EuroTimes Vol. 23 - Issue 6 by EUROTIMES

SPECIAL FOCUS GLAUCOMA CATARACT & REFRACTIVE

RE-ROTATING MISALIGNED TORIC IOLS

CORNEA

PATIENTS WITH LUPUS REQUIRE SPECIAL ATTENTION June 2018 | Vol 23 Issue 6

RETINA

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Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon

CONTENTS

Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS GLAUCOMA 4

Many glaucoma patients now can achieve 20/20 vision thanks to emerging treatments

Complex pressure relationships appear at play in glaucoma and papilloedema

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

8 A new index combines best of structure and function testing

FEATURES CATARACT & REFRACTIVE 10 Everything you ever wanted to know about phacoemulsification in high myopic eyes

16 Re-rotating

misaligned toric IOLs is always worth considering

18 ESCRS members

honoured at this year’s American Society of Cataract and Refractive Surgery Annual Meeting

19 The Hill-RBF method is one of the best for IOL calculation in short eyes

20 JCRS highlights 21 3D quantitative OCT 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.

and ray tracing show promise for achieving better outcomes for toric IOLs

www.eurotimes.org

CORNEA

P.40

22 ESCRS and EuCornea delegates reveal their diagnostic and therapeutic preferences and protocols for OSD in 2017 survey data results

25 Complications in

patients with lupus require special attention

RETINA 27 Combining vitrectomy

with cataract procedure has advantages for both patient and surgeon

29 Accurate and timely

diagnosis of uveitis can be a life-saving measure

PAEDIATRIC OPHTHALMOLOGY

YOUNG OPHTHALMOLOGISTS 38 As good as it gets? Dr Khayam Naderi’s shortlisted essay for the John Henahan writing prize

39 The great divide

32 A panel discussion examined the best options for treating retinopathy of prematurity

34 Study looks at degree of cyclotorsion in healthy adults

OCULAR 36 Space flight-associated

neuro-ocular syndrome must be solved to make way for Mars mission

Dr Lawrence Kindo’s shortlisted essay for the John Henahan writing prize

REGULARS 40 Hospital diary 41 Industry news 43 Books 45 ESCRS news 47 Outlook on industry 48 Calendar

Supplement June 2018

USING

Included with this issue... ESCRS Education Forum supplement

PRESBYOPIA TORIC LENS

Technologies to Achieve

OPTIMAL

CATARACT REFRACTIVE

Outcomes

Supported by an unrestricted educational grant from

EUROTIMES | JUNE 2018

EDITORIAL A WORD FROM EMANUEL ROSEN FRCS, FRCOPHTH

20/20 VISION

Many glaucoma patients can now achieve 20/20 vision thanks to emerging glaucoma control, ocular surface and refractive treatments

am delighted to be invited to write the editorial for the June Richard B Packard MD, DO, FRCS, FRCOphth, of London, edition of EuroTimes. UK, was one of the two Honoured Guests and received his The special focus in this issue is on glaucoma and commendation at the ASCRS opening session. includes an excellent article that discusses how new A long-serving member of the technology offers better vision and quality of life for ESCRS, Dr Packard has lectured glaucoma patients. in 60 countries, was a pioneer of Steven Vold MD told the American Society of phacoemulsification and a leader Today, many glaucoma Cataract and Refractive Surgery 2018 Glaucoma Day in in the move to microincision patients can now achieve Washington DC, USA that many glaucoma patients now cataract surgery. He continues 20/20 vision thanks can achieve 20/20 vision. to design and refine innovative As Dr Vold points out, historically, a glaucoma surgical instruments, phaco tools to emerging glaucoma diagnosis meant years of declining vision treated with and other devices. control, ocular surface and lots of eye drops and then filtration surgery, producing Also honoured was ESCRS uncomfortable blebs and complications. Saving functional Secretary Oliver Findl MD, who refractive treatments vision was the goal – and patient comfort, refractive delivered the prestigious Binkhorst quality and quality of life took a back seat. Lecture. In a wide-ranging address Today, many glaucoma patients can now achieve 20/20 on the challenge of choosing the vision thanks to emerging glaucoma control, ocular surface and right IOL power, Dr Findl noted that optical biometry, modern refractive treatments and as Dr Vold also remarks, the “vision for formulae and optimised IOL constants, and precise measurements today’s glaucoma specialists is to offer sustainable, complianceof anterior and posterior corneal curvature by two or more devices free solutions that improve vision, safety, efficacy and ultimately have greatly improved IOL selection accuracy. quality of life for glaucoma patients”. As a founding editor of EuroTimes, now in its 22nd year, I am This issue also includes the first two of five essays shortlisted for delighted to see how the magazine is continuing to evolve and the 2018 John Henahan Writing Prize for young ophthalmologists. maintain excellent standards of reporting on the latest news in The prize, now in its 11th year, is named in honour of John ophthalmology. Happy reading! Henahan, who edited EuroTimes, the official news magazine of the ESCRS, from 1996 to 2001. The topic for this year’s prize was ‘Do We Need A Randomised Controlled Clinical Trial in Cataract Surgery?’ As chairman of the judging panel I was very impressed by the high standard of entries and look forward to the presentation of the prize to the overall winner during the Video Awards Ceremony at the 36th Congress of the ESCRS in Vienna, Austria. It is always good to see friends and colleagues rewarded for their achievements and I am also very pleased to see the report in this issue of the honouring of Richard Packard and Oliver Findl at the Emanuel Rosen, Chief Medical Editor, EuroTimes, recent ASCRS Congress in Washington, DC, USA. former president ESCRS.

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), Jack Holladay (USA) , Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | JUNE 2018

ESCRS

Glaucoma Day 2018 Friday 21 September Reed Messe, Vienna, Austria

Registration & Hotel Bookings glaucomaday.escrs.org Scientific Programme organised by

SPECIAL FOCUS: GLAUCOMA

GLAU COMA 20/20 NEW TECHNOLOGY OFFERS BETTER VISION AND QUALITY OF LIFE. Howard Larkin reports

EUROTIMES | JUNE 2018

SPECIAL FOCUS: GLAUCOMA

istorically, a g l a u c o m a diagnosis meant years of declining vision treated with lots of eye drops and then filtration surgery, producing uncomfortable blebs and complications. Saving functional vision was the goal – and patient comfort, refractive quality and quality of life took a back seat. New technology has changed that, Steven Vold MD told the American Society of Cataract and Refractive Surgery 2018 Glaucoma Day in Washington DC, USA. Many glaucoma patients now can achieve 20/20 vision thanks to emerging glaucoma control, ocular surface and refractive treatments. “Our vision is to offer sustainable, compliance-free solutions that improve vision, safety, efficacy and ultimately quality of life for our glaucoma patients,” said Dr Vold, who delivered the Stephen A Obstbaum Honoured Lecture. He reviewed a range of technologies and techniques that help glaucoma patients achieve what he calls the 20/20 experience at his practice in Fayetteville, Arkansas, USA.

OPTIMAL GLAUCOMA CONTROL Excellent outcomes start with optimal glaucoma control, and traditional approaches leave a lot to be desired, Dr Vold said. He is not against eye drops. “But I do know this. Patients have a tough time putting them in.” Drugs also cause irritation and sideeffects, and this worsens as more are added. As a result, compliance is less than 50% at 12 months with one drop a day and worse with multiple drops. Trabs and tubes also have significant downsides, with loss of visual acuity among them. “Even with the best surgeons … almost one-quarter of patients lose at least two lines of vision. Who wants to sign up for that, not to mention the risk of blebitis, endophthalmitis and things like that,” Dr Vold noted. Advances in laser technology offer options, including selective laser trabeculoplasty, micropulse laser trabeculoplasty, and micropulse cyclophotocoagulation (CPC), which makes CPC viable as an early treatment, Dr Vold said. “I’m finding I have patients who don’t need anti-inflammatory medications two weeks after surgery. This totally changes the game for us.”

Micro-invasive glaucoma surgery (MIGS) offers additional options that can be combined with cataract surgery, and has quickly gained ground, while combined trab and tube procedures have declined in the last five years, Dr Vold noted. Current treatments include trabectome, the iStent, Kahook dual blade, goniotomy-assisted transluminal trabeculectomy, ab interno canaloplasty, visco360/trab360 and the CyPass microstent, with new stents and microshunts on the horizon. For surgeons looking to add MIGS, Dr Vold advised mastering at least one or two trabecular bypass procedures to start, with at least one as a standalone procedure. A supraciliary device such as the CyPass is helpful for moderate cases. For advanced cases, new filtration surgery options include the Xen implant and InnFocus microshunt, he added.

PRISTINE OCULAR SURFACE The role of ocular surface disease (OSD) and dry eye in reducing vision and quality of life in glaucoma patients is often underappreciated by clinicians, Dr Vold noted. Glaucoma medications and filtration surgery exacerbate OSD, and a multi-faceted approach is required for diagnosis and therapy, he said. Signs of OSD associated with topical glaucoma medications include tear film instability, tear hyperosmolarity, conjunctival hyperaemia, corneal and conjunctival staining and decreased tear meniscus height, Dr Vold said. Medical treatments include artificial tears, hypochlorous acid lid cleanser, anti-inflammatory medications such as steroids, cyclosporine and lifitegrast and autologous serum. Dr Vold also suggested interventional treatments. These may include punctal occlusion or cautery after controlling inflammation to deepen tear reservoir, amniotic membrane to decrease inflammation in moderate-to-severe keratitis, meibomian gland probing and expression or lipiflow to increase meibum flow, and intense pulsed light to reduce cytokine flow to eyelid margins. Eyelid surgery may be indicated in cases with entropion or ectropion or floppy eyelids, he added.

20/20+ UNCORRECTED VISUAL ACUITY While surgeons have focused on the technical success of procedures such as trabeculectomy, patients have been less than thrilled with the irritating bleb and loss of vision.

OUR VISION IS TO OFFER SUSTAINABLE, COMPLIANCEFREE SOLUTIONS THAT IMPROVE VISION, SAFETY, EFFICACY AND ULTIMATELY QUALITY OF LIFE FOR OUR GLAUCOMA PATIENTS Steven Vold MD

“Why must glaucoma patients give up the dream of great vision?” Dr Vold asked. Technologies developed for cataract and refractive patients can make a big difference for glaucoma patients as well, he noted. Astigmatism management is critical, and for glaucoma patients with 1.0 dioptre or more of cylinder to retain a significant field of vision, toric lenses can improve vision and are very stable when properly placed, Dr Vold said. Incisional approaches can be used for lower astigmatism or to fine-tune toric lenses. For patients with mild-to-moderate glaucoma, newer presbyopic intraocular lenses (IOL) may be suitable. Lenses with lower near adds and extended depth of focus greatly reduce the risk of lost contrast sensitivity and glare and halos that ruled out earlier multifocal IOLs. Laser-assisted cataract surgery and intraoperative aberrometry also can help improve visual outcomes with glaucoma patients as much as other patients. Even corneal surgery is an option. Of course, candidates for refractive approaches should be carefully screened and evaluated, Dr Vold said. But the effort is worthwhile. “If we choose wisely we can have happy patients at the end of the day.”

EUROTIMES | JUNE 2018

SPECIAL FOCUS: GLAUCOMA

PRESSURE GRADIENTS Complex pressure relationships appear at play in glaucoma and papilloedema. Howard Larkin reports

n 1908, Kasmir J Noishevsky hypothesised that depression of the optic nerve may be caused by an excess of intraocular pressure (IOP) over cerebrospinal fluid pressure (CSFP) across the lamina cribrosa – and demonstrated it two years later by boring a hole in the skull of a dog with help from the renowned Ivan Pavlov. More than a century later, evidence continues to mount that a translaminar pressure gradient is involved in papilloedema and glaucomatous excavation, as well as deformation of the posterior pole of the globe and related retinal folds. However, the relationship between CSFP and IOP is complex and cannot yet be directly measured, making it an attractive subject for further research, presenters told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA.

DEFINING TERMS Assessing effects of the translaminar pressure difference requires understanding specifically what should be measured, said David Fleischman MD, of the University of North Carolina at Chapel Hill, USA. He noted that where CSFP is measured is critical. For example, while several studies suggest a correlation between IOP

and intracranial pressure (ICP), their conclusions are suspect due to various methodological problems. More rigorous recent studies show no correlation between IOP and ICP, Dr Fleischman noted. Both IOP and CSFP can vary with posture, time of day and other factors, he added. “The translaminar pressure difference is not a static number.” Two groups have investigated the relationship of orbital CSFP and the intracranial pressure, and these were both performed in dog models with varying results. Dr Fleischman sees orbital pressure as the appropriate point to determine the translaminar pressure difference. Pressure in the orbital space differs from ICP due to the constriction of the optic canal where the optic nerve passes between the skull and the orbit, and impedes free fluid flow. Indeed, differences in size of the two optic canals may explain unilateral and asymmetric papilloedema, he notes, referencing Sohan Hayreh and two recent studies confirming Hayreh’s hypothesis (Bidot S et al. J NeuroOphthalmol 2015; 35: 31-36. Bidot S et al. J Neuro-Ophthalmol 2016; 36: 120-125). Unfortunately, no effective way of measuring orbital CSFP yet exists, Dr Fleischman said. “This is going to be a big problem for us in terms of quantitative research into

This is going to be a big problem for us in terms of quantitative research into the translaminar pressure difference David Fleischman MD

ask the experts EUROTIMES | JUNE 2018

the translaminar pressure difference. However, it also makes it an exciting opportunity for research.”

