EuroTimes Vol 23 Issue 12 Dec 2018 | Vol 24 Issue 1 Jan 2019 by EUROTIMES

SPECIAL FOCUS BEST OF THE ESCRS CONGRESS IN VIENNA

Dec 2018 | Vol 23 Issue 12 Jan 2019 | Vol 24 Issue 1

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer 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 BEST OF THE BEST 04 Key opinion leaders

discuss their highlights from the 36th Congress of the ESCRS in Vienna, Austria

06 The 2018 Ridley Medal

Lecture highlighted the benefits of “facts first”

07 Patient-reported outcomes key for Peter Barry Fellowship winner

08 The successful entries to this year’s poster awards showcased a range of topics

09 News from the FEMCAT trial

10 ‘Forceful communicator’ is winner of the John Henahan Prize

18 Dealing with corneal

wound burn and corneal incisional contracture

35 Knowing when to opt

22 Technical advancement

PAEDIATRIC OPHTHALMOLOGY

14 Same-day bilateral cataract surgery – yes or no?

for surgery in glaucoma patients

and enhancement procedures

only comes from largescale collaboration

23 JCRS update 24 News from the 2018 AAO

36 Careful follow-up required in children with Graves’ orbitopathy

Annual Meeting

25 What can surgeons do to tackle the problems of astigmatism?

CORNEA

27 The latest news in corneal

13 Winning videos

33 Ophthalmologica update

21 Multicomponent IOLs

12 The 2018 ESCRS

Practice Management Competition winners raised awareness of glaucoma in Lebanon

looked at the role of inflammation in diabetic retinopathy

GLAUCOMA

benefits of FLACS

26 Opinions differ on how

technique delivers first ESCRS Heritage Lecture

32 The 2018 Kreissig Lecture

20 The jury is still out on the

11 Inventor of capsulorhexis

highlighted innovative independent research

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.

CATARACT & REFRACTIVE

www.eurotimes.org

to approach patients with Fuchs’ dystrophy and cataract

REGULARS 39 ESCRS News 41 Books 43 Outlook on industry 45 Practice Management 46 Random thoughts 47 Calendar

cross-linking techniques

28 Customised CXL offers

new options to patients with keratoconus

29 Ultrathin DSAEK still has a role to play despite the surge of DMEK

30 MACUSTAR is hoping to

Supplement December 2018/ January 2019

Included with this issue...

inform new studies on intermediate AMD

31 Using transverse

asphericity is a new approach in IOLs

Focusing on Premium IOL Advances and Best Practices Supported by an unrestricted educational grant from

ESCRS Education Forum Supplement

EUROTIMES | DECEMBER 2018/JANUARY 2019

EDITORIAL A WORD FROM BÉATRICE COCHENER-LAMARD MD, PHD

GUEST EDITORIAL

Béatrice Cochener-Lamard MD, PHD

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener-Lamard (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)

Keeping abreast of the moment The 36th Congress of the ESCRS in Vienna was an innovative and expansive occasion

s President of the ESCRS, it was my great honour to welcome friends and colleagues from Europe and across the globe to the 36th Congress of the ESCRS in Vienna. This year’s Congress built on our shared commitment to continuously improving patient outcomes and access to excellent eye care around the world through education, research and mentoring young colleagues. Our free paper forum featured an innovative approach designed to break down the wall between speaker and audience. Multiple papers were presented at the same time in an open space with those in attendance listening in via wireless headphones in small groups. The result was a more intimate experience with freeflowing discussions. We offered more instructional courses and sponsored educational programmes, expanding topics from three to five. Hot topics included presbyopia, toric IOLs, ocular surface disease This year’s Congress and combined cataract built on our shared and minimally invasive commitment to glaucoma surgery (MIGS). To help colleagues learn continuously in depth, we added a threeimproving patient year running programme, outcomes... coordinating symposia at the ESCRS Congress and Winter Meeting and with national society meetings throughout the year. Supporting materials are published online through ESCRS On Demand and EuroTimes, and in printed newsletters and articles. For young ophthalmologists, ESCRS is offering more fellowships to attend meetings as well as media tools including free online content through ESCRS iLearn, and books, videos, landmark articles and materials for the FEBO-CR examination through the ESCRS Education Portal. At the Congress, we opened the gala President’s Dinner to young ophthalmologists to build social connections between society leaders and young, motivated colleagues. It was a very nice bridge between generations. The ESCRS annual member survey continued to yield important information on the level of practice in emerging areas such as presbyopia correction and MIGS. By expanding and tailoring the survey we hope to help build knowledge and adoption of best practices. Finally, ESCRS strengthened its commitment to improving access to eye care around the world with a plan to partner with and involve more young ophthalmologists in international programmes. This issue includes expanded coverage of this year’s Congress. We hope you enjoy reading about it and plan to attend future events.

Béatrice Cochener-Lamard MD, PHD, is Professor and Chairman of the ophthalmology department at the University Hospital of Brest, France EUROTIMES | DECEMBER 2018/JANUARY 2019

See into the future of eye surgery and patient care.

www.escrs.org

Belong to something inspiring. Join us.

SPECIAL FOCUS: BEST OF THE BEST

of the

FROM

the 36 ESCRS Congress th

This year’s Congress combined the best of research and practical applications. Howard Larkin reports on some of the highlights

t the risk of sounding biased, ESCRS Treasurer Thomas Kohnen MD, PhD, found the 36th Congress of the ESCRS in Vienna one of the most valuable ophthalmology meetings this year – and he

EUROTIMES | DECEMBER 2018/JANUARY 2019

attended events all over the world. “Because we have some basic research integrated [with clinical research and education] it is just the right amount of information for those who practise in our field,” said Prof Kohnen, who is chair of the department of ophthalmology at Goethe University, Frankfurt, Germany.

That opinion was shared by many attendees who emailed ESCRS Secretary Oliver Findl MD, founder and chair of the Vienna Institute for Research in Ocular Surgery, and chair of ophthalmology at Hanusch Hospital, Vienna. “In general, the meeting was very well received; both the content and

SPECIAL FOCUS: BEST OF THE BEST the location and atmosphere were good. Of course, these are subjective impressions, but I got a lot of feedback that it was the best ESCRS meeting until now,” Dr Findl said. The diversity of delegates and quality of presentations made the long journey from India worth it, said Soosan Jacob MS, FRCS, DNB. “It’s a treat to see so many bright minds at one place, to make new friends, meet old ones and to learn new things,” said Dr Jacob, who is director and chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India. ESCRS President Béatrice CochenerLamard observed that worldwide participation and flexibility help keep ESCRS programming current and valuable. This year notable topics included the rise of small-incision lenticule extraction (SMILE®) and transepithelial PRK in the corneal refractive realm, and the growing interest in extended depth of focus, trifocal and toric IOLs for cataract and refractive lens exchange. “Year after year the hot topics change for different reasons, and we keep on top of it,” said Dr Cochener-Lamard MD, PHD, who is Professor and Chairman of the ophthalmology department at the University Hospital of Brest, France.

MYOPIA CHALLENGES The growing prevalence and severity of myopia around the world made a research symposium on its causes and potential treatments to slow progression especially relevant, Dr Findl said. Frank Schaeffel PhD, head of neurobiology of the eye at the University of Tübingen, Germany, presented new animal research suggesting that differences in stimulation in local areas of the retina, and not just peripheral hyperopic defocus, may drive myopia progression. The findings suggest designing new lenses that project images at multiple distances may help slow progression – and going back to green or amber letters on a black background for computer monitors might help as well. However, these hypotheses have not been tested in humans, which would take years and many patients, Dr Findl noted.

It’s a treat to see so many bright minds at one place, to make new friends, meet old ones and to learn new things Soosan Jacob MS, FRCS, DNB

On the treatment side, Pauline Cho PhD, of Hong Kong Polytechnic University, presented information on using orthokeratology and specially designed contact lenses that correct peripheral defocus to slow myopic progression, though these require additional research to demonstrate and improve performance. Donald Tan MD, PhD, of the Singapore Eye Centre, reported the latest on using atropine drops. Marlies Ullrich MD, of the Vienna Institute for Research in Ocular Surgery, discussed potentially preventing retinal detachment in myopic patients with prophylactically photocoagulating areas of lattice degeneration and apical holes in patients at risk due to posterior vitreous detachment. More evidence is needed to assess efficacy and develop guidelines for prophylactic treatment, Dr Findl said. Mor Dickman MD, PhD, of Maastricht University, the Netherlands, presented animal research on scleral cross-linking to prevent progression. However, potential side-effects such as retinal toxicity and glaucoma must be examined in further research, Dr Findl noted.

PRESBYOPIA Presbyopia is another condition with unmet need around the world, Prof Kohnen said. In addition to many papers on lenticular and corneal solutions, research presentations helped show the potential for improving treatment. These included presentations of a finite element analysis of accommodation mechanisms and the functional anatomy of the zonules, which could help improve accommodating lens designs. On the treatment front, research suggests femto lentotomy might help

In general, the meeting was very well received; both the content and the location and atmosphere were good... I got a lot of feedback that it was the best ESCRS meeting until now Oliver Findl MD

For premium IOLs, extended depth of focus lenses are gaining ground “and the winner among multifocal lenses is the trifocal, especially the torics” Béatrice Cochener-Lamard MD, PHD

restore lens flexibility, Prof Kohnen noted. For premium IOLs, extended depth of focus lenses are gaining ground “and the winner among multifocal lenses is the trifocal, especially the torics”, Dr Cochener-Lamard said. Dr Jacob especially enjoyed Rudy Nuijts MD, PhD’s Ridley Medal lecture, which was entitled “Facts first – the search for evidence”. It reminded everyone that ongoing research is essential to ensure innovative new techniques, such as using femtosecond lasers in corneal surgery, live up to their potential. The practice development programme on the benefits and risks of social media, at which she presented, was helpful as well, she added. The latest developments in corneal cross-linking, surgical presbyopia correction and the video awards filled out Dr Jacob’s list of favourites. “It makes me proud when I see the skill, knowledge and ingenuity of my colleagues and peers on display,” she said. Similarly, Dr Findl found the interactive video cases instructive. “It’s fascinating to see how people work through the different steps of surgery and decide on the best course to follow. There are often several roads to Rome and there’s not always just one option that may be the right one.” EUROTIMES | DECEMBER 2018/JANUARY 2019

SPECIAL FOCUS: BEST OF THE BEST

Evidence-based

OPHTHALMOLOGY The benefits of “facts first” highlighted in Ridley Medal Lecture. Dermot McGrath reports

phthalmology can benefit from more rigorous application of evidencebased 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 at the 36th Congress of the ESCRS in Vienna. In a wide-ranging lecture entitled “Facts first – the search for evidence”, Dr Nuijts, Professor of Ophthalmology at the University Eye Clinic Maastricht, the Netherlands, focused on the challenges and benefits of using evidence-based medicine (EBM) to answer key questions in ophthalmic clinical practice. EBM advocates the use of up-to-date “best” scientific evidence from health care research as the basis for making medical decisions. The quality of evidence used to answer a particular clinical question can be schematically represented by an evidencebased medicine pyramid, said Dr Nuijts. Systematic reviews and meta-analyses are at the top of the pyramid, representing the highest levels of evidence, while expert opinion is at the bottom and therefore regarded as the least influential. At the heart of EBM is the concept that high-quality scientific research carries most weight, said Dr Nuijts. To illustrate how this might work in real terms, Dr Nuijts took the example of four research initiatives taken in recent years to search for evidence for new innovations: toric IOLs, prevention of macular oedema after cataract surgery, long-term endothelial cell loss in phakic IOLs and corneal lamellar surgery. For toric IOLs, three principal questions needed to be answered, said Dr Nuijts: do they outperform monofocal IOLs, is digital marking more accurate than manual marking and are they more cost-effective than standard IOLs? A prospective randomised controlled trial provided the answer to the first question. “We showed that uncorrected distance visual acuity (UDVA) was 20/25 or better in 70% of the toric patients compared to just 31% in monofocal group. Spectacle EUROTIMES | DECEMBER 2018/JANUARY 2019

Rudy MMA Nuijts delivering the 2018 Ridley Medal Lecture at the 36th Congress of the ESCRS in Vienna.

independence was 84% in toric versus 31% in monofocal, so the toric lenses clearly outperformed monofocal lenses,” he said. The picture was less clear cut, however, for manual versus digital marking. “We found that digital markers were better but it was not statistically significant. Better technology did not transfer into better clinical outcomes for the patients at this stage,” he said. Analysis also showed that toric lenses were less cost-effective than monofocal IOLs. “The problem here stems from the generic nature of quality-of-life questionnaires, which are not sensitive to small health gains in specialty practice,” said Dr Nuijts. The benefits of EBM were also to the fore in the landmark PREMED study, said Dr Nuijts, which concluded, among other findings, that a combination of a topical corticosteroid and a nonsteroidal anti-inflammatory drug (NSAID) is more effective than either agent alone in reducing the risk of developing cystoid macular oedema (CME) after cataract surgery in non-diabetic patients. “The study outcomes paved the way for the first evidence-based clinical guidelines to prevent CME after cataract surgery in diabetic and non-diabetic patients,” said Dr Nuijts.

EBM has also been extremely helpful in assessing endothelial cell (EC) loss with irisfixated IOLs, with Dr Nuijts’s team amassing data over 10 years from 507 eyes of 289 patients who received the Artisan myopia or Artisan toric iris-fixated phakic IOL. “While we found a 1.04% explantation rate at 10 years, which is quite acceptable, over the total follow-up period this increases to 6% and the mean time of explantation is almost 12 years. So the message here is that we really have to follow-up these patients for longer than 10 years,” he said. For endothelial keratoplasty, EBM helped answer the question of whether Descemet’s membrane endothelial keratoplasty (DMEK) delivers better outcomes than ultrathin Descemet’s stripping automated endothelial keratoplasty (DSAEK). “Overall we found that there are some indications for which the visual outcomes are better with DMEK, but the incidence of complications are higher than with ultrathin DSAEK,” he concluded. Rounding off his talk, Dr Nuijts quoted the American psychologist Carl Rogers, who said: “The facts are always friendly. Every bit of evidence one can acquire, in any area, leads one that much closer to what is true.” Rudy MMA Nuijts: rudy.nuijts@mumc.nl

SPECIAL FOCUS: BEST OF THE BEST

2018 Peter Barry Fellowship winner

Outcomes Begin Here.

This Fellowship commemorates the immense contribution made to ophthalmology. Colin Kerr reports

he winner of this year’s Peter Barry Fellowship is Andreas Frings. Peter 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. He also had a major role in bringing ESCRS academies around the world. The Fellowship of €60,000 is to allow a trainee to work at a centre of excellence for clinical experience or research in cataract and refractive surgery, for one year, anywhere in the world. Dr Frings studied medicine at medical schools in Hamburg, Germany, and Graz, Austria. He started his training in ophthalmology in 2013 at University Hospital Hamburg, Germany, and finished his training in May 2018 (working at University Hospital Düsseldorf, Germany). He also passed his national exam and EBO exam in May 2018. “Since my MD thesis in 2011, I have been focusing on issues related to cataract and refractive surgery, including topics dealing with biometry, astigmatism treatment and vector analysis, laser refractive surgery and interdisciplinary topics related to corneal biomechanics,” said Dr Frings. He has published more than 50 studies as first, last or co-author and has been involved in more than 100 presentations as Andreas Frings first, last or co-author. “I am happy to serve as a supervisor of many younger colleagues and students doing their MD thesis,” said Dr Frings. 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. “We build on existing measures and will use contemporary questionnaire development and validation methodology, including Rasch fitting, to provide a thorough evaluation of the psychometric properties of the new questionnaire,” he said. The development and validation of a concise, practical, online, self-administered, self-archiving and self-scoring PRO questionnaire for routine clinical use in refractive surgery is the primary study objective. Secondary objectives are to gather outcome data from patients before and after surgery in each of the following domains comprising key elements of visionrelated quality of life: spectacle dependence; quality of vision; eye comfort; freedom; emotional wellbeing; and overall satisfaction with the results of surgery. Andreas Frings: andi.frings@gmail.com

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SPECIAL FOCUS: BEST OF THE BEST

A wide range of topics Posters were judged based on originality, scientific quality, relevance to clinical practice and presentation. Cheryl Guttman Krader reports

Refractive Poster Award winner Anastasios John Kanellopoulos MD, Greece

he winners of the ESCRS Poster Prizes at the 36th Congress of the ESCRS in Vienna, Austria, showcased a wide range of topics.

