SPECIAL FOCUS
YOUNG OPHTHALMOLOGISTS
Jul/Aug 2018 | Vol 23 Issue 7/8
WHAT THEY DON’T TEACH YOU IN MEDICAL SCHOOL
CATARACT & REFRACTIVE | CORNEA | ESCRS CONGRESS PREVIEW RETINA | GLAUCOMA | PAEDIATRIC OPHTHALMOLOGY
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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Monica De Iscar Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org
Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983
CONTENTS
A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY
SPECIAL FOCUS
YOUNG OPHTHALMOLOGISTS 4 What they don’t teach you in medical school
6 Wise old men
Dr Joséphine Behaegel’s shortlisted essay for the John Henahan writing prize
7 Are cataract surgeons
victims of their own success?
8 Everything you ever wanted to know about your first cataract surgery
9 The ultimate priority
Dr David Chen’s shortlisted essay for the John Henahan writing prize
10 Charles Kelman’s words on inspiration and innovation
12 Brighter and better
Dr Jacinta Gong’s shortlisted essay for the John Henahan writing prize
CATARACT & REFRACTIVE 13 Examining the leading
causes for IOL explants
14 Estimates of posterior
astigmatism can be better than measurements
15 A report from Oliver Findl’s As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2016 and 31 December 2016 is 43,593.
Binkhorst Lecture at the ASCRS Annual Meeting
16 Can presbyopic IOLs give spectacle independence without losing distance?
17 FLACS and phaco offer
similar outcomes with similar complication rates
18 ESCRS delegates reveal
their favoured options for presbyopia-correcting IOLs in the 2017 ESCRS Clinical Survey of Presbyopia
21 JCRS Highlights
CORNEA 22 How effective is Omega-3 for dry eye patients?
23 Rituximab can help in
treating idiopathic orbital inflammation
ESCRS CONGRESS PREVIEW 25 Showcasing exciting
developments in cataract and refractive surgery
26 We offer a snapshot of the
six main symposia taking place at the Congress
www.eurotimes.org
RETINA 37 Human stem-cell-derived RPE transplants show good safety
38 Undetected toxic batches
of PFO can cause extreme vision loss
39 Biologics are offering
potent new weapons in treating uveitis
43 Ophthalmologica 45 Databases can help
surgeons identify risk factors for failure in retinal detachment surgery
GLAUCOMA 47 Micropulse lasers may
improve safety in surgery, though there may yet be a role for traditional lasers
48 A new survey is providing
insights into ocular surface disease and glaucoma
27 Prof Rudy MMA Nuijts, will
PAEDIATRIC OPHTHALMOLOGY
28 Take a look at the newly
50 Early intervention is key
deliver the Ridley Medal Lecture at the Congress
designed Free Paper Forum
29 Prof Thomas Neuhann will
deliver the inaugural ESCRS Heritage Lecture
33 This year’s Young
Ophthalmologists Programme promises lively interaction and discussion
34 Music and culture in Vienna
to optimal treatment of nystagmus
REGULARS
52 EBO Diploma Update 55 Outlook on industry –
Infinite Vision Optics (IVO)
57 Industry news 59 Calendar EUROTIMES | JULY/AUGUST 2018
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EDITORIAL A WORD FROM NINO HIRNSCHALL MD, PhD
GUEST EDITORIAL
Supporting YOs Young surgeons can present their own cases and discuss them their peers
Nino Hirnschall
MEDICAL EDITORS
Emanuel Rosen Chief Medical Editor
José Güell
Thomas Kohnen
Paul Rosen
INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener (France), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany) EUROTIMES | JULY/AUGUST 2018
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he first members of the Young Ophthalmologists Committee of the ESCRS (YO) were selected at the ESCRS in Vienna in 2011 and I had the honour to be part of this highly active group for the first four years. The YO Committee is chaired by Prof Oliver Findl, who deserves a lot of credit for supporting young ophthalmologists in the ESCRS. Since the first days following the establishment of the YO Committee, the ESCRS has given YOs the opportunity to influence the ESCRS programme and to add symposia specifically designed for young surgeons. I especially like the fact young surgeons are allowed to present their own cataract cases and to discuss them with Profs Findl, Morselli and Vannas during the Young Ophthalmologists Programme. This year in Belgrade at the ESCRS Winter Meeting the case presentations were a big success with a large number of listeners and a lively discussion ESCRS has given with the audience. These case YOs the opportunity discussions are always wrapped to influence the up with talks concerning single ESCRS programme surgical steps and their hurdles for beginners. I am proud to say that I was invited to talk about biometry in this session in the last years. But there is much more, such as the YO session with a different topic each year, dedicated instructional courses, surgical corneal and cataract wetlabs, just to name a few. A couple of years ago, the moderated poster sessions were introduced. In these sessions several posters are presented by a moderator together with the first author of the poster. These sessions are often used by YOs to present their studies in front of a smaller audience and to ask questions. There are also other benefits for YOs, not directly connected with the annual meetings. One example is the ESCRS Observership grant that allows young surgeons to visit another clinic and to get a €1,000 reimbursement for their stay. Another example is the iLearn platform, which is an excellent online course with more than 30 hours of material explaining all topics of cornea, corneal surgery, cataract surgery and refractive surgery (it is for free for ESCRS members). The Peter Barry Fellowship Fellowship, introduced in 2017, is given to a surgeon each year. Last year there were three winners and I was deeply honoured to be one of them. The Fellowship allows YOs to spend 12 months in another country to perform research, clinical and surgical work. In my opinion the Peter Barry Fellowship is a great idea to promote young ophthalmologists and at the same time to value the tremendous efforts of Prof Peter Barry. I should not forget to mention that the ESCRS membership is free for the first five years for residents. For more information visit: http://yo.escrs.org/
Dr Nino Hirnschall, VIROS-Vienna Institute for Research in Ocular Surgery, Hanusch Hospital, Vienna, Austria
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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
WHAT THEY DON'T TEACH YOU IN MEDICAL SCHOOL Clare Quigley reflects on a lifetime of myopia and an education in ophthalmology
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s a myope, wearing glasses and then contact lenses from the age of 11 or so, I had regular contact with optometrists during secondary school, but I had no awareness of ophthalmology. In school I liked maths and science, and EUROTIMES | JULY/AUGUST 2018
writing always interested me, but medicine was enticing. Leaving secondary school, I had to decide between medicine or a more literary degree. I reconciled my dilemma by concluding that I could be a doctor who writes, as one of my favourite authors Somerset Maugham had done, but I could not be a writer doing medicine on the side.
I studied medicine in Trinity College Dublin, and first came across ophthalmology in the summer of my second year. My Dad’s cousin Veronica Ferguson practises as a cataract and squint surgeon in London, and during that summer I opted to do an elective with her, to see what her day job was like.
SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
I learned what I now consider to be most important in my approach to work, something not overtly taught in medical school; a good attitude towards my patients and colleagues
My first day in London started with a trip to the theatre – in the Western Eye Hospital. I was a complete novice to scrubs and the surgical environment; where to stand to avoid getting in the way was my learning goal on the first day. That morning I saw cataract surgery for the first time – blown up on the theatre screen. I found it inescapably nauseating; I recall admitting feeling sick to the other medical student, and retreating to the theatre tea room for a sit-down. I recovered from the initial shock of seeing eye surgery in the flesh, and went on to watch a series of cases. Over the morning list I got used to seeing blades slicing corneas, and instruments manipulating cataracts out and lenses in, to the tune of Magic FM playing out softly, and the low hum of the phaco machine. I saw that the surgery was neat and clean, and I became familiar with the repetition of steps, case after case. During the elective I was lucky enough to be allowed access the EyeSi machine upstairs in the Western Eye. Playing with the simulator, I learned that the movements, initially unfamiliar and overly minute, with practice got smoother and easier. During that fortnight, I watched Mrs Ferguson perform elegant, life-changing cataract or squint surgeries, admiring her handiwork. In the following academic year we formally began ophthalmology in college. Our lecturer, Professor Lorraine Cassidy, was an impressive woman. She frightened us with unmissable eye emergencies, and enthralled me with the prospect of a specialty where the diagnosis was in plain view, and efficient, effective surgeries were performed. We moved from didactic lectures to our hospital placements; mine took place in the Royal Victoria Eye and Ear Hospital. My tutor there, Sorcha Ní Dhubhghaill, had an encyclopaedic knowledge of her subject. She was kind enough to take a small group of enthusiastic students for extra teaching sessions during her free time on Saturdays, to prepare us for the optional Duke Elder Prize exam. It was easy for me to rule out the other medical specialties after seeing how exciting ophthalmology was; with the added bonus that ophthalmologists seemed a content group overall, with a decent worklife balance. A period of investigating the postgraduate route towards eyes encouraged me, but also impressed on me how competitive the job market would be.
Ophthalmology was a popular choice, and the number of training posts were limited. I knew that I would need to get good grades, and add in some extras, including research, to get onto the training pathway and progress. In my third year of college, I sat the Foundation Scholarship, or schols exam, available to Trinity students. I was awarded the schols bursary, and that provided me, along with accommodation and meals through college, the funding to take a year out to do research. I settled on a Molecular Medicine MSc, incorporating an Erasmus sojourn in Strasbourg, France. In Strasbourg, I did laboratory research in a retina lab, characterising the elusive intrinsically photosensitive retinal ganglion cell. This gave me an appreciation of the resolute determination required to carry out research in basic science, when disappointingly often the cells might die, or the experiments would fail. After medical school and a year of general internship, I started as a junior doctor, or basic specialist trainee, in ophthalmology in Galway University Hospital. The learning curve was steep – at the start I did not know what I did not know, and that was frustrating. Happily, I always worked as part of a team with a registrar and consultant. I had some very patient colleagues who could be called on day or night; they taught me how to examine, how to deal with emergency referrals, and they walked me through my first steps in cataract surgery. My enjoyment of my work increased with each new skill acquired. I learned what I now consider to be most important in my approach to
work, something not overtly taught in medical school; a good attitude towards my patients and colleagues. Since early days of medical school my writing had been left aside, and I wrote only in my research, bowing to the time demands of medicine. Lately I got involved with producing the newsletter for the European Society of Ophthalmology – Young Ophthalmologists section, but otherwise I was not writing. Luckily, an ad for the John Henahan Prize caught my attention last year. I found the topic interesting and easy to write about, and was delighted to be nominated, and honoured to be ultimately awarded the prize. I did not realise it would include, on top of a generous bursary to travel to the ESCRS annual meeting, a fine trophy, in the shape of a palpebral fissure-framed eyeball – awaiting pride of place on display when I eventually have my own office. This dream became a little more real since I won the writing prize, as I was just this year awarded a post as a specialist registrar in ophthalmic surgery in Ireland – a progression not guaranteed to those who start out as junior trainees. Now I look forward to continuing to learn and develop my skills, topping off my training with a subspecialist fellowship abroad soon, alongside continuing writing. Clare Quigley is a third year resident in Sligo University Hospital and was the 2017 winner of the John Henahan Prize
Clare Quigley, winner of the 2017 John Henahan Prize
EUROTIMES | JULY/AUGUST 2018
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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
Wise old men In her shortlisted essay for the 2018 John Henahan Prize, Dr Joséphine Behaegel says there's nothing like being certain you're doing the right thing
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ot too long ago, medical decisions were based on opinions. Wise grey old men with big moustaches would teach what wiser, older men had taught them. Over time, critical thought and the scientific method crept in. The “eminence-based” medicine of the past made room for “evidencebased” medicine. The role of the doctor changed too. It shifted from the healer to a strange multitasking creature. Doctors of the past built a doctor-patient relationship. Today we are forced to manage not only patient relationships but the doctor-administrator, the doctor-computer and — often the most feared — doctor-research relationship. One day a week, I shift from my normal job as a clinical researcher back to a physician with a full day of clinic, including screening for cataracts. Patients ask questions like ‘What would you do?’ ‘Which option would you choose?’ and the classic ‘Well you’re the doc, you tell me’. As resident in training, I often feel insecure and wonder how best to guide them. Is the cataract bad enough for surgery to warrant the risks? And if it goes wrong, did I push them too hard? It can seem that “average” outcomes have become the new “failure”, and failure is the stuff sleepless nights are made of. As a relatively inexperienced resident, the best armour for this insecurity is to know that you are at least practicing some evidencebased medicine. The randomised control trial (RCT) sits at the heart of evidence-based medicine. RCTs have a design that is more powerful than other study types. They have the potential to suppress our own bias and are — at least theoretically — the ideal tool to guide physicians towards the answers they’re looking for. RCTs are great! So why don’t they inform all of our decisions? I am a clinical scientist 80% of my time and I see the problem from a different perspective. I started my research in 2015 when my “Big Bang Theory” enthusiasm was at its peak. I had some fun and geeky moments when the first positive results rolled in, but I soon realised that clinical research is not all kittens and rainbows. It’s work. Often unglamorous and tedious work, and not really what I was trained in. Each patient recruited comes with a mountain of documentation to fill in EUROTIMES | JULY/AUGUST 2018
...an RCT comparing two lens implants should steer clear of industry funding. But who else can you ask when national and international research funds are busy trying to cure paediatric cancer? and it will get on your nerves faster than acanthamoeba from a dirty contact lens. The information needs to be checked by your own team, then checked again by an independent data monitor for quality. This makes RCTs very expensive. Oh but wait, there’s more. After all the late nights and sweat-inducing research, when it’s f-i-n-a-l-l-y time to publish your data, the field has already moved on! So, go ahead and tell yourself that you probably gained a lot of life experience. And that’s almost as important as your h-index, right? The question isn’t “do we need RCTs” in cataract surgery. We do. The question is “where do we even start?”. Cataract surgery is one of the most dynamic fields in medicine, where lenses, techniques and implants keep changing. Performing an unbiased RCT can take three-to-five years. How can you be sure that the outcome will be relevant? And who will fund your RCT? As an example, an RCT comparing two lens implants should steer clear of industry funding. But who else can you ask when national and international research funds are busy trying to cure paediatric cancer? Even when you have your RCT off the ground, the pressure is so high to produce a paper that researchers can be tempted to fudge or cherry-pick their best results to get their work into the right journal. The end result is that we will never have RCTs to back up every situation, every patient and every decision. Yet decisions have to be made every day. In these moments, apart from our role as clinician, scientist, manager and communicator, we must also act as human beings. We make bespoke plans guided by our perception of the patient, our intuition, and our reading of the
patient’s expectations. So rather than being preoccupied with evidence, I prefer to think about the relevance and what the evidence can do to help me inform this person, right here. And every time I prescribe a combination of topical NSAIDs and corticosteroids after cataract surgery, I am thankful to the ESCRS who stepped up and funded the poor souls who toiled away at the PREMED study. At least in this scenario, I can rely on the best evidencebased practice. There’s nothing like being certain you’re doing the right thing. Dr Joséphine Behaegel is a resident in the University Hospital Brussels, Belgium and a researcher at the University Hospital Antwerp, Belgium
JOHN HENAHAN
PRIZE 2018
SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
7
Years of Training
on the road to success Cynthia Bradford MD has some pearls of wisdom for young surgeons. Aidan Hanratty reports
Photo by Dylan Vaughan
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re cataract surgeons victims of their own success? That was the question asked by Cynthia Bradford MD in her Mooney Lecture at the Irish College of Ophthalmologists Annual Conference 2018, held in Kilkenny, Ireland. Dr Bradford, immediate past president of the American Academy of Ophthalmology, made the analogy that cataract surgeons were not unlike downhill skiers. “It takes years of training. You must be in shape. You have to be mentally alert. You have to be prepared for the course, you have to know where you’re going, you have to maintain your balance and have just the right amount of tension and energy, you have to overcome your fear and you have to have fun.” While no one thinks that 140kmph downhill runs are easy, the public perception of cataract surgery is that it is easy. The opposite is the case. “We have many fast runs down the hill in a single surgical day,” Dr Bradford said, “and everybody expects us to have a win on every one of those surgeries.” The work begins long before surgery, however. Dr Bradford engages her patients in conversation, remarking on their outfit or asking them their pastimes. The former is an icebreaker; the latter could become key to learning what kind of vision the patient needs. “Are they a golfer or are they a reader?” This personal engagement helps the patient feel relaxed, and then allows the surgeon to tally the patient’s own description with their records and scans. Talking to patients about the pitfalls of surgery is important. A long eye may require a special order implant lens, which could limit options. Or a fellow eye with a previously inserted PMMA lens may have different optical qualities than newer implant lenses. A consultation can become a negotiation. “You have to repeat, probe and clarify,” Dr Bradford said. “We’re trying to figure what they want, what they need, and what we can do for them, and bring those three together, because what they want may not be what they need.”
Dr Alison Blake (left), President of the Irish College of Ophthalmologists, pictured with Dr Cynthia Bradford at the Irish College of Ophthalmologists Annual Conference 2018
Patients may not even need surgery. “You have to honestly evaluate the patient and decide will cataract surgery improve what they need and will it improve their vision.” Glasses or drops may help instead – no one regrets not having surgery, she said. Knowing a patient’s history helps too. A patient may have a fear of the operating room because a family member lost their sight following surgery. One patient of Dr Bradford’s was a war veteran who warned that he may “come up swinging” after anaesthetic. Cataract surgery may be a common surgery, but it’s important to remember that this is a first for the patient. This is why Dr Bradford makes such an effort to speak to patients on a personal level. “Sometimes they’re a little intimidated with us,” she told EuroTimes. “But if you break the ice with them then all of a sudden, they open up, they’re like ‘this is a real person I can talk to’.” Preparation can then begin weeks in advance. Dr Bradford advises diabetic patients to watch their blood sugar levels at least a fortnight ahead of surgery. “Patients don’t like to be cancelled, because it disappoints them, it disappoints us.”