THE ROLE OF OCT OCT provides indirect evidence of the effect of the translaminar pressure gradient on ocular anatomy in patients with intracranial hypertension, said Patrick A Sibony MD, of Stony Brook University Hospital, New York, USA. OCT shows retinal nerve fibre layer (RNFL) thickness, disc volume, globe shape deformations, retinal folds and changes due to ocular ductions. Dr Sibony considers OCT measurement of RNFL thickness the best way to monitor papilloedema progression. However, when the disc is swollen, there are segmentation artifacts that can limit its reliability. A decrease in RNLF thickness may be a sign of improvement or axonal attrition; a distinction that can only made by monitoring the visual field. OCT can also show changes in the shape and displacement of the peripapillary tissues and the lamina cribrosa in response to the intraocular and CSF pressure. Using shape analysis techniques, Dr Sibony has shown anterior shape deformations and displacements (toward the vitreous) with intracranial hypertension that moves posteriorly (away from the vitreous) after treatment. OCT may provide a potentially useful tool for gauging intracranial pressure and the translaminar pressure gradient. David Fleischman: david8fleischman@gmail.com

If you have a clinical question regarding a straightforward or complex case, send it to EuroTimes Executive Editor Colin Kerr at: colin@eurotimes.org The questions we receive will then be sent to our Medical Editors and International Editorial Board. We will publish a selection of their answers in the magazine.

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SPECIAL FOCUS: GLAUCOMA

PREDICTING PROGRESSION Practice Management

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New index combines best of structure and function testing. Roibeard Ó hÉineacháin reports

ombining the results of structural and functional tests into an estimate of retinal ganglion cell (RGC) loss in eyes with glaucoma can provide a clearer quantification of disease progression than either type of test on its own, according to Felipe Medeiros MD, Duke University, Durham, North Carolina, USA. “There is a strong need for using a combined approach for evaluating structure and function in glaucoma,” he told the 7th World Glaucoma Congress in Helsinki, Finland.

INVERSE DETECTABILITY EFFECT He noted that abundant research has shown that in some eyes glaucomatous change is detectable by changes in the optic nerve before it is detectable by visual field changes, but in other eyes the reverse is true. For example, in a recent study where he and his associates followed 462 eyes over 3.6 years with 24-2 standard automated perimetry (SAP) and optical coherence tomography (OCT), glaucoma progressed with both tests in only 4.1% of cases, while SAP detected progression in around 10% and OCT detected it in 19%. Closer examination of the data revealed that those most likely to progress based on SAP testing were those with more advanced disease, whereas those with less advanced disease were more likely to progress on OCT. Other studies have shown the same tendency of better detection of progression with structural tests in the early stages of glaucoma and with functional testing in the later stages, he noted. One explanation for the finding is that in the early stages of the disease a high proportion of RGC loss will cause only minor changes in the visual field, he said. In fact, research suggests that patients can lose around half of their RGCs before glaucoma is detectable at all by perimetry. In contrast, small amounts of structural change occurring in the later stages of glaucoma can be below the limit of detectability using current OCT technology.

INTEGRATED STRUCTURE/FUNCTION INDEX

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Dr Medeiros and his associates have therefore devised an index of glaucoma that derives estimates of RGC count from both types of measurement, the combined index of structure and function (CSFI). The new index derives functional-based estimates of RGC loss from research data from an empirical monkey model of glaucoma comparing behavioural perimetry with post-mortem optic nerve histology. The index couples the functional estimates with structural estimates of RGC loss derived from spectral-domain OCT. The CSFI is the average of structural and functional estimates weighted according to the normal effect of ageing and the effects of disease severity. In an observational study, the CFSI performed significantly better than isolated measures of structure and function for diagnosing glaucoma and discriminating different stages of the disease. The index is now available in a form that is optimised for integrating data from the Humphrey visual field analyser and Cirrus OCT (Zeiss).

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CATARACT & REFRACTIVE

PHACOEMULSIFICATION

IN HIGH MYOPIC EYES

Everything you ever wanted to know about phacoemulsification in high myopic eyes. Soosan Jacob MD reports

yes with high myopia refer to those with an axial length greater than 26mm or -6D of myopia. These eyes often develop nuclear cataract earlier and surgery has added advantages of decreased dependence on high-powered glasses. However, surgery can be more difficult and should be carried out with care.

PROBLEMS Associated co-morbidities such as openangle glaucoma, chorioretinal atrophy and macular pathology may result in less than desirable results. Complete preoperative retinal examination including periphery is important and if required any peripheral retinal lesions should be lasered. For dense cataracts precluding retinal examination, B-scan is indicated followed by a dilated retinal examination as soon as possible after surgery. Bilateral myopes should be counselled regarding need for surgery in the second eye to prevent anisometropia. Retrobulbar and to some extent peribulbar block poses the risk of inadvertent globe perforation in high myopes because of larger eye size and thinner sclera. Large eyes have lower scleral rigidity. Equatorial and zonular stretch on instilling viscoelastic or initiating irrigation causes lens-iris diaphragm retropulsion syndrome. Increased anterior chamber (AC) volume causes a reverse pupillary block by causing 360-degree irido-capsular contact. Young age and previous vitrectomy can compound this effect. Sudden backward movement and deepening of AC can cause discomfort to the patient if surgery is under topical anaesthesia. An excessively deep AC necessitates holding instruments more vertically and increases range of focus required. Reverse pupillary block can be neutralised by lifting the iris edge off the anterior capsule and allowing fluid to equilibrate between anterior and posterior chambers, thus bringing the iris, zonules and lens back to a more normal position. This manoeuvre generally brings the pupil back to original size, though miosis EUROTIMES | JUNE 2018

may sometimes occur because of prostaglandin release. The reverse pupillary block repeats on initiating infusion each time and should be tackled in a similar manner. It can be prevented by placing a rod between iris and anterior capsule each time before initiating infusion. There are also other intraoperative problems specific to large eyes. Short corneal tunnels may not be selfsealing because of lower scleral rigidity, especially if combined with other risk factors such as young A, B: Infusion pushes the iris against the anterior capsule, causing reverse pupillary block age and the need to work vertically thereby distorting Repeated shallowing of the AC, the wound. Sutures should be used when especially in the presence of vitreous required. Too long a tunnel also results syneresis, also increases risk of retinal in the need to place instruments more detachment. Gradual pressurisation and vertically leading to corneal distortion depressurisation should therefore be done and decreased visibility. by injecting viscoelastic with the left hand The cystitome shaft needs to be more before withdrawing the phaco or I/A vertical to prevent depression of the probe. New phaco machines have active posterior lip and escape of viscoelastic. fluidics and can decrease some of the Repeated refilling of viscoelastic may problems faced. still be required. The rhexis size may Despite breaking the reverse pupillary appear deceptively small due to a larger block, instruments may still need to be corneal diameter. An unintentional large placed more vertical than usual, leading capsulorhexis can result in incomplete to greater difficulty in nucleus removal overlapping of the anterior capsule around and cortex aspiration techniques. For the optic edge, thereby leading to anterior soft nuclei, prolapse and supra-capsular movement of IOL optic and a myopic phacoemulsification may be easier than shift as well as increased risk of posterior in-the-bag nuclear disassembly techniques. capsular opacification, the need for YAG These eyes have a higher risk for capsulotomy and consequently increased anterior and posterior capsular tears and risk of retinal detachment.

CATARACT & REFRACTIVE Very high myopes may be associated with progressive zonulopathy and sometimes late in-the-bag IOL subluxation. A subluxated threepiece IOL from initial surgery allows easy closed chamber translocation to secondary scleral fixation in the form of a glued IOL. An in-the-bag single-piece acrylic IOL may also be refixated using sutured segments or the sutureless glued capsular hook technique described by the author. IOL power calculation is very C, D: Lifting the iris with a rod allows fluid to equilibrate between anterior and posterior chambers important because of a higher chance of error in large zonular dehiscence. IOL implantation eyes. Current optical biometers provide should be done after refilling the bag with inaccurate axial length measurement in viscoelastic in order to prevent haptic eyes longer than 26mm as it uses the same snag on a lax capsule. Laterally displaced refractive index for all eyes. However, IOLs and rotation of toric IOLs may occur as posterior staphylomas can cause gross because of a bag-IOL diameter mismatch. errors with ultrasound biometry, optical Complete removal of viscoelastic and biometry is still preferable, even in eyes implanting a prophylactic capsular with axial length more than 30mm, despite tension ring may help. Avoiding anterior lower accuracy. IOL power may be in low capsular polishing may promote earlier plus or rarely even in the negative range. sandwiching of a toric IOL into place; Hyperopic shifts may be seen with thirdhowever, this will not be helpful against and sometimes even fourth-generation the early rotation that can occur. formulae. The Holladay 2, Olsen, Barrett

Universal II and Haigis formulae are good. The SRK/T formula may be effective between 27-29mm where a negative IOL may be required; however, very steep or flat keratometric values can confound results. If low-range single-piece acrylic IOLs are not available, a three-piece IOL may be placed.

FEMTOSECOND LASER ASSISTED CATARACT SURGERY (FLACS) Femtosecond gives an accurately sized and centred rhexis. It also allows easier disassembly of the nucleus and helps overcome challenges of in-the-bag chopping and cracking manoeuvres in a deep AC.

POSTOPERATIVE COMPLICATIONS Post-op complications that may occur include pseudophakic retinal detachment. Postoperative retinal examination is therefore a must. Steroid response may be seen, especially if also associated with young age. Weaker steroids may be used postoperatively. Though high myopic patients can be brought close to a plano refraction, loss of the easy reading ability may create unhappiness. Micromonovision may be aimed for if bilateral surgery is being performed. IOL calculation errors may require a second surgery and patients should understand this. Macular pathology may limit postoperative visual acuity attained.

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

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VIENNA 2018 36 Congress of the ESCRS TH

Main Symposia 

Corneal Cross-Linking: Current Status and Future Perspectives



The Diabetic Eye



Glaucoma for the Cataract Surgeon



Extending Depth of Focus



Refractive Surgery for High Ametropia



The Enigma of Pseudoexfoliation

22–26 September Reed Messe, Vienna, Austria

Clinical Research Symposia 

Myopia



Measuring Near and Intermediate Quality of Vision



Blue Sky Lens Research



Femtosecond Surgery

Highlights 

‘Best of the Best’ Review Session



Poster Village



Young Ophthalmologists Programme



120 Instructional Courses



77 Surgical Skills Courses

Ridley Medal Lecture Rudy Nuijts THE NETHERLANDS

Scientific Programme Registration & Hotel Bookings

www.escrs.org

36th Congress of the ESCRS 22–26 September 2018

Saturday 22 September

Sunday 23 September

Lunchtime Symposia

Boxed Lunch Included

13.00 – 14.00

Dry Eyes – Targeted Treatment as a Key to Satisfied Patients

ZEISS Satellite Meeting

Moderator:

P. Steven GERMANY

Sponsored by

Speakers:

T. Kaercher GERMANY G. Auﬀarth GERMANY P. Steven GERMANY

Sponsored by

Ziemer Lunch Symposium Sponsored by

Sponsored by

Rationalization of Prescriptive Behaviors in Ophthalmology for the Containment of Antibiotic Resistance

Trifocality in Comparison Visualization by 3D Mapping

Moderators: F. Bandello ITALY B. Malyugin RUSSIA

Sponsored by

Alcon Satellite Meeting Sponsored by

Pentacam® AXL and Corvis® ST: Taking Cataract and Refractive Surgery to the Next Level Moderators: F. Hengerer GERMANY C. Roberts USA

Sponsored by

Moderator:

S. Srinivasan UK

Sponsored by

Oculentis Satellite Meeting

Speakers:

Glaucoma Treatment: From Eyes Drops to Surgical Intervention, When and What to do?

T. Kohnen GERMANY F. Hengerer GERMANY G. Savini ITALY M. Belin USA R. Ambrósio BRAZIL R. Vinciguerra ITALY

Saturday 22 September

Evening Symposium 18.15 – 19.45 Alcon Satellite Meeting Sponsored by

ZEISS Satellite Meeting Sponsored by

MINI WELL READY EDOF IOL by SIFI: Latest International Clinical & Scientific Updates Sponsored by

Alcon Satellite Meeting Sponsored by

Sunday 23 September

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Smart Technologies – Innovations for Today’s Surgical Practices Moderator:

Sunday 23 September

Evening Symposium 18.15 – 19.45

Alcon Satellite Meeting Sponsored by

S. Morselli ITALY

Sponsored by

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CATARACT & REFRACTIVE

TORIC IOL REALIGNMENT Re-rotating misaligned toric IOLs is always worth considering. Roibeard Ó hÉineacháin reports

epositioning misaligned toric IOLs can bring visual benefits in most eyes, even in some cases where the wrong power IOL was used, reports Professor Thomas Kohnen MD, PhD, FEBO, University Frankfurt, Germany “Always calculate the benefit of re-rotation even if the IOL is on axis,” Prof Kohnen told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. He reminded the audience that, if misaligned by 10 degrees, a toric IOL will have a 34% reduction in its anti-stigmatic effect, an IOL misaligned by 30 degrees off axis will have no anti-astigmatic effect and an IOL any further off axis will actually induce astigmatism. He also noted that the posterior surface is a major contributor to miscalculation of toric IOL power. Although research has shown that the average refractive power of the posterior corneal surface is -0.33D, an eye with a sim-K of 0.1 can have a total corneal power of 1D of astigmatism.