REFRACTIVE

First prize in the Refractive Category was given to Anastasios John Kanellopoulos MD, Greece, for his poster, “Topographymodified refraction (TMR): partial to total adjustment of treated cylinder amount and axis provided by topography data measured vs using the standard clinical refraction in myopic topography-guided LASIK”. The poster describes the results of a study comparing the safety and efficacy of topography-guided myopic LASIK using a standard clinical refraction approach or the TMR strategy. Using a contralateral eye control design, the study included 100 eyes of 50 consecutive patients. Patients had one eye randomised to treatment with the standard clinical refraction approach and the fellow eye to TMR treatment. Analyses of data collected through follow-up to 12 months showed both approaches were associated with excellent refractive outcomes, predictability, and stability. However, the TMR group had superior visual acuity outcomes and significantly less residual refractive error EUROTIMES | DECEMBER 2018/JANUARY 2019

Cataract Poster Award winner Uwe Oberheide MD, Germany

and refractive astigmatism than the control group. Furthermore, analyses of total high-order aberrations, coma and contrast sensitivity favoured the TMR strategy. Dr Kanellopoulos concluded that the findings of the study may change the current clinical paradigm of the optimal subjective refraction utilised in laser vision correction. Anders Ivarsen MD, Denmark, received the second prize for refractive posters for his work on “Factors influencing the outcome of small-incision lenticule extraction for myopic astigmatism”. Another poster relating to SMILE®, “Three year observation of microdistortions in Bowman’s layer after SMILE for myopia”, by Jing Zhao MD, China, received the refractive poster third prize.

CATARACT The top two prizes in the Cataract Category went to researchers from Germany. Uwe Oberheide MD, received first prize for his poster, “Ray tracing simulations for small-aperture and toric IOLs in keratoconus eyes”. The poster explored the potential utility of implanting a small-aperture IOL as an alternative to a toric IOL in keratoconic eyes with irregular astigmatism. Interest in using a small-aperture IOL is based on the fact that limiting the optical system

to a central corneal region extends the depth of field and reduces the effect of peripheral corneal aberrations. The poster described the methods for the ray tracing simulations. In addition, it presented evaluations of focus, point spread function (PSF) and Zernike coefficients for an emmetropic eye with regular astigmatism, a phakic eye with keratoconus, and a pseudophakic keratoconic eye with best correction using a toric IOL or a small-aperture IOL. The measured PSF after toric IOL implantation and a simulation of PSF after optimised small-aperture IOL were also presented. Dr Oberheide concluded that significant improvement in image quality is achieved in keratoconus eyes using toric and small-aperture IOLs. Small-aperture IOLs, however, show slightly better image quality in the simulations. Second prize for cataract posters went to Ramin Khoramnia MD, Germany, for his study investigating “Effect of intraocular air or gas injection on hydrophilic intraocular lens material”. Nick Mamalis MD, United States, received the third prize in the category for his poster, “Evaluation of the biocompatibility of intraocular lens power adjustment using a femtosecond laser in the rabbit model”.

SPECIAL FOCUS: BEST OF THE BEST

FLACS versus phaco FEMCAT study finds outcomes similar regardless of cataract grade. Howard Larkin reports

n analysis of nearly 1,400 eyes of 870 patients participating in the FEMCAT trial comparing femtosecond laser-assisted phacoemulsification cataract surgery (FLACS) with phaco alone found no significant differences in overall clinical outcomes as measured by complication rates, post-op visual acuity, refractive error or change in corneal astigmatism, Cédric Schweitzer MD, PhD, told the 36th Congress of the ESCRS in Vienna. However, a trend toward better outcomes for lower-grade cataracts was observed in the femto group along with a trend toward better outcomes for the highest grade cataracts in the phaco group, added Dr Schweitzer, of the department of Ophthalmology at Bordeaux University Hospital, France, on behalf of the FEMCAT study group. In surgery, mean total ultrasound time and dissipated energy were lower in the

femto group for both lower- and highergrade cataracts, while mean aspiration time and BSS volume were significantly higher in the femto group. No specific issues or complications were observed related to the laser procedure, Dr Schweitzer said. The overall complication rate was 5.8%, with 5.7% in the FLACS group and 6.0% in the phaco group, an insignificant difference. Similarly, the overall rate of logMAR 0.0 best-corrected vision was 84.5%, with 83.6% and 85.4% in the FLACS and phaco groups respectively. Differences between rates of absolute refractive error of 0.75D or more and post-op corneal astigmatism change of 0.5D or greater with axis change of 20 degrees or more were also insignificant. FEMCAT is a large, randomised prospective study involving four surgeons in each of five centres operating on patients randomised to receive either FLACS or phaco alone with a sham laser procedure.

All patients received a 6.0mm hydrophobic acrylic monofocal lens, and were all operated with the same phacoemulsification machine within each centre, though different phaco machines were used at different centres. Funded by the French Ministry of Health, FEMCAT is intended to assess clinical outcomes in a real-world setting and develop an economic model and cost-effectiveness ratio for FLACS. The results so far do not appear to support a recommendation for payment for FLACS through public health insurance. “While ultrasound and energy decrease with femto cataract surgery, innovations are still needed to optimise the significant technical advantage of femtosecond laser over phacoemulsification and provide a clinical benefit for patients,” Dr Schweitzer concluded. Cédric Schweitzer: cedric.schweitzer@chu-bordeaux.fr

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SPECIAL FOCUS: BEST OF THE BEST

John Henahan Prize The winning entry for the writing competition was on the topic of “Do We Need A Randomised Controlled Clinical Trial in Cataract Surgery?” Colin Kerr reports

he winner of this year’s John Henahan Prize for Young Ophthalmologists was Dr Joséphine Behaegel. Dr Behaegel is a resident in the University Hospital Brussels, Belgium, and a researcher at the Antwerp University Hospital, Belgium. The winning entry for the writing competition was on the topic of “Do We Need A Randomised Controlled Clinical Trial in Cataract Surgery?” Emanuel Rosen, chief medical editor of EuroTimes and chairman of the judging panel, said all the submissions were of the highest quality making selection of a winner extremely difficult. “We drew up a shortlist of five entries from which we would choose the eventual winner,” said Dr Rosen. “The shortlisted essays were published in EuroTimes and anybody who read them will see what a difficult decision the judges had to make. “Randomised controlled trials (RCTs) are our guide to raising standards in cataract surgery. This winning entry not only encapsulates the essence of the importance of RCTs but is written in a style that encourages belief that the author will be a forceful communicator in her future career,” said Dr Rosen. Dr Rosen was joined on the panel by Thomas Kohnen, chairman of the ESCRS

“My PhD research gave me a Publications Committee; José Güell, lot of inspiration to write about former president of the ESCRS; this year’s subject,” said Dr Oliver Findl, chairman of the Behaegel. “I’m thankful to ESCRS Young Ophthalmologists my promotors and the people Committee; Sean Henahan, who supported me during this editor of EuroTimes; scientific journey.” Paul McGinn, editor of “Winning this prize is very EuroTimes; and Robert Henahan, rewarding. I’ve been reading contributing editor of EuroTimes. Joséphine Behaegel EuroTimes since the start of my Dr Behaegel received a travel residency and I always love the bursary worth €1,000 to attend the personal stories. Having my own 36th Congress of the ESCRS and a essay in EuroTimes is really an honour.” special trophy was presented to her at the Video Awards Session.

SCIENTIFIC JOURNEY Dr Behaegel studied medicine at Ghent University (Belgium). She started her residency in 2015 at the University Hospital Brussels, and shortly after decided to combine her training with a clinical research PhD at the University Hospital of Antwerp. Her research focuses on regeneration of the anterior cornea using cultivated limbal stem cell grafts. “This research triggered my interest in the anterior segment and I hope to continue the corneal work in a specialised centre,” said Dr Behaegel. “When I finish my PhD, I will return to full-time clinical work and would like to develop more surgical skills and complete a fellowship abroad.” Dr Behaegel said she was honoured to receive the Henahan Prize.

CALL FOR ENTRIES

INSPIRED A GENERATION

The Henahan prize is named in honour of John Henahan, who edited EuroTimes from 1996 to 2001. “John’s work has inspired a generation of young doctors and journalists, many of whom continue to work for EuroTimes. The prize will not only bring satisfaction to the winner and credit to all the contributors, but may enhance all their prospects of pursuing a medical writing aspect to their future careers. We look forward to their further contributions to EuroTimes and the Journal of Cataract & Refractive Surgery,” said Dr Rosen. Details of next year’s competition are available on www.escrs.org Joséphine Behaegel: Josephine.Behaegel@uzbrussel.be

JOHN HENAHAN

PRIZE 2019

Young ophthalmologists are invited to write an essay on “How To Balance Opthalmology And Family Life” First prize is a €1,000 travel bursary to the 37th Congress of the ESCRS in Paris, France.

CLOSING DATE: FRIDAY 29 MARCH 2019 Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org

EUROTIMES | DECEMBER 2018/JANUARY 2019

SPECIAL FOCUS: BEST OF THE BEST

Invention of the Capsulorhexis Development of the procedure highlighted in inaugural ESCRS Heritage Lecture. Dermot McGrath reports

nspiration, perspiration and a small degree of good fortune were the key ingredients in the invention of the capsulorhexis, Prof Thomas Neuhann told a packed audience at the inaugural ESCRS Heritage Lecture during the 36th Congress of the ESCRS in Vienna. “Like many inventions, the first capsulorhexis was the result of frustration with existing methods and a desire to find a better solution. There was also an element of chance in that I was faced with a special case on this particular day in 1984, which prompted me to try something different to access the lens material,” he said. The invention of the capsulorhexis, and more precisely the continuous curvilinear capsulorhexis (CCC), is credited to both Prof Neuhann and Howard Gimbel MD, who both independently applied the same circular concept, albeit using slightly different techniques. In the early 1980s, the state of the art in cataract surgery was the anterior capsulectomy for which three basis variants existed, noted Prof Neuhann: Charles Kelman’s “Christmas tree” technique, Cornelius Binkhorst’s “letter-box” opening and the more commonly used “can-opener” approach. The other contentious element of cataract surgery at the time was deciding where the posterior chamber lens would be implanted, said Prof Neuhann. The most common implantation site was the ciliary sulcus but a lot of debate focused on whether the lens might be better placed in the capsular bag “While the capsular bag was clearly the best place for the lens, the can-opener technique meant that the lenses were frequently decentred and there was a tendency for the haptics to pop out postoperatively. When this kept happening to me, I decided that either I find a solution to this or I stay in the sulcus,” said Prof Neuhann. Prof Neuhann’s eventual solution to the problem turned out to be the capsulorhexis, which he first performed on a young female patient with retinitis pigmentosa and loose zonules. “The capsule material was particularly tenacious and elastic and I simply could not get the usual can-opener technique to work. In my despair, I stuck a blade in and cut the capsule and inserted some Healon viscoelastic, which was not widely available at the time. I then took my tying forceps and tried to tear the capsule – and miracle of miracles, the tearing was much less strenuous on the capsule than trying to nick it with the capsulotome,” he said. The next step was to make the technique reproducible under conditions at the time, as viscoelastics were not generally available and Prof Neuhann had to use a tube-guided forceps with a chamber maintainer during surgery. “We eventually evolved to a needle technique because it was as sharp as a scalpel, it was viscoelastic independent and mydriasis independent. With the needle I could pull the pupillary margin back, I could make a cut with smooth edges and create two points for initiating the tear. It departed from

Prof Thomas Neuhann delivers the inaugural ESCRS Heritage Lecture during the 36th Congress of the ESCRS in Vienna, Austria

a single incision and then went 360 degrees around,” he said. To more accurately describe the new technique and differentiate it from preceding techniques, Prof Neuhann coined the term “capsulorhexis”, which uses the Greek suffix “rhexis” meaning “to tear”. At around the same time, Howard Gimbel was also experimenting with tearing out the capsule in arc-like sections, while leaving small bridges to stabilise the flap until the circle was mostly formed. “The basic principle of tearing was the same but my version ultimately stood the test of time because it proved to be a little bit more practical,” said Prof Neuhann. In recognition of the fact that they had both arrived at the same basic concept independently and around the same time, Drs Gimbel and Neuhann published a joint paper in 1990 that explained their respective contributions to the capsulorhexis breakthrough. “It was the right thing to do. My mentor Dick Kratz told me at the time: ‘I have seen so many bitter fights over priority. I think that was one of the nicest examples of resolving a priority discussion with dignity that I have ever seen.’” Professor Neuhann is the founder and current medical director of MVZ Prof Neuhann and of the ALZ Eye Clinic, and head of the eye department of the Red Cross Hospital, all in Munich, Germany. He played a key role in the development of modern cataract, refractive and glaucoma surgery techniques. He served as president of European Society of Cataract and Refractive Surgery (ESCRS) from 1998 to 2000 EUROTIMES | DECEMBER 2018/JANUARY 2019

SPECIAL FOCUS: BEST OF THE BEST

Glaucoma awareness

I N LE BA N O N

The Beirut Eye & ENT Specialist Hospital were winners of the 2018 ESCRS Practice Management Marketing Competition. General Manager Michael Cherfan explains why

he Beirut Eye & ENT Specialist Hospital (BESH) is widely regarded as one of the top specialty hospitals in the Middle East & North African region. BESH aspires to provide excellence in both medical and surgical care while operating in line with the highest international standards. BESH’s reputation for being a reference institution is rooted in the quality of medical professionals who choose to practise at the hospital. Faculty members are graduates from top North American/European medical institutions who seek to bring the latest medical thinking and techniques back to the region. As such, BESH has succeeded in coupling the country’s best eye and ENT care specialists – comprised of ophthalmology and otorhinolaryngology surgeons, optometrists, technicians and a qualified nursing team – with state-of-the-art facilities and equipment. Maintaining high service quality is a feat in any hospital anywhere in the world; however, it is even more so in Lebanon where medical institutions face a range of socio-economical obstacles. Historically, the Lebanese healthcare industry has always been one of the country’s most valuable assets. Having Arabicspeaking, “western”-educated doctors with access to modern healthcare equipment and infrastructure was, and still is, a recipe for success. However, of late, a poor economy, a gravely-in-debt state and an outdated social security system have put pressure on healthcare providers and middle-to-low income patients who struggle to afford quality healthcare. State-backed third-party payors can constitute 50% of a hospital’s admission portfolio and have long payment cycles (up to three years). As such, an institution’s ability to invest in new technologies, retain resources and maintain high-standard medical services is severely limited. It is not all bad, however! Despite the industry’s situation, BESH believes there is room for improvement on other fronts: continued medical education, staff training and patient education/awareness. In 2018, BESH organised the first Lebanese glaucoma awareness campaign as part of the World Glaucoma Week (March 12-18, 2018). The key objectives of the campaign were EUROTIMES | DECEMBER 2018/JANUARY 2019

to generate awareness about this prevalent disease and raise the hospital’s CSR profile. Visually-attractive booths were erected at two separate malls and free glaucoma screenings were offered. The staff distributed information leaflets/flyers and glaucoma simulation goggles were utilised to help visitors realise the potential effects of the condition. The twist to our campaign was our ability to leverage digital media (e.g. social media, online influencers) to generate a buzz around the topic, invite patients to the stands, and as a result, help us access a chunk of the population we would not typically reach. It was impossible to track the exact number of people who visited the stands, but more than 1,000 leaflets/flyers were distributed. We were able to gather the information for 665 patients that underwent a screening. Approximately 250 patients required further follow-up, 85% of which visited BESH for a follow-up and/or treatment. The campaign cost approximately $10,000 (€8,826), sponsored in full by a large pharmaceutical company. This sum

Courtesy of Michael Cherfan

included the booths’ production, space rental, marketing/designer fees and all the marketing collaterals. Unfortunately, patients were not flagged upon registration at BESH so a return on investment figure cannot be predicted. The campaign was a win-win-win situation benefiting our sponsor, our hospital and most importantly, the public. It was an honour to receive the first prize for the practice management competition at the 2018 ESCRS. Furthermore, the World Glaucoma Association, the Lebanese Ministry of Public Health and the Lebanese Order of Physicians all recognised the event as a success. We plan to run a bigger, better campaign next year and hope to make it more of a national affair in collaboration with other institutions.

