retinal pigment epithelial tears including large and/or high pigment epithelial retinal detachment. Withhold treatment in patients with: rhegmatogenous retinal detachment or stage 3 or 4 macular holes; with retinal break and do not resume treatment until the break is adequately repaired. Withhold treatment and do not resume before next scheduled treatment if there is: decrease in best-corrected visual acuity of ≥30 letters compared with the last assessment; central foveal subretinal haemorrhage, or haemorrhage ≥50%, of total lesion area. Do not treat in the 28 days prior to or following performed or planned intraocular surgery. Eylea should not be used in pregnancy unless the potential benefit outweighs the potential risk to the foetus. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last intravitreal injection. In patients presenting with clinical signs of irreversible ischaemic visual function loss, aflibercept treatment is not recommended. Populations with limited data: There is limited experience in DMO due to type I diabetes or in diabetic patients with an HbA1c over 12% or with proliferative diabetic retinopathy. Eylea has not been studied in patients with active systemic infections, concurrent eye conditions such as retinal detachment or macular hole, or in diabetic patients with uncontrolled hypertension. This lack of information should be considered when treating such patients. In myopic CNV there is no experience with Eylea in the

treatment of non-Asian patients, patients who have previously undergone treatment for myopic CNV, and patients with extrafoveal lesions. Interactions: No available data. Fertility, pregnancy & lactation: Not recommended during pregnancy unless potential benefit outweighs potential risk to the foetus. No data available in pregnant women. Studies in animals have shown embryo-foetal toxicity. Women of childbearing potential have to use effective contraception during treatment and for at least 3 months after the last injection. Not recommended during breastfeeding. Excretion in human milk: unknown. Male and female fertility impairment seen in animal studies with high systemic exposure not expected after ocular administration with very low systemic exposure. Effects on ability to drive and use machines: Possible temporary visual disturbances. Patients should not drive or use machines if vision inadequate. Undesirable effects: Very common: Visual acuity reduced, conjunctival haemorrhage (wAMD phase III studies: increased incidence in patients receiving anti-thrombotic agents), eye pain.

Common: retinal pigment epithelial tear (known to be associated with wAMD; observed in wAMD studies only), detachment of the retinal pigment epithelium, retinal degeneration, vitreous haemorrhage, cataract (nuclear or subcapsular), corneal abrasion or erosion, increased intraocular pressure, blurred vision, vitreous floaters, vitreous detachment, injection site pain, foreign body sensation in eyes, increased lacrimation, eyelid oedema, injection site haemorrhage, punctate keratitis, conjunctival or ocular hyperaemia. Serious: cf. CI/W&P - in addition: blindness, culture positive and culture negative endophthalmitis, cataract traumatic, transient increased intraocular pressure, vitreous detachment, retinal detachment or tear, hypersensitivity (during the post-marketing period, reports of hypersensitivity included rash, pruritus, urticaria, and isolated cases of severe anaphylactic/anaphylactoid reactions), vitreous haemorrhage, cortical cataract, lenticular opacities, corneal epithelium defect/erosion, vitritis, uveitis, iritis, iridocyclitis, anterior chamber flare, arterial thromboembolic events (ATEs) are adverse events potentially related to systemic VEGF inhibition. There is a theoretical risk of arterial thromboembolic events, including stroke and myocardial infarction, following intravitreal use of VEGF inhibitors. As with all therapeutic proteins, there is a potential for immunogenicity. Consult the SmPC in relation to other side effects. Overdose: Monitor intraocular pressure and treat if required.

Incompatibilities: Do not mix with other medicinal products. Special Precautions for Storage: Store in a refrigerator (2°C to 8°C). Do not freeze. Unopened vials may be stored at room temperature (below 25°C) for up to 24 hours before use. Legal Category: POM. Package Quantities & Basic NHS Costs: Single vial pack £816.00.

MA Number(s): EU/1/12/797/002. Further information available from: Bayer plc, 400 South Oak Way, Reading RG2 6AD, United Kingdom. Telephone: 0118 206 3000.

Date of preparation: July 2018. Eylea® is a trademark of the Bayer Group

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store. Adverse events should also be reported to Bayer plc.

Tel.: 0118 2063500, Fax.: 0118 2063703, Email: pvuk@bayer.com

P.25

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designers Monica De Iscar Ria Pollock 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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

RETINA

PAEDIATRIC OPHTHALMOLOGY

18 Treatment options for

04 How innovations

19 Screening programme

06 Early detection can lead

20 Novel gene therapy

help to address the challenges of paediatric ophthalmology to favourable outcomes in Coats’ disease

07 Staying on top of studies

can help clinicians treating retinopathy of prematurity

08 Everything you wanted to know about EDOF IOLs

12 Doctors debate pros and cons of intracameral antibiotics

13 JCRS highlights

drives improved detection and early treatment

shows promise for treating Leber hereditary optic neuropathy

CONGRESS REVIEW ESCRS focuses on innovation

22 Young ophthalmologists share their experiences

23 Congress picture gallery 26 EURETINA Congress is

the bedrock of the society

REGULARS 31 Hospital diary 33 Industry news 34 Random thoughts 37 Travel 39 Calendar

27 EuCornea shows off its vitality and well-being

28 Experience and expertise

CORNEA

on show at WSPOS Subspecialty Day

16 Medal lecture

explores corneal and conjunctival sensations

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2017 and 31 December 2017 is 45,316.

P.5

proliferative diabetic retinopathy

21 36th Congress of the

CATARACT & REFRACTIVE

www.eurotimes.org

17 Examining the benefits of cross-linking for slowing myopia progression

GLAUCOMA 29 Modern neuroimaging techniques can be useful in evaluating glaucomatous neuropathy

EUROTIMES |NOVEMBER 2018

2

EDITORIAL A WORD FROM KEN NISCHAL MD

GUEST EDITORIAL

Advancing research These are exciting times for WSPOS, and as the society continues to grow there will be even better times ahead

Ken Nischal MD

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

W

e have just returned from Vienna, where WSPOS held a very successful subspecialty day preceding the 36th Congress of the ESCRS. One of the highlights of any meeting for me is the opportunity to discuss some of the hot topics in our specialty.

So what is new in paediatric ophthalmology and strabismus?

In paediatric glaucoma, we have an ongoing discussion on the role of MIGS, and this is an area where we can expect to see a lot of work going on in the next four or five years.

Cross-linking has really taken off in paediatric cornea and people are pushing the envelope on what you There is a lot of can cross-link. exciting research When you get to retina, there is a lot of going on into exciting research going artificial retinas, on into artificial retinas, substitution vision, substitution vision, gene therapy and also gene therapy and also the clinical trial for the clinical trial for ataluren for children ataluren for children with aniridia. with aniridia Our mission at WSPOS is to advance research into all of these areas and also to make the research accessible to opthalmologists all over the world.

SHARING KNOWLEDGE

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)

When David Granet and I co-founded WSPOS one of our mantras was that paediatric ophthalmologists should not work in isolation from other specialists.

Our first meeting was in 2009 and we are very proud to say that the level of co-operation and dialogue with all of our colleagues has been dramatically transformed since that initial meeting.

WSPOS is now established globally and we are welcoming new chapters to the society every year.

We are celebrating our 10th anniverary in 2019, and this will give us the opportunity to reflect on the landmark transformation that has taken place since our formation.

These are exciting times for WSPOS, and as the society continues to grow there will be even better times ahead.

Ken Nischal is the founding co-director of the World Society of Paediatric Ophthalmology and Strabismus EUROTIMES | NOVEMBER 2018

WCPOS V | 2020 5th World Congress of Paediatric Ophthalmology and Strabismus

2–4 October 2020 RAI Amsterdam, The Netherlands Nicoline Schalij MD Local Host President

www.wspos.org

4

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Tackling the challenges of paediatric cataract surgery Innovations address existing difficulties.

Cheryl Guttman-Krader reports

P

aediatric cataract poses a number of challenges. At the World Society of Paediatric Ophthalmology and Strabismus Subspecialty Day preceding the 36th Congress of the ESCRS in Vienna, Austria, speakers described techniques and technologies for enabling successful outcomes.

A good anterior capsulotomy is critical for success in any cataract surgery, but can be particularly difficult to achieve in children. Ramesh Kekunnaya MD described the new technique of precision pulse capsulotomy (PPC; Zepto, Mynosys) as a method for allowing safe and predictable capsulotomy creation by all surgeons.

“If you can get the capsulotomy right in paediatric cataract surgery, the next steps

EUROTIMES | NOVEMBER 2018

are relatively easy. But because cataracts in children are rare, many surgeons only perform these procedures infrequently.

Using PPC helps surgeons to achieve the ultimate goal of being able to place the IOL in the bag,” said Dr Kekunnaya, Head, Child Sight Institute, LV Prasad Eye Institute, Hyderabad, India.

Dr Kekunnaya reported his experience with the Zepto in 21 eyes of 14 children (mean age 6 years). All but one child was older than age 2. Mean time for PPC was 76 seconds, and average capsulotomy size was 5.72mm.

“Interestingly, and in contrast to adults, the capsulotomy tends to be a bit bigger than planned when using PPC in children,” Dr Kekunnaya said.

As another difference compared to adults, the margin of the capsulotomy created in children using PPC has

a serrated appearance, but the edge remains very strong.

Dr Kekunnaya noted the need for data from more cases and longer follow-up.

PREVENTING VISUAL AXIS OPACIFICATION Marie-José Tassignon MD, PhD, Professor Emeritus and Immediate Past Head, Department of Ophthalmology, Antwerp University, Antwerp, Belgium, discussed implantation of the bag-inthe-lens (BIL) IOL as a safe and effective technique for maintaining a clear visual axis after paediatric cataract surgery.

After creating identically and specifically sized anterior and posterior capsulorhexes, the rims of the anterior and posterior capsule are placed in apposition into the BIL IOL’s

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Courtesy of Ramesh Kekunnaya MD A child with bilateral dense cataract due to congenital rubella syndrome

Courtesy of Marie-José Tassignon, MD, PHD

circumferential interhaptic groove.

Fusing of the capsular blades traps lens epithelial cells, preventing their escape and proliferation.

In her own series of 46 eyes of 31 children followed for five years, Dr Tassignon found an 8.7% rate of visual axis opacification (VAO). Corrected distance visual acuity (CDVA) of 0.5 or better was achieved in 31.2% of unilateral cases and 86.7% of patients having bilateral BIL IOL implantation. Glaucoma developed in one eye (2.2%).

More recently, Nyström et al. reported outcomes of BIL IOL implantation in 109 eyes of 84 children. After a median follow-up of 2.8 years, five eyes (4.6%) required treatment for VAO, CDVA was 0.5 or better in 37.5% of unilateral cases and 55.6% of children who had bilateral surgery, and glaucoma developed in 15 (13.8%) eyes.

Dr Tassignon commented: “The higher rate of VAO in my report includes my earliest cases where I was still learning.

Nyström and colleagues benefited from tips I taught them for minimising VAO.” She attributed the higher rate of glaucoma in the series by Nyström et al. to their operating on some patients just two-to-four weeks after birth.

“I stopped operating on such young children because the surgery is very difficult and results in very marked inflammation.

Now, I wait until a child is at least 2-to-3 months old,” Dr Tassignon said.

The bag-in-the-lens solution for PCO takes benefit of the Berger space to accommodate the posterior flanges and the optic US patent: 6,027,531 - PCT 120268: licensed to Morcher, Germany

IN-THE-BAG IMPLANTATION AFTER TRAUMATIC CATARACT In cases of traumatic cataract where there is partial rupture of the anterior capsule, a novel technique developed by Ken Nischal MD allows IOL implantation in the capsular bag, maintains the implant in a stable position, and reduces the risk for lens-iris capture.

He refers to the approach as the ‘banded technique’ because it converts the edge of the ruptured anterior

I stopped operating on such young children because the surgery is very difficult and results in very marked inflammation.

Now, I wait until a child is at least 2-3 months old Marie-José Tassignon, MD, PHD

5

capsule into a band of tissue that restrains the IOL. “The banded technique gives surgeons confidence to place the lens in the bag,” said Dr Nischal, Professor of Ophthalmology, University of Pittsburgh Medical Centre, Pittsburgh, United States.

“The beauty of the technique is that the band holds the optic back, but it also retracts away from the visual axis over a period of months. For that reason, I have not yet had to do an Nd:YAG capsulotomy to the band in any eye where I have used this technique.”

The banded technique is done by using a two-incision push-pull approach to create a capsulorhexis in the intact anterior capsule proximal to the rupture.

“The two-incision push-pull approach is ideal for facilitating creation of an oval opening, which is the key to the banded technique,” noted Dr Nischal.

After aspirating the crystalline lens, the posterior capsule, if it is intact, is opened with a two-incision push-pull capsulorhexis, followed by anterior vitrectomy. If the posterior capsule is also ruptured, then anterior vitrectomy is performed carefully to avoid further damage to the remaining posterior capsule.

“The two-incision push-pull approach is ideal for facilitating creation of an oval opening, which is the key to the banded technique” Ken K Nischal MD A three-piece hydrophobic IOL is introduced into the capsular bag, entering through the rupture site if the opening allows or else through the capsulorhexis.

The leading haptic is put underneath the edge of the anterior capsule and the trailing haptic is placed so that the IOL is underneath the band.

Ophthalmologists can find more information about the banded technique in a paper that will be published soon in the Journal of Cataract and Refractive Surgery.

Ken K Nischal: nischalkk@upmc.edu Ramesh Kekunnaya: rameshak@lvpei.org Marie-José Tassignon: marie-jose.tassignon@uza.be EUROTIMES | NOVEMBER 2018

6

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Paediatric Coats’ disease

ERGOJECT

™

Early treatment critical, combined laser and anti-VEGF may be effective.