Thomas Kohnen speaking at the 22nd ESCRS Winter Meeting in Belgrade, Serbia

ONLINE RE-ROTATION Prof Kohnen emphasised that using calculators and formulas that take measurements of the posterior surface into account can help avoid misalignment. There is now an online IOL calculator, available at https://astigmatismfix.com/, designed specifically for eyes with residual astigmatism following toric IOL implantation. Developed by John Berdahl MD and David Hardten MD, the toric IOL rotation calculator compares the axis of the lens with the patient’s current manifest refraction and determines whether rotating the IOL can decrease residual astigmatism. It also indicates the ideal amount of IOL rotation and the expected residual error. To illustrate the usefulness of the Berdahl-Hardten calculator, Prof Kohnen presented two examples of eyes with misaligned toric IOLs. In the first case, the axis of the IOL was at 65 degrees, as opposed to its intended axis of 92 degrees. The eye’s refraction was -3.0D sphere and +5.0 D cylinder at 120. The calculator showed that the ideal toric repositioning

would be at 92 degrees, as originally intended, and that this would leave the eye with a postoperative refraction of -0.87D. In the second case, the IOL was at its intended axis of 120 degrees, but the eye had a refraction of -2D sphere and +3D of cylinder at 40 degrees. Prof Kohnen noted that usually IOL exchange would be indicated in an eye with such a high residual refractive error. However, the online calculator showed that the ideal rotation would bring this patient close to emmetropia, with a myopia of -0.59 and a low astigmatism of 0.17D.

RE-ROTATION PEARLS AND PITFALLS Prof Kohnen noted that the ideal time for re-rotation of a misaligned toric IOL is one-to-two weeks after the implantation of the lens. By that time, the capsular wound healing will improve rotational stability, compensating for the looser fit that can result from an eye having a capsular bag that is too large for the implant.

Always calculate the benefit of re-rotation even if the IOL is on axis Thomas Kohnen MD, PhD, FEBO EUROTIMES | JUNE 2018

Changing the illumination is often helpful in eyes where IOL axis markings are difficult to see, he noted. Intraoperative optical biometry and aberrometry can be used to make axis markings intraoperatively on the cornea. The use of a viscoelastic helps protect intraocular structures and reduce the chance of sudden losses in intraocular volume. Haptic fixation may be necessary in IOLs misaligned late after capsular rupture or zonular dehiscence. When repositioning the lens, it is important to ensure that the haptics are correctly positioned in the capsular bag. Pupil dilatation can dislocate a haptic, with the result that one haptic is in the capsule and the other is in the sulcus, he pointed out. In cases where re-rotation of the IOL will not be useful, the IOL may be exchanged. The intervention is primarily indicated for cases of miscalculation or wrong IOLs. To remove the lens, the surgeon has the option of refolding it or bringing it into the anterior capsule and cutting it into pieces. Other options for patients with unsatisfactory outcomes include glasses or contact lenses, and corneal refractive surgery. Thomas Kohnen: kohnen@em.uni-frankfurt.de

NUMBER 1!

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EuroTimes Readership Study 2017

CATARACT & REFRACTIVE

Team ESCRS Captain Béatrice Cochener representing France, Sathish Srinivasan from the UK, H Burkhard Dick for Germany, and Ehyd Assia from Israel

HONOURED COLLEAGUES Dr Richard Packard welcomed as an Honoured Guest of ASCRS and Dr Oliver Findl delivered the prestigious Binkhorst Lecture. Howard Larkin reports

ncoming ASCRS President Thomas W Samuelson MD welcomed Richard B Packard MD, DO, FRCS, FRCOphth, of London, UK, as one of two Honoured Guests at the opening session of the 2018 American Society of Cataract and Refractive Surgery Annual Meeting in Washington, DC, USA. A long-serving member of the ESCRS, Dr Packard has lectured in 60 countries, was a pioneer of phacoemulsification and a leader in the move to microincision cataract surgery. He continues to design and refine innovative surgical instruments, phaco tools and other devices. Also honoured was ESCRS Secretary Oliver Findl MD, who delivered the prestigious Binkhorst Lecture. In a wideranging address on the challenge of choosing the right IOL power, Dr Findl noted that optical biometry, modern formulae and optimised IOL constants, and precise measurements of anterior and posterior corneal curvature by two or more devices have greatly improved IOL selection accuracy. Future developments such as intraoperative measurements to refine IOL EUROTIMES | JUNE 2018

of all he was humbled by the opportunity selection and adjusting lens power after to serve the profession and patients. “I surgery may further improve outcomes, am incredibly honoured to become he added. the 33rd president of ASCRS,” Outgoing ASCRS president he said. Bonnie An Henderson Another highlight of the MD reviewed ASCRS’s Congress was the 2018 accomplishments during ASCRS Cataract Surgery her 12 months in office. Dr Olympics, which pitted Henderson also highlighted surgeons from all around ASCRS’ role in shaping the world against each government regulations to other. Team ESCRS got on ensure patient access to eye the winning podium after care. “Our organisation continues to be the most vocal advocate for Richard B Packard team captain Béatrice Cochener MD, PhD, raced to victory in the anterior segment surgeons when it is Cataract Pentathlon event. the most important, period,” she said. Steve Charles MD accepted Incoming president Thomas the 2018 Charles D Kelman W Samuelson MD promised Innovator’s Award from to continue Dr Henderson’s ASCRS Annual Meeting initiatives, and pledged Programme Chair Edward to redouble ASCRS’ J Holland MD and Anne commitment to broadening Kelman. In his lecture, Dr anterior segment surgeons’ Charles, who played a major skills. role in developing vitrectomy Dr Samuelson also renewed and other ophthalmic surgery ASCRS’ commitment to ending devices, emphasised the role of avoidable blindness everywhere Oliver Findl collaboration among hundreds of through support for ophthalmic surgeons and engineers in developing education, residency programme ideas to improve patient outcomes. development and surgery missions. Most

CATARACT & REFRACTIVE

CALCULATION COMPARISON The Hill-RBF method is one of the best for IOL calculation in short eyes. Roibeard Ó hÉineacháin reports

he new extended beta version of the Hill Radial basis function (Hill-RBF) IOL calculation method appears to predict postoperative visual acuity with a degree of accuracy that is at least equal to third- and fifthgeneration IOL calculation formulas in patents with short eyes, according to a study presented by Diogo Lopes MD, Hospital Garcia de Orta Almada, Portugal. “This is the first study comparing the new extended beta version of Hill-RBF calculator with third- and fifth-generation formulas in short axial length eyes. The Hill-RBF and Holladay I formulas had the highest percentage of eyes within 0.50D of the target and the lowest median absolute errors,” Dr Lopes told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. The study involved 37 eyes of 31 cataract patients with axial lengths no greater than 22.0mm. Dr Lopes and his associates compared achieved outcomes with those predicted by four IOL power calculation formulas – Hill-RBF, Hoffer Q, Barrett Universal II and Holladay 1. They obtained biometric data with the IOLMaster 500 in all patients. The IOL models implanted in the study included the Alcon SA60AT in four eyes, the AMO Sensar AAB00 in five eyes, the AMO Tecnis PCB00 in 12 eyes and the Bausch + Lomb Akreos MI60 in 16 eyes. All patients had undergone uneventful cataract surgery within the previous two years. The researchers calculated refractive prediction with each of the four formulas in all eyes and compared the predicted with the actual refractive outcome to give the refractive prediction error, Dr Lopes explained. They found that although the Hill-RBF and Holladay formula presented a lower median absolute error (0.34D and 0.33D respectively) than Hoffer Q and Barrett (0.44D and 0.41D respectively), there was no statistically significant differences in the median absolute error between the four formulas (P>0.05). However, he pointed out that the Hill-RBF and Holladay I formulas were able to achieve the highest percentage of eyes within 0.50D of the target, 70% and 68% respectively. Prediction error ranged from -0.46D to 1.39D with the HillRBF method, from -0.84D to 1.33D with the Holladay I formula, from -0.99D to 1.31D with the Barrett calculator and -1.15D to 1.00D in Hoffer Q. “Although we have not used optimised lens constants and different IOL types, the Hill-RBF method performed at least at the same level as the other three formulas,” Dr Lopes added. Diogo Lopes: cdiogolopes@gmail.com

The Hill-RBF and Holladay I formulas had the highest percentage of eyes within 0.50D of the target and the lowest median absolute errors

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Diogo Lopes MD EUROTIMES | JUNE 2018

CATARACT & REFRACTIVE

CONGRATULATIONS! 2017 OBSTBAUM AWARD FOR BEST ORIGINAL ARTICLE

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

2017 ROSEN AWARD FOR BEST TECHNICAL ARTICLE

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

The JCRS as we know it today was born out of the amalgamation of two peer-reviewed journals, the Journal of Cataract & Refractive Surgery from the ASCRS and the European Journal of Implant and Refractive Surgery from ESCRS. The merged journal, which marked its 20th year in 2016, is the direct outcome of the spirit of friendship and cooperation that developed between the two societies, in particular between the editors at the time of the merger, Stephen A. Obstbaum, MD, in the United States and Emanuel S. Rosen, MD, FRCSEd, in Europe. In honor of their passion and foresight, the editors are pleased to announce the creation of two annual awards for articles published in the JCRS, the Obstbaum Award for Best Original Article and the Rosen Award for Best Technique Article.

JCRS HIGHLIGHTS VOL: 44 ISSUE: 2 MONTH: FEBRUARY 2018

FLACS AND PHAKIC IOLS Femtosecond laser-assisted cataract surgery (FLACS) can be applied successfully in eyes with cataract and a foldable anterior or posterior chamber pIOL in situ, a new study suggests. Investigators report their experience with five eyes in which a femtosecond laser was used to create a capsulotomy, perform lens fragmentation and create corneal incisions with the pIOL in situ. Two eyes had an anterior chamber phakic IOL in place while three had posterior chamber phakic IOLs. The capsulotomy was successful in all cases. Lens fragmentation was complete in four eyes and incomplete in one eye, where trapped cavitation bubbles in the space between the posterior chamber pIOL and anterior lens capsule were evident as a result of a shallow vault of the pIOL. Potential advantages of the FLACS approach include less endothelial cell reduction and higher capsulotomy circularity compared with conventional manual cataract surgery. T Kohnen et al., JCRS, “Femtosecond laserassisted cataract surgery in eyes with foldable anterior or posterior chamber phakic intraocular lenses”, Vol. 44, Issue 2, 124–128.

PREOPERATIVE DRY EYE Meibomian gland dysfunction is high in patients presenting for cataract surgery, report researchers who conducted a prospective study of 342 eyes of 180 patients. Patients underwent comprehensive preoperative evaluation of lipid layer thickness, partial blink rate measurements and gland structure. They also completed the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire. Fifty-two percent of patients had meibomian gland dysfunction and 56% had meibomian gland atrophy equal to or more than Arita grade 1. Meibomian gland function correlated significantly with lipid layer thickness, symptoms, age and gland atrophy. Fifty percent of patients with meibomian gland dysfunction were asymptomatic. This underscores the importance of preoperative meibomian function and structure assessment, the authors note. B Cochener et al., JCRS, “Prevalence of meibomian gland dysfunction at the time of cataract surgery”, Vol. 44, Issue 2, 144–148.

NEW TORIC IOL CALCULATOR A new algorithm that incorporates the effect of posterior corneal astigmatism appears to reduce the astigmatic prediction error after toric IOL implantation significantly. The algorithm was evaluated in a study of 274 eyes. The investigators report that this algorithm significantly reduced the centroid error in predicted refractive astigmatism. Moreover, the centroid error reduced from 0.50 @ 1 to 0.19 @ 3 when using preoperative K values and from 0.30 @ 0 to 0.02 @ 84 when using postoperative K values. Patients who had anterior corneal against-the-rule, with-the-rule and oblique astigmatism had improvement with the algorithm. In addition, the algorithm reduced the median absolute error in all groups (P < .001). C Canovas et al., JCRS, “New algorithm for toric intraocular lens power calculation considering the posterior corneal astigmatism”, Vol. 44, Issue 2, 168-174.