FRIENDLY CALMING WORDS Patients may be nervous about their operation, so Dr Bradford encourages her students to use friendly, calming words. Rather than asking if the patient feels claustrophobic when the drape is put over their face, she likes to say “I’m going to gently tuck you in”. Don’t ask patients if they’re nervous, she recommends, but ask if they’re comfortable. When they ask after the surgery if they did okay, tell them they did great. The surgeon should enjoy themselves too. “Surgery is almost like a game. You’ve just got to keep up with it, like playing soccer. You’re watching for everything, trying to make every move as good as you can and allow the next step to be successful and you just start having fun doing it,” she told EuroTimes. Ultimately, she counts herself lucky to have chosen the field of ophthalmology. “It gives us the pleasure of giving patients quality of life, with the patient perception of ‘it was absolutely nothing’.” Cynthia Bradford: cynthia-bradford@dmei.org EUROTIMES | JULY/AUGUST 2018
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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
Performing your first
CATARACT SURGERY Everything you ever wanted to know about your first cataract surgery. Soosan Jacob MD reports
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very resident’s first ever cataract surgery is almost always simultaneously a dream and a dread! It generally follows hours of didactic sessions, watching and assisting consultants and seniors operate, watching videos, reading up extensively on the internet, going through books as well as practising on simulator eyes. Nevertheless, on the day of surgery, the phaco machine, with all its fluidics and dynamics, can appear as a daunting and stern sentinel standing on guard in the OR waiting to mete out punishment at the first opportunity. Approaching your first case with the right mix of caution and confidence should, however, get you a pleasant outcome and experience. Adequate preparation and backstage efforts are important to make this first journey easy. So, how do you prepare for your first cataract surgery?
PREPARING YOURSELF This is key. It is important to spend time understanding the phaco machine that you will be using. Foot pedal practice with the test chamber gives an idea about various foot positions. Locating the reflux switch is crucial, as is recognising the various tones and pitches heard during phacoemulsification and irrigationaspiration. Phaco power modulation is important to comprehend, though often for the first case, the mentor may control these settings from the panel, and it is more important for the trainee to concentrate on the surgical manoeuvres required.
PICKING AND PREPARING THE PATIENT Picking the right case is important, and a mental checklist should be gone through for patient selection. It is important not to choose an apprehensive patient or one who is unlikely to lie still without complaining, as it is very likely that the trainee will take more time than an experienced surgeon. It is also probably better to take the first EUROTIMES | JULY/AUGUST 2018
eye of a patient, rather than choose the second eye of a patient for whom the professor finished an ultrafast and painless five-minute cataract surgery. Patients often compare and in the middle of valiant efforts at removing the cataract, it can be exasperating to hear the patient ask as to why the second procedure is not going as fast as the first did! Avoid deepseated eyes, prominent brows, excessively large or small anterior segments, nondilating pupils, phacodonesis or other similar challenging situations. The type of cataract chosen would often depend on the residency programme. Many programmes start by teaching trenching and nucleofractis by divide and conquer, and a choppable cataract with moderate nuclear sclerosis would be preferable here. Some programmes start by teaching hydroprolapse and supracapsular emulsification, and a soft cataract is better in this case. Avoid tough cataracts such as posterior polars, which can be taxing even in experienced hands; hard brown cataracts, which may end up utilising excessive phaco energy; white cataracts, which have thin, friable capsules and absent red glow; eyes with pseudoexfoliation etc.
Being seated ergonomically is important
Once the right case is chosen, prepare the eye well with a combination of topical mydriatics and NSAIDs. A good and longacting peri-bulbar block with absent ocular and lid movements can be obtained using a mixture of 2% lignocaine (with adrenaline – in the absence of contraindications) and 0.5% bupivacaine admixed with hyaluronidase. Pinkie ball or Honan balloon should be applied.
PREPARING THE OR A trolley of height suitable for one’s own seated height should be used, as there is
SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
Not having the cornea perpendicular to the microscope light results in a poor red glow and inability to have the entire field in focus
With the chin lifted and face parallel to the ground, a good red glow and focus is obtained
nothing more uncomfortable than having either to crane one’s neck forward or sit hunched over. Microscope oculars should be adjusted for height and spherical dioptre adjustment should be kept at zero. If using prescription glasses, they should preferably be worn during surgery so that everything outside of the microscope view is also clear. Phaco and microscope footpedals should be on either side and within easy reach. Sitting superiorly allows the hands to rest on the patient’s forehead and may be preferable over a temporal approach for the first case. It is important to have as a guide a mentor with whom you connect well and are comfortable with. An assistant nurse who is patient and has spent time with in-training residents is also preferable.
available. The patient should lie with head at the edge of the trolley so that the eye is easily reachable without having to lean over. Chin should be lifted up to get a good red reflex as well as for ease of access and good, even focus. Microscope foot controls should be practised beforehand and should be at neutral position with a free range for X, Y and Z axes movements. The cornea should be kept moist. Capsular staining with Trypan blue enhances visualisation. A 45-degree phaco tip allows sculpting while zero-degree tips are preferable for chopping. Prolonged surgery may result in epithelial oedema and corneal clouding. Epithelial debridement may be required to increase visibility again. At my centre (Dr Agarwal’s Group of Eye Hospitals), we use pressurised infusion with the air pump in all cases to increase safety and speed of surgery. It is useful to mentally rehearse and picture oneself doing each step and to know how to identify and prevent major
PREPARING FOR THE SURGERY Checklists are as important to ophthalmic surgeons as to airline pilots. Make sure that all equipment is in good working order and that everything you want is
complications. Knee-jerk reactions such as bringing the probe out suddenly if the posterior capsule ruptures should be avoided, and the mentor’s advice should be sought for actively during all steps. It is also important not to take shortcuts, even though you may see more experienced surgeons doing so. In the initial cases, there should be no race for time. Going step by step mentally as well as surgically helps build good surgical habits that will stand in good stead later. Finally, remember to respect the eye and do not hesitate in asking for help or in handing over the case to your mentor when required. 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. For more information on surgical steps, the reader is referred to previous articles by the author in her “Everything you ever wanted to know about…” EuroTimes column as well as to videos on her YouTube channel
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SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
The ultimate priority In his shortlisted essay for the 2018 John Henahan Prize, Dr David Chen says cataract surgery needs compassionate cataract surgeons
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or years, the randomised controlled clinical trial has been considered the gold standard in clinical experimental research. A well-conducted trial could eliminate bias, control for confounders and definitively help clinicians with decisionmaking. Publication of major prospective trials such as the SPRINT trial1 helped establish target blood pressures for patients at risk of cardiovascular events, and the CHANCE trial2 proved the benefits of dual antiplatelet agents for patients with highrisk transient ischaemic attacks. However, major randomised controlled clinical trials are time-consuming and resourceintensive – do they still have a role in cataract surgery, where surgical outcomes are already close to excellent? To answer this question, let us first look at the evolution of cataract surgery over the past centuries. Ancient techniques of cataract removal were brutal and had abysmal visual outcomes, and though there was slow refinement of techniques from intracapsular cataract extraction to extracapsular cataract extraction, cataract surgery always involved significant morbidity and prolonged visual rehabilitation. This all changed with the first phacoemulsification surgery by Dr Charles Kelman, who revolutionised the way cataract surgery was performed and drastically improved surgical outcomes. Since then, further improvement in intraocular lens designs, phacoemulsification machine mechanics and surgical techniques have progressively propelled cataract surgery to the standard we know today. Research has been an integral process of this evolution. It has helped to prove the superiority – and sometimes noninferiority – of one surgical option over another. Different randomised controlled trials showed that even though phacoemulsification was a more expensive surgery, it provided more cost-savings in the long run when compared to extracapsular cataract extraction in a developed country3; that manual small-incision cataract surgery was a preferred option for patients with white cataracts in developing countries4; and that femtosecond laser-assisted cataract surgery was not superior to standard phacoemulsification surgery in terms of visual outcomes.5 So, do we need a randomised controlled clinical trial in cataract surgery? Yes, we do – not one, but many. There are yet many clinical questions unanswered in the EUROTIMES | JULY/AUGUST 2018
As life expectancy continues to increase, the importance of performing the ideal cataract surgery becomes ever more pressing world of cataract surgery, and despite the major advancements in surgical outcomes, there are still areas for improvement that current technology does not allow. These include, briefly, accommodative intraocular lenses that allow presbyopic correction without compromises, optimum phacoemulsification settings that do not damage the endothelium without prolonging operative time, realtime anterior segment optical coherence tomography that predicts anterior chamber instability and prevents posterior capsular rupture, just to name a few. We have come a long way, but there is still a great distance to go before the cataract surgery could truly restore the function of the clear crystalline lens. As life expectancy continues to increase, the importance of performing the ideal cataract surgery becomes ever more pressing. However, randomised controlled clinical trials are time-consuming and expensive endeavours. They are well-suited for answering focused clinical questions, but the results of each trial may not be easily extrapolated to demographically dissimilar populations. The clinically controlled settings also do not always accurately reflect real-world outcomes. To answer all the questions about cataract surgeries would require many different trials, on many different populations, involving many different centres and surgeons – this may not be economically feasible. Therefore, research for cataract surgery should include more than just a randomised controlled clinical trial. It should include cross-sectional studies, longitudinal cohort studies, case-control studies and a combination of these, depending on the clinical question to answer. The consolidation of these findings could be assimilated in meta-analyses. In addition, the information technology explosion in recent years has also opened the possibility of Big Data, while the recent revolution in Blockchain technology enables potentially secure and decentralised information storage. Altogether, this information could eventually be fed into a predictive decision-making tree
where neural networks could help personalise the surgical option for the ideal cataract surgery for each unique patient. Cataract surgery needs research to get better. It needs randomised controlled trials, it needs basic science experiments, it needs meta-analyses, it needs evolution through artificial intelligence. More than just research, cataract surgery also needs years of dedication to the perfection of this delicate surgical skill. Most importantly, however, cataract surgery needs the compassionate cataract surgeon, who will never stop placing the patient’s best interest as the ultimate priority.
REFERENCES 1. Anon. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015;373:2103–2116. 2. Wang Y, Wang Y, Zhao X, et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. N Engl J Med 2013;369:11–19. 3. Minassian D, Rosen P, Dart J, et al. Extracapsular cataract extraction compared with small incision surgery by phacoemulsification: a randomised trial. Br J Ophthalmol 2001;85:822–829. 4. Venkatesh R, Tan CSH, Sengupta S, et al. Phacoemulsification versus manual smallincision cataract surgery for white cataract. J Cataract Refract Surg 36:1849–1854. 5. Manning S, Barry P, Henry Y, et al. Femtosecond laser–assisted cataract surgery versus standard phacoemulsification cataract surgery: Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg 42:1779–1790. Dr David Chen is a resident in the Department of Ophthalmology, National University Health System, Singapore
JOHN HENAHAN
PRIZE 2018
SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS
Embracing inspiration Charles Kelman said it is paradoxical that society has had a scornful attitude for those that possess creativity. Aidan Hanratty reports
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elivering the ASCRS Binkhorst lecture in 1989, Charles Kelman MD said: “I have always been a saxophone player wearing the mask of an ophthalmologist. Had it not been for my parents’ insistence I would have followed my own dream to become a musician.” Indeed, he once said that as a teenager his father caught him sneaking out of the house at 2am, hoping to run away and join Louis Prima’s band. Taking the saxophone away from the young man, his father said: “You can be a singer, you can be a composer, you can be a songwriter, you can play with bands, whatever you want. But first you'll be a doctor.” So, the young Kelman went to medical school, but he never let dust gather on his saxophone case. While undertaking his residency at the Wills Eye Hospital, he said: “I was often late for rounds and could just as easily have been found playing a horn in south Philadelphia as cutting a suture in the operating room.” Giving a speech on the subject of innovation, Dr Kelman looked at the various factors that lead to innovation. “The creative act is as close as we get to the divine. It is paradoxical, therefore, that society has always had a scornful attitude for those that possess that creativity; especially if it threatens to change the status quo.” Listing a series of qualities inherent in creative people, he asked the following question: “What chances of acceptance would an applicant for residency have armed with a letter of recommendation
which read: ‘This young man or woman is an independent type, who likes taking risks, playing around, experimenting and tends to make things very complicated. Nothing threatens him; he’s very selfassertive, unconventional, indifferent to disorder or ambiguity and is certainly offbeat. I highly recommend him for residency.” Citing the discoveries of Alexander Fleming and Harold Ridley, he quoted Nobel prize laureate Albert Szent-Györgyi: “Discovery consists of looking at the same thing as everyone else and thinking something different.”
MOMENT OF ENLIGHTENMENT Inspiration can come at the strangest time – think of Dr Kelman’s own moment of enlightenment. After two years and eight months working under a grant at the Hartford Foundation, which he had received for the promise of delivering a cataract removal procedure that would require no hospitalisation, Dr Kelman had been through a dozen different unsuccessful ideas. Having let his hair grow long and his teeth get dirty, he took himself off for a cleaning. “In the dentist's office he used this device, an ultrasonic device on my teeth. I asked him what it was, and he told me that it had a high-frequency vibration and it flicked the tartar off the teeth without disturbing the tooth itself. I got very excited, I ran out of his office with a doily around my neck shouting ‘I've got it, I've got it!’” He came back an hour later with a cataract and discovered that he could
engrave lines on the cataract, without it jumping up on his finger, which meant that he could remove a cataract without it spinning up against the corneal endothelium. Thus, the idea of phacoemulsification was born. The first procedure – which lasted 70 minutes – was a failure, as the cornea collapsed on the vibrating tip. Three years later he tried again, having incorporated an aspiration tube that prevented corneal collapse. The surgery would go through further trials, not all of them clinical, largely due to the politics at play and a resistance to new methods. “The fact that its main proponent – me – was playing the saxophone and singing in the casinos of Atlantic City and appearing on the Johnny Carson show, did not help the cause.” Having a creative mind was what drove Dr Kelman, be it with phacoemulsification or in songwriting and performing. Returning to his innovation speech, he said: “The creative thinker does not stress being correct, he stresses originality. And he accepts failure as a necessary expected part of the learning process.” Dr Kelman might have been thinking of Thomas Edison, who once said: “I have not failed. I’ve just found 10,000 ways that won’t work.” This article is based on interviews with the late Dr Kelman broadcast in the Video Journal of Cataract and Refractive Surgery celebrating the 50th anniversary of phacoemulsification. View the video at http://bit.ly/Kelman50
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Brighter and better In her shortlisted essay for the 2018 John Henahan Prize, Dr Jacinta Gong says research helps ophthalmologists objectively discern what to preserve, and what to discard
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ome years back, an elderly gentleman was on my cataract surgery list. As I prepared to operate, he remarked, “I should savour these last moments of looking through my natural lens; I’ve had it for 90 years! Tomorrow should be a change – all brighter and better?” There was a time when there was no treatment for cataracts. Once, someone who lived to develop cataracts had as little hope for a cure as someone today with palliative disease. Desperate patients were willing to undergo even risky, unproven procedures to preserve or restore their eyesight. Primitive methods of cataract removal, like couching, are now ridiculed by present-day cataract surgeons, who enjoy good results with standard phacoemulsification. Have we become complacent, as we consider how cataract surgery has progressed in the last century? Major advances, like the implantation of intraocular lenses, have largely been due to serendipity rather than concerted research. We know that fortuitous happenstance and expert opinion are not sufficient evidence upon which to base clinical practice. Highquality research is the cornerstone of safe, modern medicine. If nothing is present in the current literature on a certain topic, any practice is theoretically defensible. Do we need to critically re-appraise cataract surgery, or have we, like my patient, gotten so used to doing and perceiving things in a certain way for years, through a flawed lens of surgical inertia and reliance on historical innovations? Do we need more robust evidence, like randomised controlled clinical trials (RCCTs) in cataract surgery? Let us consider when RCCTs may be useful. A common misconception is that RCCTs are only required if a standard of care needs revision, or treatment is of untested benefit. By contrast, cataract surgery is fundamentally an elective procedure, that is voluntarily chosen by patients who have often heard of success stories. Does a procedure that is so universally accepted as beneficial, by both clinicians and the general public, have room for improvement? Even if it did, it could be unethical and difficult to recruit patients for such a study. RCCTs exist to identify a causeeffect relationship between a proposed treatment, and the outcome. What EUROTIMES | JULY/AUGUST 2018
High-quality research is the cornerstone of safe, modern medicine. If nothing is present in the current literature on a certain topic, any practice is theoretically defensible aspects of cataract surgery are amenable to analysis by RCCTs? Whilst RCCTs do exist about the steps in cataract surgery (for example, the use of intracameral antibiotics in preventing endophthalmitis), there are inherent barriers to performing RCCTs in the method and tools of cataract surgery. Part of the problem lies in the practicalities of randomisation and blinding, standardising of surgical technique and skill, and measurement of subjective outcomes. Like many other surgeries, there is a paucity of RCCTs in cataract surgery. Traditionally, surgeons are quick to adopt intuitive methods of operating, some of which are learnt from mentors and not necessarily supported by rigorous evidence. Also, large RCCTs are expensive to fund and may be infeasible to conduct in a private practice setting, where surgical reputation could compromise on impartiality, and patient numbers are generally fewer. Given the challenges and accepted benefits of RCCTs, we tend to react in two ways. Firstly, we memorise landmark trials, on the perilous assumption that their findings are still applicable decades later. It is important to critically appraise RCCTs in cataract surgery, in line with other up-to-date RCCTs. Has antibiotic resistance changed? If so, our RCCTs may need to be repeated. Secondly, we may neglect to undertake and support other forms of research like cohort studies, to our own disadvantage. Poorly conducted RCCTs are potentially more harmful than no RCCTs, and RCCTs should not be considered as the only method of legitimate research. Research, whether in the form of RCCTs or other well-designed studies, is imperative if we wish to achieve progress and precision in our practice in the 21st Century. It should not solely be commercially driven, and it should not be viewed with apathy, cynicism or pessimism. How else will we know if what
we do is beneficent and non-maleficent? We know that some of the things we do today will be frowned upon, in future generations. Conversely, some procedures that were perceived as outrageous are now common practice. Research helps us objectively discern what to preserve, and what to discard. The essence of ophthalmic research reflects the heart of the cataract surgeon – to improve safety and sight for all our patients. Like my venerable patient, we are grateful for past vision but are not blind to its shortcomings. Instead, we embrace new insights, born of cutting-edge investigative research. Tomorrow should be a change – all brighter and better. Dr Jacinta Gong is a trainee in the Ophthalmology Department, NHS Tayside, UK
JOHN HENAHAN
PRIZE 2018
CATARACT & REFRACTIVE
Reasons for IOL explants Dislocation remains the top reason overall, while glare and optical aberrations were the main causes for multifocals. Howard Larkin reports
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islocation and decentration remained the leading cause overall for intraocular lens (IOL) explants in 2017, according to the 20th annual ASCRS/ESCRS member survey of foldable IOL complications and explants. However, glare and optical aberrations were the leading cause for multifocal IOL explants, which continued to rise, Nick Mamalis MD told the American Society of Cataract and Refractive Surgery 2018 Annual Meeting in Washington DC, USA. Dislocation or decentration was by far the leading cause for explants or lens exchanges in monofocal lenses of plate, single-piece and three-piece haptic designs made of hydrophobic acrylic and silicone, Dr Mamalis reported. However, calcification was the leading cause of explants among hydrophilic acrylic, or hydrogel, lenses. “This is a very different complication profile than we are seeing in the other materials.” Among premium lenses, multifocal lenses also had a unique complication profile. They are being removed for glare, dysphotopsias and vision issues, Dr Mamalis said. Toric IOL explants, on the other hand, followed the monofocal hydrophobic acrylic and silicone lens profile, with dislocation the leading cause, he added.