Howard Larkin reports

E

arly detection and prompt, appropriate treatment of children with Coats’ disease result in favourable functional and anatomic outcomes with good globe salvage rates, Bhamy Hariprasad Shenoy MBBS, MS, FICO, FRCOphth, told the 2018 World Society of Paediatric Ophthalmology and Strabismus Subspecialty Day in Vienna.

Based on research conducted by Dr Shenoy and colleagues at Manchester Royal Eye Hospital, UK, adding anti-VEGF therapy to traditional laser photocoagulation may improve outcomes, he added.

The retrospective interventional case series involved 28 eyes with confirmed Coats’ disease in 26 patients aged 14 or under, followed for a mean of more than five years after treatment, ranging from 12 to 124 months, Dr Shenoy reported. Eleven eyes received green diode laser photocoagulation alone with a mean number of treatments of 2.7, while 17 eyes received a combination of laser and bevacizumab with a mean 2.0 treatments. Three eyes had additional vitreoretinal surgery to drain subretinal fluid and three had cataract extraction during follow-up.

THE WAY IOLs ARE INJECTED TODAY!

GOOD OUTCOMES

ONE-HANDED CONTROL! Ergoject™ -First micro-gear driven screw IOL injector for hightest precision.

Scan the following QR code for further details:

Visual acuity stabilised or improved in 82% of eyes and worsened in 18% at last follow-up, Dr Shenoy reported. Mean VA at presentation ranged from logMAR -0.12 to 3, and at last follow-up from -0.2 to 3. Anatomic outcomes were also good. All eyes had attached retinas at last follow-up, no eye declined to phthisis or was enucleated and the globe was salvaged in all cases.

Dr Shenoy noted there is a wide variability in the clinical profile of paediatric Coats’ disease patients, which involves retinal vessel telangiectasia and aneurysms at stage 1, advancing to extra-foveal and foveal exudate in stages 2a and 2b, to exudative retinal detachment, secondary glaucoma and phthisis in stages 3 to 5. In this study 24 eyes were stage 2a or 2b, three stage 3 and one stage 4, with 16 patients aged 6 years or younger. Earlier age and good visual acuity at presentation were associated with favourable visual outcomes, Dr Shenoy added.

While Dr Shenoy did not break out differing outcomes by laser-only or combination laser-anti-VEGF groups, he noted that the series included long mean follow-up for several paediatric Coats’ disease patients receiving combination therapy.

“There is a definite role for anti-VEGF in improving outcomes,” he said, emphasising that early detection and treatment are the most crucial factors for improving the odds of a favourable outcome.

Bhamy Hariprasad Shenoy: drbhamy@gmail.com

International Patent Applied

EUROTIMES | NOVEMBER 2018

Medicel AG Dornierstrasse 11 CH-9423 Altenrhein T +41 (0)71 727 10 50 www.medicel.com

There is a definite role for anti-VEGF in improving outcomes Bhamy Hariprasad Shenoy MBBS, MS, FICO, FRCOphth

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Update on

retinopathy of prematurity Screening, anti-VEGF use, new risk factors may improve detection and treatment.

Howard Larkin reports

S

taying on top of fast-moving developments may help clinicians do a better job identifying and treating retinopathy of prematurity (ROP) patients, Manca Tekavčič Pompe MD, PhD, told the 2018 World Society of Paediatric Ophthalmology and Strabismus Subspecialty Day in Vienna.

Dr Tekavčič Pompe, of University Eye Clinic, Ljubljana, Slovenia, offered a personal perspective on findings included in 350 peer-reviewed ROP papers published in the first eight months of 2018.

Combining weight gain measured during three 10-day intervals following birth with traditional ROP screening criteria of gestational age and birth weight plus hydrocephalus increased sensitivity of screening infants for retinal exams, according to the Growth-ROP (G-ROP) study group. Their retrospective study of nearly 7,500 infants with known ROP outcomes in the USA and Canada identified 100% of ROP type 1 cases while reducing babies screened by 30% (Binenbaum

G et al., JAMA Ophthalmol. 2018 Sep 1;136(9):1034-1040). However, while these criteria may be valid in North America and possibly Europe, they may not apply elsewhere, noted Dr Tekavčič Pompe. She cited a study finding that higher gestational age and birth weight than in the G-ROP study were appropriate for ROP screening in Turkey (Bas AY et al., Br J Ophthalmol 2018, epub ahead of print).

Bevacizumab doses much lower than used in adults may preserve retinal structure in ROP patients while reducing risk of systemic anti-VEGF exposure, according to the Pediatric Eye Disease Investigative group. With only four of 112 patients progressing to severe ROP, their dose de-escalation study found bevacizumab doses as low as 0.031mg had good structural outcome, though some eyes needed additional treatments (Wallace DK et al., Ophthalmology. 2018 Jun 7. pii: S01616420(18)30491-3 (epub ahead of print)).

“We have to keep in mind systemic and local impact factors,” Dr Tekavčič Pompe said.

Sophi is here.

Studies of ROP prevalence at a time when more premature babies survive were mixed, with a Taiwan study finding no increase over 10 years in overall ROP percentage, though the numbers requiring treatment grew. However, a Swedish national registry study found increases in ROP incidence, though not type 1 incidence, that appeared related to changes in target oxygen saturation, and significant regional differences in incidence and treatment rates over eight years (Holmström G et al., Acta Ophthalmol 2018 Mar: 96:142-148).

Other recent studies identified the need to pay more attention to pain relief when examining infants, independent ROP risk factors including thrombocytopaenia, anaemia and hyperglycaemia, and growing understanding of genetic influences, Dr Tekavčič Pompe said. “Genetics may be an independent risk factor, especially when we look at different incidence of ROP in different races,” she noted.

Manca Pompe: manca.tekavcic@kclj.si

Simplicity Sophi’s design is simple and straightforward.

Complexity lies inside the device and therefore facilitates a simple user handling. This helps to save time and to increase productivity.

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 | NOVEMBER 2018

7

8

CATARACT & REFRACTIVE

Everything you ever wanted to know about extended depth of focus IOLs Knowing what lenses are available for different patients is essential. Soosan Jacob MD reports

C

urrently available presbyopia correcting IOLs can be classified as pseudoaccommodative IOLs – multifocal IOLs, segmented bifocal and trifocal IOLs including the AT LARA Ž (Carl Zeiss Meditec), FineVision (PhysIOL, Belgium), PanOptix (Alcon); RayOne Trifocal (Rayner) and extended depth of focus (EDOF) IOLs; partially accommodative IOLs, such as Crystalens (Bausch + Lomb) and Synchrony dual optic IOL (Abbott Medical Optics) and accommodating IOLs such as FluidVision (PowerVision), Juvene (LensGen) etc.

EDOF IOLs have become a popular choice because of better intermediate vision with less light scatter than monofocals, smaller haloes and glare than multifocals while working unlike accommodative IOLs. Certain precautions are, however, still important while using EDOF IOLs, such as precise IOL power calculation; preoperative identification and if possible treatment of ocular comorbidities such as dry eye, epithelial basement membrane disease; surgical challenges such as pseudoexfoliation, subluxation, small pupil etc as well as conditions affecting postoperative outcome such as epiretinal membrane, diabetic macular oedema, age-related macular degeneration etc.

However, EDOFs are preferred over multifocals in eyes with maculopathy, irregular corneas or glaucoma.

Proper patient counselling and understanding patient needs is important, as is setting realistic expectations, especially with regard to the possibility of needing reading glasses, as well as the occurrence of some glare and haloes.

While multifocal IOLs have two distinct foci with blurry vision in between, EDOF IOLs work by having one elongated focal EUROTIMES | NOVEMBER 2018

An AT LARA 829MP (Carl Zeiss Meditec) being implanted

area giving an extended depth of focus.

As peak resolution is only minimally affected, reasonably clear vision is obtained at all distances (especially far and intermediate) with lesser side-effects of glare, haloes or loss of contrast as compared to multifocals. The AAO Task Force consensus statement requires EDOF IOLs to be within one line of BCVA of monofocal IOLs; to have 0.5D more of defocus than a monofocal at 20/30 level (approximately 1.25D defocus) and lastly, 50% of patients to be better than 20/30.

Although EDOF IOLs give good

uncorrected distance and intermediate vision, near vision with a higher add multifocal is better. Therefore, bilateral EDOF with -0.5 to -0.75D micromonovision strategy or a mixand-match strategy with EDOF in the dominant eye together with +3.25 near add multifocal in the non-dominant eye may be used if the patient desires more near vision.

EDOF IOLs work on different principles: A) Echelette design: The Tecnis Symfony IOL (AMO, California) was FDA approved in 2016. It is a biconvex, anterior aspheric and posterior

CATARACT & REFRACTIVE achromatic diffractive surface IOL with an echelette design and the ability to reduce chromatic aberration. Bilateral implantation with micromonovision has shown to give very satisfactory vision at all distances. The Symfony Toric IOL can also correct coexistent astigmatism. The AT LARA 829MP (Carl Zeiss Meditec) is another EDOF lens that, in pre-clinical studies, has shown higher visual acuity over a wider range of focus than Tecnis Symfony. A diffractive aspheric design, chromatic correction and smoother phase zones with shallower angles optimise contrast sensitivity and minimise light scattering and visual side-effects.

Postoperatively, patients can show over minus values on both autorefractor and manifest refraction. The highest plus possible should therefore be prescribed by using a fogging technique.

B) Small-aperture IOLs: The IC-8™ (AcuFocus) is a single-piece hydrophobic 6mm optic monofocal IOL utilising a pinhole principle (a non-diffractive 3.23mm diameter opaque PVDF mask with 1.36mm central aperture), similar to the Kamra corneal inlay, to increase depth of focus to about 3D. It is especially effective in post-LASIK eyes and corneas with irregular astigmatism. Results have shown good distance, intermediate and near vision, especially when targeting for -0.75D of myopia and it can improve up to -1.5D of astigmatism. It is also more forgiving of missing target refraction.

Posterior fundus imaging is possible through the small aperture and vitreoretinal surgery can be performed when required. The XtraFocus Pinhole implant (Morcher) designed by Trinidade et al. is a small-aperture sulcus IOL made of black acrylic with a central pinhole that extends depth of focus and can be used for high corneal irregular astigmatism such as post-RK patients.

Comment from Marie-José Tassignon: Extended Depth of Focus, also called Extended Range of Vision, is another name for low-grade accommodative range IOLs. EDOF can be achieved by different optical principles, monocular or binocular e.g.: small-aperture corneal inlays, spherical aberrations, diffractive/ refractive IOLs, mix-and-match implantation of IOLs, monovision etc. EDOF IOLs propose an intermediate solution for the patient. While bifocal (and to a lesser degree trifocal IOLs) provided sharp vision at far and at near, patient’s intermediate vision was often poor. The new profile of EDOF IOLs proposes to compensate for this intermediate vision but will not give full correction at near. This compromise will most probably be more acceptable for a larger range of patients, namely those who prefer better image quality than getting rid of spectacles for 100% of their daily activities.

It will be easier for the prudent ophthalmologist to propose an EDOF to their patients. Toric EDOFs will increase patient satisfaction, provided they are well centred. Centration remains the big issue – however, slight decentration will be better tolerated with EDOF IOLs. Marie-José Tassignon MD, PhD, Professor Emeritus and Immediate Past Head, Department of Ophthalmology, Antwerp University, Antwerp, Belgium

C) Low-near add multifocal IOLs: These are now sometimes added under the EDOF group as they are directed mainly at improving distance and intermediate vision. This includes the Lentis Comfort (Oculentis), which has an asymmetric near sector and a near add of +1.5D translating to +1D at spectacle plane. Though the add power is lower, there is still a split of light into two or three foci, which results in some contrast sensitivity loss.

D) Combination/customised technologies: A combination of EDOF technology on accommodative lens optics can add to overall benefit and increase the range of vision further.

The Swiss Advanced Vision (SAV-IOL) allows IOL customisation using a web-

based configurator to obtain desired visual outcomes by offering differing light distribution ratios for near, intermediate and distance vision.

The Mini Well Ready IOL (SIFI Medtech), based on wavefront technology, has an aspheric profile with three circular zones – central distance, surrounding distance with spherical aberration of opposite sign and a peripheral distance with monofocal characteristics that together give a range of focus.

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

ESCRS/Alcon Fellowship ESCRS supported by funding from Alcon are offering a bursary of €50,000 to a young ophthalmologist to fund one year’s fellowship training in cataract or refractive surgery at a European centre of excellence.

Deadline for applications is December 1, 2018.

Award will be made at ESCRS Winter Meeting in Athens in February 2019.

For criteria and application information go to

www.escrs.org

EUROTIMES | NOVEMBER 2018

9

10

ADVERTISING FEATURE

Streamlining efficiency in your operating room and surgical practice How single-use devices, customised packs and preloaded IOLs could save time and money.1 Howard Larkin reports

W

ith ageing populations exploding demand for cataract surgery and straining healthcare budgets, the need for increasing efficiency in cataract surgery grows more urgent every day.

At the ESONT Annual Meeting 2018 Alcon sponsored an educational session moderated by ESONT board member Margarita Acebal on how single-use devices, customised surgery packs and preloaded IOLs could significantly improve operating room efficiency and even save money – all while supporting optimal patient outcomes and experience.1,2,3,4,12

Advantages of single use2,3,4

Milenko Stojković MD, PhD, Head of Clinic for Eye Disease of the Clinical Centre of Serbia and Professor of Ophthalmology at the University of Belgrade Faculty of Medicine, knows first-hand the challenges of reusing medical devices designed for single use. He recently treated three patients for toxic anterior segment syndrome (TASS) traced to remnants of ethylene oxide used to sterilise phaco fluidics tubing designed for single use.

Prof Stojković believes the tubing was not left long enough to allow remaining ethylene oxide to evaporate. But manufacturers, understandably, do not make recommendations for sterilising single-use items, leaving providers with the burden of developing procedures on their own, mandatorily based on inadequate degree of evidence. “It’s just a wild guess you need to leave [the tubing to dry] for three days. It may be five, it may be four or seven, so it’s really dangerous to do this,” he said.