THOMAS KOHNEN European editor of JCRS

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

EUROTIMES | JUNE 2018

CATARACT & REFRACTIVE

IMPROVING TORIC IOL

CALCULATIONS

3D quantitative OCT and ray tracing show promise for achieving better outcomes. Cheryl Guttman Krader reports

ataract surgeons in the future will be using three-dimensional (3D) quantitative optical coherence tomography (OCT) imaging to obtain preoperative biometry. The information it provides should improve traditional IOL power formulas and feed into custom-eye raytracing models to customise IOL selection and the best rotation for toric IOLs, said Susana Marcos PhD, at the XXXV Congress of the ESCRS in Lisbon, Portugal. “With a single scan, the 3D quantitative OCT can determine topography, keratometry, and astigmatism of the anterior and posterior cornea and a better estimate of the effective lens position (ELP). It can also provide data on the thickness, anterior surface topography, posterior surface topography, tilt, and decentration for the crystalline lens, along with pachymetry, pupillometry, and anterior chamber depth data,” said Dr Marcos, Director, Visual Optics and Biophotonics Laboratory, Consejo Superior de Investigaciones, Científicas, Madrid, Spain. Dr Marcos demonstrated the promise of 3D quantitative OCT by reviewing findings from research that has been conducted with an experimental anterior segment spectral domain system developed by her laboratory. The custom platform uses algorithms with full distortion correction and automatic analysis tools to quantify the biometric parameters. She discussed a study showing how the system could be used to characterise changes in corneal aberrations that are caused by the surgical incision. “This is something we can incorporate in the model for better accuracy,” she said. She also reviewed an in vivo study showing how the use of the 3D imaging technique to obtain patient-specific data on

the full crystalline lens shape preoperatively improved prediction of the postoperative IOL position when compared to existing methods that are considered state-of-the-art. “It is well accepted that a more accurate estimation of the ELP will result in improved IOL power calculations, and therefore a more accurate correction of refractive error,” she said, noting that a novel OCT-based method that allowed full quantification of the crystalline lens 3D shape was associated with improvement of up to 0.6D compared with the SRK/T formula or the Olsen Constant optimised. Dr Marcos also showed how having an anatomically correct full model of the lens translates into achieving better results with toric IOL implantation. “When custom model eyes are built using patient-specific anatomical data and there is a better estimate of where the lens is going to fit, you can use these as a platform to perform ray-tracing calculations, and for example, rotate the toric lens to determine which orientation produces an optimised wavefront. Applying this approach, there is no longer any need to rely on regression or theoretical formulas or to determine the axis during surgery,” she said.

RAY TRACING Paul-Rolf Preussner MD, PhD, Professor, University Eye Hospital, Mainz, Germany, discussed the application of ray tracing to IOL formulas. Ray tracing is used by the commercially available Okulix software. Input data for ray-tracing IOL power calculation can be obtained using devices that give anterior and posterior cornea surface measurements. Currently, the Okulix software can interface with all Tomey devices, the Oculus Pentacam and the HaagStreit Lenstar, and it will be compatible with other diagnostic imaging devices soon.

I think most surgeons do not have different devices, but they still want to know what kind of accuracy to expect in an individual case Paul-Rolf Preussner MD, PhD

Dr Preussner noted that the ray-tracing prediction algorithm is the same for toric and non-toric IOLs because there should be no difference in lens position between the two types of optics, and he recommended using anterior and posterior cornea surface data for the calculation. To illustrate the performance of the software, Dr Preussner reviewed findings from a study that analysed data from 78 eyes of 56 patients implanted with different toric IOL models. Using the ray-tracing software to predict the residual refraction, Dr Preussner and colleagues showed that the cylindrical prediction error was lower when the software used preoperative keratometry, topography and tomography than if it used any of the three measurements alone. Among eyes that achieved VA ≥20/20, the median absolute cylindrical vector prediction error was only 0.38D using the combined data. A study including five “problem eyes” with a history of corneal surgery was undertaken to investigate the accuracy limits of the measuring process in such cases. All eyes were measured three times with each of three different devices (Tomey TMS-5, Ziemer Galilei G6 and Oculus Pentacam). The raw tomography data were processed by the ray-tracing software independent of the device’s software, and the vector average of the total corneal astigmatism was calculated for each of the nine measurements for each eye. The results for two eyes showed good agreement across all measurements. For two other eyes, there was reasonably good agreement but greater intra- and interdevice data spread. In the remaining eye, there were large differences in outcomes between devices and comparing the repeated measurements taken with a single device. “I think most surgeons do not have different devices, but they still want to know what kind of accuracy to expect in an individual case. My recommendation is to do repeated measurements, calculate the outcome, and use the data to inform the patient about the possibility that the outcome may not be ideal,” Dr Preussner said. Susana Marcos: susana@io.cfmac.cscic.es EUROTIMES | JUNE 2018

CORNEA

STRATEGIES

for Identifying and Treating

OSD

Before Cataract Surgery

ESCRS and EuCornea delegates reveal their diagnostic and therapeutic preferences and protocols in 2017 survey data results

ontinued advances in cataract surgery technology, such as the use of the femtosecond laser and premium IOLs, enable surgeons to achieve excellent refractive outcomes for patients, and patients in turn expect truly outstanding results. The success of todayâ&#x20AC;&#x2122;s cataract interventions, however, is largely dependent on the health of the ocular surface. Ocular surface disease (OSD) is prevalent in the cataract-age population, and its presence can affect the accuracy of preoperative measurements and IOL calculations, as well as postoperative visual quality.1 EUROTIMES | JUNE 2018

The 2017 ESCRS Clinical Survey of OSD was administered onsite at the annual meeting in Lisbon, Portugal, and available to be taken online. Of the almost 1,900 respondents, close to 60% have been in practice for more than a decade.

LOOKING FOR OSD Of the respondents, 42% said they systematically perform a check of the ocular surface as part of the preoperative cataract surgery assessment in all patients. Thirty percent systematically check for OSD in most cases, 23% said they only check if the patient presents with dry eye disease (DED) and 5% rarely or never check the ocular surface (Figure 1).

When asked about the percentage of patients who were asymptomatic to OSD prior to surgery but developed symptoms afterward, 60% of the delegates noted that this was the case in up to 10% of their patients, and 59% said somewhere between 11% and 25% of their patients. There were 18% of delegates who said that 26-to-50% of their patients develop symptoms of OSD postoperatively.

TREATMENT CHOICES â&#x20AC;&#x201C; DED

There is an ever-increasing number of treatments for OSD, from over-the-counter drops to prescription therapy, plugs or thermal expression, for example. By far, artificial tears and lubricants are the most

CORNEA

Indicate your primary therapies and treatments for managing moderate and severe dry eye (aqueous-deficient or unspecified) 100%

93% 93%

90% 80%

moderate

70%

severe

60% 52%

40%

44%

42% 43%

42%

40% 28% 30%

30%

23%

32%

30%

26%

20%

13%

16%

19%

10% 0%

2% 3% Artificial tear/lubricant

Ciclosporin (Cyclosporine)

Oral Omega-3

Thermal lid expression (manual or automated i.e. LipiFlow)

Punctal occlusion

Topical corticosteroid

Topical Azithromycin

Oral cyclines (doxycycline minocycline, etc.)

Other

Figure 2. Primary and Therapies for Moderate and Severe DED

widely used therapy by ESCRS and EuCornea delegates, with 93% of surgeons using these drops as a primary therapy in moderate and severe aqueous-deficient or unspecified DED (Figure 2). For severe disease, 52% of the respondents use cyclosporine, 44% punctal occlusion, 43% oral omega-3s and 42% a topical corticosteroid. The use of cyclosporine as a preferred therapy in patients with moderate disease dropped to 23%. More than 40% of the delegates recommend patients with moderate disease take omega-3s. Other therapies ESCRS and EuCornea delegates employ for moderate and severe aqueous-deficient or unspecified disease include thermal expression (manual or heated), topical azithromycin and oral cyclines such as doxycycline or minocycline.

TREATMENT CHOICES – MGD

DIAGNOSTIC PREFERENCES

Meibomian gland dysfunction (MGD) and Sjögren and non-Sjögren lacrimal disease remain the leading causes of evaporative and aqueous-deficient DED, according to the recent update from the TFOS International Dry Eye WorkShop (DEWS II).2 Many hybrid forms of DED exist, and they often overlap. Warm compresses are the primary therapy for MGD among the ESCRS and EuCornea delegates, with 74% using conventional methods and 34% recommending commercial products. For 17% of the respondents, meibomian gland probing is a favoured technique, 7% use thermal pulsation and 5% employ intense pulsed light.

Like the rising amount of treatment choices, the number of point-of-care tests used to evaluate the health of the ocular surface has dramatically increased in recent years, as evidenced by the survey’s results (Figure 3). To varying degrees, delegates employ the following diagnostics: • corneal and conjunctival staining; • tear break-up time; • Schirmer testing; • dry eye questionnaires; • osmolarity; • lipid layer interferometry; • meibography; • meibomian gland expression.

Are you systematically checking the ocular surface in your preoperative cataract surgery examination? 45%

42%

40% 35%

30%

23%

25% 20% 15% 10%

5% 0% Yes in all cases

Yes in most cases

Only when the patient presents with dry eye symptoms

Rarely to never

In most patients, at the initial point of care, corneal and conjunctival staining (44%) and tear break-up time (38%) are the most commonly incorporated diagnostics. Fourteen percent of respondents use Schirmer testing and 14% administer a questionnaire. On a case-by-case basis, during the consultation ESCRS and EuCornea delegates’ use of testing increased: Schirmer testing rose to 72%, tear break-up time to 55%, corneal and conjunctival staining to 44% and dry eye questionnaires to 41%. Meibography is employed by 18% of respondents and osmolarity in 16%. Some respondents indicated that they do not see the value of various diagnostic tests. Specifically, 15% do not use osmolarity, 14% do not use questionnaires and 12% replied that they do not see the value of either meibography or Schirmer testing. This question on the survey also captured delegates access to the various technology (Figure 3).

Figure 1. Ocular Surface Check

EUROTIMES | JUNE 2018

CORNEA

When do you use the following diagnostic tests? 90% 80% 80%

80%

72%

70%

63%

60%

67%

55%

50%

44%

41%

38%

40%

31%

30% 20%

14%

10% 0%

16% 11%11%

18% 7% 5%

1% 1% 3%

At the initial point of care in most patients

15%

12%

On a case by case situation, as decided during the consultation

8% 8%

14% 12% 2%

I don’t see any value in incorporating these into my practice

No access to this technology

Schirmer’s testing

Corneal and Conjunctival Staining Testing

Tear Break-up Time Testing

Osmolarity Testing

Lipid Layer Interferometry Testing

Meibography Testing

Dry eye Questionairre

Figure 3. Use of Diagnostics

BARRIERS TO ADDING NEW TESTS When asked about the barriers to incorporating advanced tear film diagnostics in their practice, 8% of the delegates said they had no objections and are currently using these tests. Delegates not using advanced methods, however, said the main reasons are a lack of access to the technologies, the tests not being covered by the health system (38% for each) and the cost to the surgeon (36%). The other objections include: • do not see the value (no difference in safety and efficacy) = 17%; • increases chair time = 17%; • disrupts practice flow = 10%.

CONCLUSION It is more common than surgeons may think for asymptomatic patients to develop symptoms of OSD after surgery, particularly in the elderly population, noted Béatrice Cochener, MD, PhD, head of the Department of Ophthalmology at Brest University Hospital and President of the ESCRS. She and colleagues recently reported a study conducted at her centre that found 52% of patients (342 eyes of 180 patients) presenting for cataract surgery had MGD identified on meibography – 49% of them were asymptomatic.3 Although only 42% of ESCRS and EuCornea delegates said they check the ocular surface as part of the preoperative cataract surgery assessment in all patients, Dr Cochener believes that surgeons should screen for OSD in most of their patients. “We know that it is always better to prevent than to treat, meaning the discovery of an EUROTIMES | JUNE 2018

We now understand that an ocular surface disease not treated before surgery, will worsen after surgery. It is the most frequent and severe postoperative complication, so it is imperative the ocular surface be examined before surgery Béatrice Cochener, MD, PhD OSD does not necessarily contraindicate the surgery, but it justifies preparing the ocular surface for surgery and informing the patient,” she said. Dr Cochener noted the importance of a careful slit-lamp exam and the utility of fluorescein to gather information about tear break-up time, disease severity, and chronicity, as well as meibum expression to evaluate the quality of the lipid layer. She noted that questionnaires yield subjective information, however, and emphasised the importance of using objective diagnostic tools to complete the picture. “We hope that refined diagnosis allowed by new platforms of diagnosis will allow more targeted treatment,” she said.

1. TFOS International Dry Eye WorkShop (DEWS II). Ocular Surf. 2017;15:269-650. 2. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. 3. Cochener B, Cassan A, Omiel L. Prevalence of meibomian gland dysfunction at the time of cataract surgery. J Cataract Refract Surg. 2018;44(2):144-148.

For more information on the ESCRS Education Forum, including video presentations, supplements and articles see forum.escrs.org

CORNEA

LUPUS AND THE EYE

SPARKtacular features in one device New OCULUS Smartfield

Complications in patients with lupus require special attention. Roibeard Ó hÉineacháin reports

ystemic lupus erythematosus (SLE) can cause serious ocular surface consequences, often requiring intensive treatment with artificial tear drops and anti-inflammatory topical medications, said Wojciech Luboń MD, Medical University of Silesia, Katowice, Poland. “In patients with SLE, ophthalmological examination is recommended at least once a year, and in a patient with severe symptoms, at least every six months,” Dr Luboń told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. To examine the frequency and diversity of ocular surface disease in patients with SLE, Dr Luboń and his associates conducted a study involving 40 patients with the condition referred to an ophthalmic outpatient clinic. The patients included 36 women and four men with a mean age of 51.7 years. All underwent an ophthalmological examination including vision testing and the ocular surface disease index questionnaire. They found that 18 of 40 patients had moderate-to-severe dry eye symptoms and corneal epithelium symptoms. The most frequent symptoms were dryness sensation in 81%, ocular discomfort such as stinging burning pain and itching in 67% and foreign body sensation in 25%. Less common complaints were light hypersensitivity in 19%, and 10% with sticky eye in the morning. In addition, 40% of patients had decreased visual acuity. Refractive errors included myopia in 52.5%, hyperopia in 12.5% and astigmatism in 32.5% of patients. Furthermore, there was lens turbidity in 17.5% of patients, and degenerative changes in the vitreous body in 37.5%. The study also noted abnormalities in retinal examinations, including dry degenerative changes in 7.5%, and irregularities in the course and calibre of retinal venous and arterial vessels in 5% of cases.