We can avoid these complications, especially dislocation and decentration, with good surgical technique Nick Mamalis MD While decentration has been the leading cause overall of IOL explants for several years, glare and optical aberrations have moved up to number two, with iritis/UGH (Uveitis-GlaucomaHyphaema) syndrome number three and calcification number four. This may be related to the numbers of lenses now in use, with multifocal IOL explants rising while hydrophilic acrylic and plate haptic silicone lenses are explanted less frequently, Dr Mamalis noted.
HISTORIC TRENDS For lenses tracked for the entire 20 years of the ASCRS/ESCRS survey, dislocation and decentration were the leading cause of explantation for monofocal threepiece acrylic and silicone lenses, and one-piece plate haptic silicone lenses, Dr Mamalis said. “We can avoid these complications, especially dislocation and decentration, with
good surgical technique,” he emphasised. A continuous curvilinear capsulorhexis that covers the lens edge for 360 degrees helps ensure capsular bag fixation. IOL power errors can be reduced with accurate measurements, while proper patient selection and preoperative counselling can help reduce multifocal explants for glare, dysphotopsias and optical aberrations. The ongoing survey is conducted by Dr Mamalis and colleagues at the Intermountain Ocular Research Centre at the University of Utah, Salt Lake City, USA, and the ASCRS Cataract Clinical Committee. It is not intended to suggest one lens is better than another, but to inform surgeons of potential complications, Dr Mamalis said. He encouraged surgeons to file a report online at the ASCRS or ESCRS Web sites whenever they explant an IOL. Nick Mamalis: nick.mamalis@hsc.utah.edu
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oric IOL calculation methods that use estimates of posterior corneal astigmatism appear to provide greater predictive accuracy than those that use direct measurements obtained with a Scheimpflug or colour-LED topography, said Tiago Ferreira MD, FEBOS-CR Hospital da Luz, Lisbon, Portugal. “We still have limited accuracy in evaluating total corneal astigmatism and, at present, directly measuring toric total corneal astigmatism for toric IOL calculation is not superior to estimating it,” Dr Ferreira told the 22nd ESCRS Winter Meeting in Belgrade, Serbia. The posterior surface of the cornea surface is the most important source of error in toric IOL power calculation. A toric intraocular lens selected based on anterior corneal measurements will overcorrect eyes with with-the-rule astigmatism and undercorrect eyes with against-the-rule astigmatism. Therefore, consideration of the posterior corneal surface is necessary for precise toric IOL calculation. However, that adds another level of complexity to the calculation and it also requires a measurement method that is highly precise and repeatable. Until such technology becomes available, the current best approach may be using estimates of total corneal astigmatism, he explained. He and his associates conducted a trial comparing the predictive accuracy of modern IOL calculation methods. That study found that the centroid prediction error was closer to zero in calculation formulas that took the posterior surface into account, such as the Barrett toric IOL calculator, compared to those formulas that only considered the effective lens position, such as the Holladay toric calculator. However, it was also noteworthy that the formulas that had the lowest centroid prediction Tiago Ferreira error were those using estimates of the posterior corneal refraction, namely, the Barrett toric calculator and the Abulafia-Koch formula, rather than those that used direct measurements with a Scheimpflug camera (Pentacam, Oculus), Dr Ferreira said (J Cataract Refract Surg 2017; 43:340–347). A subsequent study supported those findings. It compared the predictive accuracy of toric IOL calculation methodologies that estimate the power of the posterior corneal surface with those that use real measurements. They again found that a higher proportion of eyes would achieve lower refractive errors with estimates of posterior corneal astigmatism than would be achieved with direct measurements (J Refract Surg 2017;33(12):794-80). Dr Ferreira also presented preliminary findings from a study comparing the Barrett toric IOL calculator with calculations based on the real total corneal astigmatism measurements obtained using a Scheimpflug camera or a colour-LED topographer (Cassini; i-Optics). They found that the Barrett toric calculator performed best, closely followed by calculations based on colour-LED Cassini measurements, with the Pentacam-based calculations third. Tiago Ferreira: tiagoferreira@netcabo.pt
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CATARACT & REFRACTIVE
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Measuring IOL power Optical biometry, better formulae, corneal measurement improve accuracy. Howard Larkin reports
SWEPT-SOURCE OCT BIOMETRY As recently as 15 years ago, axial length measurement was a significant source of IOL power errors mostly because ultrasound was still used, Dr Findl said. Partial coherence interferometry (PCI) optical biometry changed that, nearly eliminating axial length measurement error in 95% of cases. He noted that optical biometry was born in his hometown Vienna, Austria, and that he had the opportunity to perform the first trials using this technology in the prototype setting. The latest swept-source OCT biometry better penetrates eyes with dense cataracts,
Prototype setup of intraoperative swept-source OCT
in one study successfully imaging more than 90% of eyes that failed PCI biometry (Hirnschall N et al. Ophthalmol Ther 2018), Dr Findl said. Essentially only eyes with white cataracts could not be measured. Other than variation in postoperative refraction, which cannot be addressed preoperatively, anterior chamber depth prediction is the major remaining factor in IOL power errors. Single-piece IOLs with non-angulated haptics help because they respond less to capsule fibrosis than three-piece designs (Wirtitsch MG et al. JCRS 2004), Dr Findl noted. Current IOL designs also are stable even with imperfect capsulorhexes (Findl et al. JCRS 2017). With a modern IOL the effect of the rhexis, even if it is too large or too small, is negligible for refractive outcome, he noted.
NEURAL NETWORK IOL CALCULATIONS Theoretically, machine learning networks have the potential to improve the accuracy of IOL power calculations over fixed formulae, though their black-box nature inhibits their use in understanding any underlying physiological basis for variation, Dr Findl said. However, recent tests show that they are no better than the best current formulae – at least not yet (Kane JX et al. JCRS 2017).
Measuring refraction on the operating table is another way to reduce refraction error, but it is complicated by corneal changes induced by surgery, Dr Findl noted. While intraoperative aberrometry may be useful for eyes that have undergone previous corneal surgery, it does not predict postoperative IOL position. Intraoperative OCT, where the capsule position is measured in the aphakic condition, can help better predict IOL power, but cannot predict post-op shifts from capsule fibrosis, Dr Findl said. It can be used to verify or adapt IOL choice and is especially useful for short or irregularly shaped eyes.
TORIC LENSES Measuring of posterior corneal curvature is a key step for improving toric IOL outcomes, Dr Findl said. Automated devices that help align lenses at surgery may also help. “My take-home message is: Use optical biometry and optimised IOL constants. For corneal measurements, use at least two devices if you can,” Dr Findl said. He expects better measurements to improve power calculation formulae further, and that changing IOL power in the eye may one day be possible. Oliver Findl: oliver@findl.at EUROTIMES | JULY/AUGUST 2018
Courtesy of Oliver Findl MD
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o choose the power for intraocular lenses (IOL) before 1975, Sir Harold Ridley devised a simple formula: 18.0 dioptres plus 1.25 times the preoperative prescription. “Surprisingly, about 50% of his patients were still within plus or minus one dioptre, but he had some extreme refractive surprises of nine dioptres or more,” Oliver Findl MD told the American Society of Cataract and Refractive Surgery in the 2018 Cornelius Binkhorst Lecture in Washington DC, USA. Advances in biometry and increasingly sophisticated formulae, including one developed by Richard Binkhorst, brother of Cornelius, and SRK II and SRK/T have progressively narrowed that outcome range to about one-half dioptre, said Dr Findl, of the Vienna Institute for Research in Ocular Surgery, and Hanusch Hospital, Vienna, Austria. Indeed, analysis of 2.3 million cataract surgeries in the ESCRS European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) shows that in the current era of optical biometry, 73% of patients are within 0.5D of their target refraction. “But that means that more than onequarter are actually outside of that,” Dr Findl noted. Most of the biggest misses come with short or very long eyes, he added. Today’s patients demand better, especially with multifocal or toric lenses and clear lenses exchange, Dr Findl said. Postoperative refraction is the main factor for patient satisfaction. He reviewed sources of error in IOL power calculation, and existing and emerging technologies that can further improve refractive outcomes.
CATARACT & REFRACTIVE
Pinhole IOL A new IOL that uses pinhole effect provides increased depth of focus. Roibeard Ó hÉineacháin reports
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new presbyopic intraocular lens (IOL), the IC-8 (AcuFocus), that incorporates the pinhole effect of the Kamra (AcuFocus) presbyopic corneal inlay appears to provide a high degree of spectacle independence without sacrificing distance vision, according to a study presented by Matteo Piovella MD at the 22nd ESCRS Winter Meeting in Belgrade, Serbia. “The IC-8 showed excellent visual performance at three years. IC-8 in the non-dominant eye, combined with best technology aspheric monofocal IOL in the dominant eye, provided excellent binocular distance vision. It also provided intermediate and near vision and there is no need to wear presbyopic glasses,” said Dr Piovella, Monza-Milan, Italy. The study included 19 cataract patients with a mean corneal astigmatism of 1.25 who underwent an IC-8 IOL in the non-dominant eye and either an aspheric monofocal IOL or retained their natural lens in the dominant eye. The patients were aged 45 years or older, had clear intraocular media apart from the cataract and a best corrected distance visual acuity of 20/30 or worse, as a result of the cataract. The refractive target was plano in the dominant eye and a slight myopia
The IC-8 lens from AcuFocus placed in the eye
of -0.75 sphere in the non-dominant eye implanted with the IC-8 lens At three years’ follow-up, the mean uncorrected distance visual acuity (UDVA) in the eyes with the pinhole IOL was 20/22, the mean uncorrected intermediate visual acuity (UIVA) was 20/27 and the uncorrected near visual acuity was (UNVA) 20/26. In the monofocal eyes, the mean UDVA, UIVA and UNVA were 20/19, 20/31 and 20/64, respectively. Binocularly, mean UDVA was 20/19, mean UIVA was 20/24 and mean UNVA was 20/27. Dr Piovella noted that like the Kamra inlay, the pinhole mask within the IC-8 IOL is composed of polyvinylidene fluoride and nanoparticles of carbon. It has a 1.36mm aperture, a total diameter of
3.23mm, a thickness of 5.0µm and 3,200 microperforations. He pointed out that the increased depth of field that the IOL’s pinhole effect provides compensates not only for the slight myopic refraction of the lens, but also for up to 2.0D of astigmatism. It therefore eliminates the need, in most eyes, for toric IOLs, along with their associated complexities. “You don’t need to manage the toric correction, you don’t need a toric IOL and you don’t need to get an IOL on the perfect axis. And automatically, due to this characteristic, if you surgically induce astigmatism, this technology will also take care of that,” Dr Piovella added. Matteo Piovella: piovella@piovella.com
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CATARACT & REFRACTIVE
Femto vs cataract? Major study shows no statistical difference between the two procedures. Dermot McGrath reports
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large-scale prospective, multi-centre French study comparing femtosecond laser cataract surgery and phacoemulsification showed similar outcomes and complication rates between the two procedures, according to Cedric Schweitzer MD. “We found no statistical difference between the femto and phaco treatment groups for all of the visual and refractive criteria that were evaluated. Furthermore, of the small differences that we did find between the groups, there was no evidence that there was any clinical benefit to the patient,” he told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR). Funded by €3.2m from the French health ministry, the twoyear FEMCAT study was designed to establish a scientific basis for the theoretical benefits of femto-cataract surgery compared to standard phacoemulsification. The study employed a robust methodology to limit selection bias in each of the five French clinical centres involved, said Dr Schweitzer. Four experienced cataract surgeons were selected for each participating centre, with a total of 757 eyes randomly allocated to the femtosecond laser arm and 752 to the phacoemulsification arm. “Everything was geared to make this a meaningful real-life study using surgeons of different age, training and experience,
while standardising the various surgical procedures between the two groups in order to analyse the impact of the femtosecond laser alone,” said Dr Schweitzer. He noted that each centre used the same phaco machine for all procedures, although machines could differ from one centre to another, and all patients were implanted with a standard 6.0mm hydrophobic acrylic implant. Significant improvements in visual acuity and refraction were observed in both patient groups with no significant differences between them, said Dr Schweitzer. Astigmatism outcomes were similar for both groups and no complication specifically related to the laser procedure occurred intraoperatively, he added. While no significant difference has been found between the two groups thus far, Dr Schweitzer said that the next step was to carry out further analysis of specific patient sub-groups in terms of cataract grade and surgeon experience. “Although we found no clinical advantage in using femtosecond laser cataract surgery, the technology may still potentially represent a new paradigm if certain conditions are met. Association with other innovations in fluidics and new implant designs might also help to take advantage of the highly precise cutting ability of the femtosecond laser in the future,” Dr Schweitzer said. Cedric Schweitzer: cedric.schweitzer@chu-bordeaux.fr
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from the ESCRS Clinical Survey Surgeons believe over 85% of their presbyopia-correcting IOL patients are satisfied with their vision at all distances
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y far, when surgeons technology. For me, it is customary that I SATISFACTION AT implant presbyopiaexplain to them that I correct presbyopia ALL DISTANCES correcting IOLs and astigmatism at the time of surgery.” It has often been repeated that cataract (PCIOLS) in their ESCRS Delegates identified lightpatients are increasingly savvy, expecting cataract patients, they adjustable IOLs and shape-changing that advanced technology will provide them favour trifocal options implants as other technology of future with “refractive surgery-like outcomes” according to results of the interest (Figure 1). The survey was after cataract surgery. ESCRS members 2017 ESCRS Clinical Survey of Presbyopia. administered onsite at the annual meeting in were asked about their patients’ overall When asked what technology they are most Lisbon, Portugal, and available to be taken satisfaction with their near, intermediate interested in integrating in the next five online. Of the almost 1,900 respondents, and distance vision at one year following years, trifocal/quadrafocal lenses topped close to 60% have been in practice for more PCIOL surgery (Figure 2). that list, together with extended-range-ofthan a decade. vision multifocals. These answers also align with the preferences and practice patterns of Francesco Carones What type of presbyopia-correcting IOL Which of the following presbyopia correcting MD, the medical director of technology is used in the majority of your technology are you are most interested in Carones Ophthalmology presbyopia correction patients? integrating in the next 5 years? Center, Milan, Italy. “The two major categories I use are extended range of vision (ERV) and trifocals; about half and half,” he said. Others 4.2% Extended range of 58.5% vision multifocal IOLs When surgeons were asked what percentage of their Accommodating 3.1% current cataract procedures, IOLs Trifocal/quadrafocal 56.5% for those who are candidates, IOLs involve PCIOLs, the average Extended Depth 22.3% of focus is 9%. Among the presbyopiaLight Adjustable 21.1% IOLs correcting IOL procedures performed, an average of 15% 45.2% Trifocal involved a toric PCIOL. Shape-changing 16.3% IOLs “I have a fully private Bifocal IOLs 25.2% practice, so my percentage of PCIOL procedures is 65% to 70%, Dr Carones noted. 0% 10% 20% 30% 40% 50% 0% 10% 20% 30% 40% 50% 60% 70% “Many surgeons in the European Union may not Current usage of PC IOLs Future use/interest of PC IOLs have the option of using the lens as there is no possibility to charge patients for the Figure 1. Data from the ESCRS 2017 Clinical Survey of over 1,800 ESCRS delegates EUROTIMES | JULY/AUGUST 2018
CATARACT & REFRACTIVE More than half of the surgeons said that their patients were somewhat satisfied with their near, intermediate and far vision. Almost 40% reported that patients were extremely satisfied with their near vision, and around 30% were extremely satisfied with intermediate and distance outcomes. “I believe to offer a truly refractive procedure, I need to be obsessive about satisfaction and conducting patient surveys,” said Dr Carones. “What I am really looking for is if the technology I selected for the patient meets his or her expectations. Even among the major PCIOL categories, there are differences in performance. I want to ensure that I assign patients to the specific IOL that I have learned is the best lens for them. I consider 90% or higher satisfaction as a good result.” His portfolio of ERV implants includes Symfony (Johnson & Johnson Vision), AT.LARA (Zeiss), and Mini WELL (SIFI MedTech); for trifocal lenses, Dr Carones prefers the AT.LISA (Zeiss) and AcrySof IQ PanOptix (Alcon). Another option in the ERV category is the small-aperture IC-8 IOL from AcuFocus, and PhysIOL’s FineVision is a popular trifocal implant.