SPECIAL FOCUS: BEST OF THE BEST

Videos showcase research Winning videos highlight innovative independent research. Roibeard Ó hÉineacháin reports

he winning videos in the 2018 Video Competition highlighted innovative independent research offering potential solutions to many of the unresolved issues in cataract and refractive surgery. The overall winner for this year’s video competition was Jiri Cendelin, Czech Republic, for “Iris reconstructive surgery”. The presentation described the design of a large model of the anterior eye for strategising and practising iris surgery. Ten times larger than a typical human eye, the model can be used to practise a range of surgical manoeuvres, including incisions and suture techniques, using similarly scaled tools. The model also includes scale models of capsular tension rings and aniridic IOLs for placement in the sulcus and capsule.

DIFFICULT AND SPECIAL CASES Athiya Agarwal, India, took first prize in the Difficult and Special Cases category for “Contiguous corneal delamination for giant OSSN”. She presents a casestudy in which she performed a cornealsurface-preserving technique for excising a giant ocular surface squamous neoplasia (OSSN). The neoplastic lesion measured approximately 20mm x 18mm and wrapped the entire 12 clock hours of Jiri Cendelin the cornea. Postoperatively, there were no sequelae and at the most recent evaluation the eye had a clear cornea without a residual scar and a bestcorrected visual acuity of 20/20.

bandage contact lens can reduce the early post-operative WongBaker pain scale from 8 to 2 in patients after undergoing the surface ablation procedure.

SCIENTIFIC CATEGORY Gerd Uwe Auffarth, Germany, took first prize in the Scientific category for “CSI Heidelberg: focusing on multifocal and EDOF technology”. The video presents a comparison of the peaks and ranges in focal power of three multifocal lenses and four extended depth of field lenses, using a green laser shone first through the lens and then through water stained with a fluorescent buffer to visualise the optical pathways.

RESIDENT IN TRAINING First prize in the Resident in Training category went to Akshay Kothari, India, for “Hunting the Great Whites”. The video outlines the modifications necessary in the phacoemulsification of intumescent cortically mature cataracts with a hard brown nucleus and soft cataracts with a gelatinous cortex, and how to deal with common problems of shallow anterior chambers, fragile capsules and weak zonules.

EDUCATIONAL First prize in the Educational category went to Graham Barrett, Australia, for “Plotting the right course for toric IOLs”. In it he presents his research showing that IOL calculations based on keratometry readings using the LenStar biometer would result in a higher proportion of eyes within 0.5D of emmetropia than IOL calculations using the IOLMaster 500 or the Pentacam, the greatest number achieving that refraction could be obtained using a calculation using K values obtained by all three machines. He also describes how he has integrated that potential functionality into the online Barrett Toric IOL Calculator.

HISTORICAL The winning video in the Historical category was Masara Laginaf, UK, for “The secret society of the oculists: enlightened pioneers or covert freemasons?” Dr Laginaf presents an analysis of the only recently decoded manifesto of the 18th-Century secret Highly enlightened society of oculists. The Cipher depicts the society’s arcane initiation ceremony and contrasts its members to inferior surgeons performing ocular surgery at the time. It also describes masonic rituals in great detail, suggesting a secondary motivation for the book.

INNOVATIVE In the Innovative category, Ritika Dalal, India, took first prize for “Sailing through post photorefractive keratectomy pain”, which showed how the use of a preservative-free ketorolac-soaked EUROTIMES | DECEMBER 2018/JANUARY 2019

SPECIAL FOCUS: BEST OF THE BEST

Bilateral surgery Do the benefits outweigh the risks of immediate sequential cataract procedures? Howard Larkin reports

ith the incidence of immediate sequential bilateral cataract surgery (ISBCS) ranging from nearly zero in the USA, Japan and much of Europe to 50% in Finland and 80% in the Canary Islands (Spain), the practice remains controversial. The debate surfaced once again at the 36th Congress of the ESCRS in Vienna. On the plus side, ISBCS has clear advantages for patients, hospitals and health systems, said Juan J Mura MD, MHA, of the University of Chile, Santiago. These include faster visual rehabilitation, fewer pre- and post-op visits, more efficient OR time, shorter waiting lists, lower price and most importantly, cost-effectiveness (providing better “value for money” when you compare ISBCS with delayed strategy – DSBCS), with hospital costs about $1,600 less in Canada and €500 less in the Canary Islands, and savings per patients ranging from €120 to €850, the effectiveness (using QALYs) is higher, which means maximised health for the available resources (Malvankar-Mehta M et al. Can J Ophthalmol 2013:48(6). Canary Islands government analysis). These savings and increased efficiency will become more important as demand for cataract surgery rises, Dr Mura noted. “We have to remember that resources are always scarce, especially with what is happening to our population, which is ageing rapidly.” Quicker visual rehabilitation is also a significant benefit, Dr Mura said. Patients undergoing ISBCS have better visual function and fewer difficulties performing daily tasks than patients undergoing separate procedures after the first surgery, even in the three-tofour months after a second eye surgery ISCBS maintains better patient-reporterd evaluation, although outcomes are equivalent after six-to-12 months (Lundstrom M et al. J Cataract Refract Surg. 2006;32(5):826-30.). However, there are other practical connections; for example, between first and second cataract surgeries the risk of falls resulting in hospitalisation rises to 2.14 times pre-surgery levels, and falls back to about 1.34 times after the second surgery (Meuleners L et al. Age and Aging 2014; 43:341-346). With the advent of optical biometry, refractive predictability also has improved, with studies showing ISBCS at or near separate surgery levels, Dr Mura added (Ganesh S et al. Indian J Ophthalmal 65(5)).

BILATERAL ENDOPHTHALMITIS The greatest risk of ISBCS is bilateral complications that could result in visual loss in both eyes, Dr Mura noted. However, so far only four cases of bilateral simultaneous endophthalmitis have been reported, and all four failed to follow the recommended protocol established by the International Society of Bilateral Cataract Surgeons (ISBCS). The ISBCS protocol calls for completely isolated surgeries, with nothing in contact with the first eye used for the second eye, instruments from separate sterilisation cycles, OVDs and supplies from different manufacturers or lots, separate sterile routines and independent preparation of the second eye operating field and intracameral antibiotic use. Most importantly, the complexity of the surgery should be well within the surgeon’s capabilities. This minimises the risk of systemic cross infection, Dr Mura said. At a rate of one in 5,750 individual procedures, the random risk of bilateral endophthalmitis is one in 33 million. However, this analysis does not consider risk factors not under surgeons’ control, said Myoung Joon Kim MD, PhD, of the University of Ulsan College of Medicine, Seoul, Korea. “The two eyes are not independent, there are risks that affect both eyes and we must think about this,” Dr Kim said. Patient-related risks include compromised immunity, blepharitis or eye rubbing or other habits that may increase infection risk. This cannot be screened easily at the clinic, he noted. Device-related factors such as manufacturing, cleaning or sterilisation issues could also increase systemic risk even when precautions such as using items from separate sterilisation cycles are taken, Dr Kim added. Other risks are completely unknown. In addition, delaying the second surgery creates an opportunity to correct any refractive surprise that crops up, Dr Kim said. Even with the best biometry and lens formulas about 20% of eyes are more than 0.5 dioptres off target. Delaying the second surgery allows for compensating based on experience with the first eye, he said. For these reasons, Dr Kim does not support routine use of ISBCS, though it may be appropriate for select patients, such as those requiring general anaesthesia. Juan J Mura: jmurac@vtr.net Myoung Joon Kim: mjmjkim@gmail.com

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23rd ESCRS Winter Meeting

ath ens In conjunction with the 33rd HSIOIRS International Congress

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

Main Symposia Friday 15 February

Saturday 16 February

New Advances in Glaucoma

When the Unexpected Happens

Chairpersons: V. Karampatakis GREECE S. Morselli ITALY

Chairpersons: S. Georgaras GREECE D. Spalton UK

Saturday 16 February

Sunday 17 February

Trends in Refractive Surgery

Pearls for the Young Cataract Surgeon

17.00 – 18.30

11.30 – 13.00

Chairpersons: V. Katsanevaki GREECE T. Kohnen GERMANY

Programme, Hotel Bookings & Registration Available Online

16.30 – 18.00

09.00 – 10.30

Organised by the Young Ophthalmologists Committee Chairpersons: S. Palkovits AUSTRIA C. Pedrosa PORTUGAL N. Visser THE NETHERLANDS

Other Sessions Friday 15 February

Saturday 16 February

l Basic Optics Course

l Cataract Surgery Didactic Course Part 2

l Cataract Surgery Didactic Course Part 1

l Cornea Didactic Course

l ESCRS/EuCornea Cornea Day

l Free Paper Session

l Free Paper Sessions

l Near Live Surgery Session

l HSIOIRS/Egyptian Ophthalmological

Society Symposium

Keratoconus: Diagnosis and Management l Instructional Courses

l Moderated Poster Session l Refractive Surgery Didactic Course Part 2 l ESONT didactic programme for ophthalmic

nurses & technicians

l Moderated Poster Session l Refractive Surgery Didactic Course Part 1

Sunday 17 February

l Young Ophthalmologists Programme

l HSIOIRS Symposium

Advanced Technology: Better Results?

23 l

SURGICAL SKILLS

TRAINING COURSES

Book early to avoid disappointment

www.escrs.org

CATARACT & REFRACTIVE

Complications of

C ATAR AC T SURGERY There are ways of avoiding corneal wound burn and corneal incisional contracture. Soosan Jacob MD reports

he corneal incision used in phacoemulsification plays a vital role in maintaining the self-sealing nature of the tunnel thereby preventing wound leak, shallow anterior chamber (AC) and endophthalmitis postoperatively. The self-sealing architecture of the tunnel is also extremely crucial to avoid high postoperative astigmatism and to maintain the normal shape of the cornea. Though rare, corneal incisional contracture or wound burn is a complication that every surgeon needs to be aware of as it results in irreversible damage to incisional architecture, fishmouthing and loss of integrity.

CAUSES OF WOUND BURN Back-and-forth movement of the metallic phaco tip within the sleeve that occurs during application of phaco power generates stress on the metal and creates friction that generates heat, which can be translated to the incision leading to a wound burn. Thermal damage to the collagen fibres occurs at a temperature of 60 degrees centigrade and leads to contracture and wound distortion. The phaco tip is continuously cooled by fluid entering the AC around the tip through the phaco sleeve as well as aspirated fluid exiting through the hollow bore of the tip. In addition, incisional leakage through the wound around the sleeve also helps prevent rise in temperature of corneal collagen. Phacoemulsification in the absence of adequate fluid flow through the sleeve, secondary to a tight incision or kinking of the sleeve against the wound, can lead to a corneal burn. A tight incision also decreases incisional leakage resulting in localised temperature rise at the corneal incision. EUROTIMES | DECEMBER 2018/JANUARY 2019

Back-and-forth movement of the phaco tip generates heat. A: Flow of fluid around the tip through the silicone sleeve; B: unoccluded continuous flow through the phaco tip; C: and leakage through the incision; D: all help in cooling the tip and preventing wound burn

AVOIDING WOUND BURN Corneal wound burn can be avoided by decreasing the heat built-up at the incision. This can be achieved by using lower phaco power settings, larger incisions, adequate fluid flow, modified tips and modified sleeves. High vacuum and low power with suitable power modulations avoid excessive temperature rise. The process of cavitation generates heat. Certain phaco modes are more prone to heat generation. Under similar conditions of power, stroke length and energy, longitudinal ultrasound generates more heat than torsional secondary to a lower operating frequency as well as decreased stroke length at the incision. Similarly, continuous mode phaco creates more heat than pulse mode. The off period in pulse mode allows the

tip to cool in between two pulses as well as reducing the total amount of power used and thus also the heat generated. Using a lower duty cycle minimises heat production, allows better cooling of the tip and allows aspiration of the emulsified nuclear fragments, thus decreasing heat production. Handpiece frequency and stroke length are other important factors. Higher power utilisation generates more heat. Similarly, prolonged phaco time can cause wound burns. Modifications in phaco tip design â&#x20AC;&#x201C; thinner tips, microtips, titanium tips with the same inner bore but smaller outer bore as well as modified sleeve designs with straight or spiral ribbing or other textured designs, using polyimide insulator, aspiration bypass system and

CATARACT & REFRACTIVE making sleeves stiffer to allow greater flow can help decrease wound burn. Different phaco machines employed under similar conditions with similar settings often have differing amounts of heat generation due to differences in make and design. In addition, nucleus removal technique also determines the amount of heat produced. Chop techniques use manual energy for nuclear disassembly and therefore cause less heat generation than divide and conquer, stop and chop or other techniques using ultrasonic disassembly. Free flow of fluid in and around the phaco tip is a prerequisite for efficient cooling. A tight wound can restrict fluid flow both within the sleeve as well as around the sleeve. Needle size, sleeve size and incision size should be appropriate to each other. Higher bottle height and higher aspiration flow rate both increase fluid turnover in the AC thus promoting cooling. Retention of air or viscoelastic near the phaco tip decreases efficiency of cooling mechanisms at play thus predisposing to wound burn. Clogging of the phaco needle, handpiece or tubing by viscoelastic or a dense nuclear piece leading to blocked aspiration flow can cause sudden release of heat and a corneal burn. Using ultrasound energy within viscoelastic releases heat and the incidence is higher with Healon 5, Ocucoat and Viscoat. Listening to audible sounds from the machine indicating occlusion and also making sure not to run out of irrigating fluid inadvertently are important. Viscoelastic overfill should be avoided and it should be cleared from around the phaco tip before proceeding with nuclear emulsification. Confirming free flow of fluid into the phaco tip is important before

Free flow of fluid in and around the phaco tip is a prerequisite for efficient cooling. A tight wound can restrict fluid flow both within the sleeve as well as around the sleeve initiating ultrasound. If occluded, either I/A mode should be used to clear clogged material or the phaco needle should be removed and outflow flushed to remove any clogs.

RECOGNISING WOUND BURN Lens milk is a sign of decreased flow and stagnant emulsification near the phaco tip and is seen as a cloudiness secondary to milky lenticular material with no substance seen evacuating out of the eye through the phaco tip. Phacoemulsification should immediately be stopped to avoid further worsening. Whitening and coagulation of the incision is another sign that should be recognised immediately and is secondary to damage to adjacent corneal stroma and endothelium. Other signs include incisional fish mouthing, difficult wound closure, wound leak and an unstable anterior chamber. Postoperatively, continuing leakage, shallow AC, corneoscleral melt, corneal fistula, increased risk of endophthalmitis, high postoperative astigmatism, poor uncorrected and best-corrected visual acuity, irregular astigmatism and

poor ocular surface are some of the difficulties encountered.