CONNECTIVE TISSUE DISEASE Dr Luboń noted that SLE is a connective tissue disease, the exact cause of which is not known. The condition often develops in people genetically susceptible to the disease after the activation of additional stimuli such as: infections, drugs and hormonal factors. The resulting auto-antibodies trigger an inflammatory process leading to the destruction of the affected organ. SLE commonly involves the joints, muscles, skin and mucous membranes. The disease can also involve the kidneys, heart, lungs and, as this study confirms, the visual system. Patients present varied symptoms of dry eye syndrome, including corneal abnormalities. The ocular surface disease is also associated with the use of chronic anti-lupus medication intake such as hydroxychloroquine or long-acting glucocorticoids. Patients with the condition often require intensive treatment with artificial tears and anti-inflammatory topical medication.

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Wojciech Luboń: wojciech.lubon@gmail.com EUROTIMES | JUNE 2018

EuCornea Medal Lecture Friday 21 September 14.00 – 15.00

4 Free Paper Sessions

(At the Opening Ceremony)

“Neural basis of eye surface sensations. From dryness to pain.” Carlos Belmonte

SPAIN

Corn

Registration & Hotel Bookings Available

2 Days 6 Courses 7 Focus Sessions

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European Society of Cornea and Ocular Surface Disease Specialists

Friday 21 September 13.00 – 14.00 9th EuCornea Congress 21–22 September 2018

C o r n

A Spotlight on Dry Eye Disease: The Role of Cyclosporine A Sponsored by

RETINA

VITRECTOMY PLUS PHACO Combining vitrectomy with cataract procedure has advantages for patient and surgeon. Roibeard Ó hÉineacháin reports

ombining cataract surgery with macular hole surgery can facilitate both procedures and reduce the risk of complications and other difficulties later on, said Zoran Tomic MD, Milos Eye Hospital, Belgrade, Serbia. “A combined procedure eliminates the need for a second procedure, which makes it more convenient for the patient. It also enhances visual rehabilitation and decreases costs,” Dr Tomic told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. He noted that cataract is the most common complication following vitrectomy. In fact, 95% of eyes in patients older than 50 years who undergo vitrectomy develop a significant cataract within two years. Most macular hole patients are referred from cataract surgery because they asked for cataract surgery first and were then discovered to be macular hole patients. A combined procedure provides the advantages of improved perioperative visualisation of the posterior pole and the peripheral retina, thereby allowing better control during internal limiting membrane (ILM) peeling and easier identification of small retinal tears, he pointed out. It also provides better access to the retinal periphery, allowing more complete vitrectomy, better tamponade and therefore a better result, Dr Tomic said. He added that when cataract extraction is performed before pars plana vitrectomy (PPV), the edges of the IOL and capsular opacification may interfere with his ability to visualise the peripheral retina. Performing PPV first before cataract extraction requires two surgeries, and the existing cataract can impair the perioperative view during PPV. It also entails an increased risk of capsule tearing owing to the lack of vitreous support.

REDUCING COMPLICATIONS IN COMBINED PROCEDURES He noted that the disadvantages of a combined approach include more frequent complications such as postoperative uveitis, transient elevation of IOP, dislocation of the IOL, iris capture and cystoid macular oedema. Combined procedures are also more difficult to perform and require a longer operating time. Dr Tomic noted that there are a number of measures a surgeon may take to reduce the risks of complications in the pre-, intra- and postoperative stages

Zoran Tomic speaking at the 22nd ESCRS Winter Meeting in Belgrade, Serbia

of a combined procedure. Prior to the surgery the instillation of mydriatic eyedrops containing phenylephrine, cyclopentolate and tropicamide will optimise visualisation during the dual procedure, he said. Using a smaller capsulorhexis of 4.0mm will reduce the risk of iris capture, and a posterior capsulotomy will eliminate any possibility of secondary cataract. Furthermore, modern small-gauge sutureless vitrectomy prevents spikes in IOP, as excess gas escapes through the sclerotomy.

CLINICAL EXPERIENCE SHOWS COMBINED SURGERY IS SAFE AND EFFECTIVE Dr Tomic noted that he and his associates at Uppsala University in Sweden first started performing combined phacoemulsification and PPV surgery in the year 2000, and the combined operations now account for 80% of their vitrectomy procedures. At his current base at Milos Hospital in Belgrade, he and his associates carried out a review of 200 consecutive eyes undergoing macular hole surgery in 2013 and 2014. The patients in the study had a mean age of 67 years. The mean duration of macular hole was 1.5 months, ranging from two weeks to 10 months. In 100 eyes the macular hole was small, in 88 eyes it was mediumsized and 12 eyes had large long-standing macular holes. As all patients were at least 50 years old, all but one patient underwent phaco-vitrectomy. Twenty-one eyes had a clear lens, 146 had mild cataract and 32 had moderate cataract.

Dr Tomic and his associates performed the procedures using peribulbar anaesthesia, beginning with phacoemulsification and implanting a foldable acrylic IOL though a 2.4mm clear corneal incision. The surgeons performed 25-gauge PPV, induction of a posterior vitreous detachment and dual membraneassisted inner limiting membrane peeling. Tamponade was performed with sulphur hexafluoride 20% solution. All patients underwent face-down positioning for five days, with 24-hour positioning for the first three days. Closure of macular hole was achieved in a single surgery in 90% of eyes and in all eyes with reinjection of gas, Dr Tomic said. In addition, after a follow-up of six months, 94% of eyes had an improvement of two lines or more Snellen visual acuity. In the remaining 6% of eyes, visual acuity was unchanged. Furthermore in 84% of eyes, postoperative best corrected visual acuity improved to 0.5 or better, he noted. Perioperative complications included retinal detachment in 0.5% of eyes and a retinal tear in 1% of eyes, Dr Tomic said. Postoperative complications included persistent macular hole in 2% of eyes. Re-opening of the macular hole occurred in no cases, and no eyes developed visual field defects. Reinjection of gas was necessary in 2% of eyes and endolaser treatment was required in 1.5% of eyes. The mean operating time was 45 minutes, ranging from 30 to 60 minutes, he added. Zoran Tomic: zorannos@yahoo.se EUROTIMES | JUNE 2018

18TH

EURETINA

CONGRESS 20-23 SEPTEMBER

VIENNA

2018

10 Main Sessions 5 Update Sessions 1 ESCRS/EURETINA Symposium 25 Free Paper Sessions 30 International Society Symposia 46 Instructional Courses 4 Surgical Skills Courses Keynote Lectures EURETINA Lecture Tien Wong SINGAPORE

Richard Lecture David Wong UK

Kreissig Lecture Antonia Joussen GERMANY

Young Retina Specialists Day Saturday 22 September Including the Ophthalmologica Lecture

Registration & Hotel Bookings Available www.euretina.org

RETINA

VISUAL ACUITY AND UVEITIS Accurate and timely diagnosis of uveitis can be a life-saving measure. Dermot McGrath reports

he treatment and prognosis of various uveitic entities varies greatly, so accurate diagnosis is imperative in order to get the best possible outcomes for patients over the long term, according to Prof Yan Guex-Crosier MD. “When we see a patient in the uveitis clinic we know that there is a good chance that we will be seeing them for the next 10 or 15 years, so the goal as a treating clinician is to enable them to obtain a good visual acuity with a longterm follow-up,” Prof Yan Guex-Crosier told delegates attending the 8th EURETINA Winter Meeting in Budapest. While uveitis was once considered a single disease entity, it is now known that it can be caused by a variety of autoimmune disorders, infections, malignancies (pseudo-uveitis), or it may be idiopathic in nature, said Prof Guex-Crosier. He noted that uveitis is classified into anterior, intermediate, posterior and panuveitis based on the anatomical involvement of the eye, according to the SUN classification. He added that few studies have comprehensively assessed the presence of uveitis, with prevalence estimates varying greatly, from 38 to 115 cases per 100,000 people. The greatest frequency, however, is in working-age adults, which results in a greater burden of disease. Diagnosis of uveitis includes a thorough examination and the recording of the patient’s complete medical history, said Prof Yan Guex-Crosier. “The first golden rule is to know whether the uveitis is caused by an infectious process or an underlying disease. Laboratory tests may be done to rule out some classical cause of infection or an autoimmune disorder. Exclusion of an infectious disease is mandatory because if you treat a syphilis patient, for instance, with a huge amount of immunosuppresive therapy you may well irreversibly damage their vision, as syphilis is known to be the great imitator,” he said. Another important rule of thumb is to exclude malignancy such as retinoblastoma or intraocular lymphoma that may masquerade as uveitis, said Prof Yan Guex-Crosier. “The importance of accurate and timely diagnosis cannot be overstated, as making the correct diagnosis can be lifesaving. If you start to treat what you think is simply an ocular inflammation and it turns out the patient has B-cell lymphoma, it could be catastrophic,” he said. Once non-infectious uveitis has been diagnosed, treatment, usually in the form of oral or topical corticosteroids, should begin promptly to avoid serious complications. But a switch to immunosuppressive therapies or biologic agents is necessary in a second step in the presence of severe uveitis to avoid classical systemic and ocular complications of corticosteroids. Frequent complications of uveitis include: posterior synechiae, cataracts, glaucoma, band keratopathy, macular oedema and loss of vision, said Dr Guex-Crosier. “We must know the specific complications of disease, with treatment tailored to individual patients and all the pros and cons discussed with the patient and their general practitioner. We also need to bear in mind that severe immunosuppression may also lead to opportunistic infections,” he concluded. EUROTIMES | JUNE 2018

18th EURETINA Congress 20 – 23 September

Thursday 20 September

Friday 21 September

Lunchtime Symposia

Morning Symposia

Lunchtime Symposia

Boxed Lunch Included

10.00 – 11.00

Boxed Lunch Included

13.00 – 14.00 Allergan Satellite Meeting

13.00 – 14.00

Bayer Satellite Meeting

Alimera Satellite Meeting

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Novartis Satellite Meeting Photobiomodulation: An Innovative, Mitochondria-targeted Therapy for Dry AMD and Other Ocular Diseases Moderators: J. Eells USA M. Munk SWITZERLAND

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Illuminating the Future of DME Management - Opening remarks - Approaches to managing the unmet needs in DME - Molecular mediators in the pathophysiology of DME - Broadening the DME treatment landscape: novel therapeutic approaches on the horizon - Panel discussion Sponsored by Roche

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PAEDIATRIC OPHTHALMOLOGY

LASER OR ANTI-VEGF? A panel discussion examined the best options for treating retinopathy of prematurity. Soosan Jacob MD reports

he use of anti-VEGF agents for the treatment of severe retinopathy of prematurity (ROP) appears to provide many benefits, but questions remain about the optimal regimen and longer-term follow-up issues. Shira L. Robbins MD argued in favour of anti-VEGF therapy for ROP in a session of the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India. She credited Dr Helen Mintz-Hittner, director of the landmark BEAT-ROP study that first showed the value of this approach compared with conventional laser treatment in a large cohort. The general benefits of anti-VEGF treatment include continuity of ocular development with encouragement of both short- and long-term development of the eye through progress towards normalisation of growth factors. Other benefits include better efficacy and successful treatment of more patients regardless of large areas of avascular retina. Previously, these cases of posterior disease with large avascular areas portended a strong possibility of poor outcome with traditional laser treatment. Anti-VEGF treatment also creates a potentially larger functional and structural visual field secondary to intact peripheral retina, with continued retinal vascular development and decreased chances of high myopia, said Dr Robbins, Ratner Children’s Eye Center at the Shiley Eye Institute, University of California – San Diego. Following anti-VEGF therapy, the macula also develops differently than in post-laser infants, resulting in more typical macular development. This leads to better structure on macular OCT configuration and better visual acuity, as shown in a study by Mohsenin et al. 2017, she reported. Avoiding laser reduces possible associated complications such as cataract, irregular pupils, acute angleclosure glaucoma, retinal dragging and detachment, microphthalmia and phthisis. Lasers can also lead to greater anterior segment changes with steeper corneal curvature, shallower AC and thicker lenses. Sharing Dr Mintz-Hittner’s data, she reported that in Zone 1 ROP, recurrences occurred later in the intravitreal anti-VEGF group compared to lasers alone. Recurrence clinically manifests as slow advance of retinal vessels, reappearance of plus disease and extraretinal fibrovascular proliferation. Longterm risks relate to systemic problems but these remain unproven she said, adding that further follow-up is required. EUROTIMES | JUNE 2018

Dr Shira Robbins examines a premature infant in the neonatal intensive care unit

However, risks of lenticular and retinal trauma and endophthalmitis do exist, as well as short-term risk of aggressive recurrence, especially with the aggressive form of posterior ROP. Recurrence is also seen in patients with prolonged hospitalisation, e.g. in patients with necrotising entero-colitis, broncho-pulmonary dysplasia, intravitreal haemorrhages, patent ductus arteriosus, low birth weight and low gestational age. In a panel discussion, Drs Shira Robbins, Subhadra Jalali and Lingam Gopal discussed various aspects of anti-VEGF therapy including concerns of deleterious effects on the rest of the organs, the need for randomised controlled trials, the appropriate dose and other clinical issues. Dr Gopal stated that he preferred lasers, reserving anti-VEGF treatment for cases not salvageable with laser, or for aggressive posterior ROP. He used half the adult dose of ranibizumab as it affects serum levels of VEGF minimally. He also spaced injections between the two eyes to decrease both total cumulative dose and risk of infection. Dr Robbins preferred bevacizumab for treating very posterior disease as the amount of salvaged or usable retina is typically more after treatment as compared to initial laser treatments that often have poor structural and functional outcomes. She phrased this as “buying more retina real estate for an infant”. She suggested that the dose could differ between initial treatment and treatment of recurrence and preferred simultaneous injections for bilateral disease. Dr Jalali preferred to use one-third the adult dose of bevacizumab, as it circulated in serum for longer, thus treating disease for longer periods with less recurrence.