RESIDUAL ERROR
Overall, how satisfied are your presbyopia-correcting IOL patients with their NEAR, INTERMEDIATE and DISTANCE vision outcomes at one year post-op? 70% 60%
53.9% 55.3%
Near
58.0%
Intermediate Distance
50% 40%
37.8% 33.1%
30%
28.8%
20% 10%
7.8%
9.8%
6.1%
5.9% 7.8%
0%
Extremely satisfied
Somewhat satisfied
Neither satisfied or unsatisfied
3.0% 0%
Somewhat unsatisfied
0%
0%
Extremely unsatisfied
Figure 2. Data from the ESCRS 2017 Clinical Survey of over 1,800 ESCRS delegates
In patients implanted with a presbyopia-correcting IOL, what would you consider an ideal outcome for residual astigmatic error? In these same patients implanted with a presbyopia-correcting IOL, what residual astigmatic outcomes do you believe you can realistically achieve on a regular basis?
Ideal outcome
56.2% 55.1%
Realistically achieve on a regular basis
24.6% 19.5%
17.2% 13.8%
4.7%
Astigmatism below 0.0D
To understand the delegates’ practices regarding residual astigmatic error in PCIOL patients, the survey asked about the ideal outcome for amount of residual astigmatic error and what amount they believe they can achieve on a regular basis. More than 50% said astigmatism <0.50D is an ideal outcome and that they can achieve it more than 50% of the time (Figure 3). Almost 20% said <0.25D residual astigmatism is ideal, with only about 14% responding that this is realistic to achieve on a regular basis, however. “When doing presbyopia correction, the surgeon should hit plano to give patients the best result,” Dr Carones said. “Even for 0.50D of astigmatism, I implant a toric PCIOL.” On average, the delegates said that in PCIOL patients, the lowest amount of postoperative residual cylindrical error that they consider visually significant, or likely to have an impact on visual quality and satisfaction, is about -0.62D. The average spherical deviation from the intended target ESCRS surgeons consider to be visually significant is +0.61D.
2.4%
1.8% Astigmatism below 0.25D
Astigmatism below 0.5D
Astigmatism below 0.75D
4.8%
Astigmatism below 1.0D
Figure 3. Data from the ESCRS 2017 Clinical Survey of over 1,800 ESCRS delegates
CONCLUSION According to a global IOL report from Market Scope, in 2017, the use of PCIOLs globally grew by more than 10%. Technological innovations will help drive revenues to more than $6.1 billion by 2023 worldwide.1 Overall, surgeons implanted nearly 27 million IOLs last year, “but postoperative refractive surprises and optical disturbances persist and often leave patients unsatisfied”, the reported noted. Adjustable implants that allow for postoperative fine-tuning of the IOL’s refractive power are projected to provide surgeons more confidence in providing accurate and customisable refractive outcomes. Market Scope predicts that the next generation of shape-changing accommodating IOLs will also play in expanding role in the adoption of PCIOLs. For Dr Carones, a “more perfect” IOL would be an extended-range-of-vision lens with improved near performance, or
a trifocal with enhanced quality of vision at night. For now, however: “The current generation of IOLs are performing quite well,” he said. “We have reliable technology that can be widely used.” Francesco Carones MD, is the Cofounder and Medical Director of the Carones Ophthalmology Center, Milan, Italy. He may be reached at fcarones@carones.com. 1. Doughty M. Market Scope. Patient demand for better vision will drive doubledigit growth in IOL revenues. 2018 IOL Report: A Global Market Analysis for 2017. www.market-scope.com. For more information on the ESCRS Education Forum, including video presentations, supplements and articles see forum.escrs.org EUROTIMES | JULY/AUGUST 2018
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CATARACT & REFRACTIVE
THOMAS KOHNEN European editor of JCRS
JCRS HIGHLIGHTS VOL: 44 ISSUE: 5 MONTH: MAY 2018
JOURNAL OF CATARACT & REFRACTIVE SURGERY ® SYMPOSIUM
CONTROVERSIES
in Cataract and Refractive Surgery
Sunday 23 September 14.00 – 16.00
During the 36th Congress of the ESCRS Vienna, Austria
Chairpersons: T. Kohnen GERMANY (EUROPEAN EDITOR) W.J. Dupps USA (US ASSOCIATE EDITOR)
Intraoperative OCT for the anterior segment 14.00
N. Hirnschall AUSTRIA We need it!
14.15
M. Busin ITALY We don’t need it!
14.30
Discussion
Cataract and corneal transplantation 14.40
J. Hjortdal DENMARK Combined
14.55
D. Tan SINGAPORE Separated
15.10
Discussion
Corneal refractive surgery 15.20
T. Seiler SWITZERLAND The best outcome is after PRK
15.35
E. Donnenfeld USA The best outcome is after LASIK
15.50
Discussion
16.00
End of session
FLACS BETTER FOR EYES WITH FUCH’S DYSTROPHY? Femtosecond laser-assisted cataract surgery (FLACS) offers several apparent advantages over standard phacoemulsification surgery in cases of Fuch’s endothelial corneal dystrophy, including a shorter phacoemulsification time and less ultrasound energy use, both of which have been shown to reduce endothelial cell loss and postoperative corneal oedema. Researchers conducted a retrospective study of 207 eyes of 207 patients with mild-to-moderate risk for corneal compensation, comparing outcomes in 64 FLACS cases and 143 conventional phaco cases. Clinically significant corneal decompensation was defined as corneal oedema with CDVA worse than 20/50 lasting more than three months, any case resulting in keratoplasty or both. Compared with conventional phaco, FLACS did not lower the rate of corneal decompensation in eyes with mild-to-moderate Fuch’s endothelial corneal dystrophy. The proportion of cases progressing to clinically significant decompensation (13%) was similar between groups. Indeed, several outcomes were significantly worse in the FLACS group, including a higher rate of clinically apparent oedema and greater incidence of clinically severe oedema in the early postoperative period. The researchers suggest that concurrent endothelial keratoplasty with cataract surgery (triple procedure) be considered in eyes with moderate Fuch’s endothelial corneal dystrophy. DC Zhu et al., JCRS, Volume 44, Issue 5, 534–540.
WHICH COMBINED SURGERY IS BEST? Management of patients with coexisting cataracts and glaucoma remains challenging. Surgeons have an increasing number of options when operating on patients with open-angle glaucoma and visually significant cataract. Researchers compared outcomes of phacoemulsification combined with viscocanalostomy, endocyclophotocoagulation (ECP) or ab interno trabulectomy for intraocular pressure (IOP) control and safety in a study of 109 eyes. Forty-six eyes had combined phacoviscocanalostomy, 35 had phaco–ECP, and 28 eyes phaco–ab interno trabulectomy. With a mean follow-up of 17 months, the phacoviscocanalostomy group had the lowest mean IOP, 13.5 ± 4.7 mm Hg, a 29% decrease. There was no significant difference in the final IOP between phaco–ECP and phaco–ab interno trabulectomy (16.4 ± 3.9 mm Hg, a 20% decrease versus 15.8 ± 4.2 mm Hg, a 15% decrease). The reduction in the number of medications was greater with phacoviscocanalostomy (77%) than with phaco–ECP (40%) and phaco–ab interno trabulectomy (44%). Phacoemulsification–ab interno trabulectomy had the fewest complications. Intraocular pressure spikes were more frequent in the phaco–ECP group than in the other groups. The investigators suggest a need for prospective randomised controlled studies to compare these procedures, as well as their long-term effects on IOP stability and glaucoma progression. S Moghimi et al., JCRS, Volume 44, Issue 5, 557–565.
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EUROTIMES | JULY/AUGUST 2018
EuCornea Medal Lecture
4 Free Paper Sessions 2 Presented Poster Sessions
Friday 21 September 14.00 – 15.00
(At the Opening Ceremony)
“Neural basis of eye surface sensations. From dryness to pain.” Carlos Belmonte
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Eu
Corn
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Registration & Hotel Bookings Available
SPAIN
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European Society of Cornea and Ocular Surface Disease Specialists
Friday 21 September 13.00 – 14.00 9 EuCornea Congress 21–22 September 2018
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www.eucornea.org
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2 Days 5 Courses 8 Focus Sessions
A Spotlight on Dry Eye Disease: The Role of Cyclosporine A Moderator: B. Früh SWITZERLAND Sponsored by
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CORNEA
The DREAM is over Omega-3 supplements have no effect on dry eye, major study finds. Howard Larkin reports
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o you think omega-3 helps dry eye patients? In an instant poll at the American Society of Cataract and Refractive Surgery Cornea Day 2018, 90% of ophthalmologists in the audience answered that it is beneficial for at least some patients. However, the 10% who said omega-3 is not beneficial for dry eye were correct, according to a major new study. The Dry Eye Assessment and Management (DREAM) study found no significant difference in outcomes at six and 12 months between 349 patients treated daily with 3,000mg fish oil supplement and 186 receiving an olive oil placebo in addition to ongoing treatments for moderate-to-severe dry eye disease (DED). “This National Eye Institute-supported clinical trial shows that oral omega-3 is no better than placebo in relieving signs and symptoms of dry eye disease,” DREAM Study Chair Penny Asbell MD announced at the ASCRS meeting in Washington, DC, USA. The results were simultaneously published in the New England Journal of Medicine. (DOI: 10.1056/NEJMoa1709691).
REAL-WORLD TEST The 12-month prospective randomised trial included patients at 27 centres who had DED symptoms for at least six months prior to study enrolment. Using patients already in treatment for DED replicated the conditions under which patients typically are treated, which should make the results more representative of actual clinical practice, Dr Asbell noted. The patients in the study also used or desired artificial tears at least twice daily, and many were using other treatments, including cyclosporine drops, warm eyelid soaks and lid scrubs. Participants also had at least two signs of DED such as conjunctival or corneal staining, and abnormal tear film break-up time (TBUT) or Schirmer’s test, did not use more than 1,200mg daily omega-3 supplements, and had no history of LASIK, recent ocular surgery or current contact lens use. The primary endpoint was reduction in symptoms measured by the Ocular Surface Disease Index (OSDI) instrument, with secondary endpoints changes in signs as measured by staining, TBUT and Schirmer’s. At 12 months, mean OSDI scores in the treatment group fell -13.9 points compared with -12.5 points in the EUROTIMES | JULY/AUGUST 2018
placebo group. With missing data imputed, the difference was -1.9 points, which is not statistically or clinically significant. The results were consistent across all pre-specified subgroups, including patients with moderate or severe disease and those with higher or lower omega-3 blood levels, Dr Asbell reported. Objectively, there was no difference in changes in conjunctival staining or Schirmer’s scores between the two groups, and no significant difference in corneal staining or TBUT, she added. Adverse events were also similar between the two groups. Patients receiving the active supplement, which included 2.0g EPA and 1.0g DHA, showed increased omega-3 blood levels, suggesting a compliance rate of more than 80% over the 12 months.
CONCLUSIVE EVIDENCE The DREAM study was undertaken to provide solid evidence on the efficacy of omega-3 supplements, which have been widely prescribed for DED despite limited evidence, Dr Asbell said. She noted that a 2013 American Academy of Ophthalmology Preferred Practice Pattern statement found no evidence favouring efficacy (www.aao.org/ppp), while a 2017 report from the Tear Film and Ocular Surface Society Dry Eye Workshop (DEWS II) cited mixed results among short-term studies and a lack of highquality randomised trials (Jones L et al. Ocul Surf 2017;15:575-628). So why do so many ophthalmologists
apparently believe omega-3 supplements help patients with DED? There may be several reasons, Dr Asbell told EuroTimes. Human nature is one reason. “In clinical medicine and in general humans like to determine cause and effect: If I had a glass of warm milk before bed and I slept well ‘warm milk’ must work. What appears to work for one person, we think works for everyone,” Dr Asbell said. Many are committed to “natural treatment”, and omega-3 seems like it should work; it is difficult to “give up” that point of view. She noted that both groups in the trial reported improvements in dry eye symptoms of more than 10 points, which is considered clinically significant. This suggests that listening and responding to patient concerns may be a useful adjunct to dry eye treatment. Since reporting the results on April 13, Dr Asbell has received many comments. Some questioned the use of olive oil as a placebo, suggesting that it, too, may be helpful with dry eye. However, the amount of olive oil used was insignificant (one teaspoon per day) compared with a Mediterranean diet, she said. Blood levels of olive oil compounds also were similar between the two groups at baseline and at 12 months, she added. Dr Asbell believes the trial methodology was robust and the results must be respected. “The results are pretty definitive. No matter how you look at the data, omega-3 supplements are not an effective treatment for moderate to severe dry eye disease.”
CORNEA
Using rituximab for eye patients A new approach could obviate the need for steroids in idiopathic orbital inflammation. Sean Henahan reports
T
reatment with rituximab, a drug normally associated with the treatment of nonHodgkin’s lymphoma or rheumatoid arthritis, can provide rapid resolution of symptoms in idiopathic dacryoadenitis, a form of idiopathic orbital inflammation, according to a report presented at the Association for Research in Vision and Ophthalmology (ARVO) 2018 Annual Meeting in Honolulu. Following a report that intralesional rituximab proved useful in the treatment of ocular adnexal lymphoma, US researchers conducted a study in nine patients with confirmed idiopathic orbital inflammation. Patients received a single intralesional injection of rituximab (50mg/1mL). Patients were followed for at least six months with serial exams and MRI studies. The investigators used the modified Werner classification for the grading of orbital inflammation to measure disease activity. Patients who were pregnant, or younger than 18 years of age, or with evidence of acute vision loss were excluded from the protocol. Nine patients, five men and four women, participated in the study. Patients had symptoms for about 10 days before beginning treatment. Every patient had
I think this represents a step beyond steroids. We feel this data is very promising and warrants prospective trials in the future comparing this with the current standard of care Charles Miller MD, PhD
a complete resolution of disease within four weeks of starting treatment. The mean orbital inflammation score declined steeply after treatment, reaching a high level of statistical significance (p<0.005). One patient relapsed at eight months. That patient was given another injection and had resolution of disease. “I think this represents a step beyond steroids. We feel this data is very promising and warrants prospective trials in the future comparing this with the current standard of care. Local injection of rituximab spares patients the side-effects of high-dose systemic corticosteroid treatment,” said Charles Miller MD, PhD, of the State University of New York Downstate, US, in an interview with EuroTimes.
Innovative
FIRST REPORT This was the first report of using intralesional rituximab for idiopathic orbital inflammation. Intralesional administration can be done under direct visualisation in the clinic, injecting into the palpebral lobe of the lacrimal gland. Patients first receive topical proparacaine and lidocaine gel, left on the conjunctival surface for a minute prior to injection, he explained. The fact that no patient experienced side-effects associated with rituximab treatment is noteworthy. Rituximab (Rituxan, Genentech) is a genetically engineered chimeric murine/human monoclonal IgG1 kappa antibody directed against the CD20 antigen. When given intravenously in the treatment of rheumatoid arthritis or B-cell nonHodgkin’s lymphoma, side-effects can include fever, rigors and chills. Idiopathic orbital inflammation is the most common painful orbital mass seen in adults. The benign condition presents as a marginated mass-like enhancing soft tissue involving any area of the orbit. Associated problems include proptosis, oedema and diplopia. It is essentially a diagnosis of exclusion, once infectious, inflammatory and neoplastic entities have been ruled out, he explained.