MANAGEMENT OF WOUND BURN Multiple interrupted sutures or running cross-sutures may be needed. Special “gape sutures” as described by Robert Osher can help seal the incision and minimise induced astigmatism. Tissue adhesive, bandage contact lens and aqueous suppressants may help. Seidel negativity should be confirmed. Leaving iris incarcerated has been proposed as a solution followed at a later date by separation of iris. The author has used a SMILE® lenticule as a filler graft to avoid an overly tight incision. Astigmatism can decrease after suture removal and over longer follow-up. Various means to tackle astigmatism include contact lenses, glasses, arcuate keratotomy, topographyguided LASIK, small-aperture IOL, pinhole pupilloplasty etc. 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

Grow Your Practice Through Innovation Win a €1500 Bursary.

ESCRS Practice Management and Development Innovation Award Submission Deadline Monday 29 July 2019

ESCRS

For further details visit: www.escrs.org

Practice Management

& Development

EUROTIMES | DECEMBER 2018/JANUARY 2019

CATARACT & REFRACTIVE

FLACS on trial The jury is still out on the benefits of femtosecond laser-assisted cataract surgery. Dermot McGrath reports

emtosecond laser-assisted cataract surgery (FLACS) increases the safety and efficacy of cataract removal and results in more reliable and stable postoperative outcomes, according to Zoltan Nagy MD. “FLACS advances an all-manual procedure to a precise, reproducible laser procedure. It improves certain key steps of cataract surgery such as corneal incision, capsulorhexis and lens fragmentation,” Dr Nagy told delegates attending a debate on the pros and cons of FLACS held during the World Ophthalmology Congress in Barcelona. In traditional cataract surgery, capsulotomy size is directly related to effective lens position and corneal incisions are manually executed and can be imprecise, explained Dr Nagy. “We also know that extensive phacoemulsification power is sometimes associated with corneal burn, corneal oedema and endothelial cell loss. Some studies show that cataract surgery complications are 10 times that of LASIK, ranging from common complications such as posterior capsule opacification (PCO), cystoid macular oedema, vitreous loss and endothelial cell loss up to vision-threatening complications such as retinal detachment and endophthalmitis,” he said. Corneal incisions are not optimised in current cataract surgery and can result in astigmatism and infection, said Dr Nagy. The size and centration of the capsulorhexis also tends to be variable resulting in imprecise IOL position and lens power and may lead to problems of capsular tears and PCO. Excessive ultrasound power is used for lens fragmentation which can result in delayed visual recovery, loss of endothelial cells and capsular rupture, he added.

The difference was not clinically significant and there was no difference found for uncorrected distance visual acuity Cédric Schweitzer MD EUROTIMES | DECEMBER 2018/JANUARY 2019

Some studies show that cataract surgery complications are 10 times that of LASIK, ranging from common complications such as posterior capsule opacification (PCO)... Zoltan Nagy MD While FLACS increases the safety and efficacy of cataract removal, Dr Nagy said it will not replace traditional phacoemulsification. “It will, however, replace the manually executed incision and capsulotomy steps and will effectively fragment the lens for more efficient lens removal. The ultimate goal of FLACS is to give the patient a premium surgical experience and the surgeon a procedure to be performed with confidence and predictability,” he concluded.

NO CLINICAL BENEFIT FOR PATIENTS? Presenting the arguments against FLACS, Cédric Schweitzer MD said that while femtosecond technology is undoubtedly impressive there are currently no compelling arguments to justify investment in a femtosecond laser for cataract surgery. “Femtosecond laser offers precise incisions associated with real-time imaging and clearly defined safety zones. It is very appealing technology but the reality is that this very precise cutting technology does not provide a meaningful difference in clinical outcomes for our patients,” he said. The argument that FLACS leads to reduced intraoperative or postoperative complications does not really stand up to scrutiny, said Dr Schweitzer. “If we look at posterior capsule rupture (PCR) which is the most common intraoperative complication of cataract surgery, a recent five-year audit study by Ti et al. of 48,377 phacoemulsification cases recorded 887 PCRs (1.8%). It is interesting to note that 60% of PCR cases occurred during the phacoemulsification stage, 25% during the irrigation-aspiration stage and 7% during IOL implantation. So, it is clear that FLACS cannot save all capsular rupture cases,” he said.

Another meta-analysis by Popovic et al in 2016 also found that PCR was actually more frequent in FLACS patients than those who underwent traditional phacoemulsification. For postoperative endophthalmitis, an extensive French registry study by CreuzotGarcher et al. of 6 million procedures from 2005 to 2014 showed a global decline of endophthalmitis cases from 0.145% to 0.053% related to the improvement in surgical procedure and intracameral antibiotic use, said Dr Schweitzer. In terms of visual and refractive outcomes, a recent Cochrane meta-analysis by Day et al. reported a small advantage for FLACS at six months in corrected distance visual acuity (CDVA). “The difference was not clinically significant and there was no difference found for uncorrected distance visual acuity,” said Dr Schweitzer. Furthermore, the recent FEMCAT large-scale prospective, multi-centre French study of some 1,500 cases found no significant difference in terms of overall complication rates, best-corrected visual acuity (BCVA), mean absolute refractive error or postoperative changes in corneal astigmatism between FLACS and standard phacoemulsification, he added. Summing up, Dr Schweitzer said despite the high precision of tissue cutting and safety, there is no evidence that FLACS improves health benefits for patients. “It is more expensive and time consuming. It could, however, represent a new paradigm if there is further improvement in femtosecond laser innovation or association with other innovations in fluidics and new implant designs,” he said. Zoltan Nagy: nagy.zoltan_zsolt@med.semmelweis-univ.hu Cédric Schweitzer: cedric.schweitzer@chu-bordeaux.fr

CATARACT & REFRACTIVE

Multicomponent IOLs offer benefits IOL with exchangeable optic allows for easier enhancement procedures. Roibeard Ó hÉineacháin reports

he multi-component Precisight intraocular lens (InfiniteVision Optics) can allow the precise predictable adjustment of postoperative refraction through exchange of the anterior optical element, without exchanging the entire IOL, said Harvey Siy Uy MD, Peregrine Eye and Laser Institute, Makati, Philippines. “This lens provides a safe, consistent and efficient method of improving refractive and visual outcomes after cataract surgery. The enhancement procedure is fast, easy to learn and enables surgeons to optimise refractive outcomes,” Dr Uy told the 36th Congress of the ESCRS in Vienna, Austria. Dr Uy and associates assessed the predictability of enhancement procedures in a series of 30 patients who had manifest refraction spherical equivalent (MRSE) greater than 0.75D following cataract removal and implantation of a preassembled, multi-component IOL into the capsular bag. The surgeons performed the enhancement procedures from three months to one year after the primary surgery. It involves separating the front lens from the base lens and removing it through the original incision using IOL forceps. Then a new front lens with a different refractive power was injected into the anterior chamber and attached to the base lens, Dr Uy explained. Following the enhancement procedure, the mean uncorrected visual acuity improved from a pre-enhancement value of 0.2 logMAR to 0.0 logMAR (p=0.008). In addition, the mean MRSE improved from a pre-enhancement value of +1.39D to +0.09D after enhancement (p=0.0002). Furthermore, after enhancement, all eyes had UDVA of 0.1 logMAR or better. Dr Uy noted that all of the procedures were completed within five minutes or less. None of the eyes developed significant adverse events. Furthermore, there was no change in the anterior chamber depth after the procedure, nor was there was a significant decrease in endothelial cell density. Patients who could benefit from multicomponent IOLs include patients with refractive errors, those who are intolerant of multifocal IOLs and those who decide that they would like to try multifocality, Dr Uy said. A difficulty with treating presbyopia with multifocal IOLs in the past has been the difficulty of predicting patient satisfaction and tolerance of multifocals. An early IOL exchange in cases of dissatisfaction is easier but will not give patients time to neuroadapt. IOL exchange at a later stage is more complicated because of fusion of the capsule. However, because its base lens and haptics remain in place during enhancement procedures, the Precisight has no such time limitations. Harvey Siy Uy: harveyuy@yahoo.com

...all of the enhancement procedures were completed within five minutes or less. None of the eyes developed significant adverse events

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CATARACT & REFRACTIVE

Engineers in ophthalmology Today’s technological marvels are products of large-scale collaboration. Howard Larkin reports

idley, Binkhorst, Kelman, Barraquer – the names of the great innovators in ophthalmology are well known and celebrated with, among other things, named lectures at clinical meetings around the world. But without the concerted efforts of thousands of engineers and surgeons, the highly integrated, efficient and ergonomic instruments ophthalmic surgeons rely on today would not be possible, Steve Charles MD told the American Society of Cataract and Refractive Surgery in the 2018 Charles D Kelman Innovators Lecture. First trained as an electrical and mechanical engineer, from his days as a medical student at Bascom Palmer, Dr Charles always intended to do both microsurgery and engineer better medical technology. “Techniques don’t work without technology; you can’t do phaco without surgical technologies,” said Dr Charles, of the University of Tennessee and founder of the Charles Retina Institute, Memphis, Tennessee, USA. He emphasised the evolutionary and iterative nature of technology development. Fame and vanity patents mean nothing on their own, Dr Charles said. “If multiple surgeons and multiple engineers collaborate and we keep the patient and patient outcomes in mind,” however, “then good things happen.”

COMPLEXITY AND TEAMWORK Very few devices are the invention of a single person, and as complexity goes up, so does the need for large teams in improving technology, Dr Charles said. The first vitrectomy machine was the invention of one man, Jean-Marie Parel for Robert Machemer MD, Dr Charles noted. But modern vitrectomy systems like the Alcon Constellation, for which Dr Charles is the principal architect, are the work of more than 100 engineers. “[There are] 650,000 lines of code, 14 processors, so you need mechanical, electrical, regulatory compliance, EMI/RFI, all sorts of manufacturing engineering and software engineering,” he said. EUROTIMES | DECEMBER 2018/JANUARY 2019

Steve Charles accepts the 2018 Charles D Kelman Innovator’s Award from ASCRS Annual Meeting Programme Chair Edward J Holland and Anne Kelman

The key is that the original machine introduced a workable system of surgery, not just an instrument, and that system has been continuously refined, Dr Charles said. Tracing the evolution of vitrectomy as an example, Dr Charles noted that the next big evolution was invention of the three-port 20-gauge axial system by Conor O’Malley MD and engineer Ralph Heinz. Castigated initially, it was a major step forward, making the procedure more flexible by allowing infusion without the cutter in the eye. It is the basis of systems used today. Developing lighter, disposable, selfsharpening and dual-action cutters were a series of major innovations that increased cutting speed from about 400 to more than 10,000 per second today. Another critical element is aspiration fluidics, a technology that Dr Charles has helped develop for years. The first Machemer machine used a manual syringe operated by an assistant. “That’s like driving a car and having your next-door neighbour who had too many beers operate the gas pedal,” Dr Charles said. This was followed by a rack and pinion syringe drive and then foot pedalcontrolled aspiration that gave the surgeon direct control.

More recently, faster processor response time, faster responding, auto-emptying aspiration chambers, foot pedals that allowed aspiration with or without cutting and chambers with multiple control valves and optically controlled fluid levels have made vitrectomy systems ever more stable and responsive, allowing surgeons to focus on the patient, rather than running the machine. “We went from two- or three-second response times to 100 milliseconds,” he said.

SYSTEM INTEGRATION Today’s systems are the product of integration, with all functions, including lasers, built into a single device controlled through a single interface, another approach Dr Charles helped pioneer. These now allow the surgeon to do with one piece of equipment what once took a room full of separate boxes run by at least one assistant. Each advance addressed issues with existing technology, Dr Charles said. “It isn’t about taking credit or getting your name on it or making money; it is about what was wrong with the last step and how do you go to the next step.” Steve Charles: scharles@att.net

CATARACT & REFRACTIVE

CONGRATULATIONS! THOMAS KOHNEN European editor of JCRS

JCRS HIGHLIGHTS VOL: 44 ISSUE: 11 MONTH: NOVEMBER 2018

POWER PREDICTION IN SHORT EYES IOL power prediction in eyes with short axial lengths continues to be a challenge. Indian researchers conducted a retrospective study in 50 eyes of 50 patients with axial lengths less than 22mm, comparing six IOL power formulas: the Barrett Universal II, Haigis, Hoffer Q, Holladay 2, RBF Method and SRK/T. To eliminate bias, the study used partial coherence interferometry, implanted the same IOL type and had the same surgeon perform all the surgeries and same refractionist conduct all the biometric analyses. The team applied the Friedman test to compare the median absolute error between the six formulas after the zeroing of the mean numerical error. The formulas were equally accurate in predicting the IOL power in the study eyes. They conclude that larger studies will be needed to determine the formula of choice in patients with short axial lengths. AK Shrivastava et al., JCRS, “Precision of intraocular lens power prediction in eyes shorter than 22 mm: An analysis of 6 formulas”, Vol. 44, Issue 11, 1317-1320.

EPI-ON CORNEAL CROSS-LINKING A new corneal cross-linking technique could help eliminate the potential complications associated with conventional epi-off surgery, a new study suggests. Some 512 eyes of 308 patients with keratoconus or forme fruste keratoconus, and 80 eyes of 55 patients with ectasia after LASIK, were treated with a new riboflavin formulation without epithelial removal, then exposed to UV light (365nm) at 4mW/cm2 with on-off cycling for 30 minutes. The riboflavin formulation did not contain dextran. It was optimised at a specific concentration, pH and osmolarity to enhance absorption and it contained sodium iodide, which acted as an excipient. Uncorrected and corrected distance visual acuities improved by 1 to 1.5 Snellen lines at one and two years postoperatively (P<0.0001). Mean Kmax decreased by 0.48D at two years. R Doyle Stulting et al., JCRS, “Corneal crosslinking without epithelial removal”, Vol. 44, Issue 11, 1363-1370.

SMILE RETREATMENT OPTIONS Small-incision lenticule extraction (SMILE®) retreatment is performed when the refraction is overcorrected or undercorrected or optical regression has occurred. Because it is a relatively new surgery, data on the retreatment rates are limited. Options include surface ablation, thin-flap LASIK, secondary SMILE and cap-to-flap procedures. To help surgeons choose the option tailored to their specific patient needs, Moshirfar and colleagues constructed a chart of the major advantages and disadvantages of each retreatment option and the available visual outcomes. They also designed a simple algorithm that might provide additional help in selecting the appropriate retreatment, each of which are described in detail. M Moshirfar et al., JCRS “Surgical options for retreatment after small-incision lenticule extraction: Advantages and disadvantages”, Issue 11, 1384-1389.

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 | DECEMBER 2018/JANUARY 2019

CATARACT & REFRACTIVE

Promise and challenges Ophthalmology is well positioned for value-based care, AAO meeting hears. Howard Larkin reports

he road to the future for our profession has never been more promising or challenging,” AAO President-Elect George A Williams MD told the opening session of the American Academy of Ophthalmology 2018 Annual Meeting in Chicago. New therapies and technologies for preserving and restoring sight are the promise. How society will pay for them is the challenge, said Dr Williams, a retina and vitreous specialist who practises in Royal Oak, Michigan, USA. In the USA, it is widely accepted that about $1 trillion of the $3.5 trillion spent annually on health care is wasted on low-value care and over-treatment, Dr Williams noted. As a result, payment is moving from a volumebased system to a value-based system. “Today ophthalmologists and all physicians practice in a world of measured performance and cost transparency. In the coming years the metrics will become more difficult and the bright light of accountability will shine even brighter,” Dr Williams said. Patients, insurers, government and businesses will have more performance data and will hold physicians accountable for delivering value. “The obvious question is what is value and who shall define it,” Dr Williams said. The positive impact that services have on individual patients’ quality of life is a critical

factor – and one that ophthalmology is well prepared to demonstrate, he added. “I believe we should embrace this transition, because in a true value-based system, ophthalmology wins,” said Dr Williams, who for years has worked with government agencies on value-based care. He cited the 98% success rate of cataract surgery in restoring vision for life for a cost of less than $2,000 as an example of the value ophthalmology brings. “What we do changes lives.” Supporting data gathering through AAO’s Intelligent Research in Sight (IRIS) registry is critical to getting the word out. With more than patient records from 52 million patients to date, IRIS is the world’s largest clinical database, Dr Williams noted. With its contributions to improving the quality and effectiveness of ophthalmic care and making the case for its value to patients, IRIS has changed and will continue to change the AAO, moving it toward greater value for patients, Dr Williams said. “We have chosen the road to demonstrate the value of ophthalmic care. It will not be straight, it will not be easy. But we know where we are going.” Injuries from unapproved ocular cell injection therapies are underreported by the clinics administering them, said researchers from the University of Rochester and the University of Miami.