Reuse of single-use products and use of various cleaning agents were shown to be significant TASS contributing factors in a large international study. Other reuserelated TASS causes include endotoxins

Medical devices marked by the single-use symbol (left) are not intended to be reprocessed; Custom-Pak® Surgical Procedure Packs combine all products necessary for each surgical procedure

from ultrasonic baths and residual lidocaine, viscoelastics and benzalkonium chloride from topical anaesthetics and antibiotics from previous surgeries.5 “While TASS is one of the most feared cataract surgery complications, it is far from the only reuse-related problem,” Prof Stojković noted. He has treated endophthalmitis cases, including several related to lint from reused compresses that have infected surgical wounds.

Inadequate cleaning of phaco irrigation/aspiration instruments may also risk endophthalmitis.6 “Surgical difficulties due to damage is another risk of instrument reuse,” Prof Stojković noted. He cited two studies suggesting phaco tips should be used only once.

A recent study found reuse increased torsional phaco time and energy in hard cataracts. Another found deteriorated cutting edges and deposition of biological material on reused tips.7,8 “Steam and vapour sterilisation also can damage and dull knives, scissors and forceps, often rendering them incapable of performing precise surgical tasks, such as constructing self-sealing incisions,” Prof Stojković added.

“Still, budget and supply shortages push many centres to reuse singleuse devices,” Prof Stojković said. But

considering the financial and human cost of resulting complications, any potential savings could be illusory.

“There is a good reason to use these devices only once,” he concluded.

Customised surgical packs

Customised surgical procedure packs can help to improve many aspects of cataract surgery, including increasing efficiency in the operating room (OR), easing compliance with regulations and reducing costs related to packaging waste.1 Including all essential items for surgery in a single package may also lower total costs by reducing storage space, as well as staff time spent on materials handling, sterilisation and OR setup.

“The advantages offered by prepackaged surgical kits for cataract surgery are well known in my OR practice,” said Cristina Vatovec, scrub nurse at the Eye Clinic, University of Trieste, Italy. Using Alcon Custom-Pak® increases efficiency at virtually every step.

Surgical kits comply with all European Union laws, regulations and Eucomed guidance,4 including listing indications and providing references stickers for tracing by patients and hospitals. “This significantly reduces staff effort for tracking multiple individually packaged devices, and because items are used only

ADVERTISING FEATURE once, it reduces time spent re-labelling reused devices,” Ms Vatovec said.

Customised packs reduce staff time – and the risk of staff errors – for handpicking several items before surgery.

“This helps prevent waste and delays, and may lead to safe and efficient intraoperative management of the procedure,” Ms Vatovec noted. Removing items from a single sterile container instead of opening 20 or more individual packages reduces setup time and OR turnover time as well.

“Including all items for surgery in a single pack helps train newly hired nurses in learning skills rather than gathering items and opening packages,” Ms Vatovec added. Customised packs cut down on inventory ordering, checkin, verification and management time.

For a practice doing 3,000 surgeries annually, they can eliminate 50,000 or so packages, reducing waste and waste management costs significantly.9 Ms Vatovec has found manufacturers very co-operative when it comes to customising surgical kits. “The key is to ensure that the kits include everything that’s needed and nothing that isn’t,” she said. Continuous review by surgeons and nurses is required to ensure kit contents keep up with new surgical techniques and emerging practice requirements.

The packs are personalised to meet the specific needs of the surgical team, and components are packed in the order the customer specifies, called sequencing, creating efficiency in the operating room.

For maximum efficiency, pack needs should be planned in advance and co-ordinated with the manufacturer to ensure timely delivery. In case of dropped items, extra supplies of individual items should be kept on hand.

“Uniform packs have made a significant contribution to our surgery centre’s efficiency,” Ms Vatovec said.

Preloaded IOLs

Loading intraocular lenses (IOLs) into injectors is one of the most complex and challenging surgical preparation steps. “Using preloaded IOLs reduces stress on staff, reduces risk of lens haptic positioning problems, reduces risk of scratches on the IOL optic and may reduce overall surgery time,” said Cristina Garcia Gutiérrez, scrub nurse at Hospital Miguel Servet, Zaragoza, Spain.

Manually loading IOLs into injectors “is difficult and it should be a walk in the park”, Ms Garcia Gutiérrez said.

“Switching to the preloaded Alcon UltraSert® IOL system has eased the problem in my centre, reducing preparation time, lens delivery and unfolding time and total procedure time, as well as staff costs,” she added.

Ms Garcia Gutiérrez cited a study

The UltraSert® Pre-loaded Delivery System is designed to safeguard cataract surgical outcomes by protecting every detail of IOL delivery.

of 220 procedures comparing three preloaded and one manual delivery system. The preloaded systems reduced effort in surgery, and the UltraSert® preloaded delivery system also resulted in less wound stretch and less induced corneal astigmatism one day after surgery than the others.10 Similarly, an ex vivo study of porcine eyes showed some variation in ease of use among six preloaded insertion systems, with UltraSert® scoring easy on all parameters.11 “Preloaded IOLs are much more likely to deliver the lens correctly into the capsule,” Ms Garcia Gutiérrez noted. An internal Alcon study found preloaded IOLs were inserted with the leading haptic correctly positioned 98% of the time.12 “In my experience for the last three years we have been using the Alcon preloaded IOLs, it has been even better than that,” she reported.

Preloaded lenses eliminate one of the most difficult training tasks, Ms Garcia Gutiérrez said. “It’s hard to teach a new colleague to fold the lens without touching it.” Eliminating the task could increase efficiency by avoiding the need to bring in an experienced nurse to load the injector, or delaying surgery to have the surgeon do it.

Using IOL injectors may also reduce the risk of endophthalmitis compared with forceps insertion.13 “Considering that preloaded IOLs save time, training and the risk of improperly inserted or damaged IOLs, using them is not a difficult choice,” Ms Garcia Gutiérrez said. “Preloading reduces stress and leaves more time for the patient and that is what it is all about.”

The bottom line

The ophthalmologic market has been facing an increasing amount of business funded through public tenders as healthcare budgets come under heavier pressure to control costs: as such, it’s more than important to look into products and solutions that can increase efficiency and ensure better workflow, ultimately driving cost reduction.

Assessing the impact of single-use devices and customised surgical packs

on every aspect of patient outcomes and clinic management is essential to understand the broad scope of efficiency, effectiveness and cost savings benefits they may provide.1,2,3,4,12 All opinions are based on healthcare professionals’ own clinical experience 1 Gonzalez T et al. Operating Room Time Savings with the Use of Splint Packs: A Randomized Controlled Trial. Arch Bone Jt Surg 2016; 4(1): 10-15 2 MHRA Regulating Medicines and Medical Devices; Single-use medical devices implications and consequences of reuse, Dec 2013 3 Report on the issue of the reprocessing of medical devices in the European Union, in accordance with Article 12a of Directive 93/42/ EEC; Brussels, 27.8.2010 4 EUCOMED White Paper on the reuse of single use devices; Dec 15, 2009 5 Cutler Peck CM et al. Toxic anterior segment syndrome: common causes. J Cataract Refract Surg 2010; 36(7): 1073-80 6 Leslie T et al. Residual debris as a potential cause of post-phacoemulsification endophthalmitis.

Eye (Lond). 2003 May;17(4):506-12 7 Demircan et al. The Impact of Reused Phaco Tip on Outcomes of Phacoemulsification Surgery. Current Eye Research 2016; 41(5): 636642.

8 Cecchini P et al. Chemical and physical analysis of phaco handpiece tip surfaces before and after cataract surgery. J Cataract Refract Surg 2017; 43(8):1107-114 9 Luthe R. The Leader of the Pack: Prepackaged surgical kits make for a smoother and more profitable surgery. Ophthalmology Management March 1, 2009 10 Mendicute J et al. Comparison of incision size and intraocular lens performance after implantation with three preloaded systems and one manual delivery system. Clin Ophthalmol 2018; 12:1495-1503) 11 Nanavaty MA et al. Evaluation of reloaded intraocular injection systems: Ex vivo study. J Cataract Refract Surg 2017; 43:558-563 12 Alcon Data on File. TDOC-0053876 (July 11, 2017) 13 Weston K et al. An 8-year retrospective study of cataract surgery and postoperative endophthalmitis: injectable intraocular lenses may reduce the incidence ofpostoperative endophthalmitis. Br J Ophthalmol 2015;99(10): 1377-1380)

SGU-18-MK-ADV-001

11

12

CATARACT & REFRACTIVE

Intracameral antibiotics prophylaxis Pros and cons of intracameral antibiotics highlighted in debate.

Dermot McGrath reports

T

here is still no broad consensus on the safety, efficacy and necessity of intracameral antibiotics (ICA) to prevent postoperative endophthalmitis, delegates attending the World Ophthalmology Congress in Barcelona were told.

In a special session devoted to controversies in cataract surgery, Steve Arshinoff MD, FRCSC, presented the case for routine prophylaxis with ICA while Andrzej Grzybowski MD, PhD, argued against.

Dr Arshinoff said that he routinely uses intracameral moxifloxacin in all his unilateral and bilateral cataract surgeries, and that he based this decision on the weight of published evidence in the scientific literature.

“While it became popular to use intracameral antibiotics after the ESCRS study in 2006, it was actually studies by Gimbel and Gills in the early 1990s that gave us the first conclusive evidence that this approach works. There have been many more studies since, totalling about 6 to 7 million eyes, all of which show about an 80% reduction of infection irrespective of the starting point in endophthalmitis rates,” he said.

Dr Arshinoff’s own study of the use of ICA in immediate sequential bilateral cataract surgery in 125,000 eyes echoed the results in the scientific literature. “Without antibiotics the infection rate was about one in every 2,000 cases whereas when intracameral cefuroxime was used the rate fell to one in every 9,175 cases. The infection rates with intracameral vancomycin or moxifloxacin were still lower, making the overall rate using intracameral antibiotics one in 16,800 cases,” he said.

Dr Arshinoff noted that a review by Per Montan MD found 24 studies encompassing about 6 million surgeries showing about an 80% reduction of endophthalmitis infection rates with ICA. “There were two studies of about 90,000 surgeries that showed no benefit, but I reviewed those two papers and both used too low a dose of intracameral antibiotic for it to be effective. If you don’t put enough in the eye, you don’t get much effect,” he said.

In terms of the best intracameral antibiotic to use, Dr Arshinoff said that studies by Libre et al. in 2017 and Bowen et al. in 2018 indicate that moxifloxacin appears to be the safest and most effective for endophthalmitis prophylaxis, but appropriate dosing is key.

EUROTIMES | NOVEMBER 2018

In terms of the published data, Dr Grzybowski said that the overall picture is not as coherent as many would like to believe.

“The only controlled randomised prospective study was the ESCRS trial. All of the others were retrospective studies, which show a huge variation of 1.3 up to 28 times the effect from intracameral antibiotics on endophthalmitis rates, so it is not consistent.

It should also be noted that none of the studies started with a very low endophthalmitis rate of 0.02-0.04%, which is quite common LACK OF EVIDENCE today in many developed countries, so Presenting the case against there is no compelling evidence that routine ICA use, Dr intracameral antibiotics is effective Grzybowski said that under such conditions,” he said. many surgeons have Even the landmark ESCRS still not adopted the study should not be read as a practice because of a straightforward endorsement lack of clear evidence of ICA used as prophylaxis, from randomised, trials said Dr Grzybowski. as well as potential risks “The ESCRS study showed from compounding or about a five-fold reduction in mixing antibiotic solutions Steve Arshinoff the endophthalmitis rates with when no approved formulations intracameral antibiotics. However, are commercially available in some what is often overlooked is that the same countries. For many years it was believed study showed that there was a six times that Vancomycin IC is safe – today it is higher rate of endophthalmitis with a clear known that it might lead in some cases to corneal incision versus scleral tunnel incision. retinal vasculitis (HORV) and a very poor Another interesting finding from the study outcome. Cefuroxime, propagated by ESCRS was that silicone IOLs were related to a 3.13 as the best IC antibiotic in last 10 years, times higher endophthalmitis rate. Yet we is known not to cover certain important seem to have focused only on the use of bacteria, i.e. Enterococcus sp., and because of intracameral antibiotics and forgotten about that in Sweden the practice of supplementing these other elements,” he said. it with ampicillin in some cases was started.

Dr Grzybowski cited two major studies Moxifloxacin is very commonly used in that showed no effect of ICA for routine general medicine and in ophthalmology, prophylaxis, and said that many other what might soon lead to increase in bacterial studies have shown the effectiveness resistance and loss of its activity to many of topical antibiotics in attaining a low microorganisms. infection rate.

“The reality is that there is no perfect “We also conducted a recent study intracameral antibiotic available at the comparing endophthalmitis rates and moment in terms of safety and antibacterial practice patterns in different parts of the activity and we still have much to learn about world and we found that the infection rate their side-effects and toxicity. It is possible in countries not using ICA is very similar to to have as low an endophthalmitis rate as those that do use them,” he said. “I believe 0.02% with no intracameral antibiotics. It is that the appropriate use of povidone-iodine also important to note that the studies in the and uncomplicated surgery with waterproof scientific literature show a decreased risk of incision are much more important than IC endophthalmitis infection mostly in cases antibiotics in standard cases.” with as high a pre-existing endophthalmitis Steve Arshinoff: ifix2is@gmail.com rate 0.2%, as seen in the as ESCRS Study, so it is probably reasonable to use intracameral Andrzej Grzybowski: antibiotics in high-risk cases,” he said. ae.grzybowski@gmail.com “Vancomycin and cefuroxime are less effective than moxifloxacin due to injected dose over minimal inhibitory concentrations (MIC) ratios not being as good, and also time dependence, which means that they need to be in the anterior chamber for much longer.

However, no matter what drug we use the infection rate will never go to zero and we can always do better and we find new ways to make things safer,” he said.