Discussing long-term safety issues of intravitreal injections, Dr Robbins noted that she had not seen any case report to date reporting any physical malformation or other organ system damage secondary to treatment. Larger studies showed contrasting reports, with one study showing effect on neurodevelopment, while the other did not show any. Panellists noted some of these babies would have neurodevelopmental disease secondary to the natural course of prematurity itself, and it is sometimes difficult to determine if any effects are secondary to treatment or prematurity.

PARENTAL COUNSELLING There was universal agreement that parental counselling was important to maintaining a balanced representation of information regarding benefits and possible side-effects, per available scientific evidence. It is also important to stress to parents the need for close and diligent follow-up. Parents in the US also need to know that anti-VEGF treatment of ROP is not yet FDA approved. During the adjusted age of 45-55 weeks, close follow-up was recommended every week in the active phase, as that is when most recurrences happen. Longer follow-up is required as recurrences have been reported even later than with laser treatment. The subtlety of recurrences and possibility of their being missed in the absence of angiography, the importance of careful examination, and issues that may arise with repeated exposure to general anaesthesia are also factors to consider in ROP. Shira L. Robbins: srobbins@ucsd.edu

Photography by Peter Durdaller

WSPOS

World Society of Paediatric Ophthalmology & Strabismus

S U B S P E C I A L TY D A Y Friday 21 September 2018, Vienna, Austria

Preceding the 36th Congress of the ESCRS, 22 â&#x20AC;&#x201C; 26 September 2018 Rare Diseases

ROP

Strabismus

Paediatric Cataract

Chairpersons: D. Bremond-Gignac FRANCE S. Wei Leo SINGAPORE

Chairpersons: G. Binenbaum USA M. Tekavcic-Pompe SLOVENIA

Chairpersons: R. Hertle USA M. Younis LEBANON

Chairperson: R. Kekunnaya INDIA

Registration, Hotel Bookings & Programme Information

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Friday 21 September Lunchtime Symposium Boxed Lunch Included

Integrated Intraoperative OCT in Paediatric Ocular Surgery

PAEDIATRIC OPHTHALMOLOGY

Left: Fig 1 The Clement Clarke synoptophore, model 2003 (Haag-Streit UK Ltd, Harlow, UK)

Courtesy of Dr Sara Flodin

Below: Fig 2 The Single Maddox Rod

TESTING CYCLOTORSION Study looks at degree of cyclotorsion in healthy adults. Soosan Jacob MD reports

significant number of healthy adults have some degree of cyclotorsion, suggesting a need to be alert for even low levels that could interfere with vision, according to Dr Sara Flodin, SU Mรถlndal Gothenburg, Sweden. Speaking at the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India, she presented her research studying the standard reference range of cyclotorsion in a healthy adult population. She explained that although literature shows different methods for measuring cyclotorsion, none are standardised and very little is documented about the recommended method of use, the reproducibility and the reliability of measurement results. Since subjective torsion testing records the response of perceived torsional orientation of an object, and binocular single vision is affected by torsion, it is important to know how much torsion is significant and how much is present in adults in general. The aim of her research, therefore, was to find out the degree of cyclotorsion in a healthy adult population and to establish a general reference range to aid in clinical management of patients suffering from disruption of binocular viewing and image fusion. Some 120 volunteers EUROTIMES | JUNE 2018

...low levels of cyclotorsion are to be expected upon clinical investigation of non-strabismic individuals Dr Sara Flodin

(60 males and 60 females) between the ages of 18 and 69 years were included to establish a statistically significant reference interval, in accordance with the guidelines of the Clinical and Laboratory Standards Institute (CLSI). Healthy, non-strabismic adults with normal vision were included. Patients unable to speak or understand Swedish, those with manifest strabismus, previous ocular surgery, diplopia, medications that may affect the eyes in any way or with neurological or circulatory illnesses were excluded. This, she said, ensured a naive population, as none of the subjects had undergone orthoptic investigations previously. Cyclotorsion was assessed using the synoptophore and the single Maddox rod, and a positive value was assigned to intorsion and a negative value to extorsion. Healthy non-strabismic adults in all age groups showed low values of cyclotorsion in the study, with a

mean value for the whole sample of -1 degree for both methods. The standard reference range of cyclotorsion for men and women was roughly between -0.8 and -1.6 on single Maddox rod and -0.8 and -1.7 on synoptophore. The only significant difference was an increase in excyclotorsion with age (p=0.026). Dr Flodin concluded that low levels of cyclotorsion are to be expected upon clinical investigation of non-strabismic individuals. A small increase in cyclotorsion, of even two degrees or less, may be sufficient to disrupt the ability to fuse binocular images. She also said that the study demonstrated the importance of investigating cyclotorsion in patients experiencing fusional problems. When values are outside the reference ranges, cyclotorsion and other fusional components need to be evaluated, she emphasised. Sara Flodin: sara.flodin@vgregion.se

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OCULAR

SOLVING THE

SPACE PUZZLE Space flight-associated neuro-ocular syndrome must be solved to make way for Mars mission. Howard Larkin reports

uring and after prolonged space flight, about half of flyers experience hyperopic shift, and a majority of those studied show optic disc oedema, globe flattening, choroidal folds and sometimes cotton wool spots, and these effects often persist long after return to normal gravity. In some flyers, the neuro-ocular findings appear to correlate with mildly elevated cerebrospinal fluid (CSF) pressure. The findings can affect the choroid, the retina and the optic nerve, Andrew G Lee MD told the American Academy of Ophthalmology 2017 annual meeting in New Orleans, USA. Understanding the mechanisms involved is crucial to enable years-long flights to Mars, and could shed light on terrestrial vision problems such as idiopathic intracranial hypertension and postoperative vision loss in spinal surgery. EUROTIMES | JUNE 2018

However, determining the relationship between CSF pressure and space flightassociated neuro-ocular syndrome (SANS) has been challenging, added Dr Lee, who holds ophthalmology, neurology and neurosurgery appointments at Houston Methodist Hospital, UTMB Galveston, Baylor College of Medicine and the Center for Space Medicine, Texas A & M College of Medicine, The University of Iowa, the UT MD Anderson Cancer Center in Texas and Weill Cornell Medical College, New York City, USA.

ONGOING RESEARCH Part of the difficulty in assessing SANS is reflected in the length of time it took to characterise it. Choroidal folds were first observed in an astronaut returning from the International Space Station in 2003, followed by observations of optic disc oedema and cotton wool spots in flyers through 2008. By that time flyers were equipped with higher-magnification reading glasses in anticipation of the hyperopic shift often seen on long flights.

...determining the relationship between CSF pressure and space flight-associated neuro-ocular syndrome (SANS) has been challenging... Andrew G Lee MD

OCULAR

ANSWERS NEEDED FOR MARS FLIGHT Closer to home, research into the interaction of CSF pressure and IOP may produce insights for treating idiopathic intracranial hypertension and vision loss after spinal surgery – and understanding these earthbound conditions could help solve the zero-G riddle. “We see some of the same things in SANS as with cephalic fluid shift in the head-down prone spine surgery, which is ischaemic optic

Images courtesy of NASA

Several months into a 200-day mission in 2009, astronaut Michael Barratt MD noticed his near visual acuity declining, especially in his right eye. He and another physician on board conducted ophthalmoscopic exams on each other and thought they saw disc oedema. Within six weeks NASA sent up additional diagnostic equipment, and high-resolution fundus imaging and ultrasound showed flattening of the globe and marked distension of the optic nerve, as well as slight disc oedema in Dr Barratt’s right eye. Spinal taps also have been performed to assess cerebrospinal opening pressure after flight in some cases, and these have been slightly elevated. Initial results of this research were published in 2011, and recurrent SANS on a second flight was documented in 2013, Dr Lee noted. Astronauts now routinely undergo and perform visual acuity, fundus, ultrasound, IOP and OCT exams on one another in flight, and undergo orbital 3T MRI scans and VA exams before and after flight, Dr Lee said. The goal is to understand better how zero gravity might affect longer space flights, including whether the condition continues to progress, or if it plateaus. Another question is why not all flyers experience SANS. In particular, it does not seem to affect women as much according to Dr Barratt, though they may be more susceptible to radiation effects of interplanetary flight.

Astronaut Michael Barratt, Expedition 19/20 flight engineer, is pictured near a tomato floating freely in the Zvezda Service Module of the International Space Station

neuropathy and related vision loss, so there are some potential terrestrial analogues that could help answer the question of what is going on in space,” Dr Lee said. It may be that weightlessness increases CSF pressure while IOP remains normal, resulting in a flattening of the globe and disc oedema, Dr Lee said. This hypothesis is consistent with the slow resolution in disc oedema seen when flyers return to earth, which could be due to the compartmentalised anatomy of the optic nerve channel. However, the estimate flight duration time to Mars will be about 15 months, and the problems currently seen begin within a few days of zero-G, and can become significant problems after three-to-six months, Dr Lee pointed out. “We’ve got to learn more about this problem to prepare for any potential manned mission to Mars in 2030.” Andrew G Lee: aglee@houstonmethodist.org

Michael Barratt holds storage containers with his legs while floating in the Kibo laboratory of the International Space Station

INDIA VISIT OUR WEBSITE FOR INDIAN DOCTORS

www.eurotimesindia.org EUROTIMES | JUNE 2018

YOUNG OPHTHALMOLOGISTS

AS GOOD AS IT GETS? In his shortlisted essay for the 2018 John Henahan Writing Prize, Dr Khayam Naderi says randomised controlled trials allow ophthalmologists to reflect on existing practices and consider potentially superior methods

he butterflies always start the evening before. Following a gruelling game of tennis to close my weekend, I stroll out of the courts for the journey home when the familiar feeling of anticipation for the morning ahead takes hold. For tomorrow morning is my weekly cataract list. And despite entering my third year of ophthalmic training the exhilaration is yet to diminish, instead evolving from anxiety-heavy ambivalence to increasing elation and a growing sense of expectation as I continue to build on my skills as an ophthalmic surgeon. I will never forget the sense of achievement after my first completed case, nor the congratulatory handshake from my proud supervising consultant at the time. In fact, at the start of my training I considered myself to be a more ‘medically orientated’ ophthalmologist, as I greatly enjoyed the array of fascinating cases encountered in clinic. But as I gained more surgical experience and expertise, this notion has certainly been challenged as I strive to grow into my dual roles as both clinician and surgeon. It is fair to say that like many ophthalmology trainees my weekly cataract list is one of the highlights of my week.

AS GOOD AS IT GETS? Going back to medical school statistics lectures, I recall how randomised controlled clinical trials (RCTs) were introduced as the absolute pinnacle of evidence-based medicine (despite their respective limitations), which continues to shape both medical and surgical practice. The current significance of RCTs in cataract surgery today, however, may be less obvious. It is almost tempting to present the argument that in the developed world cataract surgery is already being practised to a very high standard. Advancements in surgical techniques and equipment have led to positive visual outcomes and low complication rates. Hence, the old adage: why fix something that is not broken? Furthermore, it can also be argued that perhaps research resources can instead be directed elsewhere, such as in progressive sight-threatening conditions such as wet age-related macular degeneration and EUROTIMES | JUNE 2018

It is almost tempting to present the argument that in the developed world cataract surgery is already being practised to a very high standard glaucoma. Therefore, do we actually need a randomised controlled clinical trial in cataract surgery?

A MATTER OF PERSPECTIVE The advances in medicine over the last century have been staggering, with further developments and breakthroughs continuing to come thick and fast. As doctors we aspire to build on our existing knowledge in order to provide the best available care for our patients. Cataract is a leading cause of reversible blindness worldwide and with a growing elderly population at our doorstep the demand for cataract surgery will continue. As mentioned, cataract surgery is already being practised to a high level. However, due to the complexities of such an intricate operation, where a host of patient and surgical factors come in to play to determine the final outcome, it can be argued that there is always room for improvement. One of the first nuggets of wisdom I received at the start of my training was to “respect each case – no two cataracts are the same”. And from personal experience I can testify that encountering one floppy iris does not mean that you have seen them all! The potential for marginal gains in cataract surgery can lead to additional finetuning of an important operation, with further room for trials on a plethora of factors, ranging from surgical techniques to the choice of intraocular lens. Aspiring for perfection rather than resting on our laurels to meet evergrowing patient expectations. Indeed, incorporating any potential changes into our daily practise to improve patient care requires reliable, statistically significant evidence. As doctors we all have to critically appraise any study findings put forward to us. And RCTs are the highest level of

research study design to show us that there may be different or indeed totally new approaches that can allow us to progress. Providing of course, we are satisfied with the evidence on offer! In this regard, it is also important to note that we do not undermine the respective merits of other research methods such as cohort studies and case series, which are of value in their own right. Undergoing cataract surgery is common and is now almost a rite of passage. The evidence provided by randomised controlled trials allows us to reflect on our existing practise and consider potentially superior methods of performing cataract surgery. In turn, we will continue to strive for the highest standards of care and minimise the risk posed to our patients who, along with their consent, have given us their trust. Dr Khayam Naderi is a third year trainee at Broomfield Hospital, Chelmsford, UK

JOHN HENAHAN

PRIZE 2018

YOUNG OPHTHALMOLOGISTS

THE GREAT DIVIDE In his shortlisted essay for the 2018 John Henahan Writing Prize, Dr Lawrence Kindo says marrying innovations in cataract surgery with affordability should be the goal for ophthalmologists

hat would you say if you were asked, “Has innovation and development in cataract surgery reached its zenith?” With modern technology making inroads into every field of expertise, I would most certainly blurt out, “Maybe cataract surgery has seen its heyday, but there is still much to be desired!”