Sophi is here.

AAO HIGHLIGHTS • Steven T Charles MD was named AAO 2018 Laureate based on his lifetime work developing techniques and technology for vitreoretinal surgery. • Philip J Rosenfeld MD, PhD, delivered the Jackson Memorial Lecture outlining the development of anti-VEGF therapy for treating wet AMD, and the epic struggle with industry and the FDA to preserve patient access to compounded bevacizumab as an affordable alternative. • A device for delivery of ranibizumab for periods up to one year for patients with age-related macular degeneration may be available in about three years following a successful trial, said researchers at Wills Eye Hospital. The device could reduce the need for frequent intravitreal injections while improving outcomes. • Metformin, commonly used to control type 2 diabetes, may be protective against development of age-related macular degeneration, according to researchers in Taiwan. • A popular online symptom checker operated by WebMD incorrectly diagnosed ocular symptoms 74% of the time and often underestimated their severity, often leading to inappropriate recommendations for self-care, found a study by researchers at McMaster University in Canada.

Safety Regarding hygiene and safety Sophi strikes new paths. The Clean Venturi Pump and the automated Cassette Slot-In-System reduce the risk of contamination. The IOP Control Pump is designed for high chamber stability.

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.

EUROTIMES | DECEMBER 2018/JANUARY 2019

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CATARACT & REFRACTIVE

Astigmatism the final frontier

stigmatism is an issue in all forms of visual intervention, from spectacles and contacts, to corneal surgery, LASIK and lens implantation. EuroTimes talked to Noel Alpins MD, Medical Director, New Vision Clinics, Melbourne, Australia, about ongoing efforts to deal with astigmatism associated with cataract surgery.

How are we doing in terms of assessing cataract patients for pre-operative astigmatism, and planning accordingly? Measuring the preoperative corneal astigmatism has certainly become more accurate as the technology has improved. Tomography devices have the ability to measure the posterior cornea and with this and other information quantify a total corneal astigmatism. The parameter known as corneal topographic astigmatism total (CorT Total) first described in 20151 has been shown to provide a more accurate measure of corneal astigmatism that includes the posterior cornea than those that only measure anterior cornea such as simulated keratometry, manual keratometry and automated keratometry. I use the CorT Total when planning toric IOLs to obtain an accurate toricity of the IOL power, when planning limbalrelaxing incisions (LRIs) and when treating astigmatism by Vector Planning in refractive laser surgery. What can we do to reduce or eliminate iatrogenic astigmatism associated with cataract surgery? The surgeon can harness the primary phaco incision to reduce the corneal astigmatism by placing it at the steepest corneal meridian. It is important that the Flattening Effect (FE)2 is determined from aggregating results from previous surgical cases – that is, the amount of flattening the incision induces at the planned incision meridian. Looking at my own results, a close to astigmatically neutral incision is obtained when I place a 2.2mm incision on the flat meridian of the corneal astigmatism or on the

20 OD/200 OS meridian, ergonomically comfortable for a RH surgeon.3 I use this when planning a toric IOL procedure and do not want to change the corneal astigmatism after preoperative measurements and calculations have been performed, to avoid any inaccuracies in the planned toric IOL. Placing the phaco incision on the steep corneal meridian can also introduce a useful flattening change in the corneal astigmatism with spheric implants. However, a refractive surprise can occur by rotating the astigmatism as a result of the torque effect of SIA, which can often disappoint when alignment is a priority. So if the corneal astigmatism is against-the-rule and a temporal incision is used, be as accurate as possible with placing the incision on the steep meridian and know how much astigmatism you are able to reduce when planning for the best toric IOL choice. Remember the SIA and FE of the incision increase with increasing astigmatism.4 At the extremes, what are the lowest and highest amounts of astigmatism that can be treated predictably? The minimum toric IOL I would implant would be 1.50D toricity at the IOL plane. With corneal astigmatism of 1.25D or less, I would proceed with an LRI or place a 3mm phaco incision on the step corneal meridian to minimise the astigmatism postoperatively. My preference is for a spherical cornea rather than an astigmatic cornea and a toric IOL which can degrade the visual quality postoperatively. The maximum toricity I have implanted was a ZCT700 (AMO) IOL, which is approximately 4.80D at the corneal plane, but there are implant powers readily available above this amount. How good are toric IOLs now, and how are we doing with issues such as decentration? Toric IOLs have certainly improved in optical quality and range of parameters available in recent times – with good alignment and effective choice of toric power they are very beneficial to the patient's spectacle-free visual outcome after

Courtesy of Noel Alpins, MD

Evolving solutions to reduce astigmatism in cataract surgery. Sean Henahan reports

The corneal topographic astigmatism total (CorT Total), which includes the posterior cornea, is closer to the refractive cylinder than CorT anterior and Simulated Keratometry.

cataract surgery. I find that incorporating iris imaging using CallistoTM or VerionTM is more reliable and accurate than marking the eye. This has been borne out by several studies. The challenge of centration is that when implanting a toric multifocal IOL, the IOL is primarily centred according to the rings to be concentric with the undilated pupil. The secondary priority is that the toricity is aligned to the correct axis – the imaging lines do not necessarily need to overlap the toric marks on the IOL but must at a minimum be parallel to them, giving priority to the multifocal IOL centration. For more detailed information on astigmatism and cataract surgery refer to: Alpins N. Practical Astigmatism: Planning and Analysis. Thorofare, NJ:SLACK:2017 1. Alpins N, Ong JKY, Stamatelatos G. Corneal topographic astigmatism (CorT) to quantify total corneal astigmatism. J Refract Surg 2015; 31(3):182-186. 2. Alpins NA. Vector analysis of astigmatism changes by flattening, steepening, and torque. J Cataract Refract Surg 1997 December;23(10):1503-14. 3. Alpins N, Ong JKY, Stamatelatos G. Asymmetric Corneal Flattening Effect After Small Incision Cataract Surgery. J Refract Surg 2016 December;32(9):598-603. 4. Chang SW, Su TY, Chen YL. Influence of Ocular Features and Incision Width on Surgically Induced Astigmatism After Cataract Surgery. J Refract Surg. 2015; 31(2): 82-88. EUROTIMES | DECEMBER 2018/JANUARY 2019

CORNEA

Cataract and Fuchs’ Many factors determine if surgery will be combined or sequential. Cheryl Guttman Krader reports

hen patients with Fuchs’ dystrophy develop cataract, surgeons are faced with deciding whether to operate on the cataract, the cornea or both and in what order if they choose to stage the procedures. Discussing these questions at the 36th Congress of the ESCRS in Vienna, Austria, Jesper Hjortdal MD, PhD, and Donald Tan MD agreed that there are no one-size-fitsall answers. Both surgeons said that they generally do a triple procedure because then patients need only one surgery and benefit with a faster visual recovery. However, the decision is multifactorial. “We need to take into account patients’ rising expectations for visual quality along with the rapidly changing field of corneal transplantation. Surgeon experience and the learning curve of Descemet membrane endothelial keratoplasty (DMEK) remains a major factor in the process of deciding whether to stage or combine the surgeries. When in doubt, the safest approach is always defensible. Although there are advantages of a combined procedure, it is probably often safer to do the surgeries sequentially,” said Dr Tan, Adjunct Professor, Singapore National Eye Centre, Singapore.

KEY QUESTION Whether the patient’s visual symptoms are related to the corneal disease and/or the cataract is a primary consideration for surgical planning. Whereas blurred vision is a symptom of both cataract and Fuchs’ dystrophy, diurnal fluctuation is a sign of early corneal decompensation from Fuchs’ dystrophy. “Patients with significant Fuchs’ dystrophy will notice difficulty in the morning and improvement later in the day,” said Dr Hjortdal, Clinical Professor of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark. Other features to look for when assessing the severity of the corneal disease include the presence of bullae, which is seen on slit lamp examination and associated with intermittent pain, poor low contrast visual acuity and increased corneal thickness. Dr Hjortdal noted that in a study including 89 patients with grade 2 or worse Fuchs’ dystrophy and needing cataract surgery, only 35 patients went on to endothelial keratoplasty (EK) after cataract surgery. The only factors that predicted need for EK were epithelial valley determined EUROTIMES | DECEMBER 2018/JANUARY 2019

by confocal microscopy and central cornea thickness (CCT). A CCT cut-off of 611 microns had 80% specificity and 63% sensitivity for predicting later EK surgery. Dr Tan outlined indications for choosing among the surgical options that considered the various clinical scenarios that are encountered along the spectrum of coexisting cataract and Fuchs’ dystrophy and the advantages and disadvantages of the various surgical options. He said that cataract surgery alone may be done for an older patient with significant cataract who may be less visually demanding and has minimal corneal changes. At the other end of the spectrum are patients who might be younger who have minimal lens opacity with significant corneal disease and higher visual expectations. Starting by performing EK only in these patients is a good choice because it is easier and will preserve accommodation. In patients with significant cataract and endothelial disease, a less experienced transplant surgeon may choose to do the cataract surgery first because with a stable IOL complex, EK done as a second procedure will be easier. However, the EK procedure may best be done first if there is severe corneal oedema limiting visualisation for cataract surgery. “The latest approach among cornea specialists is to do DMEK first and cataract surgery after the corneal curvature has stabilised because this approach gives better refractive accuracy and a better chance of achieving emmetropia,” Dr Tan said.

Courtesy of Jesper Hjortdal MD, PHD

A slit-lamp image of a patient with Fuchs’ dystrophy

APPROACH FOR COMBINED SURGERY Dr Hjortdal said that the triple procedure is usually straightforward. He performs conventional phacoemulsification, makes the capsulorhexis a little smaller to keep the IOL in place during the graft portion of the procedure and does not constrict the pupil. IOL power calculations must account for a hyperopic shift related to the graft procedure. “In performing the IOL calculations, surgeons should aim for 1.25D more myopia when performing DSAEK and for 0.5-to-1.0D more myopia if doing DMEK,” Dr Hjortdal said. Because EK does not affect spherical aberration, surgeons can choose an aspheric IOL that compensates for corneal spherical aberration. Jesper Hjortdal: jesper.hjortdal@clin.au.dk Donald Tan: donald.tan.t.h@singhealth.com.sg

Patients with significant Fuchs’ dystrophy will notice difficulty in the morning and improvement later in the day... Jesper Hjortdal, MD, PHD

CORNEA

Cross-linking techniques Fine-tuning CXL parameters for optimal clinical outcomes. Dermot McGrath reports

especting certain technical parameters 45mW/cm2. While the treatment time could be reduced in the application of corneal crosswith higher power densities, the key question is whether linking (CXL) will help physicians shorter irradiance duration diminishes the efficacy of achieve greater consistency in the CXL treatment, said Dr Seiler. outcomes when treating patients Two different groups who initially evaluated the with keratoconus, Professor Theo Seiler MD, PhD, topic came up with completely opposite conclusions, told delegates attending a joint ESCRS/EuCornea said Dr Seiler. symposium on cross-linking at the 36th Congress of His own study of the issue, however, concluded Theo Seiler the ESCRS in Vienna. that using higher UV irradiances combined with shorter Since the introduction of CXL into clinics, many changes treatment times reduces the efficacy of the treatment. to the original Dresden protocol have been proposed, such as “Shorter operation times may be achieved by increasing the new light sources with shorter treatment times due to higher irradiance from 3mW/cm2 up to 15mW/cm2 without loss of efficacy if the application time is adjusted,” he said. irradiances and new solutions with shorter imbibition times. For riboflavin application, using hydroxylpropyl “I think now is a good opportunity to answer some of methylcellulose (HPMC) solution offers some clear advantages the questions that my colleagues frequently ask about the over Dextrane, said Dr Seiler. application of CXL in their clinics – how much energy to “With HPMC the cornea swells by 8%, whereas with dextran use, as well as various questions around oxygen and riboflavin 20% it shrinks significantly, which occasionally led to epithelial use,” he said. damage. So using HPMC shortens imbibition time from 30 Key parameters of the Dresden protocol included removing minutes to 10 minutes and also makes it safer,” he said. the central 8-10mm of the epithelium and applying a 0.1% For effective cross-linking to occur, a certain amount of riboflavin solution in 16% dextran to the corneal surface oxygen is required to be present in the cornea, said Dr Seiler. followed by 30-minute exposure to 365nm ultraviolet light with Whereas the standard Dresden protocol occurs slowly an irradiance of 3mW/cm2, said Dr Seiler. “We now know that effective CXL entails three key ingredients: enough for the oxygen to replenish, some accelerated CXL ultraviolet light, riboflavin and oxygen," he said. protocols consume too much oxygen too quickly. In terms of ultraviolet parameters, Dr Seiler noted that lamps on the market now offer UV-irradiances ranging from 3mW/cm2 to Theo Seiler: c/o claudia.kindler@iroc.ch

10th EuCornea Congress

13 – 14 September 2019 | Paris Expo Porte de Versailles

www.eucornea.org EUROTIMES | DECEMBER 2018/JANUARY 2019

CORNEA

Advantages of customising CXL Corneal cross-linking gets personal with topographic guidance. Dermot McGrath reports

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

ustomised or topography-guided CXL, also known as CuRV (Customised Remodeled Vision), may offer keratoconus patients a new option in personalised CXL with the potential for improvements in visual outcomes, according to François Malecaze MD, PhD. “The goal is to selectively cross-link weaker zones on the cornea by administering customised UV patterns, and this approach holds the promise of further optimisation in the future,” Dr Malecaze told delegates at a joint ESCRS/ EuCornea symposium on “Corneal Cross-Linking: Current Status and Future Perspectives” in Vienna. There are two main theoretical advantages of CuRV, noted Dr Malecaze. “Biomechanical analyses of keratoconic corneas using Brillouin microscopy have shown that weakening is concentrated within the area of the cone. A customised treatment, therefore, should induce a local stiffening, flatten the cone and consequently, improve visual function,” he said. To administer the TG-CXL treatment, the epithelium is removed mechanically over the region designated for UV-A treatment, said Dr Malecaze. Dextran-free riboflavin 0.1% (VibeX Rapid; Avedro) is then instilled on the debrided stroma every two minutes for 10 minutes and a UV-A irradiation pattern programmed for each patient using the Mosaic System (Avedro). “It is essentially a multifocal treatment with the maximal dose delivered at the apex of the cone,” said Dr Malecaze. Summarising the clinical results of four different published studies of customised cross-linking thus far, Dr Malecaze said that best-corrected visual acuity (BCVA) showed a significant improvement of one-to-three lines of visual acuity (LogMAR) after treatment in two studies and a trend towards improvement of one-to-two lines in the other two trials. Corneal regularisation also improved significantly by at least 1.0D and the cone flattened in all treated study groups. Dr Malecaze noted that TG-CXL induces a greater flattening effect than conventional CXL, as well as producing a gradient in the biological response to treatment from the area of the cone to the surrounding area. “It is also very important to note that the side-effects are the same as for conventional CXL. This means that even if maximal energy is delivered at the thinnest point, the endothelial cell count remained stable in all of the studies,” he said. The next step will be to deliver a truly personalised treatment using epi-on CXL for better patient comfort and supplemental oxygen with Boost Goggles for more enhanced flattening effect, he said. “It holds a lot of promise. TG-CXL is safe and efficient to treat progressive keratoconus and is currently the most adapted solution to customise treatment to each patient. Promising improvement is expected with the introduction of trans-epithelial riboflavin solution and oxygen saturation,” he said. François Malecaze: malecaze.fr@chu-toulouse.fr

EUROTIMES | DECEMBER 2018/JANUARY 2019

CORNEA

DMEK or Ultrathin DSAEK DMEK is gaining fans, but DSAEK remains preferable for certain indications. Dermot McGrath reports

hile corneal transplantation surgery in recent years has seen a shift towards Descemet’s Membrane Endothelial Keratoplasty (DMEK) for the reported benefits of quicker healing and better visual outcomes, procedures such as ultrathin Descemet’s Stripping Automated Endothelial Keratoplasty (UT-DSAEK) still have a valuable role to play for certain indications, according to Massimo Busin MD. “DMEK is a viable option for some indications, but there are still many complex cases, with poor visibility and certain comorbidities for instance, that are better suited to UT-DSAEK. There is a substantial difference between the two procedures in terms of technical difficulty, and while probably there is faster visual rehabilitation with DMEK, in the long run it seems that the results are quite similar especially if we use thin DSAEK grafts for our surgeries,” he told delegates attending the 9th EuCornea Congress in Vienna.