CATARACT & REFRACTIVE

CONGRATULATIONS! THOMAS KOHNEN European editor of JCRS

JCRS HIGHLIGHTS VOL: 44 ISSUE: 10 MONTH: OCTOBER 2018

SMILE, FS-LASIK AND THE EOZ How do small-incision lenticule extraction (SMILE®) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) compare in terms of postoperative effective optical zone (EOZ)?

A retrospective study compared the effects of both surgeries on the EOZ, that is, the area of corneal surface with a high level of optical quality and the portion of the ablation that achieves full correction. The study of 76 eyes of 76 patients found that both SMILE and FS-LASIK resulted in EOZ reduction during correction of myopia. However, SMILE resulted in less reduction than FS-LASIK and was associated with corneal asphericity changes and epithelial thickening. This was the first study to look at this question. The researchers call for further studies to look at the effect of EOZ on visual quality. J Hou et al., JCRS, “Comparison of effective optical zone after small-incision lenticule extraction and femtosecond laserassisted laser in situ keratomileusis for myopia”, Vol 44, #10, 1179-1185.

BEST IRIS-CLAW IOL IMPLANTATION Iris-claw IOL implantation carries lower risk for endothelial damage and glaucoma than angle-supported lens implantation, but is considered a more difficult surgery. A single surgeon evaluated the outcomes of 76 iris-claw IOL implantations, comparing different surgical techniques. The results were analysed by the incision type (corneal versus scleral tunnel) and lens position (peripapillary versus retropupillary). All patients had significant improvements in distance visual acuity.

Mean uncorrected distance acuity was significantly better in the scleral tunnel incision group, with significantly less surgically induced astigmatism seen in that group. Although endothelial cell loss was lower in the retropupillary position, the difference was not significant. A Hernández Martínez et al. JCRS, “Iris-claw intraocular lens implantation: Efficiency and safety according to technique”, Vol 44, #10, 1186-1191.

RESIDUAL ASTIGMATISM AND UDVA Residual astigmatism after multifocal IOL implantation has been shown to reduce the effectiveness of that IOL type. Astigmatism has also been shown to worsen visual acuity. However, residual astigmatism following implantation of both monofocal and multifocal IOLs has an impact on uncorrected distance visual acuity (UDVA), a large database analysis suggests. A review of 1,919 records collected at a website designed to assist with postoperative analysis of residual astigmatism after toric IOL implantation indicated that residual refractive astigmatism had a similar effect on worsening UDVA in eyes with monofocal or multifocal toric IOLs, regardless of whether the latter were diffractive or extended depth-of-focus IOLs. The axis of the residual refractive astigmatism (grouped into WTR, ATR and oblique astigmatism) did not make a clinical or statistical difference in visual acuity in patients with a monofocal toric IOL. JP Berdahl et al., JCRS, “Effect of astigmatism on visual acuity after multifocal versus monofocal intraocular lens implantation”, Vol 44, #10, 1192-1197.

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.

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

EUROTIMES | NOVEMBER 2018

13

14

ADVERTISING FEATURE

Strategies to reduce posterior capsule rupture (PCR) risk: consensus from a panel of UK surgeons In July 2018, a group of experienced UK cataract surgeons with an active interest in training met to discuss strategies to prevent posterior capsule rupture (PCR), based on their own experience and evidence from clinical practice. This article highlights the key themes that emerged from that meeting and is intended to provide food for thought for surgeons and trainees as they look at their own practices.

PCR: HOW MUCH FURTHER CAN WE GO? PCR is one of the most frequently cited complications that occurs during cataract surgery, and is widely considered to be a quality indicator for surgery.1 PCR increases the risk of vision loss after surgery along with the likelihood of other postoperative complications such as retinal detachment and endophthalmitis.2,3 A recent retrospective analysis of the cost of managing PCR suggested a significant increase in cost compared with uneventful cataract surgery.4 This finding has been further supported by research that

“A number of validated tools now exist to assist surgeons to stratify the risk of intra-operative complications. It’s crucial that evaluating surgical complexity is integrated into cataract pathways to ensure that the operating surgeon’s level of experience matches the individual patient’s needs.” David Lockington quantified the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery.5 Cataract surgery is the most commonly performed surgical procedure in the UK.1 The number of surgeries is increasing year on year and the demand for cataract services is predicted to rise by 25% over the next 10 years and by 50% over the next 20 years.6

Stage when PCR occurred Group 1: metal-tipped I/A handpiece

Group 2: CapsuleGuardTM handpiece

0%

12%

21% 24%

48%

7%

57%

14% 8%

8%

Irrigation aspiration IOL insertion

Capsulorhexis

Unknown

Phacoemulsification

Figure 1: Maubon & Ursell concluded that the surgeons using CapsuleGuard™ (Group 2) had no I/A-related PCR complications vs 12% in the group using metal-tipped I/A handpieces (Group 1). Reproduced from Maubon & Ursell, 2018.

As the demand on cataract services rises, greater visibility of PCR rates has also been afforded by the creation of the National Ophthalmology Database (NOD) – enabling the audit of procedures performed in England and Wales. This enhanced visibility around surgical outcomes has reinforced the focus for surgeons and hospital trusts to look at strategies to make improvements in patient outcomes. The latest NOD report, issued in August 2018, revealed that rates of PCR in England and Wales are declining and are now estimated at an average of 1.4%, versus 2.0% in 2010, equating to around 2,500 fewer cases annually.1 However, the audit report suggests there is still variation across hospitals and highlights that there is further room for improvement to bring PCR rates down even more.

STRATEGIES TO REDUCE THE RISK OF PCR

Three main areas were identified by the panel of surgeons as being crucially important in reducing the risk of PCR: 1. Pre-surgical PCR risk stratification – identifying patients at greater risk of complications, proactively managing their risk and assigning those at greater risk to more experienced surgeons; 2. Appropriate use of technology that minimises the risk of complications; 3. Close supervision, training and development of trainee surgeons to

ADVERTISING FEATURE

B

C

Images courtesy of Colin Vize.

A

15

improve competence and confidence in dealing with more challenging cases.

“The silicone-tipped I/A handpiece is more “forgiving” than conventional handpieces, a feature which is of particular benefit for trainee surgeons.

I see it as a valuable tool for even the most experienced surgeons – we routinely use it across all our cases.”

Paul Ursell 1. Pre-surgical stratification of patients based on risk of PCR Risk stratification of surgical cases with regard to PCR is important to enable appropriate use of resources and skills, and ultimately to ensure the best possible outcome for the patient.7 A number of methods for risk assessment have been evaluated. Two such models, both recently published, were discussed. The first assessed the impact of stratifying patients according to a preoperative risk assessment on the rate of vitreous loss. Higher-risk patients were allocated to more senior surgeons. The study showed that the relative risk of vitreous loss dropped by >20% after the introduction of a risk scoring form (p=0.045).8 A further study, validated in over 8000 cases, also provides evidence for the value of risk assessment in mitigating against potential complications.9 In this protocol, patients were given a complexity score and assigned to surgeons based on the number of surgical cases performed by the surgeon as opposed to their level of training. In both cases the result was that surgical lists were compiled based on the risk stratification, with more complex cases reserved for the most experienced surgeons.

2. Technology to reduce the risk of PCR Up to 25% of PCRs occur during I/A.10 The use of silicone-tipped I/A handpieces has been reported to reduce the number of PCRs that occur during I/A. A retrospective analysis from one hospital saw PCR rates amongst trainees reduced with use of a siliconetipped I/A handpiece (CapsuleGuard™).11 However, this was not statistically significant when adjusted for differences between the two groups. The study did, however, provide conclusive evidence that PCR occurring during I/A was completely eliminated when CapsuleGuard™ was used – the group using CapsuleGuard™ had no I/A-related PCR complications vs 12% in the group using metal-tipped I/A handpieces (Figure 1).

These results mirrored the surgeons’ own experience in their practice.

Scanning electron microscopy reveals that the surface of the lumen within metal-tipped handpieces have a rough surface while the CapsuleGuard™ is more uniform. It is believed by the group that this means the posterior capsule is less likely to rupture if engaged during I/A (Figure 2). Figure 3 shows the CapsuleGuard™ being used in surgery.

Ideally, conclusive evidence for the use of silicone-tipped I/A handpieces would be obtained through a randomised, controlled trial. However, this instrument is routinely used by many surgeons, therefore gathering prospective data on its use vs metaltipped I/A handpieces is challenging and considered by some not to be in the interest of patients as the comparator group would be exposed to avoidable risk.

“In our busy unit, procedure volumes have increased, yet PCR rates have declined and continue to do so.

They are currently well below the national average. I believe that this improvement is in part due to the improved level of simulation training offered to trainees which better prepares them for surgery, and the introduction of silicone-tipped I/A. In parallel with rates of PCR declining, the expenditure on anterior vitrectomy has also gone down, as well as the on-costs of dealing with these complications.”

Colin Vize 3. Supervision and development of trainees Finally, and crucially, the training and development of the next generation of cataract surgeons is imperative if PCR rates are to continue to decline. Close supervision and training to improve competency in preventing and managing PCR is key, but this must be balanced with the need to safely expose trainees to more risky cases in order for them to learn and build confidence.

WHAT NEXT? The increased visibility of complication rates through the National Ophthalmology Database audit has shone a spotlight on PCR rates as a marker of quality of cataract

Image courtesy of Zac Koshy.

Figure 2: Scanning electron microscope images showing A) Metal-tipped reusable B) Metal-tipped single-use C) CapsuleGuard™ silicone-tipped I/A handpieces. The surface of the lumen within the metaltipped handpieces have a rough, sandpaper-like surface, whilst the lumen in the CapsuleGuard™ is more uniform meaning that when the posterior capsule is engaged it is less likely to rupture.

Figure 3: CapsuleGuard™ can be effectively used to polish cortical filaments off the posterior capsule with less fear of rupture.

surgery. The transparency around individual surgeons’ and hospital outcomes has reinvigorated research into strategies to improve PCR rates. This appears to be working – PCR rates are in decline.

However, more still needs to be done to further lower the incidence of PCR and to reduce variation in outcomes. As a surgical community we must continue to challenge ourselves to improve our skills and knowledge and push for access to technology which can support us to achieve better outcomes for our patients.

Contributors: Zachariah Koshy, University Hospital Ayr David Lockington, Gartnavel General Hospital Tom Poole, Frimley Park Hospital Paul Ursell, Epsom and St Helier University Hospitals NHS Trust Colin Vize, Hull & East Yorkshire Eye Hospital This article was commissioned by Bausch + Lomb.

REFERENCES 1. National Ophthalmology Database Audit, 2018 2. Jacobs PM. Eye (Lond). 2008;22:1286-9 3. Blomquist PH, Rugwani RM. J Cataract Refract Surg. 2002; 28:847-52 4. A Comparison of Costs for PCR and Non-PCR Patients: Findings from a cohort of cataract surgery patients at Frimley Park Hospital Unpublished report sponsored by Bausch & Lomb UK Limited 5. Jamison A, Benjamin L, Lockington D. Eye (Lond). 2018 6. Royal College of Ophthalmologists. The Way Forward. 2017 7. Narendran N et al. Eye. 2009; 23: 31–37 8. Davidson A, Benjamin L. Poster presented at ASCRS. 2018 9. Nderitu P, Ursell P. JCRS. 2018; 44: 709-717 10. Ti S-E et al. Am J Ophthalmol. 2014;157:180–185 11. Maubon LG, Ursell PG. Exp Rev Ophth. 2018.

16

CORNEA

Corneal sensation Researchers are exploring the neural basis of ocular sensations.

Dermot McGrath reports

M

ajor advances have been made in recent blinking, wound healing and modulation of tear production and years into understanding the characteristics secretion. and neural basis of corneal and conjunctival Corneal nerves are functionally heterogeneous, noted Dr sensations such as dryness, discomfort and Belmonte: about 20% respond exclusively to noxious mechanical pain, Carlos Belmonte MD, PhD, said in forces (mechano-nociceptors); 70% are additionally excited by the keynote EuCornea Medal Lecture at the extreme temperatures, exogenous irritant chemicals and endogenous 9th EuCornea Congress in Vienna. inflammatory mediators (polymodal nociceptors); the remaining “Ophthalmologists have traditionally dedicated very limited 10% are cold-sensitive and increase their discharge with moderate attention to the study of the non-visual sensory cooling of the cornea (cold receptors). Each of capacities of the eye. This is because pain, the these types of sensory fibres contribute distinctly most relevant symptom of disease in most to the discomfort and pain sensations evoked by medical specialties, rarely accompanies the the tissue damage accompanying ocular surface main ocular pathologies such as cataract, disorders, he said. This damage always produces retinal degeneration, refractive defects and local inflammation, and a certain level of lesion glaucoma,” said Dr Belmonte, Professor of the affected nerves, which vary depending on Emeritus at the Instituto de Neurociencias, the type of eye disorder.

Universidad Miguel Hernandez-CSIC Spain.

For instance, lesion of ocular surface nerves This initial lack of interest has reversed is consubstantial to some surgical interventions rapidly in recent years with the development on the eye, whereas inflammation is limited. of invasive, sophisticated surgical procedures Nerve injury also occurs, albeit in lesser degree to treat patients suffering ocular pathologies, in a number of contact lens users, in elderly and the increasing use of contact lenses and the in dry eye patients. On the other hand, local Carlos Belmonte high incidence of dry eye among the growing inflammation of the eye surface tissues is the most population of elderly people, noted Dr Belmonte. relevant sign in allergic, immune and infectious Using cellular, electrophysiological and behavioural techniques, eye diseases, while noxious effects on nerves are less prominent.