THE GREAT DIVIDE Consider the following scenario. Crouched awkwardly over a clunky operating microscope, peering through the oddly placed eyepieces, within the claustrophobic confines of a make-shift operating room in the hindquarters of a pickup van parked right across a grubby street corner, a senior doctor and his cheerful assistant are busy operating on the eye of an old man from the shoddy neighbourhood. Thanks to the mature cataract in both his eyes and to his abject poverty, he is virtually blind. The 20-minute trial in the back of the van is the only way he hopes to see again. With the bare essentials sponsored by a generous benefactor, the surgeon manages to perform an extracapsular cataract surgery, even placing an intraocular lens in the old man’s eye. God willing, it should be an uneventful recovery. He shall see again! Millions across the world are faced with similar situations, particularly in the Third World countries of Asia and Africa. The odds are so pitiable that even couching, an obsolete and outright dangerous practice with its attendant unacceptable sequelae, is still in vogue among quacks in some parts of Nigeria. Such are the situations where innovation and affordability do not see eye to eye, particularly when resources worth millions are spent on research and development. The urgency to provide basic ophthalmic care to every human being far outweighs the burden of advanced care for the select few who can afford it.

A HISTORICAL PERSPECTIVE Thinking of cataract surgery as the ophthalmologist’s bread and butter is not a new idea, and rightly so. Not only is cataract surgery the most common ocular surgery performed in the world, it is also one of the commonest surgeries

of any kind, ever known to mankind. From the grotesque and almost nonlegal practice of couching to the almost magical phacoemulsification surgery practised widely across the globe, the amazing world of cataract surgery has reached its pinnacle with laser-assisted phacoemulsification surgery and intraocular lens implantation. Does the buck stop there? Of course, no. It was often surmised that not much had changed since the first extracapsular cataract surgery by French ophthalmologist, Jacques Daviel, on April 8, 1747. But, soon enough, it was surpassed by the enterprising discovery of artificial intraocular lens transplant surgery in the 1940s by the English ophthalmologist, Sir Nicholas Harold Lloyd Ridley, despite much opposition by contemporaries in the field. Had it not been for his doggedness and his documented demonstrations of success, the world would have been a duller place for millions across the globe! Charles D. Kelman in 1967, did one better, inspired by his dentist’s ultrasonic probe when he introduced the Gold Standard in cataract surgery, the phacoemulsification technique, earning him the pseudonym “Father of Phacoemulsification”. Smaller incisions, improved intraocular lens materials and design, development of viscoelastics, safer anaesthetic delivery and surgical techniques have further improved the safety profile, surgical outcome, and patient satisfaction after cataract surgery.

NEWER HORIZONS Concepts in cataract surgery have thus evolved from the archaic intracapsular cataract surgery with thick, unsightly, distortion-prone glasses for regular postoperative use, to the almost physiological, accommodative intraocular lens implanted eye. Laser-assisted cataract surgeries are paving the way for newer developments in robotic and robot-assisted cataract surgeries with the promise of precision, accuracy and safety, sans the adverse events. But, how would these futuristic developments take centre-stage if they fail to prove themselves against the current Gold Standard? Scientific innovation cannot prosper without randomised control studies to prove that a certain therapeutic measure is better than, equal to, or non-inferior to the de-facto Gold standard.

Not only is cataract surgery the most common ocular surgery performed in the world, it is also one of the commonest surgeries of any kind, ever known to mankind THE FINAL ROUND-UP While we talk of the latest cutting-edge technology and innovation to deal with the most complex problems faced by ophthalmologists the world over, we should not ignore the underprivileged who are still victims of couching and other substandard practices in a modern world. Our endeavours should be to research, study, develop and compare affordable surgical practices and technology supported by clinical trials, thus hitching advanced technology with patient-safety, ease-of-use, accessibility and affordability. While it poses the biggest challenge for our generation, marrying innovations in cataract surgery with affordability should be our goal, if our aim is to cater to all segments of our society. Dr Lawrence Kindo is a secondyear resident in the Department of Ophthalmology, Armed Forces Medical College, Pune, Maharashtra, India

JOHN HENAHAN

PRIZE 2018 EUROTIMES | JUNE 2018

HOSPITAL DIARY

ON THE SAME PAGE

In the second of two articles, Leigh Spielberg MD discusses the importance of efficient collaboration with trusted colleagues very step was like A week later, the effusion had walking on egg shells, disappeared! The IOP OS was still so I took it slow. Careful a bit high, so I referred the patient capsulorhexis with to Koen for further follow-up. He frequent OVD-refills of fine-tuned the glaucoma meds the anterior chamber; and referred the patient back to delicate hydrodissection; and his local ophthalmologist. meticulous divide-and-conquer I had learned a lot from phaco. I had to enlarge the main this case, not only in terms of port to insert the wider cartridge management strategies and needed for the high-dioptre IOL. surgical techniques, but also I didn’t want to risk allowing regarding efficient collaboration the lens to get stuck in the with trusted colleagues. incision, unroll in the anterior With the trend towards niche chamber or sneak a haptic into subspecialisation, we have all the sulcus. I slid the lens into developed our own, decreasingly the bag, sutured the main port, overlapped knowledge sets. This to reduce the likelihood of IOPcan be a disadvantage when drop and choroidal effusion, treating patients with acute and proceeded to vitrectomy. pathology whose management Just as a hypermetropic eye requires a multidisciplinary can make for a difficult phaco, approach. However, this performing a vitrectomy is also increased subspecialisation a legitimate challenge. There means that there is a larger pool is rarely a posterior vitreous of knowledge from which to detachment and there isn’t draw. Collaborative technology, much room to manoeuvre to like group texting, allows us to induce one. In this case, I had harness this pool almost instantly. to use ILM-forceps to detach the One of the paediatric posterior hyaloid from the optic ophthalmologists who works disc. I always imagine the horror where I trained, and who of a glaucoma specialist if one regularly receives referrals from Increased subspecialisation means that were to see this manoeuvre; one across the country for impossibly there is a larger pool of knowledge... millimetre in the wrong direction rare problems, harnessed the and a few hundred-thousand experience of his colleagues nerve fibres could be destroyed instantly, ruining a lifetime’s worth worldwide via an online forum. I remember a particular case in of effort to save them. which a young patient of his had no discernible retina and only the Once the PVD had been induced, I breathed a sigh of relief; most rudimentary vestige of an optic disc. He posted the details of the rest of the vitrectomy proceeded pleasantly and uneventfully. this case online and received advice from the other side of the world. What a relief! The ideal situation would be for everyone to know everything. Upon completion of surgery, I sent the following to our clinic Yet clearly, this isn’t possible. Further, I noticed the beneficial WhatsApp group: “Update from the OR. Surgery OD completed. effect of having all parties concerned being on the same page while Core VTX > phaco + IOL > completion of VTX, including treating a particularly difficult case. It helps us avoid the situation induction of PVD (a real joy in a +11D eye, let me tell you) + in which a patient appears in our subspecialty clinic, referred from 360° laser + some gas to keep the eye pressure stable and prevent a colleague, and we are then tasked with trying to decipher the effusion due to IOP-drop. Koen: thanks for the advice.” thoughts and intentions of our colleagues’ treatment plans. It also The next day, the IOP was 12mmHg and there were no gives us a certain feeling of “ownership” over the case, increasing complications. “Cornea still oedematous in every layer, but our feeling of involvement. otherwise looks good so far!” I wrote to the group. Other uses of technology include protocols, accessible via The next day, I performed the same surgery in the left eye as intranet, that outline the steps that should be taken when patients in the right. Fundus exam on post-op day one revealed choroidal with acute pathology of complex nature presents to our department. effusion inferior, which increased in size by day one. I was These include things like perforating trauma, endophthalmitis and worried it might continue to enlarge and encompass the posterior corneal ulcer. Protocols not only allow everyone to be on the same pole, despite a normal, stable IOP of 12. Koen Vermorgen, my page, but also allow ophthalmologists in training to initiate the glaucoma-specialist colleague, advised me to continue giving first several steps of management, confident that they are doing Diamox, as this would help keep the effusion under control. the right thing and not forgetting any crucial steps. Meanwhile, I wanted to increase the IOP, so I brought the patient The last I heard of our hypermetropic patient, he was doing well. back to the OR and filled the anterior chamber with Endocoat. This combination seemed to do the trick; the IOP increased Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent slightly and the effusion stopped growing. I examined the University, Belgium. The first part of this article appeared in patient daily until I was certain that the effusion was decreasing. EuroTimes Vol 23 Issue 2 page 34 Illustration by Eoin Coveney

EUROTIMES | JUNE 2018

INDUSTRY NEWS

INDUSTRY

NEWS

Nd:YAG Laser

510(K) FDA CLEARANCE

Q-LAS 2018

Topcon Medical Systems has received 510(k) clearance from the FDA for its DRI OCT Triton Series. “The DRI OCT Triton features exceptionally easy image capture and a 1 micron, 1050nm light source with a scanning speed of 100,000 A-scans/second,” said a company spokesman. In a press release announcing the FDA 510 k clearance, Topcon said that in addition to anterior segment scanning, the DRI OCT Triton can visualise deeper pathology, rapidly penetrating ocular tissues such as the choroid and even the sclera, without being obscured by media opacities or haemorrhage. “The DRI OCT Triton can visualise from vitreous through to sclera at the press of a single button with high sensitivity and speed. The instantaneous capture of a high-density data cube, comprised of 512 B-scans, reduces interpolation between slices and allows the most revealing imagery,” according to Topcon. www.topcon-medical.eu

FUELLING INNOVATION

NOVEL DEVICE

Avedro, Inc has announced that it has secured $25 million in financing led by Lilly Asia Ventures (LAV) with major participation from existing investors OrbiMed Advisors, InterWest Partners and HealthQuest Capital. “Avedro’s mission is to develop non-invasive corneal remodelling treatments that protect and improve vision and dramatically better patients’ lives,” said Reza Zadno, PhD, CEO of Avedro. “This new funding brings together an exceptional syndicate of investors who are committed to helping us achieve this goal.” www.Avedro.com

MED-LOGICS, Inc. has received the CE Mark for the CataPulse Lens Removal System. A spokesman for the company said the CataPulse Lens Removal System is considered by British Standards Institute to be a Novel Device because there is nothing similar on the market. “The CataPulse System has been proven to provide Rapid Visual Recovery for Refractive Lens Exchange patients due to the clinical advantages offered by this patented “Ultrasound Free” technology,” said the spokesman. www.mlogics.com

s ENT t Focu o p s i IGNM r L T A S U FOC SAFE

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EUROTIMES | JUNE 2018

BOOK REVIEWS

PUBLICATION DISEASES & DISORDERS OF THE ORBIT & OCULAR ADNEXA EDITORS AARON FAY AND PETER DOLMAN PUBLISHED BY ELSEVIER

EVERYTHING YOU NEED

BOOK

REVIEWS

BRIDGING THE KNOWLEDGE GAP PUBLICATION THE EYE: BASIC SCIENCES IN PRACTICE EDITORS JOHN V. FORRESTER, ANDREW D. DICK, PAUL G. MCMENAMIN, FIONA ROBERTS AND ERIC PEARLMAN PUBLISHED BY SAUNDERS LTD Naming a textbook The Eye is quite a bold move, as it’s impossible to fit all there is to know into a single volume. Subtitling it “Basic Sciences in Practice” makes it more manageable. This book, published by Elsevier and edited by many, bridges the gap between knowledge of the basic sciences of the eye (anatomy, biochemistry and physiology) and all that can go wrong with it. It covers the foundations of our field. Each of the following

nine topics has its own chapter in this 500page book: anatomy, embryology, genetics, biochemistry, physiology, pharmacology, immunology, microbial infections and pathology. I found it interesting and somewhat exciting to review some of the subjects that I hadn’t seen in a while: how exactly does the retinal vasculature develop in utero? How does an EOG work? The text is supplemented by extensive and detailed illustrations, photographs and medical images as well as clinical correlates and other pearls. The book is intended for early-career visual and ophthalmic scientists as well as younger ophthalmology residents, who must develop a wide knowledge base before moving on. Indeed, the first-year residents in our department are required to study it for the annual exam.