STABLE CURVE Prof Busin said that while DMEK has become more popular in the United States in recent years, the uptake has not been as dramatic as some had predicted. In 2011, the number of DSAEK procedures was 21,100 compared to 343 DMEK. Five years later, the number of DMEK cases increased to 6,459 while DSAEK remained stable at 21,858. For 2017, 20,993 DSAEK procedures were performed compared to 7,622 DMEK cases. “The percentage gains year on year for DMEK have been decreasing and there is a stable curve for DSAEK because it has been decreasing very slowly at about 2% a year. I think this tells us that we are almost reaching a balance

There are eyes that are good for DMEK, and certainly the number increases with surgical experience. However,there are other situations where DSAEK can be done and should be preferred to DMEK Massimo Busin MD

between the two procedures where they both have a role to play depending on the particular eye that we need to treat,” he said. Prof Busin said that DMEK is a good option, for instance in patients with Fuchs’ endothelial dystrophy, intact posterior capsule and normal anterior segment anatomy, and is also viable in failed DSAEK after penetrating keratoplasty cases. “There are eyes that are good for DMEK, and certainly the number increases with surgical experience. However, there are other situations where DSAEK can be done and should be preferred to DMEK,” he said.

COMPLEX CASES It is best to avoid DMEK in eyes with a shallow or poorly visualised anterior chamber, or those with communication between the anterior chamber and vitreous cavity, through which the donor endothelium may dislocate posteriorly and air tamponade may be challenging, said Prof Busin. Similarly, UT-DSAEK may be better adapted to more complex cases with ocular comorbidities such as glaucoma or severe pseudophakic bullous keratopathy, and aphakic or vitrectomised eyes. “Normal anatomy allows you to do DMEK or DSAEK or even PK in certain cases. In visually compromised eyes, however, such as after multiple retinal surgeries, it makes no sense to do DMEK hoping for a better visual result when the visual potential is so poor. Such patients end up happy with a visual improvement from hand motion to counting fingers by doing a DSAEK. “So, we can perform DMEK under optimal conditions, but in other cases can still perform DSAEK whilst retaining the advantages of a lamellar graft compared to a PK,” he said.

COMPARABLE VISUAL OUTCOMES While better visual rehabilitation is often cited as a motivating factor for some surgeons to convert to DMEK, Prof Busin said that the picture is actually more complex in reality. He noted that some of the results in the scientific literature compare DMEK to standard DSAEK rather than UT-DSAEK, which provides better visual outcomes thanks to thinner, more uniformly cut grafts. He also said that his own long-term data shows comparable visual outcomes for UT-DSAEK compared to DMEK. “At six months the percentage of patients attaining 20/20 with UT-DSAEK is lower than DMEK, but five years after surgery we have similar rates of patients obtaining 20/20 and 20/25,” he said. Although rejection rates are slightly higher with UT-DSAEK compared to DMEK, Prof Busin said that this is balanced out somewhat by the higher complication rate associated with DMEK, in particular for surgeons who are new to the procedure. Massimo Busin: massimo.busin@unife.it EUROTIMES | DECEMBER 2018/JANUARY 2019

RETINA

9th EURETINA Winte r Me etin g

Prague 2019 1–2 March 2019 Clarion Congress Hotel Prague, Czech Republic Early Bird Registration Deadline 14th February Exhibition & Sponsorship Opportunities Available

www.euretina.org

Understanding intermediate AMD MACUSTAR study looking for useful endpoints for intermediate AMD. Leigh Spielberg MD reports

n order to prevent or delay the progression of intermediate age-related macular degeneration (iAMD) to late-stage AMD, the functional deficit in iAMD must first be characterised. The goal of the MACUSTAR Consortium is to seek novel clinical endpoints for clinical trials in iAMD so that interventional studies can be implemented, Frank Holz MD, from the co-ordinating centre in Bonn, Germany, said during a session of the 18th EURETINA Congress in Vienna. MACUSTAR is funded by the European Innovative Medicines Initiative (IMI), the world’s largest public-private partnership in life sciences. IMI works as a partnership of the European Commission and EFPIA (European Federation of Pharmaceutical Industries and Associations). The MACUSTAR consortium includes researchers from the Netherlands, France, Portugal and the UK. It also includes industrial companies Bayer, Zeiss, Novartis and Roche. The total funding is €16 million for this study. EVICR.net is also involved in the study. “AMD is a progressively degenerative disease than can lead to the advanced stages of neovascular AMD and geographic atrophy with subsequent visual loss. Despite a prevalence of approximately 15% in people over the age of 55 years, there are currently no available treatments to counteract the progression of iAMD,” noted Dr Holz, University of Bonn, Germany. Currently, no outcome measures are clinically validated and accepted as clinical endpoints for regulatory agencies for drug development in iAMD. As clinical endpoints currently accepted by regulators cannot detect functional loss or patientrelevant impact in iAMD, the goal of MACUSTAR is to develop clinical endpoints in three main categories: function, structure (imaging) and patient-reported outcomes. Robert Finger MD, also of Bonn, brought delegates up to speed regarding the ongoing MACUSTAR project. “Functional testing in MACUSTAR is used to identify and validate visual function outcomes that reliably capture the functional impairment in iAMD and to establish the discriminatory power of these variables in relation to differentiating between disease stages and thus allowing for the assessment of progression of AMD,” said Dr Finger. Structural endpoints will be determined by standard retinal imaging, such as OCT, scanning laser ophthalmoscopy, fundus autofluorescence, fundus photography and fluorescein angiography, and innovative modalities such as quantitative autofluorescence, OCT-angiography and swept-source OCT. Candidate endpoints include scotopic and mesopic microperimetry, dark adaptation, contrast sensitivity and the implementation of a specifically developed patientreported outcome measure, the Vision Impairment in Low Luminance (VILL) questionnaire. This covers areas such as reading, mobility, safety and socio-emotional well-being, all with a focus on light conditions such as low contrast and low luminance that become challenging for people with iAMD. Recruitment in 20 clinical sites across Europe will continue until February 2019, with the goal of including 750 patients: 600 patients with intermediate AMD; 50 with no abnormalities (or normal ageing changes); 50 with early AMD and 50 with late AMD. These patients will be followed up for three years. Frank Holz: holz@ukb.uni-bonn.de Robert Finger: Robert.Finger@ukb.uni-bonn.de

EUROTIMES | DECEMBER 2018/JANUARY 2019

RETINA

IOLs can improve vision in AMD Hyperaspheric IOL provides good results in patients with maculopathy. Roibeard Ó hÉineacháin reports

he Eyemax™ (London Eye Hospital Pharma) enhanced breadth of focus IOL can improve distance and near vision in eyes with cataracts and macular disease, said Federico Badala MD, Milan, Italy. “As cataract surgeons we are all aware of the concept of changing asphericity to increase depth of focus. This lens introduces a new concept, which is the use of transverse asphericity. It is well known that longitudinal asphericity can be used to change depth of focus. For the first time, the Eyemax uses both longitudinal and transverse asphericity to increase breadth of focus,” Dr Badala told the 36th Congress of the ESCRS in Vienna Austria. He noted that the Eyemax IOL is an injectable, hydrophobic acrylic lens designed to improve the quality of retinal image in all areas of the macula up to 10 degrees from fixation, therefore patients with central macular scar but relatively healthy surrounding macula Federico Badala can benefit from this implant. Designed for insertion into the capsular bag, the lens has an optic diameter of 6.0mm, an overall length of 11mm and modified C-loop haptics.

IMPROVED VISUAL ACUITY Dr Badala presented his findings from a prospective case series of 96 eyes with cataract and maculopathies that underwent standard phacoemulsification with Eyemax IOL implantation. All had at least six months’ follow-up (range six-18 months). All patients were left intentionally hyperopic to get additional magnification from spectacle correction. He noted that visual acuity improved significantly in all patients. Corrected distance visual acuity improved by a mean of 14 EDTRS letters overall. Among those with macular dystrophies, including retinitis pigmentosa, Best’s Disease and Stargardt’s disease, there was a gain of 11-12 letters, but among those with AMD there was a gain of 16 letters. He added that although the implant can be used in one eye without inducing aniseikonia, patients implanted bilaterally achieve a better than expected outcome. “We hypothesise that when the lens is implanted in both eyes the brain receives the good image from each eye and neuroadaptation sums up the two images and gives the patients a better ability to read,” Dr Badala explained. He added that it is unlikely that the visual improvement is simply due to the removal of the cataract, since reports in the literature show similar patients gaining only 6.5/7.5 ETDRS letter following cataract surgery with conventional IOL implantation. “The Eyemax IOL shows promising results in improving distance and near vision in eyes with cataracts and macular degeneration. Near visual acuity seems to benefit more than distance visual acuity. Patients implanted bilaterally seems to get a better outcome,” he summarised. Federico Badala: info@microchirurgiaoculare.com EUROTIMES | DECEMBER 2018/JANUARY 2019

RETINA

Insights into diabetic retinopathy The 2018 Kreissig Lecture looked at the role of inflammation in the disease. Leigh Spielberg MD reports

oes inflammation cause nervous system. It is known that microglia diabetic retinopathy, or is are activated in neuro-inflammation. Thus, it an epiphenomenon of Dr Joussen’s interest in inflammation as an the disease? This mystery early target in diabetic retinopathy. was addressed by Professor Dr Joussen explained that there is an Antonia M. Joussen, Charité University inhibition of retinal pathology in long-term of Medicine and Berlin Institute of Health, Germany, during her 2018 Kreissig Award Lecture at the 18th EURETINA Congress in Vienna. Dr Joussen’s lecture, entitled “Diabetic Retinopathy: A Neuroinflammatory Disorder?”, covered the breadth of her research, which investigates ocular angiogenesis with a particular focus on diabetic retinopathy. Dr Joussen reminded delegates that despite advances in the medical treatment of diabetic macular oedema and surgical Antonia M. Joussen delivered the 2018 Kreissig Award Lecture treatment of proliferative diabetic retinopathy, visual function often does not improve. diabetic mice in which genes encoding for “Pericytes loss is an early event crucial inflammatory proteins had been in diabetic retinopathy,” Dr Joussen knocked out. reminded delegates. “And pericyte “In knock-out mice with no depletion directly induces inflammatory inflammation, the retinal capillary net responses in endothelial cells and remains intact,” she said, suggesting that infiltration of macrophages.” these capillaries are indeed destroyed by Microglial cells, the resident macrophage an inflammatory process. cells in the retina, are the first and main form But is inflammation purely an enemy, or of active immune defence in the central does it have some positive effects in diabetic

retinopathy? Initially, there is a certain degree of beneficial inflammation in the retina, but when it becomes excessive, it becomes destructive, she explained. In order to treat diabetic retinas before they lose structure and function, new compounds are being both investigated and developed to target inflammation. Therapy of type 2 diabetes with salicylates (such as the compound contained in aspirin) indicates the relevance of cytokines in glucotoxicity. Others include IL-1β receptor blockers, IL-1β -specific antibodies and TNFα-inhibitors. The Kreissig Award, which has been presented yearly since 2004, is given for outstanding contributions to the understanding and treatment of retinal diseases. Professor Ingrid Kreissig, for whom the award is named, joined Dr Joussen on stage at the end of the latter’s presentation. “I would like to thank you so much for this stimulating lecture in which you present the complex disease mechanisms in such a manner that we all understand it and remain enchanted,” said Dr Kreissig. Antonia M. Joussen: antonia.joussen@charite.de

Observership Programme

Applications NOW OPEN

500

ü Each grant totals €1 the ü The duratshionip of is one

observer month to be utilised in 2019

Deadline for applications: 31 January 2019 Observerships must be undertaken at a listed European hospital or university setting

EUROTIMES | DECEMBER 2018/JANUARY 2019

www.euretina.org

10 grants will be awarded annually

RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 241 ISSUE: 1

SD-OCT IMPROVES CLINICAL JUDGMENT IN AMD

TREQ-BLUE THE PUREST OF ALL DYES TESTED

Spectral domain optical coherence tomography (SD-OCT) can enhance clinical decision-making in the management of neovascular age-related macular degeneration (AMD) prospective observational clinical study. It showed that in residents with three-to-four years’ experience and specialists with more than five years’ experience, SD-OCT helped guide both groups’ recommendations for further treatment at four weeks’ follow-up (p=0.001 and p=0.0002) in 49 eyes of 44 neovascular AMD patients who underwent a loading dose of vascular endothelial growth factor (VEGF)-inhibitors. C Volz et al, “Spectral Domain Optical Coherence Tomography Allows the Unification of Clinical Decision Making for the Evaluation of Choroidal Neovascularization Activity”, Ophthalmologica 2019, Volume 241, Issue 1.

SUB-TENON INJECTIONS PROVIDE AN ALTERNATIVE TO INTRAVITREAL APPROACH Sub-tenon triamcinolone acetonide (STTA) injections can be an effective alternative to intravitreal triamcinolone acetonide (IVTA) injections during cataract surgery in the treatment of diabetic macular oedema (DME), according to the results of a retrospective study. A review of the medical records of 67 eyes of 53 DME patients who underwent cataract surgery showed that both STTA and IVTA resulted in significant improvements in best-corrected visual acuity at three and six months. However, only 13 eyes in the IVTA group required other therapies compared to 21 eyes in the STTA group (p<0.05). One case developed intraocular pressure elevation after IVTA and underwent selective laser trabeculoplasty. T Tatsumi et al, “Comparison of the Efficacy of Sub-Tenon versus Intravitreal Triamcinolone Acetonide Injection during Cataract Surgery for Diabetic Macular Edema”, Ophthalmologica 2019, Volume 241, Issue 1.

FIRST RANIBIZUMAB BIOSIMILAR SHOWS EFFICACY IN RVO The results of a retrospective study suggest that the Ranibizumab biosimilar, Razumab® (Intas Pharmaceuticals) is safe and effective in the treatment of retinal vein occlusion (RVO). In 160 RVO patients who received three or more injections of Razumab between January and August 2016, the mean logMAR best-corrected visual acuity (BCVA) improved from a baseline value 0.76 to 0.73 at four weeks (p=0.0656) and 0.55 at eight weeks (p<0.0001. The proportion of patients with intraretinal fluid and subretinal fluid decreased over the same period from 70.63% to 30.0% and from 65.63% to 24.38%. No new safety concerns were observed. S Sharma et al, “Real-Life Clinical Effectiveness of Razumab® in Retinal Vein Occlusion: A Subgroup Analysis of the Pooled Retrospective RE-ENACT Study” Ophthalmologica 2019, Volume 241, Issue 1.