Dr Belmonte’s research has shown how corneal nerves are Accordingly, intensity, quality and duration of discomfort and pain responsible for sensations of touch, pain, and temperature and also sensations in these different disorders vary markedly. play an important role in the regulation of spontaneous and reflex “Inflammation and nerve injury have important short- and longterm consequences on the architecture, molecular organisation and excitability of sensory neurons,” Dr Belmonte said. Under pathological conditions such as allergic keratoconjunctivitis, surgical injury or dryness of the ocular surface, the activity of ocular surface neurons changes markedly, initially as the result of short-term changes in ion channel expression secondary to local release of inflammatory agents and nerve injury and later by long-lasting modifications in gene expression, explained Dr Belmonte. This leads to the development of spontaneous activity and of abnormal responsiveness to natural stimuli, which cause spontaneous pain and dysesthesias.

Inflammation and nerve injury have important shortand long-term consequences on the architecture,molecular organisation and excitability of sensory neurons

Carlos Belmonte MD, PHD

Carlos Belmonte: carlos.belmonte@umh.es

Peer Review Open Access Journal For more information go to www.eucornea.org EUROTIMES | NOVEMBER 2018

CORNEA

Cross-linking may help slow myopia Research is ongoing in an area with limited treatments available.

Leigh Spielberg MD reports

Outcomes Begin Here.

C

ross-linking, better known as a treatment for corneal ectasia, may have a role to play in slowing the development of pathological myopia, according to Mor Dickman, Maastricht University Medical Centre, The Netherlands.

“The sclera is in fact a dynamic tissue capable of alteration, which unfortunately allows myopic progression to occur,” said Dr Dickman at a session of the 36th Congress of the ESCRS in Vienna in September 2018.

His presentation, “Scleral Cross-Linking for Myopia”, was part of an ESCRS Clinical Research Symposium on myopia.

Dr Dickman’s research concerns the use of scleral crosslinking to slow or halt the ocular elongation that can lead to pathological myopia.

“The pathophysiology of myopic progression is locally driven. Hyperopic defocus, in which the image is projected ‘behind’ the retina, results in a blurred image on the retina.

This optical signal elicits a chemical signal, which then results in a mechanical response in the sclera, namely ocular elongation.”

So, what are the changes that we see in the scleral microstructure of highly myopic eyes as compared to controls? Increased extracellular matrix modelling, decreased intramolecular cross-links, biomechanical weakening as well as myofibroblast differentiation are involved. These all seem to play a significant role in axial length progression, he explained.

However, this biomechanical weakening, and thus elongation, might be counteracted by collagen cross-linking, a technique that is currently used to treat corneal abnormalities such as keratoconus and ectasia.

MECHANICAL DEFICIENCY “Cross-linking normally plays an important role in stabilising the hierarchical structure of the sclera, both during development and ageing. The scleral cross-linking that is seen with age may explain the arrest of myopic progression in later life. The goal of cross-linking the collagen would be to address this mechanical deficiency prior to the development of chorioretinal pathology,” said Dr Dickman.

Dr Dickman’s team has tested the technique in rabbit models.

Both riboflavin and genipin have been shown to be effective.

“We used atomic force microscopy and strip extensiometry to demonstrate that scleral cross-linking increases the strength of both internal and external sclera in rabbits. This led to effective arrest of axial elongation,” he reported.

Dr Dickman is currently working on improving the safety of the technique, particularly with regards to potential sideeffects such as retinal toxicity.

The disadvantage of this approach, however, is that it is an invasive treatment for disease prevention that might interfere with normal development. Further, the sclera itself his limited accessibility and visualisation, making treatment less straightforward than cross-linking the cornea.

Nevertheless, there are limited effective treatment alternatives and this modality is less invasive than retinal surgery techniques. Research is ongoing.

True Surgical Solutions PREMIER EDGE® SCALPELS Safety and standard disposable

6.25mm and 7.0mm diameter

OASIS® IRIS EXPANDER

CHANG HYDRODISSECTION CANNULA Sterile 10 per box

Ask us where to buy?

Email: International@oasismedical.com Premier Edge® and Oasis® names & logos are registered trademarks of OASIS® Medical, Inc. 514 S Vermont Ave, Glendora, CA 91741. LIT-SRG-IntAd1-Nov Rev.0 10.2018

EUROTIMES | NOVEMBER 2018

17

RETINA

Treatment for PDR More data needed for anti VEGF treatments in high-risk proliferative diabetic retinopathy patients. Dermot McGrath reports

W

hile the use of antiVEGF injections offers exciting possibilities for the treatment of proliferative diabetic retinopathy (PDR), it is still too early to determine the extent to which they will change current clinical practice, according to Alistair Laidlaw, MD FRCS FRCOphth.

“The anti-VEGF drugs are very promising but the evidence so far is in low-risk groups.

We really don’t know how effective these treatments are in high-risk categories. The drugs are very expensive compared to laser treatments and the patients need intensive follow-up. We also don’t know about long-term effect and whether anti-VEGF succeeds in switching off the disease forever or just delaying its progression,” he told delegates attending the 8th EURETINA Winter Meeting in Budapest.

In an overview of the pathophysiology and treatment options for PDR, Dr Laidlaw, Consultant Ophthalmic Surgeon at St Thomas’ Hospital London, United Kingdom, said that the role of the vitreous in the disease process should not be underestimated.

“One of the take-home messages today is that PDR is actually a misnomer and should more properly be called proliferative diabetic vitreo-retinopathy (PDVR). As part of the disease process, the vitreous itself is affected with alterations in vitreous collagen, fibronectin-induced vitreoretinal adhesion and vitreous liquefaction. The vitreous shrinks with vitreoschisis and patchy retinal adhesion, which then pulls tangentially on the retina. It is a biochemical process leading to a mechanical effect. It is the vitreous traction on the retina or retinal new vessels that causes the vision loss,” he said.

Non-PDR is clinically measured by examination of the retina, applying the 4-2-1 rule, said Dr Laidlaw: 4 quadrants with blot haemorrhages, 2 quadrants with venous beading and 1 quadrant with intraretinal microvascular abnormality (IRMA). Severe disease is the presence of one out of the three criteria, very severe two out of three, and aggravated very severe equates to all three of these criteria being present. “If a patient has severe NPDR, then they have a 17% chance of developing high-risk characteristics of PDR within the next year and are at risk of vision loss from PDR,” he said.

If new vessels are present they can be divided into high-risk or low-risk PDR. EUROTIMES | NOVEMBER 2018

“One of the take-home messages today is that PDR is actually a misnomer and should more properly be called proliferative diabetic vitreo-retinopathy (PDVR) Alistair Laidlaw MD, FRCS, FRCOphth

High-risk characteristics are new vessels at the disc of more than a third of disc area, new vessels less than this size with a pre-retinal or vitreous haemorrhage or new vessels elsewhere with a pre-retinal or vitreous haemorrhage. Low-risk PDR involves new vessels that do not meet those criteria.

Panretinal laser photocoagulation (PRP) remains the standard treatment for PDR, noted Dr Laidlaw, highlighting the results of the landmark Diabetic Retinopathy Study, which found that patients who received PRP had significantly better results than those who received no treatment. PRP reduced the risk of severe visual loss by more than 50%. Untreated eyes had a vision loss rate of 16.3%, whereas treated eyes only had a vision loss rate of 6.4% over two years.

“High-risk characteristics used to be the threshold for application of panretinal laser,” said Dr Laidlaw. “The reason why there has been mission creep in terms of performing laser earlier is that the 48-month results were not just clearly in favour of treatment for the high-risk patients but also for those with lowrisk PDR. The risk of severe vision loss was 9% for PRP-treated eyes compared to about 17% for observation. That is a big difference, particularly when one considers the difficulty many of us have with getting these patients to come back regularly,” he said. It is for this reason that many doctors have been applying PRP in patients with low-risk characteristics or severe non-PDR. Looking at the clinical trial data for anti-VEGF treatments, Dr Laidlaw said that the evidence from both the DRCR.net Protocol S and the UK-based CLARITY trials herald a potentially promising new era in pharmacological treatments for PDR. It should be noted, however, that around half of the patients in each study did not have highrisk PDR. This means that the short-term risk of sight loss in each study was not that high. It also means that there are few data on the effect of anti-VEGF injections in patients with very extensive new vessels: such patients

may be at risk of developing tractional complications from anti-VEGF therapy.

Protocol S, which compared the efficacy of prompt PRP to 0.5mg ranibizumab with deferred PRP, demonstrated that the visual acuity outcomes at two years were at least equivalent in both groups, with the mean change in visual acuity in the ranibizumab group demonstrating non-inferiority, and area under the curve analysis demonstrating superiority of the ranibizumab group.

Decreased incidence of vitrectomy was also seen in this group. Protocol S included patients with diabetic macular oedema.

In the CLARITY trial, patients with PDR who were treated with intravitreal aflibercept had an improved outcome at one year compared with those treated with PRP. A significant proportion of eyes showed total regression of retinal new vessels in the aflibercept group, said Dr Laidlaw.

These first trials are very encouraging; however, anti-VEGF injecitons are expensive and not without risk; there may also be a greater burden of follow-up visits for patients undergoing injection therapy for PDR and there are only short-term results so far.

Alistair Laidlaw: alistair.laidlaw@gstt.nhs.uk

Courtesy of Alistair Laidlaw MD, FRCS, FRCOphth

18

Persistent and stable new vessels following PRP. The retinopathy is not biochemically active. More laser will not cause complete regression

RETINA

Screening for DR must be extended Detection and treatment of diabetic retinopathy has improved but battle not yet over. Dermot McGrath reports

T

he introduction of systematic screening for sight-threatening diabetic retinopathy has been a major driver of improved detection and early treatment in Europe and worldwide over the past decade. The battle is far from over, however, with the global prevalence of diabetes mellitus expected to double by 2030, according to Simon Harding FRCS, FRCOphth.

“Unfortunately, there are still lots of people losing vision from diabetes and this is mainly due to poor engagement, late presentation, progression to advanced disease and to fragmented health services. The good news is that there are a lot of global initiatives being led by many organisations to try to address this,” he told delegates attending the 8th EURETINA Winter Meeting in Budapest.

Professor Harding, Chair of Clinical Ophthalmology at the University of Liverpool, United Kingdom, said that the system for screening for DR in the United Kingdom has developed considerably since the initial screening programme was first introduced in Liverpool in 1991.

“We started in Liverpool in 1991 before screening for DR had really been thought about. We are now covering a city population of about 450,000 in community centres using technician-based photography and grading. If people screen positive, they are then referred along to an ophthalmologist for determination of the presence or absence of sight-threatening DR and then for onward referral to the hospital,” he said.

The success of the Liverpool DR screening programme ultimately led to the approach being applied at a national level, said Prof Harding.

QUALITY ASSURANCE “In England we are now screening over 2 million people, equivalent to the entire diabetic population of England. We perform a two-to-three stage human grading with full quality assurance. Through the systematic approach we have made significant progress in the United Kingdom: diabetes has fallen to the fourth commonest cause of visual impairment in the last 10 years in people of the working age population. We like to believe that this is due to our screening programme,” he said.

While much has been achieved, the goal now is to emulate the achievement of Iceland, said Prof Harding, where there have been no cases of vision loss due to diabetes in the last 10 years. The focus has now turned to fine-tuning the screening system in place to make it more cost-effective, said Prof Harding.

“We are spending 80 million pounds a year in England to screen these individuals, and the rates of retinopathy are quite low so we are looking at the viability of extending the screening interval to biannually for people at low risk based on the previous and current retinal image,” he said.

“The team at Liverpool have also developed an variable interval approach adding early recall for people at higher risk and also including the most informative clinical risk factors of HbA1c, blood pressure and lipids.

“To optimise the approach, we have been testing a risk calculation engine to determine personalised risk for each individual patient, with the approach currently being validated in a randomised clinical trial,” said Prof Harding.

EUROTIMES | NOVEMBER 2018

19

20

RETINA

Gene therapy for LHON

D

Researchers encouraged by clinical trial results, but puzzled by outcomes.

Sean Henahan reports

espite some unexpected but very promising results in latestage clinical studies, researchers remain optimistic about the therapeutic potential for a novel gene therapy candidate for the treatment of Leber hereditary optic neuropathy (LHON).

José-Alain Sahel MD presented an update on clinical trials with rAAV2/2-ND4 (GS010, GenSight Biologics), a gene therapy that targets LHON. He presented Phase I/II 18-month results at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting in Honolulu. Speaking immediately before ARVO, Dr Sahel also presented Phase III data from the REVERSE trial at the 5th Annual Retinal Cell and Gene Therapy Innovation Summit.

In June 2018, he presented more extensive data at the World Ophthalmology Congress in Barcelona.

The apparent good news is that patients receiving a single intravitreal injection of GS010 in the worse seeing eye showed clinically meaningful improvement of +11 ETDRS letters at the 48-week mark.

The confounding news is that fellow eyes receiving sham injections did almost as well, showing an improvement of +10 ETDRS letters, not expected given all that is known about the natural history of the disease.

The lack of statistically significant difference between the groups meant that the study did not meet its primary endpoint, defined as a 15-letter difference in visual acuity between active and sham-treated eyes. The study did not include a true control or untreated group.

Nonetheless, the study did meet secondary endpoints, measured as a change in ganglion cell layer macular volume as demonstrated with spectral domain optical coherence tomography (SD-OCT).

These measurements showed a statistically significant difference in retinal ganglion cell macular volume measured from baseline in GS010-treated eyes compared to sham-treated eyes. Eyes receiving the sham injection showed a loss of 0.038 cubic mm of macular ganglion cell volume, while treated eyes preserved their ganglion cell volume. A statistically significant difference was also observed between GS010and sham-treated eyes for the change in thickness of the temporal quadrant of the retinal nerve fibre layer – where José-Alain Sahel MD

These measurements showed a statistically significant difference in retinal ganglion cell macular volume...

EUROTIMES | NOVEMBER 2018

the ever-important papillo-macular bundle lives – showing relative preservation from baseline to week 48. These findings would appear to be the first case of a treatment producing neuroprotection of neurons and central nervous system axons in human genetic disease.