A HIGHLY USABLE HANDBOOK

PUBLICATION THE NEURO-OPHTHALMOLOGY SURVIVAL GUIDE 2ND EDITION AUTHORS ANTHONY PANE, NEIL MILLER & MIKE BURDON PUBLISHED BY ELSEVIER

The Neuro-Ophthalmology Survival Guide is a highly usable handbook that compresses the wide and sometimes unwieldy field of neuroophthalmology into 350 pages. It is organised according to patients’ presentation. Rather than grouping disorders anatomically or pathologically, each chapter covers a specific complaint. For example: Chapter 3: Swollen Disc(s), Normal Vision; Chapter 4: Transient Visual Loss; Chapter 5: Double Vision. This makes it easy to use on a day-to-day basis without having to memorise its contents. Examination checklists, flowcharts and approaches to specific problems like anisocoria allow the reader to open the book to a specific page and get to work. Differential diagnoses abound, and the authors always make it clear when urgent referral is required, as opposed to reassurance. This can make a world of difference for both doctor and patient. This book is a must-have for neuro-ophthalmology fellows and is also very useful for the rest of us who examine eyes daily, from trainees to practising ophthalmologists, neurologists and optometrists. If it saves even one unnecessary referral, or, more importantly, correctly advises an urgent one, it is worth your while. Like the other Elsevier titles reviewed here, this book includes full access to the eBook via ExpertConsult.com.

Diseases & Disorders of the Orbit Ocular Adnexa is a large, comprehensive textbook that covers everything one needs to know about the periocular structures. The book is divided into six sections: neoplastic; inflammatory; vascular; congenital; structural; neurologic; traumatic; and degenerative. It is intended for study rather than for day-to-day clinical use. Photographs, illustrations and radiological correlates give a good understanding of the complex relations between structural abnormalities and clinical presentation. This book is perfect for orbital and oculoplastics fellows, and practising subspecialists can benefit from the newer developments described. General ophthalmologists might consider it a good reference for difficult cases, and residents can consider it to see whether this subspecialty is one they would like to pursue.

PUBLICATION VITREORETINAL DISEASE: DIAGNOSIS, MANAGEMENT & CLINICAL PEARLS EDITORS INGRID U SCOTT, CARL D REGILLO, HARRY W FLYNN, JR, GARY C BROWN PUBLISHED BY THIEME

EVERY MAJOR TOPIC Vitreoretinal Disease: Diagnosis, Management & Clinical Pearls is another comprehensive textbook, covering every major topic of the posterior segment. Each of the 40 chapters covers one pathologic entity: super-common ones like AMD; less common ones like sickle cell retinopathy; and interestingly named subsets like hyaloideoretinopathies. Up-to-date information on imaging, classification and treatment modalities make this book worthwhile, as do the interspersed “pearls,” “controversial points” and “special considerations.” This book is perfect for retina fellows. General ophthalmologists who would like an update knowledge could greatly benefit as well. It can also be useful for technical and nursing staff when a particularly unusual case is encountered.

LEIGH SPIELBERG MD Books Editor If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | JUNE 2018

ESCRS NEWS

ESCRS

NEWS

Distinguished speakers at the ESCRS Academy in Zagreb

ESCRS ACADEMY TAKES PLACE IN ZAGREB The ESCRS Academy in Zagreb, Croatia, took place on Saturday 10 March during the XIII Congress of Croatian Society of Cataract and Refractive Surgeons. After an introduction by Prof Nikica Gabric and Prof David Spalton, Prof Béatrice Cochener gave an excellent talk on managing meibomian gland disease. Different diagnostic and therapeutic methods were explained, such as intense pulsed light therapy and thermal pulsation systems. After that Prof Spalton gave a talk about pseudo lens exfoliation, especially about short-term and long-term complications. After his talk there were many questions from the audience, confirming how important this topic is. Dr Alja Crnej talked about IOL exchange and she brought many videos showing different surgical techniques. Some of the videos showed tricky cases and that led to a fruitful discussion. Dr Cedric Schweitzer talked about the French FEMCAT study. Although femtosecond laser-assisted cataract surgery (FLACS) could be useful in the future, Dr Schweitzer showed that FLACS does not yet fulfil expectations. Prof Simonetta Morselli gave a talk concerning depth-of-focus IOLs. Different concepts, advantages and disadvantages were presented, as was the ideal patient. I was allowed to talk about hitting the refractive target. I had the opportunity to meet ophthalmologists from Macedonia, Bosnia, Slovenia, Serbia and of course Croatia. It was a great evening and a great opportunity to meet the members of the ESCRS again, but also to get to know Prof Gabric, Prof Iva Dekaris, Dr Ante Barisic, Dr Biljana Kostovska and many others.

Take control of your future. Belong to something powerful. Join us.

– Nino Hirnschall

www.escrs.org ESCRS RELEASES NEW CATEGORY ON PLAYER: ADVANCED INSTRUCTIONAL COURSES ESCRS has created a brandnew category on the Media Player (player.escrs.org). Selected advanced Instructional Courses from recent congresses will be published online, adding approximately 50 hours of brand-new, highquality content. These

are recommended for all ESCRS members as essential viewing. Courses on a wide range of topics such as ‘Management of Paediatric Cataract’, ‘SMILE’ and ‘Correcting Presbyopia using Corneal Inlay Technologies’ are already available online.

EUROTIMES | JUNE 2018

OUTLOOK ON INDUSTRY

A LEGACY OF INNOVATION

New technology toric and presby IOLs build on OPHTEC’s patient-focused tradition. Howard Larkin reports

fter introducing the Artisan irisclaw phakic intraocular lens more than 30 years ago, the late Jan GF Worst MD faced a challenge. Surgeons from all over the world needed training on implanting the new lens – but it took half a dozen weeks and half a dozen signatures to schedule operating room time at the local hospital. So, Dr Worst prevailed on his wife and business partner, Anneke Worstvan Dam, to build an outpatient surgery centre next to the manufacturing plant they had built in Groningen, the Netherlands, after founding OPHTEC BV in 1983. Still today as a community clinic staffed by six ophthalmologists, that centre continues to shape the company’s products, says OPHTEC President and CEO Erik-Jan Worst. “We do engineering while sitting next to a doctor. Our connection to the surgeon is as close as you can imagine,” said Mr Worst, who grew up in his parents’ business. The live surgery centre next door also keeps workers focused 100% on patients, Mr Worst added. “You don’t make something that ends up in a box and eventually gets in somebody’s eye; no, you actually see the patient walking out with the patch on their eye. We are very close to the reality of surgery. If we have a problem we know right away, and if [a product] works well we also know.”

incorporates an aspheric cylinder correction into an aspheric optic using a conic profile with continuous transition between zones of differing power. This produces an optic with uniform power along the length of all meridians, which makes the correction independent of pupil size. It also widens and increases the power of the cylinder correction zone at the periphery, making the lens more forgiving of rotational misalignment. Transitional blending also greatly reduces glare and halos, and extends depth of focus, Mr Worst noted. Sales have increased dramatically as the advantages of DEEP INSIGHT YIELDS NEW PRODUCTS the design are recognised, particularly for improving night vision, he added. Constant dialogue with practising surgeons Developed with assistance from Jaume helped OPHTEC as the firm focused on Pujol PhD, of the Polytechnic University of improving cataract surgery lenses in the past Catalonia in Barcelona, a similar blended few years, Mr Worst said. The first target was optic known as Continuous Transitional making toric lenses less sensitive to rotation Focus (CTF) is incorporated into OPHTEC’s and pupil size. Precizon Presbyopic IOL, which is The problem is optics, Mr Worst planned for commercial launch this said. Most toric lenses use an year. The lens provides blended aspheric main optic, but a spheric transitions between multiple cylinder optic. The resulting far and near focus areas across optical interaction produces its surface, extending depth of a narrow cylinder correction vision and providing broad, that diminishes in power along clear retinal images across a wide, meridians as it moves away from continuous range of defocus, Mr the lens centre. This makes the lens Worst said. very sensitive to misalignment with Erik-Jan Worst Similar to the Precizon Toric, the the axis of astigmatism, particularly presby lens is more forgiving of decentration as the pupil dilates in darkness, exposing and tilt than conventional diffractive or peripheral cylinder correction that is refractive multifocal optics, Mr Worst narrower and less powerful than the central added. Precizon Presbyopic “has the least correction. The optical interaction of spheric halos and glare in the marketplace, which is and aspheric elements also causes glare and one of the most common complaints about halos, which worsen at night. multifocal lenses”, he said. OPHTEC’s solution is the patented Developing these innovative toric and Transitional Conic Toric (TCT) optic multifocal optics involved a long period included in the new Precizon Toric IOL. It

OPHTEC’s Precizon Toric IOL, designed to tolerate misalignment

of trial and error, Mr Worst said. Because human vision is so complex, moving from a model that looks good in bench testing to one that really works in patients’ eyes required endless adjustments. Prototypes were installed in cameras and used by engineers around the office and outside, and the designs were altered to compensate for problems that emerged. “With multifocal lenses, you compensate.” OPHTEC plans to make the CTF optic available in an Artiflex lens, allowing phakic patients to benefit. But effective as the Precizon Presbyopic may be, it can be improved, Mr Worst said. “We are convinced that no one multifocal lens solution fits all patients. You need to be customised. You get your data and you make a lens for that patient, a customised solution. That is where we are going,” Mr Worst said. However, current regulatory practice makes gaining approval for a customised approach difficult. Still, pursuing such innovation honours his father’s legacy, Mr Worst concluded. “He was a person who could think outside the box. He could think about things other people would not accept as quickly. You’re always wrong when you’re right too early.” EUROTIMES | JUNE 2018

CALENDAR

The 9th EURETINA winter meeting will take place in Prague

↙

LAST CALL

JUNE 2018

EyeAdvance 2018

1–3 June Mumbai, India http://eyeadvance.com/

World Congress on Clinical, Pediatric and Neuro Ophthalmology

4–5 June Osaka, Japan https://neuro.ophthalmologyconferences.com

XLIX Congress of Polish Ophthalmologists

7–9 June Katowice, Poland https://pto.com.pl/zjazd2018

31st International Congress of German Ophthalmic Surgeons

14–16 June Nuremberg, Germany http://www.doc-nuernberg.de/index-e.php

3rd World Eye Bank Symposium

15 June Barcelona, Spain http://www.gaeba.org/events/ 3rd-world-eye-bank-symposium-gaeba/

WOC 2018

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

Aegean Cornea XIV

JULY

SEPTEMBER

1st OCT-Angiography Summer Academy (OSA)

9th EuCornea Congress

2–3 July Créteil, France http://www.creteilophtalmo.fr/osa

31st APACRS Annual Meeting 19–21 July Chiangmai, Thailand http://www.apacrs2018.org/

AUGUST Baltic Eye Surgeons Talk Show Vol. 6

24–26 August Rigas Jurmala, Latvia http://balticeye2018.com/

SEPTEMBER ALACCSA-R LASOA 6–8 September Santiago, Chile https://www.alaccsasantiago2018.com/

18th EURETINA Congress 20–23 September Vienna, Austria www.euretina.org

29 June – 1 July Mykonos, Greece http://www.aegeancornea.gr/

33rd Annual Meeting of the JSCRS 29 June – 1 July Tokyo, Japan http://www.jscrs.net/jscrs2018/ eng/index.html

EUROTIMES | JUNE 2018

The 2018 EURETINA, EuCornea and ESCRS Congresses will take place in Vienna

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

2018 WSPOS Subspecialty Day 21 September Vienna, Austria www.wspos.org

36th Congress of the ESCRS 22–26 September Vienna, Austria www.escrs.org

OCTOBER Ophthalmic Imaging: from Theory to Current Practice

12 October Paris, France http://www.vuexplorer.com/en/congres

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

CALENDAR

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

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

OCTOBER NEW AAO Annual Meeting

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

2019

FEBRUARY

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

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

SEPTEMBER

NEW ASCRS•ASOA Symposium and Congress

NEW 19th EURETINA Congress

JUNE

NEW 10th EuCornea Congress

3–7 May San Diego, USA www.ascrs.org

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

5–8 September Paris, France www.euretina.org

13–14 September Paris, France www.eucornea.org

↙

MARCH NEW 9th EURETINA Winter Meeting

MAY

23rd ESCRS Winter Meeting

ath ens In conjunction with the 33rd HSIOIRS International Congress

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

www.escrs.org EUROTIMES | JUNE 2018

When you want to connect to consistent, long-term IOP control with a proven safety profile

It only takes ONE CYPASS® MICRO-STENT IS ALL IT TAKES TO DELIVER ON THE PROMISE OF MIGS

IN CONJUNCTION WITH CATARACT SURGERY FOR PATIENTS WITH MILD TO MODERATE PRIMARY OPEN-ANGLE GLAUCOMA: • 77% of patients maintained a ≥20% reduction in IOP at two years, and 85% were still medication free1 IN A STANDALONE PROCEDURE WHERE PREVIOUS MEDICAL TREATMENTS FAILED: • 34.7% reduction in IOP from baseline at one year2 FOR AN EXPERIENCE LIKE NO OTHER, CONNECT WITH AN ALCON REPRESENTATIVE TODAY.

*At the time of enrollment, conventional incisional glaucoma surgery was considered by the investigator as being indicated in nearly all eyes (98% or 64 of 65). References: 1. Vold S, Ahmed IIK, Craven ER, et al; for the CyPass Study Group. Two-year COMPASS trial results: supraciliary microstenting with phacoemulsification in patients with open-angle glaucoma and cataracts. Ophthalmology. 2016;123(10):2103-2112. 2. García-Feijoo J, Rau M, Grisanti S, et al. Supraciliary micro-stent implantation for open-angle glaucoma failing topical therapy: 1 year results of a multicenter study. Am J Ophthalmology. 2015;159(6):1075-1081.