Competitive
Cost Effective
Charles Miller: charles.miller@downstate.edu EUROTIMES | JULY/AUGUST 2018
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VIENNA 2018 36 Congress of the ESCRS TH
22â&#x20AC;&#x201C;26 September Reed Messe, Vienna, Austria
Registration & Hotel Bookings www.escrs.org
ESCRS VIENNA PREVIEW
RIDLEY MEDAL LECTURE
HERITAGE MEDAL LECTURE
EXPLORING VIENNA
Interview with Rudy Nuijts SEE PAGE 27
Interview with Thomas Neuhann SEE PAGE 29
Enjoy the sights in historic Vienna SEE PAGE 34 & 35
Vienna awaits ESCRS
36th Congress will showcase exciting developments in cataract and refractive surgery, with presentations from key opinion leaders in ophthalmology
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housands of ophthalmologists from all over the world are getting ready to attend the 36th Congress of the ESCRS in Vienna, Austria. The Congress, which convenes from 22-26 September 2018, will showcase some of the most exciting developments in cataract and refractive surgery, with presentations from some of the key opinion leaders in the world of ophthalmology. “We are very excited to be returning to Vienna for our annual Congress,” ESCRS President Béatrice Cochener told EuroTimes. “We last held our Congress in Vienna in 2011 and we look forward to renewing acquaintances with old friends and also building new friendships. With so much on offer, it will be impossible for delegates to attend every session and in this special preview in EuroTimes, we give a snapshot of what is on offer,” said Dr Cochener. The highlights of this year’s Congress include the Main Symposia, Clinical Research Symposia, Best of The Best Review Session, the Video Awards and the Young Ophthalmologists Programme. This year’s Ridley Medal lecture, “Facts First”, will be delivered by Prof Rudy MMA Nuijts, the Netherlands. “I want to point out the value and the importance of evidence-based medicine in anterior segment surgery. Nowadays we really need to prove why we are doing a certain treatment and why we believe this treatment has value in comparison to
THE 36TH ESCRS CONGRESS BY NUMBERS
ESCRS president, Béatrice Cochener
another treatment,” said Prof Nuijts. “We are also delighted to announce that for the first time we will be presenting the ESCRS Heritage Lecture,” said Dr Cochener. “The lecture will celebrate the rich history of anterior segment surgery and the inaugural lecture ‘The Capsulorhexis’ will be delivered by Thomas Neuhann, Germany. Prof Neuhann is a former president of ESCRS,” said Dr Cochener, “and it is fitting that he should be invited to deliver this lecture.” Dr Cochener said that it was important to acknowledge the invaluable support of the ophthalmic industry for the Congress,
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Instructional Courses
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and she looks forward to seeing the latest technologies during the exhibition, which has become an integral part of the Congress. “Finally,” said Dr Cochener, “let us remember that at the end of long days of discussion and debate, we should take the opportunity to explore Vienna. It is truly a beautiful city and part of the experience of attending the Congress will be to visit the city’s historical sites and sample its cuisine. We look forward to seeing you!” Full details of the programme are available at www.escrs.org
Surgical Skills Courses
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Main Symposia EUROTIMES | JULY/AUGUST 2018
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ESCRS VIENNA PREVIEW
A packed programme Sorcha Ní Dhubhghaill gives an overview of the main symposia taking place at the 36th congress of the ESCRS
F
rom 22 to 26 September, the 36th congress of the ESCRS takes places in Vienna. The ESCRS meeting is always a highlight on the calendar of ophthalmologists across Europe. And this year, the meeting is bundled with EuCornea and EURETINA, making beautiful Vienna the place to be this September. The ESCRS programme is as packed and intense as usual. Some of the biggest attractions of the event are the main symposia. There are six main symposia spread out over the conference. As these sessions fill up quickly and often offer standing room only, it is best to come early. Here is a brief teaser of what to expect from the main symposia this September:
CORNEAL CROSS-LINKING On Saturday morning, Roberto Bellucci and EuCornea President Elect Jesper Hjortdal will be chairing a session about the state of the art of corneal cross-linking. If you are looking to integrate CXL safely into your refractive practice, you will not want to miss this. The session will cover everything from the basics of biomechanics to the newest crosslinking approaches. Laser surgery in ectatic conditions can be challenging and part of this session will cover strategies to combine cross-linking with LASIK and keratoconus so you can safely expand your laser practice and improve your management of complex corneal diseases. What to do, how to do it and when. All secrets will be revealed.
THE DIABETIC EYE On Saturday afternoon, ESCRS President Béatrice Cochener and EURETINA President Sebastian Wolf will team up for a joint symposium on the diabetic eye. The ageing population means that we will all be seeing more diabetic patients in our clinics and we need to adapt our approach. This session will provide a refresher course in the newest concepts and treatments in diabetes and then move on to the practical. Expert advice on timing your surgery, preparing your patient and managing complications to the newest evidence-based guidelines will help all of us get the best out of these cases.
GLAUCOMA FOR THE CATARACT SURGEON On Sunday morning, Simonetta Morselli and David Spalton host a session on glaucoma. With the newer minimally EUROTIMES | JULY/AUGUST 2018
invasive glaucoma surgery techniques, more and more of us cataract surgeons are expanding our practice into glaucoma treatment. This session will dive into the new imaging techniques, drugs and surgical approaches such as intracanalicular, suprachoroidal and subconjunctival devices. It’s not all about the new and novel though, as they will also present the case for the tried and trusted trabeculectomy, which still plays a key role in glaucoma surgery.
EXTENDING DEPTH OF FOCUS On Monday morning, Michael Amon and Thomas Kohnen will chair a session to tackle the next generation of presbyopia corrections. The session begins with the basics of lens optics and how IOLs perform on the optical bench. It then moves on to the practical, covering extended depth of focus lenses as well as novel technologies that could make it to the clinic soon. While most of this symposium will cover advanced multifocal techniques, the humble monovision will also make an appearance.
REFRACTIVE SURGERY FOR HIGH AMETROPIA The main symposium on Tuesday morning will cover some of the trickiest refractive patients that we see; the high ammetropes. Alex Day and José Güell will cover the problem of treating outliers in our practice.
The session starts by defining our optical and anatomical limits to keep our surgeries within a safe zone. Then refractive laser surgery for the high myope will be covered. Which laser is best? Smile, LASIK or RPK? Then intraocular surgery in long eyes and short eyes will be covered, each with their specific risks and complications. The session concludes with a review of high astigmatism correction. Everything you need to treat the edge cases.
THE ENIGMA OF PSEUDOEXFOLIATION The final major symposium, on Wednesday morning, will cover a common condition complicating cataract surgery, pseudoexfoliation. The session begins with a basic overview, covers epidemiology and genetics, and then moves on to intraoperative complications. But pseudoexfoliation not only complicates the primary surgery but can also cause serious lens luxations many years later. These can be complex, difficult to manage and ask more of the anterior segment surgery. In this symposium, experts in lens fixation will describe their approaches to lens suspensions, to rescue patients when the lens falls. Sorcha Ní Dhubhghaill MB PhD MRCSI(Ophth) FEBO. Anterior Segment Ophthalmic Surgeon, Department of Ophthalmology, University Hospital Antwerp, Belgium
ESCRS VIENNA PREVIEW
Putting facts first Prof Rudy MMA Nuijts MD PhD, who will be delivering the Ridley Medal Lecture at the 36th Congress of the ESCRS in Vienna, reflects on his long and varied career
I
am very honoured and humbled to have been asked to give the Ridley Medal Lecture: what more can you expect from a scientific career? There’s been only one Medal lecture delivered by a Dutch ophthalmologist at an ESCRS Congress before, Jan Worst, who delivered the Binkhorst lecture in 2000, and to be put on a similar level as a giant like him is incredibly honourable. The title of my lecture will be “Facts First”. The idea behind it is to point out the value and importance of evidencebased medicine in anterior segment surgery. A core principle of modern medicine is to base treatment and policy decisions on the highest-quality, openly and objectively derived scientific data. Together with my research team I have tried to design studies that give us answers to the intriguing questions we have. The answers to these questions are Rudy MMA Nuijts with Laura Wielders, following the presentation of the results of the ESCRS PREMED Study in Lisbon last year gaining increasing importance in the context of cost-effectiveness and value based health care. So, for example, is a toric lens better than a other hand, FLACS has given us very innovative solutions when monofocal IOL, and up to which level of astigmatism? We found doing very complex cataract surgery. out that, although the toric IOL was very effective for the patient So, expectations and outcomes are sometimes at variance with in terms of improving distance uncorrected vision, it was not costone another, and that is why we as ophthalmologists have to effective, at least in the Netherlands. communicate to our peers what the evidence is for certain scientific Other questions that I’ve tried to answer in my career are in claims that are being made by doctors and also by the industry. I the fields of refractive surgery and corneal surgery. For example, believe that academia has a very important role in designing those during the years 2005 to 2010 we investigated the practicality of kinds of studies and also coming up with answers. That is what we making endothelial grafts with the femtosecond laser. try to do here on a consistent basis. A final example of course is the Our idea was that it might be very cost-effective to have a ESCRS PREMED study, where we tried to find the best approach femtosecond laser in an eye bank where you could make all the for preventing cystoid macular oedema after cataract surgery in endothelial grafts that were needed and then distribute them routine phaco and in patients who have diabetes. to all the corneal surgeons in the country. But it turned out that, at Registries are also important in terms of evidence-based that time, although astigmatism was significantly lower, quality of medicine and I have been involved in establishing the European vision provided by a graft made by the femtosecond laser was actually Cornea and Cell transplantation registry (ECCTR). The format not better than what we could achieve with penetrating keratoplasty. and the backbone are being created and now the database is being Later on, we compared endothelial grafts created with a femtosecond filled with data from countries that have already national registries laser with those produced manually with a microkeratome and we like Scandinavia United Kingdom the Netherlands, and we are found that the microkeratome actually produces smoother grafts having discussions with France and Germany and some eastern with better visual outcomes. So sometimes, a fancy technological European countries. Registries provide real-world big data and innovation does not bring us in every aspect what we expect from it. can sometimes answer questions on a wider perspective, but when Another example of femtosecond laser technology is its use it comes to measuring the effect of specific interventions I believe in cataract surgery. The EUREQUO femtosecond laser-assisted that randomised clinical trials remain an invaluable instrument. cataract surgery (FLACS) study led by Prof Mats Lundström, in which I was also involved, and the FEMCAT study showed us Rudy Nuijts was interviewed by Roibeard Ó hÉineacháin, again that FLACS has not brought us what we expected. On the Contributing Editor, EuroTimes
Rudy MMA Nuijts is Professor of Ophthalmology and Director of the Cornea Clinic and the Center for Refractive Surgery at the Department of Ophthalmology, University Medical Centre Maastricht, the Netherlands. He was a research fellow at Emory Eye Center, Atlanta, in 1989 and 1993, where he identified the aetiology of Toxic Anterior Segment Syndrome (TASS). He was also the lead investigator in the ESCRS PREMED study. He is currently Chairman of the Netherlands IntraOcular Implant Club (NIOIC), treasurer of the Dutch Corneal Society and he is a Board member and Director of the ESCRS and was for eight years ESCRS treasurer.
EUROTIMES | JULY/AUGUST 2018
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ESCRS VIENNA PREVIEW
Experience the Forum The newly designed Free Paper Forum will allow delegates to attend parallel sessions and represents an evolutionary step for the ESCRS
I
n Ancient Rome, the forum was a public square and a gathering place for discussions, debates and meetings where some of the great thinkers of the day would exchange views and disseminate knowledge. This year in Vienna, the ESCRS is bringing the forum into a modern setting with the first ever Free Paper Forum. In a specially designed room, delegates will be able to attend parallel sessions staged at a number of pods around the room. “The idea is really to provide a platform for informative, productive and relaxed interaction to enable delegates to experience free papers in a more stimulating way,” says Béatrice Cochener, President of the ESCRS. “As a Society, we are always looking at ways to evolve,” said Dr Cochener, “and as the president of ESCRS, I believe that the Free Paper Forum will be one of the highlights of this year’s meeting.”
POSTER VILLAGE As in previous congresses, another major attraction for delegates in Vienna will be the Poster Village, which was first launched at EUROTIMES | JULY/AUGUST 2018
The idea is really to provide a platform for informative, productive and relaxed interaction to enable delegates to experience free papers in a more stimulating way Béatrice Cochener MD PhD the XXXII Congress of the ESCRS in London in 2014. A highly interactive area where particularly interesting posters are presented by the authors in an informal atmosphere, there are three different formats of poster presentation on offer at the Village: ePoster terminals, presented poster sessions and moderated poster sessions. The ePoster terminals give delegates access to the posters in electronic form to be browsed at leisure, while the presented poster sessions enable small groups to discuss with the authors and obtain more detail on their research in an informal setting. For the moderated poster sessions, a designated moderator presents a thematic summary of the posters contained in that
session, followed by a question-and-answer session with the authors and audience debate. The focus is firmly on audience participation and interaction to derive the maximum benefit from the presentation. First, second and third prizes of €2,000, €1,000 and €500 will be awarded to the best cataract and refractive posters at the Congress. Posters are judged based on: Originality, scientific quality, relevance to clinical practice and presentation. Bursaries have also been awarded to ESCRS trainee members with a high scoring accepted free paper or poster. The bursary grant includes free registration to the congress and an allowance of €1,000 to cover flight and hotel costs.