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EUROTIMES | DECEMBER 2018/JANUARY 2019

5-8 September 2019 Abstract Submission Deadline 14 March 2019

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GLAUCOMA

Choices in surgery Choice of devices depends on extent of disease, presence of cataract. Leigh Spielberg MD reports

believe that the risk of “Supraciliary stent implantation is (MIGS) offers an alternative to highglaucoma surgery should very straightforward, with very good outflow, low-resistance surgical options not exceed the disease perioperative IOP and less steroid like supraciliary or transscleral methods risk,” said Thomas response,” he said. that may ‘steal’ flow from physiological Samuelson, University of This is his preferred approach when pathways and suffer surgical complications. Minnesota, Minneapolis, USA, during the canal is compromised or when one In this sense, MIGS has forever changed his presentation at an ESCRS Main is willing to take more risk in light of the management of combined cataract and Symposium: Glaucoma for the Cataract disease severity. glaucoma, he noted. Surgeon during the 36th Congress of the “I approach the canal first, but “I find the canal to be very predictable. ESCRS in Vienna. I utilise the supraciliary option when Remember, in mild-to-moderate disease, Dr Samuelson, a needed,” he said. glaucoma specialist Implantation and the current of the CyPass president of the creates a controlled American Society of cyclodialysis with Cataract & Refractive stented outflow to Surgery, delineated the supraciliary his approach to space. However, glaucoma surgery. Alcon announced on Besides keeping risk August 29, 2018, an as low as possible, he immediate, voluntary prefers to “retain the market withdrawal outflow tract’s normal of the CyPass microphysiology when stent after researchers feasible”. detected a concerning “The Level 1 rise in endothelial evidence that cataract cell loss compared surgery lowers IOP with patients who in most patients underwent cataract with elevated IOP is surgery alone. This undeniable, which is difference was not the foundational basis apparent at the of combined surgery two-year followof phacoemulsification up, but only became and MIGS,” said Dr apparent at five years Thomas Samuelson, ASCRS President, spoke at the ESCRS Main Symposium: Glaucoma for the Cataract Surgeon Samuelson. postoperatively. This evidence Indeed, the addition comes from the five of the MIGS procedure prospective, randomised MIGS trials in to cataract surgery must be safe. And it the trabecular meshwork is moderately which the control (phaco) arm significantly must be synergistic with phaco, which dysfunctional, but not completely shot. lowered IOP. enhances physiological outflow through Why abandon it?” he asked. How best to manage coincident the trabecular meshwork. By using intracanalicular surgery, cataract and glaucoma? In cases in “Iatrogenic vision loss keeps me awake at Dr Samuelson attempts to improve the which cataract surgery alone is likely night,” he said. physiological system before abandoning it. to deliver insufficient IOP-lowering, a And although MIGS can be very successful, “I treat mild-to-moderate phakic complementary procedure is required. Dr Samuelson reminded delegates to be glaucoma, including combined surgery, “There are two broad classes of incisional willing to admit when it’s time to move on differently than pseudophakic glaucoma. glaucoma surgery. On the safer but maybe to a more aggressive approach. Once the eye is pseudophakic, I am far less efficacious end of the spectrum, we can How to decide between canal, transscleral more willing to give up on the trabecular perform surgery to augment physiological or supraciliary? meshwork and Schlemm’s canal.” outflow,” he said. “It’s not simply a matter of device label However, when intracanalicular This refers to canal surgery, and and disease severity. Severity is important, approaches will not provide sufficient includes devices such as the iStent but it is only one factor. One must also IOP-lowering, a more aggressive approach (Glaukos) and the Hydrus stent consider compliance, medication tolerance is warranted. When greater efficacy is (Ivantis). Both are intracanalicular and, most importantly, the likelihood and required, surgery can be performed to devices that are inserted into Schlemm’s velocity of disease progression,” he advised. bypass physiological outflow, said Dr canal to maintain patency and increase Samuelson, referring to supraciliary trabecular outflow. Thomas Samuelson: approaches, as with the CyPass Micro-incisional glaucoma surgery twsamuelson@mneye.com micro-stent, and transscleral approaches. EUROTIMES | DECEMBER 2018/JANUARY 2019

PAEDIATRIC OPHTHALMOLOGY

Treating Graves’ disease in children Rare condition in paediatric patients warrants close monitoring. Dermot McGrath reports

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

raves’ disease is an uncommon condition in children, occurring about 0.02% of the paediatric population. Thyroid eye disease is even more rare and the symptoms are generally much milder than in adults and typically respond well to local treatment and control of the disturbed thyroid function, according to Andrea Papp MD, PhD, FEBO. “Although the course of paediatric Graves’ orbitopathy was mild to moderate in most of our patients, these young patients still require careful follow-up as severe, sight-threatening orbitopathy requiring immunosuppression may occur at a young age in a rare subset of patients,” she told delegates attending the World Society of Paediatric Ophthalmology and Strabismus Andrea Papp (WSPOS) Subspecialty Day at the 36th Congress of the ESCRS in Vienna. Graves’ disease, also known as toxic diffuse goiter, is an autoimmune disease that affects the thyroid and is the most common cause of hyperthyroidism. Dr Papp’s retrospective case series studied the demographics, risk factors, clinical features and treatment options of children and adolescent patients with Graves’ diseases presenting at the thyroid eye clinic of the University Eye Hospital in Vienna, Austria over a period of five years. A total of 48 patients were identified with Graves’ orbitopathy, all bilateral cases with a female to male ratio of about 3 to 1. The mean age at presentation was 12 years with a range from 2 years to 18 years. In terms of ethnicity, 40 patients (83%) were Caucasian, four (8%) were Asian, three (6%) were African and one (2%) was of Arabic descent. Risk factors identified in the cohort included a positive family history in eight cases (17%), active smoking in 16 children (33%) and passive smoking in eight (17%). Additional autoimmune disorders were detected in three patients (6%), she said. In terms of disease activity and clinical features, mild disease was diagnosed in 49%, moderate in 40% and severe paediatric orbitopathy in 11%. The principal clinical features included exophthalmos in 77%, lower eyelid retraction in 75%, upper eyelid retraction in 52%, conjunctival injection with sicca in 48%, ocular pain in 44%, lid oedema and/or erythema in 38% and acquired epiblepharon in 4%. Ocular motility involvement occurred in 38%, with limitation of abduction in 27% and elevation deficit in 21%. Symptomatic optic neuropathy was detected in 6% of patients, she added. The mainstay of therapy is lubricating eye drops and ointments, which is effective in most cases, noted Dr Papp. Systemic control of disturbed thyroid function was indicated in three-quarters of patients and 23% received combination therapy with beta blockers. Five patients, however, required intravenous methylprednisolone pulse therapy that resulted in prompt clinical improvement without considerable side-effects, she concluded. Andrea Papp: andrea.papp@meduniwien.ac.at

EUROTIMES | DECEMBER 2018/JANUARY 2019

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

2â&#x20AC;&#x201C;4 October 2020 RAI Amsterdam, The Netherlands Nicoline Schalij MD Local Host President

www.wspos.org EUROTIMES | MONTH YEAR

EUROTIMES | MONTH YEAR

ESCRS NEWS

ESCRS

NEWS

Paul Rosen delivered the 2018 Peter Barry Memorial Lecture

Barry memorial lecture covers trauma in the eye

Paul Rosen, Consultant Ophthalmic Surgeon, Oxford University Hospital Trust, UK, and a former president of the ESCRS, delivered the 2018 Peter Barry Memorial Lecture at the Royal Victoria Eye and Ear Hospital, Dublin, Ireland. The topic of Dr Rosen’s lecture was “Cataract Surgeon meets Retinal Surgeon: Front to Back or Back to Front?” Introducing his talk, Dr Rosen said that Peter Barry was an ESCRS icon and had served as a board member, treasurer and president of the society. When he became president, said Dr Rosen, Peter Barry had certain priorities, which were youth, education and research. Peter Barry fulfilled these priorities by establishing the Young Ophthalmologists group with Oliver Findl, initiating the Endophthalmitis Study and becoming actively involved in the EUREQUO project, said Dr Rosen. In a wide-ranging lecture, Dr Rosen described the interface between cataract and retinal surgeons focusing on the eye and trauma. “Trauma surgery, in relation to the eye,” said Dr Rosen, “is where the anterior and posterior segment meets, and ideally in the same surgeon.”

EUROTIMES EYE CONTACT VIDEOS

New EuroTimes Eye Contact video interviews from the 36th Congress of the ESCRS in Vienna, Austria, are now available online. In these interviews, key opinion leaders talk about some of the hot topics discussed at the Congress including ocular surface disease, toric IOLs and Fuchs’ Dystrophy.

Join

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EUREQUO is free of charge for all ESCRS members

www.eurequo.org

To watch these videos, go to http://player.escrs.org

EUROTIMES | DECEMBER 2018/JANUARY 2019

San Diego 2019

Save the date Friday, May 3 – Monday, May 6, 2019

Make the most of your time at the ASCRS•ASOA Annual Meeting and attend our EyeWorld multi-supported CME and Corporate Events. They are a great opportunity to network with your colleagues while learning tips and techniques from the experts.

Registration opens in January 2019

CME Educational Symposium

Among the topics to be covered in these sessions are: • Updates on diagnosing and treating the ocular surface, including dry eye disease and meibomian gland disease • New developments in glaucoma medical and surgical treatment options • Maximizing presbyopia-correcting outcomes • Successfully integrating toric IOLs and improving results and patient satisfaction • Mastering phaco dynamics, fluidics, power, and nuclear disassembly • Modern laser vision correction • A discussion on recent developments in anti-inflammatory therapeutic treatments

Corporate Education

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are: • • • • •

New developments in surgical instrumentation Considerations in the selection of a premium IOL New developments in laser vision correction Advanced IOL technology Discussion of technological advances and breakthroughs in cataract surgery • Update on crosslinking • Advances in diagnostic and imaging equipment

meetings.eyeworld.org Topics are subject to change.

BOOK REVIEWS PUBLICATION THE EYE IN PEDIATRIC SYSTEMIC DISEASE EDITORS ALEX V. LEVIN AND ROBERT W. ENZENAUER

LEIGH SPIELBERG MD Books Editor

BOOK

Reviews PUBLICATION TAYLOR & HOYT’S PEDIATRIC OPHTHALMOLOGY & STRABISMUS EDITORS SCOTT R. LAMBERT AND CHRISTOPHER J. LYONS

Covering the entire spectrum

Taylor & Hoyt’s Pediatric Ophthalmology & Strabismus (Elsevier) is a 1,000-page, 107-chapter textbook that covers the entire spectrum of paediatric eye disease. Edited by Scott R. Lambert and Christopher J. Lyons, it is a comprehensive, full-fledged reference text that can serve as the cornerstone of an ophthalmologist’s knowledge in this subspecialty. High-quality photographs, including fundus and OCT, drawn from paediatric specialists around the world, make this text especially attractive. Particularly helpful, especially for the general ophthalmologist, is Section 7: Common Practical Problems. Each chapter in this section covers one single presenting complaint, such as “I think my baby can’t see!” and “My child seems to hate the bright light”. These chapters provide a step-by-step approach to each problem and include direct references to the chapter in which each potential diagnosis is further discussed in detail. Purchase of this book provides the reader with access to the eBook via Expert Consult eBooks, allowing electronic access on a variety of platforms. This includes a series of videos that accompany the text. This book is ideal for paediatric ophthalmology fellows and specialists, general ophthalmologists without direct, immediate access to paediatric specialists and anyone particularly interested in immersing him/herself in the field.

PUBLISHED BY ELSEVIER

PUBLISHED BY SPRINGER

KNOWING WHEN TO REFER Ophthalmologists working in large hospital centres with a significant population of paediatric patients with systemic disease will find The Eye in Pediatric Systemic Disease to be a crucial addition to their armamentarium. This textbook covers the ocular manifestations in all paediatric disease, from haematologic to infectious and from psychiatric to traumatic. Patients are often referred to ophthalmologists with a potential diagnosis. It is then up to us to examine the eyes to see whether the disease’s typical signs are present. This book covers both common and rare paediatric afflictions. After having read the disease’s definition, history, epidemiology, systemic manifestations and ocular manifestations, the reader is likely to be able to adequately respond to the questions posed by the referring physician. This book is intended for paediatric and general ophthalmologists and could be useful for paediatricians who would like to know when to refer to ophthalmologists.

PUBLICATION RETINA: MEDICAL & SURGICAL MANAGEMENT EDITORS ATUL KUMAR AND RAGHAV RAVANI PUBLISHED BY JAYPEE

THE SURGEON’S GUIDE TO SMILE

PUBLICATION THE SURGEON’S GUIDE TO SMILE EDITORS DAN Z. REINSTEIN, TIMOTHY J. ARCHER AND GLENN I. CARP PUBLISHED BY SLACK INCORPORATED

Small-incision lenticule extraction (SMILE®) is gaining in popularity. The Surgeon’s Guide to SMILE (Slack Incorporated) seeks to provide a thorough guide to performing the procedure. Written by Dan Z. Reinstein, Timothy J. Archer and Glenn I. Carp, this guide can both get a surgeon started and refine a more experienced surgeon’s technique. This book is written to provide step-by-step assistance from day one. The first few chapters describe the history of intrastromal refractive surgery, its advantages over its predecessors and the manner in which a preoperative assessment should be conducted. Docking, centration and cyclotorsion receive attention in their own chapter, followed by the actual photodisruption by the femtosecond laser and specific instructions on how to optimise energy and spot spacing settings. Particularly useful for the starting surgeons were the chapters on which surgical instruments to select and how to manage patient anxiety. The latter includes specific sentences to say to patients, such as when placing a lid speculum. “It will feel very strange at first, but just keep looking straight ahead, in about 30 seconds you won’t even know this is here.” This book is ideal for fellows in refractive surgery as well as general ophthalmologists who are entering the refractive field and are considering adding SMILE to their offerings.

THE LATEST IN QUALITY IMAGING Retina: Medical & Surgical Management (Jaypee) takes on an ambitious task. Most retina books cover either medical or surgical, but this does both at once. As ophthalmology has become highly imaging-based, textbooks have had to play catch-up. Books from just a few years ago have become nearly irrelevant due to their reliance on outdated imaging like previousgeneration OCTs. This textbook avoids this by utilising the latest not only in OCT but also OCT angiography, wide-field photography and intraoperative OCT. This text is intended for vitreoretinal specialists and fellows, as well as general ophthalmologists who treat retinal disorders themselves. Purchase includes full access, with added features, to eMedicine360.com. If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | DECEMBER 2018/JANUARY 2019

OUTLOOK ON INDUSTRY

Rayner bets on ePRO App providing three years of patient follow-up, sulcus trifocal among new offerings. Howard Larkin reports

aluable as they are, tests of visual acuity and target refraction after cataract surgery don’t tell the whole intraocular lens (IOL) outcomes story. Patient satisfaction and function, such as spectacle independence and night vision, are also important, as are longterm visual outcomes and complications, such as posterior capsule opacification (PCO). Yet gathering such data can be difficult and time consuming, noted Tim Clover, CEO of Rayner. So the Worthing, UK-based firm – which is the worlds’ first IOL manufacturer – developed RayPRO, a mobile phone and web-based app for collecting patient reported outcomes (PROs) for three years after surgery. The goal is to paint a more complete portrait of patient satisfaction for purposes of quality improvement, demonstrating value to purchasers and complying with new EU rules for post-market tracking of medical device performance. Previewed at the 36th Congress of the ESCRS in Vienna, Austria, RayPRO was developed specifically for cataract surgery and is available free of charge to all users of Rayner IOLs. “Every Rayner IOL now comes with up to three years’ follow-up data that surgeons can use to better understand how their work translates to patient satisfaction,” Clover said. RayPRO will be available in Android and Apple versions and through web browsers in English, French, German, Italian, Spanish and Portuguese from January 2019, but interested users are able to sign up now on the website www.rayner.com.