Eyes receiving the experimental agent also showed clinically significant improvement in contrast sensitivity, a meaningful metric of visual function more applicable to real-life conditions, while those receiving sham injections remained stable. Pelli-Robson evaluations indicated that logCS, a measure of contrast sensitivity, almost doubled in the GS010treated eyes compared to sham-treated eyes.

This conglomeration of evidence suggests that GS010 treatment had a direct biologic and physiological impact of GS010 on the anatomy relevant to LHON, according to Dr Sahel, who is the director of The Vision Institute, Paris, France and Chairman of the Department of Ophthalmology at the University of Pittsburgh. Dr Sahel is also a scientific co-founder of GenSight Biologics.

The researchers also found hopeful hints in post hoc analyses.

For example, those patients who began the study with better visual acuity showed a trend towards better outcomes, improving by 12 letters at 48 weeks compared with the sham group’s fourletter improvement.

Another interesting observation was that visual acuity improvement was far more likely to occur in patients with a history of vision loss of less than nine months prior to treatment.

Patients less than 21 years old also tended to do better.

All 37 participants in the REVERSE trial will be evaluated again at 96 weeks. Those data are expected to be reported in early 2019.

Follow-up studies will be conducted out to five years.

LHON is a maternally inherited disorder associated with a mutation in mitochondrial DNA. GS010 was designed to rescue retinal cells affected by the G11778A mutation of the mitochondrial ND4 gene. It is delivered by a single intravitreal injection via an adeno-associated virus vector. The therapeutic gene produces a functional protein that restores the deficit in mitochondrial function.

The REVERSE study is one of three ongoing Phase III clinical studies now under way with GS010. The patients enrolled in REVERSE have a history of vision loss of six months to one year, while the RESCUE trial is applying the identical approach in patients presenting with vision loss of six months or less prior to treatment.

A multi-centre randomised double-blind, placebo-controlled study, dubbed the REFLECT study, is now enrolling patients. That study plans to enrol 90 LHON patients who will receive either bilateral intravitreal injections of GS010, or an injection of GS010 in one eye and a placebo injection in the fellow eye.

José-Alain Sahel: j.sahel@gmail.com

ESCRS VIENNA REVIEW

VIENNA 2018 In a wide-ranging lecture entitled “Facts first”, Prof Nuijts, professor of ophthalmology at the University Eye Clinic Maastricht, The Netherlands, focused on the challenges and benefits of using evidencebased medicine (EBM) to answer key questions in ophthalmic clinical practice.

He noted that decision-making in medicine traditionally relied on the opinion of a prominent physician – so-called “eminence-based care”.

“Our training has been rooted in eminence-based decision-making based on our clinical experience. However, we need to remember that clinical experience may cynically be described as ‘making the same mistakes with increasing confidence over an impressive number of years’,” said Dr Nuijts.

HERITAGE LECTURE

Rudy MMA Nuijts, who delivered the Ridley Medal Lecture at this year’s Congress, with ESCRS President Béatrice Cochener

Congress focuses on innovation

T

he ESCRS will continue to innovate and fine-tune its mission to better serve the interests of its members through high-quality clinical research and education, Béatrice Cochener, ESCRS President, told delegates at the official Opening Ceremony of the 36th ESCRS Congress in Vienna.

Welcoming more than 9,000 delegates from more than 123 countries, Prof Cochener said that this year’s Congress offered a first-rate scientific programme and a wide range of symposia, courses and wet labs covering most major fields of ophthalmology.

“The numbers tell their own story. At this year’s congress we have 16 symposia, 572 free papers, 120 instructional courses, 77 wet labs, and a very well supported trade exhibition with over 326 exhibiting companies taking part,” she said.

The phenomenal success of the ESCRS has been built on a culture of innovation and a desire to keep pace with the evolving needs of its members, explained Prof Cochener.

Prof Cochener said it was important to adapt and introduce new features to the Congress and this year’s Congress saw the introduction of the Free Paper Forum, which

was designed to facilitate greater interactivity between presenters and the audience.

ESCRS also continued its three-year multi-sponsored educational programme combining symposia, newsletter, online forum and didactic articles.

Another new initiative launched at the Congress was the European Registry for Childhood Cataract Surgery (EURECCA), spearheaded by Marie-José Tassignon.

This follows in the footsteps of EUREQUO and is designed to improve outcomes and quality assurance in infants and children.

FACTS FIRST Ophthalmology can benefit from more rigorous application of evidence-based medicine that integrates individual clinical expertise with the best available external clinical evidence from systematic research, said Rudy MMA Nuijts MD, PhD, in his Ridley Medal Lecture delivered as part of the Opening Ceremony of the 36th Congress of the ESCRS. “This principle of the integration of clinical expertise with scientific evidence is very alive and relevant today. We have registries, artificial intelligence and image analysis, which will all help us to answer clinical questions more efficiently,” he said.

Another major highlight of the meeting was the inaugural ESCRS Heritage Lecture, which was delivered by the renowned German surgeon and past ESCRS President Thomas Neuhann.

Prof Neuhann’s lecture focused on the invention and evolution of the capsulorhexis, a key step in modern cataract surgery, and one which represented a significant advance on previous methods used to open the anterior capsule in order to access the lens material.

At the end of the lecture Prof Neuhann received the ESCRS Heritage Lecture Trophy from Professor Béatrice Cochener, President of the ESCRS

PETER BARRY FELLOWSHIP The winner of this year’s Peter Barry Fellowship was Andreas Frings from Würzburg, Germany.

The Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. Dr Barry was among the pioneers who laid the foundation of the ESCRS and served there for more than 25 years as a board member, treasurer and president.

The Fellowship of €60,000 is to allow a trainee to work anywhere in the world at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, for one year.

Dr Frings started his Peter Barry Fellowship in August 2018 at Moorfields Eye Hospital, Refractive Surgery Service, under the supervision of Mr Bruce Allan.

His project involves the psychometric evaluation and calibration of a novel patient reported outcome (PRO) measure for refractive surgery patients developed for use as part of the National Dataset in Refractive Surgery.

EUROTIMES | NOVEMBER 2018

21

22

ESCRS VIENNA REVIEW

VIENNA 2018

ESCRS delegates run for Eye Care

Some of the delegates and presenters who attended the Young Ophthalmologists Programme session

T

YOs share experiences

he Young Ophthalmologists Programme (YOP) day-long session devoted to the topic “Starting Phaco” was one of the highlights of the 36th Congress of the ESCRS in Vienna, Austria.

The session was chaired by Oliver Findl, Simonetta Morselli and Kaarina Vannas, and took young ophthalmologists on an instructive journey through the various key stages of phacoemulsification, from incisions through to hydro-dissection, fragmentation and IOL implantation, as well as discussing complications and difficult cases.

One of the reasons why the YOP has proven to be so successful is that the emphasis is placed firmly on interaction and participation rather than passive learning, with the young ophthalmologists providing the backbone of the session in the form of video cases they submit illustrating problems encountered or mistakes made in the course of their own first steps into cataract surgery.

“We call the video presentation section ‘Learning from the Learners’, which nicely sums up what we are trying to do. We are very grateful to the young ophthalmologists who submit their videos for scrutiny as it’s a very brave thing to do, highlighting one’s errors for the benefit of discussion and helping others overcome EUROTIMES | NOVEMBER 2018

similar situations that might crop up in their own surgeries,” said Oliver Findl, Chairperson of the YOP. “The format of the session, in which a didactic lecture by an experienced surgeon is followed by video cases presented by young ophthalmologists, lends itself to interaction and discussion,” said Dr Findl.

“Everybody can take something home, because these are the type of experiences that we all have as surgeons, particularly when we are starting out in our surgical careers.” he said.

One of the key messages that the YO Committee tries to emphasise is that there are not always right and wrong answers when dealing with difficult surgical situations.

“We have an experienced panel of surgeons, and one of the things that has emerged frequently at our previous sessions is that there are several ways of dealing with a complication or an issue that arises during surgery,” he said.

On the Sunday of the Congress, the Young Ophthalmologists Session discussed targeting emmetropia in cataract surgery.

The session explored a range of topics including What is emmetropia?, Let’s measure the eye, Formulas to be applied, Choosing the best IOL for each patient and Things that you need to consider during and after surgery.

The inaugural Johnson & Johnson Vision Run brought together ESCRS delegates, their families and citizens of Vienna who rose at dawn to raise money for the Eye Care Foundation.

More than €2,000 was raised, which will support the Foundation’s vision of establishing good and affordable eye care in developing countries. The Foundation has projects in Nepal, Cambodia, Vietnam, Laos and Tanzania.

Conditions were ideal and while the sky was overcast, a light, cool, breeze provided welcome relief for more than 120 runners taking part in the run on a beautiful autumn’s day in Prater Park.

The overall winner was Abdullah Al-Safran, who led the field home in an excellent 17 minutes and 27 seconds, with Flemming Moller in second place in 18:24 and Ruben Andersen third in 18:40.

Arguably the performance of the day came from the women’s winner Kathrine Tilma, who raced home in 19 minutes 38 seconds, leading the majority of the male athletes home.

Dr Tilma, a cataract surgeon in Denmark, had a big smile on her face as she crossed the line.

“It is nice to run,” she said, as she was congratulated by her fellow competitors.

In second place for the women was Dyane Herbert at 22:46 and Pricila Bonetti at 23:52 in third.

For the full results from the Vision Run race see https://jnjvisionrun.com/results.html.

For more information on the Eye Care Foundation go to https://eyecarefoundation.eu/

23rd ESCRS Winter Meeting

ath ens

In conjunction with the 33rd HSIOIRS International Congress

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

Preliminary Programme, Hotel Bookings & Registration Available online

www.escrs.org

24

VIENNA PICTURE GALLERY

PICTURE GALLERY

EUROTIMES | NOVEMBER 2018

VIENNA PICTURE GALLERY

EUROTIMES | NOVEMBER 2018

25

26

EURETINA VIENNA REVIEW

18TH EURETINA CONGRESS

VIENNA 2018

EURETINA President Sebastian Wolf

Annual congress is bedrock of society

T

he spotlight will be firmly on education and research as the European Society of Retinal Specialists seeks to extend the scope of its activities over the next few years, Sebastian Wolf, President of EURETINA, said at the official opening ceremony of the 18th EURETINA Congress.

“We have taken active steps to increase our activity in education in recent years, introducing a successful winter meeting to the calendar and revamping our webpage with easier access to On Demand educational resources. We have also developed InSight, a new CME-accredited interactive learning platform for our members with a wide range of courses on offer,” he said.

The annual congress will also continue to serve as the bedrock from which EURETINA will continue to reach out and serve its members, said Prof Wolf.

“Our annual congress has always sought to showcase cutting-edge research in retina while also providing quality education through courses and wet labs. The formula works very well, enabling delegates to attend main sessions and obtain a comprehensive overview of important developments as well as participating in specific courses to improve their surgical skills,” he said.

Research will also feature prominently in future developments, said Prof Wolf.

“Our society can do a lot more to shed light on key questions of clinical practice EUROTIMES | NOVEMBER 2018

that are beyond the scope of industry. This is why we have partnered with Fight for Sight to provide funding of up to €2 million for clinical research to address the best treatment option for sub-macular haemorrhage caused by AMD,” he said.

Prof Wolf added that EURETINA has also decided to fund other clinical research for European-based non-interventional studies and will be unveiling details on how to apply for such funding in the near future.

In welcoming over 5,600 registered delegates to Vienna, Dr Wolf said that EURETINA has continued to surpass all expectations in terms of attendance at its annual congress.

“We have come a long way since our first congress in 2001 where we welcomed 200 delegates in Hamburg and we have now grown into what has become the largest retina meeting worldwide,” he said.

With a global epidemic of diabetes and diabetic retinopathy (DR) looming on the horizon, public health systems need to plan ahead to reduce the impact of DR-related visual loss through more effective screening programmes that harness the latest deep learning and artificial intelligence applications, said Professor Tien Yin Wong PhD, FRANZCO, in his EURETINA Lecture.

“It is timely to look at this problem as diabetic retinopathy is a global epidemic of major impact that needs populationwide, international strategies to tackle properly,” he said.

Race through a leafy oasis The 7th annual Retina Race, sponsored

by Novartis in aid of the sight-saving charity Orbis, has become a regular and well-supported feature of the EURETINA Congress since the first race took place in Milan in 2012.

This year’s race took place in humid running conditions over five kilometres around the picturesque Prater Park, a leafy oasis in the heart of Vienna.

The first male competitor past the winning post was Maximilian Pfau from Germany, who completed the course in a blistering 16 minutes and 52 seconds, followed by Thue Bram from Denmark and the appropriately named Julien Bullet from France, who both finished under 18 minutes.

The first female competitor to cross the line was Sonja Kleinlogel from Switzerland who clocked in at a very fast pace of 20 minutes and 34 seconds, followed by Chantal Dysli from Germany and Georgia Siasou from Greece.

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

Emma Hett, corporate partnerships manager at Orbis, also thanked all the participants for playing their part in raising money to go towards much-needed prevention of blindness programmes in the developing world.

Stephane Wolf of Novartis thanked everyone who took part in the race and said he hoped to see even more people taking part next year when the 19th EURETINA Congress will be held in Paris, France.

Corn

e

Eu

a

a

Eu

EUCORNEA VIENNA REVIEW

e

C o r n

European Society of Cornea and Ocular Surface Disease Specialists

Jesper Hjortdal

The cornea and how it relates to IOP Friedrich Kruse, President of EuCornea

A firm platform for future growth

T

he increasingly international dimension of EuCornea was highlighted as a sure sign of the vitality and well-being of the Society at its 9th Congress.

Welcoming delegates to Austria’s historic capital city, Friedrich Kruse, President of EuCornea, expressed satisfaction with the momentum that the organisation has built up in a relatively short time.

“This year I am delighted to say that we have over 630 delegates from 63 countries registered for our Congress. This underlines the truly international nature of our Society and the impact that EuCornea has made in such a relatively short time,” he said.