ESCRS VIENNA PREVIEW
ESCRS Heritage Lecture Prof Thomas Neuhann reflects on a landmark moment in cataract surgery. Dermot McGrath reports
T
he renowned German surgeon and past ESCRS President Thomas Neuhann has been invited to deliver the inaugural ESCRS Heritage Lecture at the 36th Congress of the ESCRS in Vienna in September. Prof Neuhann’s lecture will focus on the invention and evolution of the capsulorhexis, a key step in modern cataract surgery, and one which represented a significant advance on previous methods used to open the anterior capsule in order to access the lens material. The invention of the capsulorhexis, and more precisely the continuous curvilinear capsulorhexis (CCC), is credited to both Prof Neuhann and Howard Gimbel MD, who both independently applied the same circular concept albeit using slightly different techniques. Prof Neuhann told EuroTimes that he was honoured to have been asked to deliver the inaugural ESCRS Heritage Lecture at the invitation of Béatrice ESCRS president Thomas Neuhann with Patrick Condon (left) and Ulf Stenevi (right), at the ESCRS Congress in Vienna, 1999 Cochener, current President of the ESCRS. “I would like to thank Béatrice and the ESCRS for this singular honour. I was told that the lecture is At around the same time, Howard Gimbel was also experimenting being introduced as a means of highlighting important landmark with tearing out the capsule in arc-like sections while leaving small moments and developments in the history of cataract and refractive bridges to stabilise the flap until the circle was mostly formed. surgery. I suppose it can be considered a bonus if the inventor of “The basic principle of tearing was the same but my version the technique is still alive to give the lecture!” joked Prof Neuhann. ultimately stood the test of time because it proved to be a little bit While the capsulorhexis has become part and parcel of modern more practical,” explained Prof Neuhann. “I had only one opening cataract operations, it is easy to forget that the technique was not in the capsule from where I tore out 360-degrees, whereas Howard always the preferred means of creating an opening in the anterior created two, three or four openings in the capsule and then united capsule. From Vogt’s technique using toothed forceps, Charles those by tearing,” he said. Kelman’s “Christmas tree” approach in the late 1960s, through Recognising that they had both arrived at the same basic to the popular “can-opener” technique in the 1970s and 1980s, concept independently and around the same time, Drs Gimbel surgeons had long searched for the optimal means of sculpting an and Neuhann decided to put aside any question of priority by aperture in the anterior capsule. publishing a joint paper in 1990 that explained their respective “In the early 1980s there was a bit of controversy around the contributions to the capsulorhexis breakthrough. question of whether we should go into the capsular bag with our “It was the right thing to do. My mentor Dick Kratz told me at lenses or should remain in the sulcus,” recalled Prof Neuhann. the time: ‘I have seen so many bitter fights over priority. I think “While the capsular bag was clearly the best place for the lens, the that is about the nicest way to handle such a thing that I have ever can-opener technique meant that the lenses were frequently decentred come across.’” and there was a tendency for the haptics to pop out postoperatively. When it happened to me, I said to myself either I find a solution to The inaugural ESCRS Heritage will take place this or I stay in the sulcus. I thought it better to be old-fashioned but on Monday 24 September at 10.30 effective rather than going with the trend and putting in decentred lenses with the risk of haptic displacement,” he said. Prof Neuhann’s eureka moment came in the autumn of 1984 Professor Thomas Neuhann is founder and medical director of the when he was faced with a female patient with retinitis pigmentosa MVZ Prof Neuhann, Munich, Germany. He studied ophthalmology and loose zonules. at the University Ophthalmological Clinic in Heidelberg before “I simply could not get this can-opener technique to work. Every pursuing his career in Mainz and Munich. time I tried to nick the capsule the whole lens would move and I was As well as co-inventing the capsulorhexis technique, Prof Neuhann afraid of ripping out the zonules. In my despair, I stuck a blade in is also credited with refining the technique for trabeculotomy and cut the capsule and inserted some Healon viscoelastic, which and popularising the use of intrastromal corneal ring segments to was not widely available at the time. I then took my tying-forceps stabilise and correct severe and irregular astigmatism for patients and tried to tear the capsule – and miracle of miracles, the tearing with keratoconus. was much less strenuous on the capsule than trying to nick it with the Prof Neuhann also founded and runs the Corneal Bank of capsulotome. This was how my first capsulorhexis was performed – Munich, which provides corneas for between 1,000 and 1500 it was a mixture of relief and elation that it actually worked,” he said. transplants annually. He has received many international awards To more accurately describe the new technique and and distinctions during the course of his career, serving as differentiate it from preceding techniques, Prof Neuhann coined President of the ESCRS from 1998 to 2000. the term “capsulorhexis”, which uses the Greek suffix “rhexis” meaning “to tear”. EUROTIMES | JULY/AUGUST 2018
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Saturday 22 September
Saturday 22 September
Lunchtime Symposia
Lunchtime Symposia
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
Dry Eyes – Targeted Treatment as a Key to Satisfied Patients Moderator:
P. Steven GERMANY
T. Kaercher GERMANY Focusing on the lipid layer: what treatment options are available G. Auffarth GERMANY Post-operative use of EvoTears
®
Sponsored by
13.00 – 14.00
Moderator:
T. Seiler SWITZERLAND
Speakers:
B. Malyugin RUSSIA S.P. Chee SINGAPORE J. Mehta SINGAPORE
Moderator:
O. Findl AUSTRIA
Sponsored by
Iridex Satellite Meeting
®
®
Pentacam AXL and Corvis ST: Taking Cataract and Refractive Surgery to the Next Level
T. Kohnen GERMANY Pentacam AXL – clinical results
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F. Hengerer GERMANY Modern patients screening and IOL power calculation
Moderators: F. Bandello ITALY B. Malyugin RUSSIA
G. Savini ITALY Taking advantage of total corneal astigmatism for toric IOLs
F. Scaglione ITALY Antibiotic resistance: an emerging problem
M. Belin USA Incorporating the Belin ABCD progression display in your CXL practice
T. Kohnen GERMANY Antibiotic resistance and antibiotic prophylaxis in ophthalmic surgery
R. Ambrósio BRAZIL Enhanced Ectasia diagnosis with integrated Scheimpflug imaging: essential concepts & meta-analysis
L. Rossetti ITALY Antibiotic resistance and antibiotic therapy in ophthalmology
The Future of Vision from the Leaders in Multifocality
Sponsored by
Moderators: F. Hengerer GERMANY C. Roberts USA
Rationalization of Prescriptive Behaviors in Ophthalmology for the Containment of Antibiotic Resistance
Lunchtime Symposia Boxed Lunch Included
Ziemer Lunch Symposium
P. Steven GERMANY Differentiated consideration of patients as a prerequisite for targeted therapy
Saturday 22 September
R. Vinciguerra ITALY In-vivo corneal biomechanical changes after collagen cross-linking in patients with progressive keratoconus
Sponsored by
Sponsored by
Mastering Toric IOLs – Preoperative Pearls & Practices for Post-Operative Success Moderator:
R. Zaldivar ARGENTINA Pearls and pitfalls of pre-operative education on astigmatic correction O. Findl AUSTRIA Hitting the mark: advanced biometry to account for astigmatic correction F. Kretz GERMANY Precise implantation: tips and techniques to improve intra-operative alignment & post-operative outcomes To Be Confirmed Expanding options for patient expectations in today’s cataract refractive surgery
Sponsored by Sponsored by
B. Dick GERMANY
36th Congress of the ESCRS 22–26 September 2018
Saturday 22 September
Sunday 23 September
Evening Symposia 18.15 – 19.45
®
Lunchtime Symposia
Lunchtime Symposia
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
The New CyPass Ultra System : One Step Closer to Safe, Consistent and Long-term IOP Control for your POAG Patients with and Without Cataract
Complex Cataracts
Moderator:
Sponsored by
L. Au UK
Sponsored by
Cross-Linking Grand Rounds: Innovative New Treatment Options Moderator:
R. Rajpal USA
Panelists: T. Seiler SWITZERLAND F. Malecaze FRANCE P. Stodulka CZECH REPUBLIC J. Marshall UK Sponsored by
Sunday 23 September
Lunchtime Symposia Boxed Lunch Included
13.00 – 14.00 Climbing the Next Peak: Enhanced Technologies to Take your Patients to the Next Level Moderator: K. Gundersen NORWAY Sponsored by
Sunday 23 September
Moderator:
R. Osher USA
Speakers:
B. Malyugin RUSSIA R. Osher USA
Sponsored by
MINI WELL READY EDOF IOL by SIFI: Latest International Clinical & Scientific Updates G. Auffarth GERMANY
V. Camps SPAIN Aberrometric profile of the MINI WELL & MINI WELL Toric V. Caparas PHILIPPINES Changing paradigm in presbyopia correcting IOLs: First experience with the MINI WELL Ready P. Rozot FRANCE Comparison of visual results of SIFI MINI WELL versus 3 other EDOF-IOLs E. Pedrotti ITALY MINI WELL and MINI WELL Toric: clinical results and patients selection G. Auffarth GERMANY MINI WELL Ready: results from the fusion European multicenter trial Sponsored by
Moderator:
V. Borderie FRANCE
F. Goes BELGIUM How I integrated total cornea power (TCP) in my refractive practice
Pearls for Improved Refractive Outcomes with Cataract Surgery
Moderator:
Optimizing your Clinical Practice with OCT and OCT-Angiography
V. Borderie FRANCE The role of epithelium thickness mapping (ETM) in corneal disorders M.C. Savastano ITALY Diagnosing and following-up on retinal pathologies with AngioVue OCTA L. Di Antonio ITALY OCT-Angiography in optic nerve head disorders Sponsored by
Management of the Ocular Surface in Ocular Surgery Moderator:
B. Cochener FRANCE
C. Cagini ITALY Ocular surface disorders after cataract surgery M. Labetoulle FRANCE Intracameral mydriatics in diabetic patients R. Nuijts THE NETHERLANDS Cost effectiveness of a new intracameral procedure Sponsored by
Nidek Satellite Meeting Sponsored by
Sunday 23 September
Sunday 23 September
Sunday 23 September
Lunchtime Symposia
Lunchtime Symposia
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
Navigating Laser Vision Correction in 2018 – Tailored Patient Treatment Approaches
Multifocality in Comparison – Clinical Results and 3D-Visualization of Trifocal and "EDOF" IOLs
INFOCUS – 2 Minutes to Enhanced IOL Experience! Debating the Topics Most Important to Your Practice
Sponsored by
Moderator:
S. Srinivasan UK
Speakers:
J. Fernandez SPAIN M. Assouline FRANCE G. Scharioth GERMANY
Moderators: A. Brezin FRANCE S. Al-Messabi UNITED ARAB EMIRATES
Smart Technologies for Today’s Surgical Practices Moderator:
S. Morselli ITALY
Smart engineering – overview of the TECHNOLAS TENEO 317 model 2 VICTUS FLACS + ZeroPhaco – the smart approach Next-Gen enVista platform – experience with the new enVista Smart IOL material Smart fluidics management – clinical experience with the Stellaris Elite and Adaptive Fluidics Sponsored by
All you Ever Wanted to Know About the Leading Cause of Dry Eye and Never Dared to Ask
Sponsored by
Rayner: Leading the Way to Offer More Patients a Trifocal Solution: Surgeon Panel Discussion on RayOne Trifocal and New Sulcoflex Trifocal Moderator:
O. Findl AUSTRIA
Speakers: M. Amon AUSTRIA F. Llovet-Osuna SPAIN T. Ferreira PORTUGAL A. Mularoni ITALY M. Kacerovsky CZECH REPUBLIC Sponsored by
Sponsored by
Moderator: Sponsored by
I. Stalmans BELGIUM
Sponsored by
Monday 24 September
Lunchtime Symposia Boxed Lunch Included
13.00 – 14.00 Achieving Precise Refractive Outcomes with Biotech Premium IOLs Moderator:
B. Toygar TURKEY
G. Auffarth GERMANY Evaluation of a new hydrophobic preloaded IOL S. Ganesh INDIA EYECRYL TRI – Actv IOLs: my experience
Moderators: F. Carones ITALY M. Teus SPAIN
Glaucoma Treatment: From Eye Drops to Surgical Intervention, When and What to do?
Evening Symposium 18.15 – 19.45
Streamlining Efficiency in Your Operating Room and Surgical Practice Moderator: M. Acebal SPAIN Sponsored by
A. Agca TURKEY Refractive & safety outcomes of EYECRYL PHAKIC & EYECRYL PHAKIC TORIC IOLs: my long-term experience S. Goel INDIA Next generation pre-loaded IOL system – Optiflex Genesis Comfort NY E. Otero COLOMBIA EYECRYL TORIC IOLs: pearls for success Sponsored by
36th Congress of the ESCRS 22–26 September 2018
Monday 24 September
Monday 24 September
Monday 24 September
Lunchtime Symposia
Lunchtime Symposia
Lunchtime Symposia
Boxed Lunch Included
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
13.00 – 14.00
Advancing Cataract Surgery with the Minimally Invasive Approach Leveraging Alcon Technologies Moderator
R. Ruiz Mesa SPAIN
Sponsored by
Innovative Solutions for Presbyopia and Refractive Errors Moderators: P. Stodulka CZECH REPUBLIC R. Shetty INDIA
The World’s First Sinusoidal Trifocal IOL, Acriva Trinova: A Novel Approach to Trifocal IOL Technology Moderator:
R. Bellucci ITALY
Sponsored by
Sponsored by
Shedding Light on the Management of DED Moderator
N. Maichuk RUSSIA
Challenging Conventional Wisdom in Anterior Surgery
Sponsored by
Moderator:
A New Perspective in Dry Eye Treatment: The Role of Coenzyme Q10 Moderator:
S. Ahmad UK
L. Baydoun GERMANY
S. Priglinger GERMANY EVA: how the latest innovations in phaco have improved my cataract surgery
J. Wolffsohn UK Corneal pain without stain: the role of symptom assessment
P. Rothschild FRANCE VisionBlue - all stains are not the same (Part 1): why performance matters!
R. Mencucci ITALY Corneal pain with stain: the pathological dry eye
S. Srinivasan UK VisionBlue - all stains are not the same (Part 2): why purity matters!
H. Dua UK Stain without corneal pain: the painless epithelial defect
L. Baydoun GERMANY DMEK - past to present: reviewing progress and results of a revolutionary technique
® ®
K. Gumus TURKEY CoQ10 panel: role of Coenzyme Q10 in supporting corneal healing & recovery Sponsored by the eye health company
Sponsored by
The Great Debate: Phaco Versus Manual Small Incision Non-Phaco Cataract Surgery in the Developing World Moderator:
R. Walters UK
R. Walters UK Introduction L. Benjamin UK The pros and cons of phaco G. Tabin USA The pros and cons of MSICS R. Walters UK Discussion Sponsored by
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EXPLORING VIENNA
VIENNA
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TO HEAR ...
VOICES FROM HISTORY An audible artwork echoes across Vienna’s Heldenplatz twice a day this year. Called ‘Voices’, it is a sober memorial of Hitler’s annexation of Austria, which was proclaimed from the balcony of the Hofburg Neue Burg wing 80 years ago. The artist is Susan Philipsz, a former Turner prize winner, whose installation was commissioned by the House of History (scheduled to open in November 2018). Ms Philipsz has said she wanted to recognise all those who disappeared after the Anschluss and that this sound – four notes achieved by rubbing a finger on water-filled glasses – most closely replicates that of human voices. ‘Voices’ can be heard for 10 minutes each day at 12:30 and at 18:30.
OPERA ONLINE Listen to the Vienna State Opera live streaming of selected performances via the internet on your computer or Smart TV and via Wiener Staatsoper Live App on your smartphone or tablet. The streamings are broadcast with a time-delay to suit local prime time. Choose between a full recording or a live edited version. Ondemand streams are also available and can be played back for one week. Find the programme at https://www.staatsoperlive. com/en/live/. Live streaming costs €14.00; On-demand stream: €5.00; Digital programme: €2.69.
SHEETS AHEAD OF OTHER MUSIC SHOPS Who’s that pianist? It could be you. If Vienna’s musical ambience makes you want to join in, head for Musikhaus Laimer’s music shop. A piano is available for customers who want to try out some new sheet music and there’s plenty to try out. This is one of the city’s largest music shops, with more than 400,000 titles in its database of books and sheet music. Laimer’s clientele includes many notable musical institutions and orchestras and its offerings encompass almost every musical genre. International shipping is available. Laimer’s is located near the House of Music, at Hegelgasse 7, 1010 Wien. http://www.musikhaus-laimer.at/. Open Monday-Friday, 09:30-18:00, Saturday 10:00-13:00, closed Sunday.
EUROTIMES | JULY/AUGUST 2018
Music in the air
Vienna has a soundtrack and culture all of its own. Maryalicia Post suggests ways to tune in
I
f you like music, you’ll love Vienna. With three opera houses and a constant schedule of musical performances, the city is a music lover’s home from home. In fact, it was once literally home to Schubert, Strauss and Shoenberg who were born here; it became home to Mozart, Beethoven, Haydn, Brahms and Mahler. Mozarthaus, the composer’s former residence at Domgasse 5, can be visited (http://mozarthausvienna.at), as can the newly opened museum in Beethoven’s house, Probusgasse 6 in Heiligenstadt. https://www.wienmuseum.at/en.html The famous Vienna State Opera offers more than 50 operas and ballet works on around 300 days per season. The repertoire ranges from the Baroque to the 21st Century. Audience members can individually switch on subtitles in a choice of languages. In April, May, June, September and December, more than 80 opera and ballet performances will be screened live on Herbert-von-Karajan-Platz in front of the opera building on a 50m² screen. Watch and listen free of charge. The world-famous Vienna Boys’ Choir appears regularly as part of the Vienna Hofmusikkapelle at the Holy Mass in the Hofburg Chapel on Sundays (September to June). Buy tickets online at http:// www.hofmusikkapelle.gv.at. They also appear at the MuTh, their new concert hall in the Augarten, which opened in 2012. (MuTh is an abbreviation of
“Music and Theatre”.) The MuTh is located right next to the Augartenpalais, where the Vienna Boys learn, live and sing. www.muth.at If you would like to wield the baton yourself, head for the House of Music where you can ‘virtually’ conduct the Vienna Philharmonic and capture your personal version of ‘A Little Night Music’ on CD. The building’s seven floors house astounding sound technologies plus mini museums dedicated to great Austrian composers.