IMPROVING SURGEON AND PRODUCT PERFORMANCE Surgeons register patients at the time of surgery, and patients then receive five questionnaires by email over three years. These include questions about satisfaction with the surgeon and hospital one week after surgery and satisfaction with surgery outcomes, spectacle independence at various distances and achievement of target refraction three months after surgery. Satisfaction with surgery outcomes and any visual disturbances are checked at one year. At one, two and three years after surgery patients are asked about the need for any additional procedures, such as Nd:YAG capsulotomy or a laser refractive correction, in the previous 12 months. Surgeons can access RayPRO information any time via an online dashboard that

includes both their individual proprietary material, outcomes and a ranking the new lens virtually of a surgeon’s composite eliminates vacuoles RayPRO performance and the associated score – which combines “glistenings” seen in satisfaction and refractive some hydrophobic lenses, target attainment measures Clover said. This reduces – compared with peers light scatter and improves by country, continent or optical performance. Tim Clover worldwide, Clover said. The 6mm lens is preloaded in To protect patient privacy, data Rayner’s RayOne injector allowing are anonymised, and surgeons can only smooth delivery through a sub-2.2mm access their own individual data. However, incision. Clover believes these favourable the data can be used to support surgeon’s qualities will give Rayner an edge as it enters recertification and audit requirements, and the hydrophobic IOL market, which makes may be helpful for promoting services to new up about two-thirds of global IOL sales, patients. Clover noted. Clover anticipates that RayPRO data from These new products are driving compound hundreds of thousands of patients will help sales growth of more than 20% annually, Rayner improve its products as well, shedding Clover said. They result from a renewed light on questions such as what factors might focus on IOL innovation since Rayner shed lead to PCO or lens dislocation. “With tens its optical shop operations when Clover took of millions of cataract surgeries every year, over as CEO in 2015. Since then Rayner basing decisions on clinical studies covering has made five acquisitions, partnered with 50 to 100 patients isn’t sufficient,” Clover said. surgeons and university researchers and hired 10 PhDs and engineers focusing on SULCOFLEX TRIFOCAL commercialising new products. As a private, independent company JOINS NEW HYDROPHOBIC all Rayner profits go into R&D to further ACRYLIC IOL improve product performance, Clover said. Rayner also unveiled the first trifocal “Our strategic aspiration is to improve visual supplementary IOL at ESCRS 2018 outcomes with our unique combination of Vienna. Designed for placement in the IOLs, OVDs, Corneal Pharma and RayPRO sulcus, the Sulcoflex Trifocal brings system. We have no interest in going into the benefits of improved near and the phaco or diagnostic machine market. We intermediate vision to patients who want to be the IOL partner of choice for already have a monofocal aspheric or cataract surgeons all over the world.” monofocal toric lens implanted in the capsular bag, Clover said. The Sulcoflex Trifocal employs optics improvements first released in the RayOne Trifocal capsular bag IOL last year, Clover said. These include minimising the number of diffractive steps to reduce visual disturbances such as glare and halos, and 89% light transmission to the retina to improve contrast sensitivity and low-light performance. Early surgery reports suggest the lens is easy to implant and may provide better centration than capsular bag-fixated lenses, which is critical to achieve peek optical performance with multifocal lenses.

AND A NEW GLISTENING-FREE HYDROPHOBIC IOL Earlier this year Rayner launched its first hydrophobic acrylic IOL, the RayOne Hydrophobic. Made of an ultra-purified

The Rayner Sulcoflex Multifocal IOL

EUROTIMES | DECEMBER 2018/JANUARY 2019

INDUSTRY NEWS

INDUSTRY

NEWS

New platform replaces several devices with one

Are you ready for the next step? Belong to something energetic. Join us.

www.escrs.org

EUROTIMES | DECEMBER 2018/JANUARY 2019

Heidelberg Engineering has announced the CE-marking of ANTERION. “ANTERION is a multimodal imaging platform, which can replace several devices, including corneal topographers and tomographers, pachymeters and biometers,” said Jacqueline Sousa Asam, MD, Medical Science Liaison at Heidelberg Engineering. “That leads to great improvement in the workflow and patient comfort in busy clinics, since moving patients can be unpleasant and time consuming. In addition, ANTERION displays information in very comprehensive layouts together with high-resolution OCT images, which also makes surgical planning faster and more efficient,” said Dr Sousa Asam. https://www.heidelbergengineering.com/int/company

SMALL-APERTURE INTRAOCULAR LENS AcuFocus has received approval for an Investigational Device Exemption (IDE) from the US Food and Drug Administration (FDA) to conduct a study of its IC-8 small-aperture intraocular lens (IOL). The IC-8 IOL is a clear monofocal lens with an embedded mini-ring or pinhole in the centre. It is designed to increase a patient’s natural range of vision by extending the focus of light rays that enter the eye. “Achieving IDE approval was the next milestone as we seek premarket approval in the US,” said Al Waterhouse, AcuFocus Chief Executive Officer. http://www.acufocus.com

EYE DROPS FOR VKC Santen UK Limited has launched Verkazia eye drops emulsion containing 0.1% (1mg/ml) ciclosporin for the treatment of severe vernal keratoconjunctivitis (VKC) in children from 4 years of age and adolescents. “We know how important this new treatment option is for children suffering from this serious and lifechanging condition,” said Dr Atiya Kenworthy, Medical Affairs, Santen. The recommended dose will be one drop administered four times a day to each affected eye, 15 minutes after any other eye drops. http://www.santen.com/

PRACTICE MANAGEMENT

Compliance is a must How GDPR protects both ophthalmologists and their patients. Aidan Hanratty reports

ata is the new oil. So says involves an assessment of the risks of any Brian Honan, CEO and breach of security as well as an assessment of Principal Consultant in all measures to address such risks. BH Consulting, a Dublin, What many people have noticed about Ireland firm that specialises GDPR is the severity of the potential in cybersecurity and information security punishments in the wake of a security advisory services. Just like oil, when data is breach: €20m or 4% of total worldwide mishandled or dealt with inappropriately, annual turnover – whichever is higher. So, it can have devastating consequences for there is a lot at stake for data processors. all involved, Mr Honan told the US communications giant Verizon Practice Management and report that 84% of security Development programme breaches are down to poor at the 36th Congress of the passwords. That means that ESCRS in Vienna, Austria. the time for “password” A person’s basic and “password1” is gone. information can be worth What can practices at least $5 (€4.40). That’s do to protect their information such as their patients’ data? Mr Honan name, address, mother’s recommends first of all maiden name and so on. The that you identify what data more information criminals you hold, and how. Is it on a Brian Honan have about a subject, the more computer or in a filing cabinet? that subject can be profiled for Is it on devices that are encrypted scams or further exploitation. Health and and secure? Do your employees have access? medical records, meanwhile, can be bought Do they take it with home with them? and sold online for $50 (€44) to $60 (€53). Mr Honan says that if you send business So, it makes sense to keep the data that your information via a personal email address, you patients entrust to you safe. may have inadvertently breached GDPR by There are many things to be said about transferring data outside the EU to the US, the General Data Protection Regulation if that is where your email provider is based. (GDPR), which came into force in May It’s important to establish policies for 2018. It takes precedence over all existing any subject access requests that come data protection laws throughout the EU. It in. Data subjects have the right to access applies to residents, not citizens of the EU. any data you may hold on them, be it Data can be anything from a subject’s name in total or regarding specific dates. Data or address to more specific information processors have 30 days to respond to any such as bank details, x-rays or the GPS such requests, otherwise subjects can go to location from their phone. data regulators and complain, which could Of particular interest is medical data, lead to punishments and fines. which falls under the area of special category Policies should be in place for dealing data. GDPR states that: “Special categories of with data – who is allowed to handle patient personal data which merit higher protection information? Where can it be stored and should be processed for health-related how? Who is allowed access? “Once you've purposes only where necessary to achieve these things written down as a policy, it is easy those purposes for the benefit of natural to communicate and it dictates to the whole persons and society as a whole.” Such data organisation what is allowed and what’s not requires a higher level of protection, so allowed,” Mr Honan advises. anyone processing a lot of such data must do Keeping systems up to date is key, as a data protection impact assessment, which is installing and maintaining anti-virus

software. “Monitor and respond” is the best approach. “If someone suddenly starts accessing patient records at 2am on a Sunday morning from somewhere in China and they just left the office to go home to London, well then that should ring some alarm bells.” Furthermore, just as medical colleagues share practical experience at meetings like the 36th Congress of the ESCRS, so they should share information on data management and protection. “You guys are the experts in your industry. You know what data is important to you. If you suffer a security breach, wouldn't it be good to be able to share with somebody else so they don't suffer the same thing?” Mr Honan asks.

FREE RESOURCES He recommends security awareness training for your staff. As well as that, there are a number of free resources to help keep practices informed. The European Union Agency for Network and Information Security (ENISA) has free information on data protection and how you should protect the data entrusted to you (https://www.enisa.europa.eu/). The UK Information Commissioners Office has a step-by-step Self-Assessment Tool (https://ico.org.uk/) that guides users through what is needed to protect information. The Irish Data Protection Commissioner has a website called http://gdprandyou.ie that gives advice for both individuals and organisations on what one should know and what one should be doing. Mr Honan pointed out ISO 27001, the international, globally-recognised standard for managing risks to the security of information you hold. It sets out the requirements for any information security management system, which is a systematic approach to managing sensitive company information so that it remains secure. “At the end of the day,” Honan says, “your computer is only as secure as the person who uses it.” Brian Honan: brian.honan@bhconsulting.ie EUROTIMES | DECEMBER 2018/JANUARY 2019

RANDOM THOUGHTS

Ophthalmology Leaders As a physician, you’re more than just the doctor. You must also be an effective organiser and facilitator of a large group of staff. Maryalicia Post reports

Dr David Evans, CEO Ceatus Media Group, speaking at the ESCRS Practice Management and Devlopment Programme during the 36th Congress of the ESCRS

here are many reasons for choosing a career in ophthalmology. For many aspiring ophthalmologists, it’s probably the blend of medicine and surgery, the appeal of the technical environment and the satisfaction of healing and helping. An interest in leading a business practice isn’t normally high on the list. Yet in real life it turns out that ‘leadership’ comes with the job. And the first task is knowing where you’re going. Here’s how one business guru puts it: “All successful physician practices have a clear vision of their reason for existence… This can be referred to as the corporate culture or the core values of the company that clearly defines the values and preferred expectations of behaviour.” LinkedIn recently sent out an article on ‘building a great company culture’. The piece is written by Claude S Silver, Chief Heart Officer at VaynerMedia. A ‘heart officer’ is not someone who deals with cardiac arrest in the office setting – in this case it turns out to be someone heading up what used to be called ‘Human Resources’. It’s Claude’s job to show love and empathy to the employees while monitoring their performance, thus motivating them to do their best for the team of which they are a part. Without going so far as to employ a EUROTIMES | DECEMBER 2018/JANUARY 2019

heart officer, if you’re ready to consider sharpening up your office practice, an internet search turns up an article that outlines the ‘10 hallmarks of leadership in an ophthalmologist's practice’. Realistically enough, it begins by flagging up the need to find the time: “At least eight additional hours per week on top of your core job as an ophthalmologist.” And just as realistically the author points out that: “ophthalmic microsurgery is the domain of slow, cautious, 100% perfection. Ophthalmic leadership is the domain of well-intended, timely approximations of 80% perfection. Or less… get on with it.”

EFFECTIVE ORGANISER The article ends with this cautionary note: “Most patients can choose from whom

they receive care. Even if they love the ophthalmologist, they might go elsewhere if the office is poorly run. As a physician, you’re more than just the doctor. You must also be an effective organiser and facilitator of a large group of staff.” Whether you have a “large group of staff” or simply one or two overworked employees, a checklist of who does what in an ideal world – an outline of the ‘five key roles in the ophthalmic practice’ – is a useful checklist. Ophthalmologists who wish to develop their leadership skills are also encouraged to attend the Practice Management and Development Programme at the 37th Congress of the ESCRS in Paris, France, which takes place from 14-18 September, 2019

Ophthalmic microsurgery is the domain of slow, cautious, 100% perfection. Ophthalmic leadership is the domain of well-intended, timely approximations of 80% perfection. Or less… get on with it Claude S Silver, Chief Heart Officer at VaynerMedia

CALENDAR

↙

LAST CALL

DECEMBER 2018

Arab International Ophthalmology Congress 7–8 December Dubai, UAE www.menaophthalmologycongress.com

The Arab International Ophthalmology Congress will take place in Dubai, UAE

2019

FEBRUARY

Cataract Surgery: Telling It Like It Is

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

15–17 February Athens, Greece www.escrs.org

↙

23rd ESCRS Winter Meeting

Snowmass Retina & Eye 2019

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

MARCH 9th EURETINA Winter Meeting

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

Retina World Congress

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

NEW 17th Congress of the Black Sea Ophthalmological Society 19-21 April Istanbul, Turkey http://bsos-istanbul2019.org

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

The International Meeting of the Egyptian Vitreoretinal Society (EGVRS) will take place in Cairo, Eygpt

EUROTIMES | DECEMBER 2018/JANUARY 2019

CALENDAR

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

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

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

SEPTEMBER

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

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

37th Congress of the ESCRS 14-18 September Paris, France www.escrs.org

2020 MAY ASCRS•ASOA Symposium and Congress 15–19 May Boston, USA www.ascrs.org

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

OCTOBER

20th EURETINA Congress

38th Congress of the ESCRS

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

11th EuCornea Congress 2–3 October Amsterdam, The Netherlands www.eucornea.org

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

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

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

Eye Contact Interviews Video of the Month

Video Journal of Cataract & Refractive Surgery

Young Ophthalmologists Videos: “My Early Surgeries” Online Museum

player.escrs.org EUROTIMES | DECEMBER 2018/JANUARY 2019

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

NOVEMBER AAO Annual Meeting 2020

14–17 November Las Vegas, USA www.aao.org

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To learn more about the AcrySof® IQ PanOptix® Presbyopia-Correcting IOL, talk to your Alcon representative. For further information please refer to AcrySof® IQ PanOptix® Directions For Use and AcrySof® IQ PanOptix® Toric Directions For Use. * Trademarks are the property of their respective owners. 1. Investigation of ACRYSOF® IQ PanOptix™ Presbyopia Correcting IOL Model TFNT00. Alcon data on file. 0053776. Effective date Jan 2018. 2. García-Pérez et al. Short term visual outcomes of a new trifocal intraocular lens. BMC Ophthalmology (2017) 17:72. 3. Lawless et al. Visual and refractive outcomes following implantation of a new trifocal intraocular lens. Eye and Vision (2017) 4:10. 4. Gundersen GK, et al. Trifocal intraocular lenses: a comparison of the visual performance and quality of vision provided by two different lens designs. Clinical Ophthalmology 2017:11 1081–1087. 5. Monaco G, et al. Visual performance after bilateral implantation of 2 new presbyopia-correcting intraocular lenses: Trifocal versus extended range of vision. Cataract Refract Surg 2017; 43:737–747. 6. Ruiz-Mesa R, et al. A comparative study of the visual outcomes between a new trifocal and an extended depth of focus intraocular lens. Eur J Ophthalmol 2017. 7. Clinical Investigation of Visual Function after Bilateral Implantation of Two Presbyopia-Correcting Trifocal IOLs. Alcon data on file. TDOC – 0053796. Effective date 19- Dec 2017. 8. PanOptix® Diffractive Optical Design. Alcon internal technical report: TDOC-0018723. Effective date 19 Dec 2014. 9. Estimation of Light Energy Distribution for PanOptix® IOL. Alcon data on File. TDOC-0051365. Effective date Nov 2015.

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