Launched in 2009 in Barcelona during the XXVII Congress of the ESCRS, the first EuCornea Congress was held in Venice in 2010 and has now firmly established itself as a major point of reference for cornea specialists.

Dr Kruse said that he was gratified to see so many delegates coming to Vienna to support the meeting and said it provided a firm platform for the future growth of EuCornea.

He told delegates that EuCornea’s mission was to try to enlarge the knowledge of corneal and ocular surface disease. With that in mind, EuCornea had organised a wide range of symposia and courses and were very proud that they had a great number of original papers and posters

presented at this year’s Congress, he said.

Dr Kruse encouraged delegates attending the congress to become full members of EuCornea if they had not already done so.

“New members can avail of all the benefits of membership including access to the online journal, which is picking up pace and making its mark in corneal and ocular surface disease as well,” he said.

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

MEDAL LECTURE As part of the Opening Ceremony, Carlos Belmonte of Alicante, Spain, delivered the EuCornea Medal Lecture on the topic of the “Neural basis of eye surface sensations: from dryness to pain”.

Major advances have been made in recent years into understanding the characteristics and neural basis of corneal and conjunctival sensations such as dryness, discomfort and pain, said Prof Belmonte, Emeritus Professor of human physiology at the Medical School, University Miguel Hernandez in Alicante, Spain.

“Ophthalmologists have traditionally dedicated very limited attention to the study of the non-visual sensory capacities of the eye,” he said.

Cornea characteristics can affect the accuracy of IOP measurements, but their influence also varies depending on the tonometry technology that is used, Jesper Hjortdal MD, PhD, told attendees at the 9th EuCornea Congress.

Dr Hjortdal said that central corneal thickness has a large effect on Goldmann applanation, air-puff and rebound tonometry. The IOP reading obtained with these technologies may be artificially low in eyes with a thin cornea and overestimated if the cornea thickness is greater than the normal range, he explained.

Dr Hjortdal noted that corneal curvature might also be predicted to affect IOP measurements considering that a steeper cornea would be more difficult to applanate or indent than a flatter cornea.

Available studies, however, indicate that at least when using Goldmann applanation tonometry, corneal curvature appears to have a minimal effect on the IOP readings.

CORNEAL STIFFNESS Corneal stiffness would also be expected to influence corneal applanation, and in contrast to curvature, corneal stiffness has been shown to affect IOP readings.

Dr Hjortdal noted that IOP will be underestimated in eyes with keratoconus and overestimated in eyes with conditions associated with increased corneal stiffness, including corneal scarring and mucopolysaccharidosis.

Of the available devices for measuring IOP, digital contour tonometer readings are possibly least influenced by corneal factors, said Dr Hjortdal, Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark.

“However, this technology is cumbersome, time-consuming, and more expensive to use,” he concluded.

EUROTIMES | NOVEMBER 2018

27

28

WSPOS VIENNA REVIEW

WSPOS S U B S P E C I A L TY D A Y

Excellent WSPOS interaction

T

WSPOS World Society of Paediatric Ophthalmology & Strabismus

S U B S P E C I A LT Y DAY Friday 13th September 2019 Preceding the 37th Congress of the ESCRS, 14 – 18 September 2019

www.wspos.org EUROTIMES | NOVEMBER 2018

he WSPOS Paediatric Subspecialty Day in Vienna offered insights into a variety of paediatric ocular issues that can affect the anterior segment, posterior segment and ocular motility.

The Subspecialty Day comprised several symposia, some of which were conducted by experts in the field, and some of which were selected free papers moderated and presented by experienced ophthalmologists.

The day kicked off with a session on rare diseases that can affect the eye and there was an emphasis not only on aniridia but also on ocular surface issues, which are increasingly being recognised to affect children.

Topics in this session included: How to manage cataract in uveitis in children, Complex ocular dermoids management, Update in Coats’ disease, The role of ocular surface disease on congenital aniridia and Paediatric cross-linking.

The session on Retinopathy of Prematurity (ROP) brought together experience and expertise from all over the world and afforded discussion about the treatment options for this disease on an evidence-based platform. A wide range of topics were discussed including: Risk in ROP screening, Foveal vascular changes in preterm children and Clinical profile and treatment outcomes following laser monotherapy and combination therapy with bevacizumab in paediatric Coats’ disease.

The day was punctuated by a lunchtime symposium generously supported by an educational grant from Zeiss, where the use of Integrated Intraoperative OCT in Paediatric Ocular Surgery was discussed.

EXPERTISE FROM AROUND THE WORLD A unique aspect of the WSPOS key educational forums, such as the subspecialty day, is the gathering of expertise from all over the world. The Paediatric Cataract session drew on experts like Marie-José Tassignon, Ramesh Kekunnaya and Daniel Salchow, who discussed a variety of aspects in this field. Perhaps, more unusually, there was a discussion about visual outcomes in cataract surgery in children with congenital glaucoma from doctors from both India and Saudi Arabia. Ken Nischal (pictured, inset) also described a new banded technique for traumatic cataract.

The Strabismus session included lively topics such as: Complications of strabismus surgery, Results of the multicentre convergency insufficiency treatment trials, Latest advancements in minimally invasive strabismus surgery, Correcting vertical strabismus by operating horizontal muscles, Intermittent exotropia review and The case for non-absorbable sutures in strabismus surgery. Another very interesting topic during this session was a presentation on strabismic amblyopia undiagnosed by primary care in children younger than three years old.

GLAUCOMA

Glaucoma and the brain Glaucomatous neuropathy extends throughout the visual system.

Roibeard Ó hÉineacháin reports

G

laucomatous neuropathy is not limited to retinal ganglion cells but also extends throughout the visual system. Modern neuroimaging techniques can provide a useful tool to evaluate the disease in humans in vivo, said Carlo Nucci MD, PhD, Full Professor of Ophthalmology at University of Rome Tor Vergata, Italy.

In a series of studies he and his associates have conducted, neuroimaging with diffusion tensor magnetic resonance imaging (MRI) showed that, in the optic nerve and optic nerve radiations, glaucomatous visual field loss was associated with a progressive increase in mean diffusivity and a progressive decrease in fractional anisotropy, both of which are biomarkers of axonal damage, he told the 13th European Glaucoma Society Congress in Florence, Italy.

They also observed that in patients with early glaucoma the damage to the optic nerve was predominantly located at the proximal retrobulbar region, whereas in patients with advanced glaucoma, the optic nerve’s distal end was also damaged.

More recently they have conducted a study using the newer, diffusion kurtosis MRI. They found that the damage in glaucoma reached into white matter tracts, which are involved in the processing and integrating of visual information in the brain.

Dr Nucci noted that there is also evidence that in glaucoma there is damage to the magnocellular layer of the lateral geniculate nucleus, which is important in fixation and maintaining a stable image during saccadic eye movements.

In a study evaluating patients’ eye movements during reading, using a text-imprinted microperimeter screen and a highfrequency eye tracker, his team observed that patients with glaucoma had very specific alterations in their eye movement.

GLAUCOMA AND ALZHEIMER’S DISEASE In most patients, the intraocular pressure (IOP)-related death of retinal ganglion cells is the most likely initiating pathogenic mechanism for the more pervasive features of glaucomatous neurodegeneration, Dr Nucci said. However, the presence of a pre-existing neurodegenerative process might also render these cells more susceptible to local stress factors, he noted.

There are several links between glaucoma and other neurodegenerative diseases including Alzheimer’s disease, he added. In a recent study, he and his associates found that patients with Alzheimer’s disease had a five-times higher frequency than controls of glaucoma-like alterations in both the retinal nerve fibre layer, as detected by Heidelberg retinal tomography, and the visual field, as measured with frequencydoubling technology.

Furthermore, there was no link between the damage and IOP levels.

Carlo Nucci: nucci@ med.uniroma2.it

...there is also evidence that in glaucoma there is damage to the magnocellular layer of the lateral geniculate nucleus

NUMBER 1!

80% of readers say it's an interesting read Reach

45,316

*

*Average net circulation for the 10 issues circulated between 1 February 2017 to 31 December 2017.

See www.abc.org.uk Results from the

EuroTimes Readership Study 2017

Carlo Nucci MD PhD EUROTIMES | NOVEMBER 2018

29

HOSPITAL DIARY

The Gift

D

Thank-you gifts are neither frequent nor expected in vitreoretinal surgery. Leigh Spielberg MD reports

Illustration by Eoin Coveney

octor, what something in mind that had would make moved me, but she didn’t know you happy?” she what I was talking about. asked.

“You don’t have to spend any “I beg your money at all. A simple thank-you pardon?” I replied, as I looked note would be perfect,” I clarified. up from my notes.

I was thinking about a specific “I mean, what can I get for you thank-you note that I had received to thank you for the treatment a short time earlier, a heartfelt you gave me?” message from someone who Ms Charlier was a I had treated for a very dense, 60-something woman whom I very sudden and unexpected had treated several days earlier vitreous haemorrhage. This is a for a full-thickness macular hole. favourite pathology of mine: with She was the friendly yet hypersimple surgery, patients’ vision nervous type of patient for can improve from vague hand whom every bit of information motion to 20/20 vision almost regarding the pathology, immediately. He had written a treatment and recovery was short, sincere letter that I keep in a both fascinating and terrifying drawer in my office. I have re-read at once. The type of patient who it several times, and every time, it would never be able to make gives me more satisfaction than up her mind about whether she any other token of appreciation wants to undergo vitrectomy for could. It is something that my a macular pucker (prognosis too children will read sometime, and unpredictable; natural history it will undoubtedly make them not too terrible), and would proud. It will also help them start hyperventilating in the understand why I might have examination room if told that occasionally missed their ballet she has a retina that needs to be performance or soccer game. reattached within 24 hours.

The letter also makes me laugh.

A macular hole is the The patient who wrote it, a vibrant By some stroke of luck, I had correctly “perfect” pathology for this man in his 70s, had gone online identified Ms Charlier as this “type”, type of patient. As a semito look for risk factors that might urgent, semi-elective problem, have caused the haemorrhage. and had helped her navigate the stress it’s critical enough that it has Although it was in fact due to and confusion of her new problem to happen soon, but not so peripheral exudative haemorrhagic urgent that the treatment plan chorioretinopathy, which I (operate today or tomorrow) will cause the patient to faint. informed him was nearly always idiopathic, he had become convinced By some stroke of luck, I had correctly identified Ms Charlier that it was due to Viagra. So shocked was he by the haemorrhage and as this “type”, and had helped her navigate the stress and its temporary blindness that he swore never to take Viagra again. confusion of her new problem. Mind you, the results of the He was satisfied with this conclusion, but his wife did not seem to surgery were not yet known; a gas bubble still filled the eye and appreciate my inability to convince him otherwise. I don’t think she’ll an OCT wasn’t possible. The visual acuity was thus currently ever forgive me for that. I tried my best to change his mind, but to no worse than before surgery. However, I had informed her about avail. I wish it could have been otherwise, but it’s nevertheless quite everything (possible subconjunctival haemorrhage, hyperaemia, funny in retrospect. mild ocular irritation, gas bubble, positioning, progressive visual Vitreoretinal surgeons are not the public’s favourite eye doctors. recovery), so she was reassured.

That is clearly reserved for cataract and refractive surgeons, whose And so, her desire to thank me with a gift was not (yet) for the work is considered the next best thing to magic. Besides vitreous vision that she had recovered, but rather for the emotional support haemorrhage, floaters and the occasional astonishingly rewarding that I had given.

BCVA after macular hole, macula-off detachment or trauma, the In Belgium, the customary thank-you gift is a bottle of wine results of a VR surgeon’s work are usually not as lovely as those after or champagne. The first time you receive this from a patient, the laser refractive surgery. Thus, thank-you gifts are neither frequent feeling is spectacular. You feel like you’ve exceeded expectations nor expected. Both we and our referring ophthalmologists know the and have done what we all entered medicine to do. It also boosts value of our work, and that is more than enough. your self-esteem, which, as far as vitreoretinal surgery goes, can But I now know exactly what my answer is to the question, always use a little boost.

“How can I thank you?”

But, like the bubbles in champagne, it is fleeting, transient, And I look forward to reading what Ms Charlier will write. evanescent, ephemeral.

Dr Leigh Spielberg is a vitreoretinal and cataract surgeon “A letter,” I said, rather unexpectedly. at Ghent University, Belgium “I beg your pardon?” she replied, understandably. I had EUROTIMES | NOVEMBER 2018

31

INDUSTRY NEWS

NEWS IN BRIEF IOP DRUG UNDER REVIEW

INDUSTRY

NEWS

Better correction with IOLMaster

Curvature of the posterior cornea can throw off toric IOL power calculations by half a dioptre or more, often resulting in significant over-correction of with-the-rule astigmatism and under-correction of against-the-rule astigmatism. The new IOLMaster® 700 with Total Keratometry, introduced by Carl Zeiss Meditec at the 36th Congress of the ESCRS 2018, helps solve the problem by measuring both anterior and posterior cornea curvature.

To process Total Keratometry data Zeiss also introduced the Z CALC 2.0 software package.

Z CALC 2 incorporates new formulae that make use of posterior cornea data rather than constants to calculate toric power and axis values.

Integrating data from multiple diagnostic and treatment devices not only improves patient outcomes it also improves practice workflow and efficiency, said Ludwin Monz PhD, president and CEO of Carl Zeiss Meditec. Efficiency will be more important as populations age and reimbursement falls, he added. “We are trying to come up with solutions that help with the growing numbers of patients." https://www.zeiss.com

PRECEYES SURGICAL SYSTEM

LIGHT INDUCED VISUAL-RESPONSE

Preceyes B.V. demonstrated the PRECEYES surgical System at the 18th EURETINA Congress. Surgeons were invited to test the system and perform a robot-assisted peeling on a model. The 30-minute demonstration involved an introduction to the system and model, a manual peeling trial and a robotassisted trial. Feedback was collected in a short interview.