Glimpse of Vindobona
EXPLORING VIENNA
Hofburg Palace
You won’t be in Vienna’s inner city long before you’re approached by someone dressed in 18th-Century costume selling tickets to a concert in the Hofburg Palace. Touristic? Yes. A fun evening? Yes. It’s a light-hearted concert including the most popular waltz and operetta pieces by Johann Strauss as well as opera arias and duets by Wolfgang Amadeus Mozart. Concerts begin at 8.30pm. ‘Traditional wine tavern music’ comes with your dinner at the Zwoelf Apostelkeller, an inner-city restaurant with a rustic air. A likeable pair of musicians – violinist and accordionist – stroll the vaulted 600-year-old rooms of this cellar, perhaps playing at your table. You won’t be the only tourist, but chances are you’ll enjoy it anyway. Open daily. https://www. zwoelf-apostelkeller.at/index_en.html For an overview of what’s on in ballet, opera and classical music, and for tickets online, have a look at https://www. vienna-concert.com/ In 1784, Emperor Joseph II issued a decree allowing vintners to sell their newly fermented wine without tax and directly to the customer. An evergreen bough, a buschen, hanging outside the gate would signal that the wine was ready. Eventually the vintners began providing wooden tables under the arbours for their guests and setting out a variety of snacks to go with the wine. The rustic wine tavern that evolved from this is called a ‘heuriger’, meaning ‘this year’s’, referring to the young wine. Vienna is said to be the home of the heuriger and from there the concept spread across Austria. A 15-minute taxi journey from Reed conference centre brings you to Mayer am Pfarrplatz, a typical heuriger (and Vienna’s smallest vineyard). They mainly produce Gemischter Satz, a blended wine from two or more different grape varieties
grown in the same vineyard and vinified together. This wine has gained DAC status. Other white varieties are Grüner Veltliner, Weissburgunder and Rheinriesling. Red wines to try are Blauer Zweigelt, Blauburgunder and Cabernet Sauvignon. Enjoy a relaxed meal or a simple snack with your wine. Towards the rear of the garden is the entrance to a newly opened museum, the little house where Beethoven lived and worked in 1817 and where he created his Symphony No. 9. For details of the heuriger and of the Beethoven Museum visit: www.http://www.pfarrplatz.at/en/ In the First Century AD, the Roman legion set up a military encampment in Vindobona, their name for Vienna. As wine was included in the legionnaire’s rations, an already flourishing wine culture was not the least of the area’s attractions. Under Emperor Probus the Celtic wine was improved with Italian grafted grapevines. For 350 years Roman soldiers were stationed here, protecting the northern border of the Roman Empire. At one time the population rose to 30,000. An excavation in front of the Hofburg Palace on Michaelerplatz reveals traces of Vindobona. You peer down at a Roman road junction and foundations of houses dating from between the 1st and 5th century AD. The famed Spanish Horses enjoy one of the world’s most prestigious homes in a wing of the Hofburg Palace. Part of Vienna’s culture since 1565, this traditional riding school for Lipizzan horses invites the public to watch morning training Tuesday-Friday mornings (free with Vienna Pass). A new series of occasional exhibition evenings, A Tribute to Vienna, presents the Ballet of the White Stallions alternating with musical performances by the Vienna Boys’ Choir. One of two September Tribute performances is scheduled for Friday, 21 September, the evening before the ESCRS Congress opens in Vienna. For further information about all Spanish Riding School performances: www.srs.at
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TAKE THE FLOOR Every year, at more than 450 balls, Viennese young and old will spin to the strains of a waltz. Many will have learned or honed their skills at Elmayer, an institution that has flourished since the turn of the last century. If you have a partner and are free on a Saturday from 16.00-17.00, drop in to one of the open sessions/lectures given in English. The cost is €50 per couple and there’s no need to register. Otherwise arrange a one hour-long private lesson; come as part of a couple or dance with an Elmayer teacher at a time to suit you. (In either case bring leather-soled shoes) www.elmayer.at
TAKE A TRAIN For an amusing tour of Vienna’s wine-growing villages, try a ride on a Lilliput train. Heurigen Express One starts in Nussdorf and travels through the Vienna woods, passes elegant villas and ancient wine houses. Train Two starts in Strebersdorf, taking a circular route through Strebersdorf and Stammersdorf with stops at wine taverns in the area. Trains operate April 1 to October 31; Train One leaves every Friday, Saturday, Sunday and holidays from Nussdorf from 12:00 to 18:00 on the hour. Train Two trundles off on Saturdays, Sundays and holidays from Strebersdorf at 14:00 to 20:00 on the hour. Round trip €9.90, one way €5. Tickets on the train. www.liliputbahn.com
TAKE A TOUR Fans of the film classic The Third Man have a choice of two tours: Third Man Walk – In the Footsteps of a Film Classic, an above-ground walking tour covering locations in the city, and a separate tour of the sewer system where some the most iconic scenes were shot: www.drittemanntour.at. Film fanatics will enjoy the Third Man Museum; from September 1, 2018 this small private museum offers a fascinating exhibition on the making of the film, which captured Vienna’s situation after the war and made the city a “movie star”. 3mpc.net
At the Heuriger
EUROTIMES | JULY/AUGUST 2018
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ESCRS VIENNA PREVIEW
An instructive journey The Young Ophthalmologists Programme at the ESCRS Congress in Vienna promises lively interaction and discussion
“
E
ver tried. Ever failed. No matter. Try again. Fail again. Fail better.” – Samuel Beckett, Worstword Ho, 1983
These words from the great Irish writer Samuel Beckett allude to the narrow line between failure and success. As with all of Beckett’s words, they are open to interpretation, but it is undoubtedly the case that we can sometimes learn more from our mistakes than our successes. That is why the Young Ophthalmologists Programme (YOP) day-long session devoted to the topic “Starting Phaco” will be one of the highlights of the 36th Congress of the ESCRS in Vienna, Austria. The session, which takes place on Saturday 22 September from 08.30 to 16.00, will be chaired by Oliver Findl, Simonetta Morselli and Kaarina Vannas, and will take young ophthalmologists on an instructive journey through the various key stages of phacoemulsification, from incisions through to hydro-dissection, fragmentation and IOL implantation, as well as discussing complications and difficult cases.
INTERACTION AND PARTICIPATION One of the reasons why the YO Programme has proven to be so successful is that the emphasis is placed firmly on interaction and participation rather than passive learning, with the young ophthalmologists providing the backbone of the session in the form of video cases they submit illustrating problems encountered or mistakes made in the course of their own first steps into cataract surgery. “We call the video presentation section ‘Learning from the Learners’, which nicely sums up what we are trying to
Some of the delegates and presenters who attended the Young Ophthalmologists Programme session during last year’s Congress in Lisbon
do. We are very grateful to the young ophthalmologists who submit their videos for scrutiny as it’s a very brave thing to do, highlighting one’s errors for the benefit of discussion and helping others overcome similar situations that might crop up in their own surgeries,” said Oliver Findl, Chairperson of the YOP. The format of the session, in which a didactic lecture by an experienced surgeon is followed by video cases presented by young ophthalmologists, lends itself to interaction and discussion,” said Dr Findl. “Everybody can take something home, because these are the type of experiences that we all have as surgeons, particularly
Everybody can take something home, because these are the type of experiences that we all have as surgeons, particularly when we are starting out in our surgical careers Oliver Findl EUROTIMES | JULY/AUGUST 2018
when we are starting out in our surgical careers.” he said. One of the key messages that the YO Committee tries to emphasise is that there are not always right and wrong answers when dealing with difficult surgical situations. “We have an experienced panel of surgeons, and one of the things that has emerged frequently at our previous sessions is that there are several ways of dealing with a complication or an issue that arises during surgery,” he said. On Sunday 24 September, the Young Ophthalmologists Session will discuss targeting emmetropia in cataract surgery. This session will explore a range of topics including ‘What is emmetropia?’, ‘Let’s measure the eye’, ‘Formulas to be applied’, ‘Choosing the best IOL for each patient’ and ‘Things that you need to consider during and after surgery’. “We are very much looking forward to this year’s ESCRS Congress and I look forward to meeting and talking to the young ophthalmologists who continue to make a huge contribution to our society,” said Dr Findl.
RETINA
Stem cell implant study Human stem-cell-derived RPE transplants show good safety with hints of functional improvement. Sean Henahan reports
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arly analysis from a study of human embryonic stem cell (hESC)-derived retinal pigmented epithelium (RPE) implantation suggests the procedure is well tolerated in patients with dry AMD, with some indication of structural retinal improvement, according to Eyal Banin MD, PhD, HadassahHebrew University Medical Center, Jerusalem, Israel. Dr Banin’s group, in collaboration with Dr Benjamin Reubinoff from Hadassah, developed a xeno-free, directed differentiation protocol for derivation of RPE cells from hESCs in-vitro. The proprietary product, called OpRegen, was further developed and carried through the translational phases by CellCure, Ltd., (a subsidiary of BioTime, Inc.) and is now being tested in an FDA-approved Phase I/ IIa clinical trial in Israel and in the USA (NCT02286089). Dr Banin presented information from the first nine patients with advanced dry AMD and geographic atrophy (GA) who received a subretinal injection of Opregen cells in suspension at the Association for Research in Vision and Ophthalmology 2018 Annual Meeting, in Honolulu, Hawaii. All patients had dry AMD with geographic atrophy and best-corrected acuity of worse than 20/200 at the time of enrolment. Patients received from 50k to 200k cells delivered in a balanced saline suspension. The cells were delivered by subretinal injection following conventional 23- or 25-gauge vitrectomy. Patients received systemic immunosuppression one week prior to treatment until up to one year after. The procedure appears to have been well tolerated, with no serious systemic treatment-related adverse effects noted. With up to two years of follow-up, bestcorrected acuity has remained stable in treated eyes. Best-corrected acuity has also remained stable in untreated eyes. Improvement noted in one treated eye could probably be attributed to clearing of the vitreous and posterior capsule opacity during surgery, Dr Banin noted.
IMAGING STUDIES The researchers performed retinal function and structure assessment throughout the study. In addition to best-corrected acuity they used colour fundus photography, optical
With up to two years of follow-up, best-corrected acuity has remained stable in treated eyes. Best-corrected acuity has also remained stable in untreated eyes Eyal Banin MD, PhD coherence tomography (OCT) and fundus autofluorescence imaging techniques. Imaging studies showed the creation of subretinal blebs during surgery followed by absorption of the subretinal fluid within 48 hours and healing of the injection site within a few weeks. Imaging also showed signs of subretinal pigmentation in the treated areas accompanied by hypo- and hyperfluorescent spots on fundus autofluorescence imaging that developed over the first one-to-three months postoperatively. Particularly interesting was the appearance of irregular subretinal hyperfluorescence on OCT imaging of treated areas, and taken together, the imaging results suggest potential engraftment of the transplanted cells. These findings persisted throughout follow-up for up to two years in the firsttreated patients, although slow loss of cells could be occurring.
STRUCTURAL IMPROVEMENT In a few patients, there were signs of altered or reduced drusen in the treated areas, and possible restoration of the RPE layer. Potential structural improvement was seen in the photoreceptor layer and ellipsoid zone where the cells were injected. Surgery-related adverse events included conjunctival haemorrhage, worsening of cataract and epiretinal membrane formation. Seven of nine patients developed new or worsening epiretinal membranes. Four of these were considered to be mild, and three were more advanced. None of these cases required intervention. Some of these cases may have been associated with incomplete vitrectomy or efflux of RPE cells, he noted. No unexpected ocular adverse events occurred. The phase I/II study is ongoing. A new cohort will involve 12 patients with less advanced disease (visual acuity of 20/100 or worse), and smaller areas of geographic atrophy.
OpRegen cells are created using a proprietary process that drives the differentiation of human pluripotent stem cells to generate high-purity RPE cells (Idelson et al., Cell Stem Cell, 2009 2;5(4):396-408). The cells generated with the system are ‘xeno free’, are derived from an NIHapproved hESC line produced under GMP conditions and underwent extensive safety testing prior to being approved by the US FDA for the current clinical trial. Prior to testing the stem cell-derived RPE cells in humans, researchers conducted animal studies. Upon being injected in rats, the RPE cells formed monolayers, polarised and began to function. Both structural and functional improvements were observed (McGill et al., Transl Vis Sci Technol;6(3):17). The current study also compared findings observed in pig eyes and human study participants. In vivo OCT studies conducted following transplantation showed similar findings in the form of irregular subretinal hyper-reflectance in the area of transplantation. In the pig eyes, following enucleation, subretinal layering of the human hESCRPE transplanted cells was evident and proven by immunohistochemical staining using a human-specific marker. The researchers thus believe that the hyperreflectance on OCT also seen in the human patients correlates with the presence of the transplanted cells. More than a dozen research groups around the world are working on other approaches to stem cell-based RPE cell transplantation for dry AMD. One group recently reported promising phase I results with a clinical-grade retinal implant made of hESC-derived RPE grown on a synthetic substrate. The implants were well tolerated and one patient showed improvement in visual function (AH Kashani, Science Translational Medicine, Vol. 10, Issue 435, eaao4097). EUROTIMES | JULY/AUGUST 2018
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RETINA
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Extreme vision loss Undetected toxic batches of PFO and related products cause extreme vision loss. Roibeard Ó hÉineacháin reports
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Courtesy of Dr Miguel Serrano. Hospital Universitario. Canary Islands, Spain
he current EU and International Standards Organisation’s (ISO) approved procedures for determining the safety of medical devices used for vitreoretinal surgery may need to be re-evaluated, according to J Carlos Pastor MD, PhD, IOBA (Eye Institute), University of Valladolid, Valladolid, Spain. “Perfluoro-octane has been used for many years, with an apparent safety. But cases of acute toxicity related to three different products have been reported in 2013, 2015 and 2016. We do not know the exact reasons, but what is important is that the final and finished product is completely safe and that is achieved by performing appropriate cytotoxicity tests,” Dr Pastor told EuroTimes in an interview. The cases included seven in Chile and four patients in Spain who underwent surgery with the PFO product, Meroctane (Meran), produced in Turkey, and 117 cases in Spain following surgery with AlaOcta PFO (Alamedics), produced in Germany. There were a further four cases with patients who underwent surgery with Bio Octane Plus – a mixture of 90% PFO and 10% perfluorohexyloctane produced in India – as an endotamponade (Pastor, J. C. et al., Retina. 2017 Jun;37(6):1140-1151). Toxicities varied between patients but were commonly characterised by low visual acuity the day after surgery, optic nerve atrophy and acute retinal necrosis, sometimes leading to retinal holes and relapse of retinal detachments, and retinal vascular occlusion. In the cases involving AlaOcta and Bio Octane plus, Dr Pastor and his associates were able to identify the cause in the majority of
cases as the presence of contaminants in the PFO preparations. The toxicity of the products was not detectable by the indirect testing approved by ISO International Standards, but was detectable by a direct testing means developed at the IOBA institute. With the cases involving a contaminated batch of Meroctane, the investigations carried out by another group were unable to identify the cause of the problem, and did not review cytotoxicity testing.
DIRECT TESTING vs INDIRECT TESTING
Dr Pastor noted that the independent testing facility that originally tested the contaminated AlaOcta batches used a technique in which cell cultures are placed in contact only with culture media extracts from PFO, an approach currently deemed acceptable by the ISO. But PFO is not directly tested since its toxic derivatives are immiscible in water and therefore also in culture media. The contaminated batch of Bio Octane Plus was tested using an agarose overlay method, in accord with ISO 10993 protocols. “Both tests were indirect and both tests complied with the ISO norms, but it is obvious that they were unable to detect the toxic batches,” Dr Pastor said. The IOBA group therefore has developed a direct contact method, using cultures of retinal cells of human origin (ARPE-19), which is capable of detecting toxic lots that current standard testing procedures might miss. Using this method, they were able to identify toxic batches in which chemical analysis revealed the presence of two hydroxyl compounds, an acid and an alcohol, and benzene derivatives as the cause of acute toxicity in the case of the contaminated batches of AlaOcta (Retina 2017; 37:1140-1151). In the contaminated Bio Octane Plus batches, bromotributyl stannane was present at levels several-fold higher than is necessary to induce severe retinal toxicity. Yet to be determined are the how the toxic agents came to be in the PFO products. “Information coming from the companies is very limited. Alamedics One month after surgery in a non-complicated retinal detachment. There is complete optic nerve atrophy and areas of retinal and choroidal atrophy covering the posterior pole
EUROTIMES | JULY/AUGUST 2018
Non-complicated retinal detachment, 10 days after surgery. Almost 50% of the vitreous cavity still filled with gas. Retinal tissue appears whitish and some haemorrhages cover the posterior pole. Patient is in amaurosis since the day of surgery
went bankrupt and has disappeared. We have tried to contact Biotech Vision Care, but they have not responded yet. We have identified the toxic substances but because we do not have information on the manufacturing process we are not sure where the primary problem is located,” Dr Pastor noted. At present, the IOBA team is collaborating with the European Health Authorities through the Spanish Agency of Medicine and Medical Devices (AEMPS) to introduce modifications in the ISO norms regarding the cytotoxic tests, to promote the use of direct testing methods and eliminate the use of indirect testing methods. “Unless this change is achieved, and implemented, companies cannot be sure what they will have to do in the area of safety.” Dr Pastor said. The safety of PFO will also be the topic of a working group meeting during the EURETINA congress in Vienna, said Sebastian Wolf MD, Bern University Eye Clinic “This was not only a Spanish problem. There have been cases reported in Switzerland and Germany using the PFO from the same company. An independent working group meeting during EURETINA will discuss how testing of these substances can be improved. This group is an interest group independent from EURETINA, but we support them. “Currently, it is quite easy to obtain CE mark for these substances, probably too easy. I think there is now a new European regulation for all medical devices (like PFO). These may prevent such toxicity problems in the future, but we have to examine the toxicity test on an expert panel. I think it would be very helpful to have a registry like the EUREQUO for reporting such problem,” Dr Wolf told EuroTimes. J Carlos Pastor: pastor@ioba.med.uva.es Sebastian Wolf: Sebastian.Wolf@insel.ch
RETINA
New treatments for uveitis arsenal Biologic response modifiers offer new options for third-line treatment. Dermot McGrath reports
A
growing array of ‘biologics’ offers uveitis specialists potent new weapons in their therapeutic arsenal that may potentially benefit some patients with refractory non-infectious posterior uveitis, according to Emmett T. Cunningham MD, PhD. “While corticosteroids remain the mainstay of therapy, followed by non-corticosteroid immunosuppressive agents such as methotrexate and azathioprine, there is an interesting list of potent third-line treatments that may prove useful when conventional therapies have failed or been poorly tolerated,” Dr Cunningham told delegates attending the 8th EURETINA Winter Meeting in Budapest. Although corticosteroids are inexpensive, fast acting, potent and flexible, they are often used “for too little and too long”, said Dr Cunningham. “They are used too little because people are afraid to use them and they don't want to use high doses. And they are used for too long because patients are frequently undertreated and so have to stay on the medications, which can lead to a long list of complications associated with their long-term use,” he said. Although originally developed to treat systemic inflammatory diseases such as Behçet’s disease, juvenile idiopathic arthritis (JIA), ankylosing spondylitis and similar diseases, biologic response modifiers, or biologics for short, have been increasingly used off label for the treatment of noninfectious uveitis and other ocular inflammatory diseases, said Dr Cunningham. He noted that the most commonly studied systemic biologics for uveitis to date are tumour necrosis factor (TNF)-α inhibitors, primarily infliximab and adalimumab.