This next-generation system is designed to provide increased surgical precision. The system’s safety and viability for intraocular robotic surgery have been successfully evaluated in a first-in-human study.

Prof Marc de Smet MDCM, PhD, Chief Medical Officer said: “The robot can and will play an ever-increasing role in current surgery and enable new surgical procedures. Our PRECEYES Surgical System will provide increased precision where and when it is required by a surgeon, and it is anticipated that it will foster more consistency in the conduct of surgical tasks.” http://www.preceyes.nl

Diopsys introduced the concept of Light Induced Visual-Response (LIV) to delegates at the 36th Congress of the ESCRS. Earlier this year, Diopsys reframed the kind of testing performed on its medical devices. A company spokesman said the decision was an acknowledgement that visual electrophysiology testing has a perception within the eye-care community that does not reflect the modern protocols and platforms Diopsys provides. By using patented skin sensors Diopsys LIV testing is patient friendly and because of the small physical footprint of their devices, testing is readily accessible to clinicians.

“When we heard from physicians that traditional electrophysiology testing might be too complicated and might not be relevant to everyday practice, we sensed a need to clarify what Diopsys platforms add to routine eye care. In talking about LIV, we are calling it exactly what it is: a measure of electrical response within the cells along the visual pathway to a light-based stimulus,” said Bill Shields, Vice President, International Sales, Diopsys. http://diopsys.com

Aerie Pharmaceuticals has reported that the European Medicines Agency (EMA) has accepted for review the Marketing Authorisation Application (MAA) for Rhokiinsa® (netarsudil ophthalmic solution) 0.02%.

Rhokiinsa is currently marketed as Rhopressa® in the United States and is indicated for the reduction of elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension. An opinion from the EMA’s Committee for Medicinal Products for Human Use on the MAA for Rhokiinsa is expected in the second half of 2019.

“We are delighted that the European regulatory authorities have accepted our Rhokiinsa filing for review. If Rhokiinsa is approved, we plan to submit an MAA for Roclatan™ shortly thereafter,” said Vicente Anido, Jr., Ph.D., Chairman and Chief Executive Officer at Aerie. www.aeriepharma.com

ULTRA-WIDEFIELD DEVICE Optos has launched its latest ultra-widefield device to the European ophthalmic market.

“Monaco is set to revolutionise the way eyecare professionals examine the eye and is the only ultra-widefield retinal imaging system with integrated Optical Coherence Tomography,” said an Optos spokeswoman.

Gareth Steer, Vice President Sales, Europe at Optos, said: “Monaco is a unique imaging system, which can capture ultra-widefield red/green and autofluorescence images, as well as having Optical Coherence Tomography capability. The device is very comfortable for patients and can capture all three modalities in under two minutes. https://www.optos.com/en/products/Monaco

FEMTOSECOND LASER PLATFORM Ziemer Ophthalmic Systems has announced development activities to incorporate lenticule extraction capabilities for its LDV Z8 femtosecond laser system.

“From the very first days of developing the femtosecond laser the Ziemer R&D team has continuously focused on adding new surgical applications to the femtosecond portfolio,” CEO and President Frank Ziemer said. “I am very proud to announce the Ziemer team has developed a new method for corneal surgery by equipping our flagship FEMTO LDV Z8 device with the capability to also perform low energy lenticule extraction,” he said.

“Beside our strong focus on the cataract femtolaser market, we have dedicated a tremendous amount of time and effort to make significant progress in successfully implementing our low energy pulse management concept for new corneal applications,” said Mr Zeimer. www.ziemergroup.com.

EUROTIMES | NOVEMBER 2018

33

34

RANDOM THOUGHTS

Greens are good for you Relieving stress is always a challenge for ophthalmologists.

Maryalicia Post reports

T

‘Earth heading for 25-hour day.’ he headline gave me a flutter of anticipation. We all know that ‘work expands to fill the time allotted to it’ and now at last the shoe might be on the other foot – time expanding to accommodate the pressure of work. But no. The article goes on to explain the extra hour is due to the slower rotation of the earth around the sun and won’t be ours to spend for 200 million years.

So that means the over-stretched among us – and that’s most ophthalmologists – will continue to fit 25 hours of work into a 24-hour day and look for other ways to reduce stress, anxiety and depression. A meta review of studies at www.sciencedirect. com suggests a novel approach… ‘nature therapy’– aka light gardening.

IMPROVED ATTENTIVENESS Fortunately for the city dweller, you don’t even need a garden. The main benefit comes from the interaction with nature itself. Not only do mood and creativity get a boost, other studies confirm that tending your aspidistra may lead to less sickness and improved attentiveness too.

An entertaining way to start is with the Plant Life Balance app from RMIT and

Melbourne University. Take a picture of your space, choose the visual effect you’d like, then follow instructions to add the appropriate plants. The app calculates the therapeutic benefits of your new decor. Download at iTunes and the Google Play Store.

A residual benefit of houseplants is cleaner air. Even NASA weighs in on the ability of plants to remove “volatile organic compounds which lurk around the average office, in carpets and furnishings, solvents and ink” (https:// spinoff.nasa.gov). A NASA publication,

10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

www.eucornea.org EUROTIMES | NOVEMBER 2018

How to Grow Fresh Air: 50 Houseplants That Purify Your Home or Office, explains: “Plants emit water vapour that creates a pumping action to pull contaminated air down around a plant’s roots, where it is then converted into food for the plant.”

A TED talk, How to grow fresh air by Indian environmentalist Kamal Meattle, winnows the list down to three common plants that do the job: Areca palm, mother in law’s tongue and the money plant.

Greens really are good for you. http://maryaliciatravel.com/

Take control of your future.

www.escrs.org

Belong to something powerful. Join us.

37

T H

CO N GRESS

PARIS

E XPO, 14

–

18

OF

P O RTE

DE

THE

E SC RS

V ERSAI L L ES

S EP TEMB ER

2 019

P A R I S 2

0

1

P A R I S w w w. e s c r s . o r g

9

EXPLORING ATHENS

Monastiraki square

ATHENS

3

TO READ...

LEARN ABOUT THE TOWERING GENIUS OF ANCIENT ATHENS The Rise of Athens: The Story of the World’s Greatest Civilization by Anthony Everitt. The author says he asked himself: “How was it that this tiny community of 200,000 souls or so (in other words, no more populous than, say, York in England or Little Rock in Arkansas) managed to give birth to towering geniuses across the range of human endeavour and to create one of the greatest civilisations in history?” His answer forms the basis of this highly readable book. Anthony Everitt is a British academic whose previous works are on Roman history. The Rise of Athens is available as a Kindle book, in hardback and paperback. Published by Random House, 2016.

A PERSONAL TAKE ON ATHENIAN CUSTOMS AND TRADITIONS Eurydice Street: A Place in Athens by Sofka Zinovieff.

The author, a journalist and anthropologist, accompanied her expatriate Greek husband on a posting back to Athens in 2001. As a student, she had fallen in love with Greece and on moving to Athens with her husband and young family she was enthusiastic about turning herself into an authentic Athenian. It wasn’t that easy. Her memoir is a lively and companionable blend of personal recollection and a depiction of Athens tavernas, theatre companies, demonstrations and preserved customs and traditions. In this fresh and funny record of that time, she writes of her discoveries of the effect of Athens’ past and how it haunts its present. Published by Granta Books; paperback New Ed edition. 2004

‘MESSENGER FROM ATHENS’ INVESTIGATES IN THIS ISLAND MURDER MYSTERY The Messenger from Athens by Anne Zouroudi.

This is the first in a series of eight detective novels featuring Hermes Diaktoros “the messenger from Athens”. He arrives to investigate the death of a young woman whose body has been found at the foot of a mountain.

As the investigation proceeds (murder? suicide?) the characters who live in this island village reveal their true natures. A second mystery is Hermes Diaktoros himself. Who sent him and how could he know so much of the local domestic history? First published in 2007, this 2017 edition is a new “Author’s Cut”, revised and in parts rewritten for its tenth anniversary.

Published by Kounelaki, 2018, available in paperback and Kindle editions.

Take a closer look

There’s more to Athens than just classical antiquities, as a local guide can show you. Maryalicia Post reports.

In the 17th and 18th Centuries, wealthy young British men (and some women) undertook an educational rite of passage called the Grand Tour. Hiring a local expert – dubbed a ‘bear-leader’ – to unlock the secrets of each destination became standard, and the guided tour was launched. Today, following a guide is still the quickest and surest way to get a taste of local culture, to go ‘behind the scenes’ and to experience the city in a meaningful way While antiquities tours are the most popular excursions in Athens, local walking tours of neighbourhoods, often combined with an introduction to Greek food, are an attractive option. They offer a couple of hours of relaxation along with an introduction to new foods, a look at unfamiliar areas, and perhaps a chance to meet new friends.

Tours by Locals offers a typical ‘small group’ Athens Food and Wine tour that starts in Monastiraki square, takes in the flea market, stops for locally made pastries and a coffee and continues to the central food market. Food and wine tasting in a renowned delicatessen follows and sets you up for lunch. There’s also time for souvenir shopping, of course. This five-hour walking tour runs every day but Sunday (when the market is closed). Details at www.toursbylocals.com. For a one-on-one private food tour, check out Athens Walks Tour Company. Their customisable tour is suitable for vegetarians and their website is at www.athens-walks.com If an evening outing would fit your schedule better, consider the alluringly titled ‘Athens Twilight Small Group Tour with Drinks and Meze Dishes’. This guided walking tour takes a small group to visit three bars and to hear live guitar folk music at a bouzoukia venue. You’re

introduced to local spirits like ouzo and raki paired with meze (Greek finger food).

‘Rooftop views and secret gardens’ are promised on this three-and-a-half-hour tour. Dress is ‘smart casual’ and you’ll need a government-issued ID. Visit www.athensurbanadventures.com And finally, make a note of George’s taxi tour. For a truly bespoke outing, this established Greek-American family business is in a class by itself. I used George’s taxi for a trip to Epidaurus, 160km from Athens in the Peloponnesian hills, where the physician-god Asklepios established his sanctuary in the 4th century BC. A fascinating small museum on the site includes steles detailing some 70 cures attributed to Asklepios and a testimonial from the Athenian woman, Ambrosia, whose sight was restored here. The guidebook available at the desk fills you in. Visit the adjacent theatre, which is still in use, and consider rounding out your excursion with a visit to Poseidon’s temple. For a tour quote contact www.taxigreece.com The theatre at Epidaurus

EUROTIMES | NOVEMBER 2018

37

5-8 September 2019 Instructional Course & Symposium Abstract Submission Deadline 20 December 2018

Le Palais des Congrès Paris, France

www.euretina.org

CALENDAR

The 9th EURETINA Winter Meeting will take place in Prague, Czech Republic

MARCH

APRIL

9th EURETINA Winter Meeting

46th EFCLIN Congress Exhibition

2019

Retina World Congress

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

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

MARCH 8th World Glaucoma Congress

27–30 March Melbourne, Australia www.worldglaucomacongress.org

APRIL International Meeting of the Egyptian Vitreoretinal Society (EGVRS)

25–27 April Brussels, Belgium www.efclin.com

MAY

↙

DECEMBER Arab International Ophthalmology Congress

ASCRS•ASOA Symposium and Congress 3–7 May San Diego, USA www.ascrs.org

NEW The 45th Annual Meeting of the European Paediatric Ophthalmological Society May 30–June 1 Riga, Latvia https://www.epos-focus.org/

10–12 April Cairo, Egypt www.egvrs.org

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

EUROTIMES | NOVEMBER 2018

39

40

CALENDAR

MAY 16th South East European Congress of Ophthalmology May 31–June 2 Prishtina, Kosovo http://www.shofk.org/shofk/

JUNE SOE Congress 2019 13–16 June Nice, France www.soevision.org

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

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

WSPOS Subspecialty Day 13 September Paris, France www.wspos.org

The 37th Congress of the ESCRS, 19th EURETINA Congress and 10th EuCornea Congress will take place in Paris, France

2020 MAY

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

15–19 May Boston, USA www.ascrs.org

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

11th EuCornea Congress

NOVEMBER

2–3 October Amsterdam, The Netherlands www.eucornea.org

JUNE

AAO Annual Meeting

OCTOBER 38th Congress of the ESCRS

1– 4 October Amsterdam, The Netherlands www.euretina.org

NEW ASCRS 2020

37th Congress of the ESCRS

OCTOBER 20th EURETINA Congress

NEW World Ophthalmology Congress (WOC) 26–29 June Cape Town, South Africa http://woc2020.icoph.org/

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus 2– 4 October Amsterdam, The Netherlands www.wspos.org

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

Prague 2019 1–2 March 2019 Prague, Czech Republic Free Paper & Poster Submissions open until 20th December Exhibition & Sponsorship Opportunities Available

www.euretina.org EUROTIMES | NOVEMBER 2018

3–7 October Amsterdam, The Netherlands www.escrs.org

NEW AAO Annual Meeting 2020 14–17 November Las Vegas, USA www.aao.org

Stressless.

It’s touchless.

SmartSurf ACE – the smoother way

True innovative leadership is when others follow.

Proven results: 825,000 TransPRK/ SmartSurf ACE procedures!

SmartSurf ACE Gentle: No touch, no suction, no incision, no cut • Safe: High cornea stability • Stress-free: Faster treatment – in a single step • Excellent clinical outcomes • Economical: Easy to use, time-saving, low investment www.schwind-smartsurf.com

SmartSurfACE is an innovative surface ablation method that combines the benefits of touch-free TransPRK surface treatment with SmartPulse technology.

It works without touching the eye, so there is no blade, no flap and no incision, and the procedure results in a very smooth corneal surface even right after surgery. Your patients will experience less discomfort and enjoy good vision sooner. Treatment is faster, and outcomes are excellent. It’s the smoother way to good vision.

SCHWIND eye-tech-solutions · fon: +49 6027 508-0 · email: info@eye-tech.net · www.eye-tech-solutions.com · #SchwindLaser