SECOND AGENT “Infliximab led the vanguard of this approach to treatment and was first approved 20 years ago for rheumatoid arthritis. It is typically a 4-to-6mg/kg dose given intravenously for about two or three hours, so not very convenient for the patient. The fact that the antibody has murine components also means that it must be given concomitantly with a second agent such as methotrexate to prevent host rejection,” he said. Adalimumab is a fully human monoclonal antibody against TNF-α, approved for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and other indications. “It is administered as a subcutaneous injection, first with a loading dose of 80mg, which is then halved every other week, so it is much more convenient than an intravenous infusion. It is the only systemic non-corticosteroid agent that has been approved by the US Food and Drug Administration (FDA) for the treatment of non-infectious uveitis, which was a big hurdle to cross,” he said. Biologics may potentially be used as first-line treatments for uveitis related to Behçet’s disease and JIA, said Dr Cunningham. They are not recommended for the treatment of infectious uveitis, and their use may also initiate or worsen demyelinating disease, he concluded. EUROTIMES | JULY/AUGUST 2018
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Thursday 20 September
Friday 21 September
Lunchtime Symposia
Morning Symposia
Boxed Lunch Included
10.00 – 11.00
13.00 – 14.00 Clinical Advances and Applications with Swept Source OCT & Angiography
Thursday 20 September Lunchtime Symposia Boxed Lunch Included
13.00 – 14.00 Allergan Satellite Meeting Sponsored by
Moderator: J.M. Ruiz-Moreno SPAIN J.M. Ruiz-Moreno SPAIN SS OCT Angio in the diagnostic of pre-oftalmoscopic diabetic retinopathy C. Hoyng THE NETHERLANDS Vascular flow changes in macular telangiectasia type 2 in OCT-A L. Pierro ITALY OCT-A in optic nerve pathology P. Keane UK SS OCT Angio in proliferative diabetic retinopathy
Photobiomodulation: An Innovative, Mitochondria-targeted Therapy for Dry AMD and Other Ocular Diseases Moderators: J. Eells USA M. Munk SWITZERLAND J. Eells USA Overview of the mechanism and application of PBM in retinal disease K. Valter AUSTRALIA From bench to bedside – PBM in preclinical studies S. Markowitz CANADA LIGHTSITE I Clinical analysis of the safety and efficacy of photobiomodulation in subjects with dry age-related macular degeneration M. Munk SWITZERLAND Morphological analysis: evaluating the impact of photobiomodulation using multimodal imaging description Sponsored by
Friday 21 September Morning Symposia 10.00 – 11.00 The OCTA Trinity GERMANY
K. Bailey Freund USA Dense B-Scan OCTA in AMD D. Pauleikhoff GERMANY OCTA in AMD A. Pollreisz AUSTRIA OCTA in Vascular Diseases Sponsored by
Moderator: P. Lanzetta
ITALY
Welcome and introductions Proactive dosing with aflibercept T&E with aflibercept: updates from ALTAIR T&E with aflibercept: updates from ARIES Staying ahead of retinal disease: the importance of a proactive approach Summary Sponsored by
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Moderator: D. Pauleikhoff
Proactive Dosing for Effective Patient Management: What do the Latest Data Show?
Seeing the Future: Gene Therapy for Inherited Retinal Disease Moderators: B. Leroy BELGIUM C. Fasser SWITZERLAND C. Fasser SWITZERLAND, B. Leroy BELGIUM Welcome and introduction D. Fischer GERMANY Understanding inherited retinal diseases from a clinician and patient perspective To Be Confirmed The importance of genotyping: who, how and why? B. Leroy BELGIUM Great expectations: exploring recent innovations in gene therapy Q&A Sponsored by
Friday 21 September
Friday 21 September
Lunchtime Symposia
Lunchtime Symposia
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
Ranibizumab – New Evidence; New Insights: Partnering for Better Patient Outcomes
200 Ultra-Widefield Retinal Imaging: Clinical Advances And Emerging Applications
Moderator: N. Eter GERMANY
Moderator: L. Aiello USA
N. Eter GERMANY Welcome
Speakers: L. Aiello USA S. Sadda USA T. Peto UK R. Tadayoni FRANCE
N. Eter GERMANY Ranibizumab in retinal diseases: Looking beyond the decade R. Tadayoni FRANCE Clinical cases: the experts’ viewpoint - clinical case I P. Schlottmann ARGENTINA Clinical cases: the experts’ viewpoint - clinical case II A. Koh SINGAPORE Clinical cases: the experts’ viewpoint - clinical case III Panel discussion Sponsored by
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Moderator: N. Bressler USA
VIENNA 2018
Saturday 22 September Morning Symposia 10.00 – 11.00 Alcon Satellite Meeting Sponsored by
Retinal Wide-field & Multimodal Imaging Moderator: U. Schmidt-Erfurth AUSTRIA Speakers: U. Schmidt-Erfurth AUSTRIA S. Sadda USA R. Abreu Gonzalez SPAIN Sponsored by
Illuminating the Future of DME Management
18th EURETINA Congress 20 – 23 September
Lessons Learned from the Real World: Improving Patient Care Moderator: J-F. Korobelnik FRANCE Welcome and introductions
Allergan Satellite Meeting Sponsored by
Changing the Course: Disease Modification with Intensive Early Treatment for DME Moderator: I. Pearce UK Welcome and introductions Improving quality of life with diabetes: striving for excellent vision
N. Bressler USA Opening remarks
RWE: evolution of a key information source
R. Tadayoni FRANCE Approaches to managing the unmet needs in DME
Focus on aflibercept: the latest evidence from clinical practice
Delve into the design: the multitargeted MoA of aflibercept
Consider the clinic: improving practice with RWE
Examine the evidence: aflibercept in DME
Summary Sponsored by
Choice of anti-VEGF and treatment regimen: clinically relevant insights from the DRCR Network
Alimera Satellite Meeting
Summary and questions
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A. Loewenstein ISRAEL Molecular mediators in the pathophysiology of DME P. Dugel USA Broadening the DME treatment landscape: novel therapeutic approaches on the horizon Panel discussion Sponsored by Roche
18th EURETINA Congress 20 – 23 September
VIENNA 2018 Saturday 22 September
Saturday 22 September
Saturday 22 September
Morning Symposia
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Lunchtime Symposia
10.00 – 11.00
Boxed Lunch Included
Boxed Lunch Included
13.00 – 14.00
13.00 – 14.00
SubLiminal Laser Therapy: When Subthreshold Laser Yields Good Macular Outcomes Moderator: V. Chong UK V. Chong UK SubLiminal laser in macular diseases
Innovations to Inspire New Surgical Techniques Moderator: J. van Meurs THE NETHERLANDS M. Romano ITALY Fluid dynamics with a hypersonic probe: balance between acceleration and flow
S. Younis UK Efficacy of SubLiminal laser in IPCV aflibercept resistant cases
Y. Le Mer FRANCE Vitreous removal with Stellaris Elite: from cutting to liquefaction
A. Filloy SPAIN Our first year of lessons learnt with SubLiminal laser for DME and CSC
F. Fayyad JORDAN Management of complex cases using a complete 27 gauge portfolio
L. XiaoLing CHINA Conventional threshold laser vs SubLiminal laser in CSC
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Advancing Therapy for nAMD Moderator: U. Schmidt-Erfurth AUSTRIA U. Schmidt-Erfurth AUSTRIA Welcome and introduction A. Loewenstein ISRAEL nAMD: challenges and opportunities for disease management F. Holz GERMANY Therapeutic innovations for nAMD P. Dugel USA Advanced clinical development programs for nAMD: new potential for disease control Panel discussion and Q&A Sponsored by
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Saturday 22 September Lunchtime Symposia Boxed Lunch Included
13.00 – 14.00 2RT for Early AMD: The Role of Nanosecond Laser Therapy
How can Innovation Deliver Real Benefits to Improve VR Surgery?
ZEISS Satellite Meeting
Moderator: P. Stalmans BELGIUM
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J. Fortun USA How more options in fluidics can benefit complex cases
Breaking News in Retina
M. Romano ITALY Why surgical liquids purity matters?
Moderator: U. Chakravarthy UK
P. Stalmans BELGIUM How my preferred VR system just got better!
Speakers: R. Guymer AUSTRALIA J. Marshall UK R. Finger GERMANY
R. Avci TURKEY Why instrument innovations give more options for my complex VR surgery
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A. Minnella ITALY How to identify patients at risk of retina in routine clinical pratice? A. Garcia Layana SPAIN New trends in retina prevention T. Aslam UK Patient well-being in retina F. Bandello ITALY To be confirmed Sponsored by
RETINA
SEBASTIAN WOLF Editor of Ophthalmologica
OPHTHALMOLOGICA VOLUME 240 ISSUE 1
VITRECTOMY SUCCESSFUL IN CASES WHERE VITREOLYSIS FAILS Vitrectomy with internal limiting membrane peeling leads to closure of macular holes even in cases of prior failure to close them by injection of the vitreolytic agent, ocriplasmin, new research suggests. In a retrospective case series study involving three eyes of three consecutive patients who had enlargement of macular holes following ocriplasmin intravitreal injection, the performance of vitrectomy, internal limiting membrane peeling and gas injection a few months later resulted in closure of the macular holes in all eyes. In addition, visual acuity ranged from 20/80 to 20/40 before ocriplasmin injection and from 20/32 to 20/25 18 months after vitrectomy. A Benarous et al, “Long-Term Results of Vitrectomy for Macular Holes after Failure of Vitreolysis”, Ophthalmologica 2018, volume 240, issue 1.
EYES WITH DRY AMD BENEFIT FROM SILDENAFIL Treatment with the phosphodiesterase inhibitor, sildenafil, offers significant potential to patients for vision retention following macular degeneration, a new report suggests. In a study involving four patients with macular changes associated with age-related macular degeneration, such as soft and hard and acquired vitelliform lesions in the fovea, and a patient with Best vitelliform macular dystrophy disease, all eyes appeared to benefit from PDE6. In addition, the patient with Best disease had a significant improvement in vision as well as in photoreceptor and ellipsoid layers. DJ Coleman, “Treatment of Macular Degeneration with Sildenafil: Results of a Two-Year Trial”, Ophthalmologica 2018, volume 240, issue 1.
ask the experts As part of our ongoing service to our readers, we are introducing a new feature to EuroTimes, the official news magazine of the ESCRS. 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 be sent to our Medical Editors and International Editorial Board. We will publish a selection of their answers in the magazine.
MONTHLY ANTI-VEGF DOSING BETTER FOR NEOVASCULAR AMD WITHOUT PVD In eyes with neovascular age-related macular degeneration but lacking a posterior vitreous detachment (PVD), pro-re-nata (PRN) anti-VEGF regimens appear to be less effective than monthly dosing, a new study suggests. A retrospective sub-analysis of 64 eyes from 64 neovascular patients from two prospective clinical trials showed that eyes without PVD gained a mean of only 0.3 letters, compared to 9.2 letters among those with PVD. The difference between PVD and non-PVD groups was highly significant (p = 0.003). among those treated on a PRN basis, which had a mean loss of five letters and a mean gain of 11.9 letters, respectively. However, there was no significant difference in letters gained or lost between the PVD and non-PVD groups who received monthly dosing, with respective mean gains of 4.3 letters and 7.8 letters (p = 0.424). P Gil et al “Influence of the Vitreoretinal Interface on the Treatment with Anti-VEGF for Exudative Age-Related Macular Degeneration”, Ophthalmologica 2018, volume 240, issue 1. Ophthalmologica is the peer-reviewed journal of EURETINA
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EURETINA is delighted to announce the
7th Retina Race at the 18th EURETINA Congress in Vienna
Date: Saturday 22 September 2018, 6.30am Registration Fee: Ă?40 in aid of Orbis
Information at www.euretina.org
RETINA
Retinal detachment
SURGERY
Databases highlight risk factors for failure in detachment surgery. Dermot McGrath reports
I
nformation mined from the EURETINA and the British and Eire Association of Vitreoretinal Surgeons (BEAVRS) retinal detachment (RD) databases is enabling vitreoretinal surgeons to identify and quantify with much greater precision the potential risk factors for failure in RD surgery, according to David Yorston MBChB. “So far, we have over 6,000 retinal detachments in the database, of which the great majority have been entered by surgeons from the UK. It costs virtually nothing to accumulate a large amount of data, and we have shown the proof of principle that online data collection in a collaborative way is feasible and relatively simple,” Dr Yorston told delegates attending the 8th EURETINA Winter Meeting in Budapest. Dr Yorston, Consultant Ophthalmologist at Tennent Institute of Ophthalmology, Gartnavel Hospital, Glasgow, UK, presented data based on 4,400 RDs entered before 1 February 2017 by BEAVRS members. The data showed that the peak incidence of RD is in the seventh decade, with right eyes affected more than left. A majority, 63%, were males. Some 80% of the RDs were due to a horseshoe tear followed by round holes and retinal dialyses. The great majority of detachments were treated with 23-gauge vitrectomy, and just 10% with scleral buckle, said Dr Yorston. To focus on the adjusted failure rates, scleral buckle surgeries were excluded and only patients who were treated with a primary vitrectomy were included. This left slightly less than 4,000 eyes, with a failure rate of just over 13% and a follow-up of 91%. Risk factors for failure included inferior breaks, grade-B or -C proliferative vitreoretinopathy, total detachments and schisis RD. “We all know that the greater the extent of the RD, the more likely the chance of experiencing a primary anatomical failure. But perhaps what we did not realise was the extent to which the risk increases going from 11 o’clock hours to 12 o’clock hours.
So far, we have over 6,000 retinal detachments in the database, of which the great majority have been entered by surgeons from the UK. It costs virtually nothing to accumulate a large amount of data
The risk doubles, so something more is happening with total retinal detachments,” said Dr Yorston. While inferior breaks were also shown to be a risk factor for failure, the progression was not linear. “There was no increase in risk between breaks at 12 o’clock to 3 o’clock, it increased slightly at 4 o’clock and then doubles from 5 to 6 o’clock,” he said. Summing up, Dr Yorston said that the greater the extent of the detachment, the greater the risk of failure, and that the risk increases dramatically with a total detachment. Patients with inferior breaks have a worse prognosis and the risk increases significantly with a break near 6 o’clock. “I believe that this is also the first study to report that endolaser may be associated with a greater risk of failure than cryotherapy, and because this takes account of case complexity it is not just because these are the more complex detachments,” he concluded.
International Annual Course and Workshop
Diagnostic Ultrasound October 8 – 11, 2018 University Eye Clinic Mathildenstrasse 8 Munich, Germany
B-scan | Standardized A-scan | UBM
www.echography.com
David Yorston MBChB EUROTIMES | JULY/AUGUST 2018
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18TH
VIENNA
EURETINA
CONGRESS
2018
20-23 SEPTEMBER
Keynote Lectures
EURETINA Lecture
Kreissig Lecture
Tackling the Global Burden of Diabetic Retinopathy: From Epidemiology to Artificial Intelligence
Diabetic Retinopathy: A Neuroinflammatory Disorder?
Antonia Joussen GERMANY
Tien Wong SINGAPORE
Richard Lecture Physics of Internal and External Tamponade
David Wong UK
Full Programme Available on our Newly Designed Website
www.euretina.org
GLAUCOMA
What is best laser for glaucoma? Is there still a role for diode lasers, or should micropulse lasers take their place? Howard Larkin reports
D
ue to its high absorption by melanin in the target tissues of the ciliary bodies, diode 810nm lasers made transscleral cyclophotocoagulation (TSCPC) less destructive than earlier lasers for treating glaucoma. Now micropulse laser technology may improve safety even more. Still, there may yet be a role for traditional diode lasers, according to presenters at the American Society for Cataract and Refractive Surgeons Glaucoma Day 2018 in Washington DC, USA. Arguing for continued use of diode lasers, Jeffrey Kammer MD, of Vanderbilt Eye Institute, Nashville, Tennessee, USA, noted that the technology reliably reduces IOP and has a safety profile comparable to the gold standard procedures trabeculectomy and tube shunts. He said that concerns over drastic complications, especially phthisis, are overstated.
NO PHTHISIS Dr Kammer referenced a prospective study involving 66 patients with neovascular glaucoma comparing diode TSCPC with the Ahmed shunt. Mean IOP was reduced 57% in the diode group compared with 48% in the shunt group. No phthisis cases occurred in the diode group and two in the shunt group (Yildirim, J Glaucoma, 2009). “Even in the worst of the worst glaucoma, phthisis was not an issue,” Dr Kammer said. Other studies have shown diode TSCPC is safe in eyes with good vision, defined as 20/60 or better (Rotchford AP et al. Br J Ophthalmol 2010.), and even as a primary treatment, achieving visual acuity and IOP-lowering results comparable to medications in a contralateral eye study (Egbert PE et al. Arch Ophthalmol 2001). Robert Noecker MD of Yale University and Quinnipiac University responded that micropulse laser technology is a better alternative because it is less likely to burn tissue. “Diode might be okay for end-stage cases, but generally we want to ‘first do no harm’.”
REDUCING HEAT BUILD-UP Micropulse lasers reduce IOP as much as diode lasers, with better success after 18 months, Dr Noecker said (Tan A et al. Clin Experiment Ophthalmol 2010;38(3):266-72). And rather than using a continuous burst of energy as does a traditional diode laser, micropulse technology pulses the laser, reducing heat build-up. According to a study at the National University Hospital in Singapore, diode laser tip temperature exceeds 550 degrees C, whereas micropulse laser tips peak at 35 degrees C. This can cause burns, which lead to coagulative necrosis, which continues to progress indefinitely. The result is unstable IOP reduction, hypotony and even phthisis – which does happen, Dr Noecker said. “You don’t want something you can’t reverse from overtreatment, and that is really the true problem with traditional transscleral.”
ESCRS
Glaucoma Day 2018 Friday 21 September Reed Messe, Vienna, Austria
Programme, Registration & Hotel Bookings glaucomaday.escrs.org
Robert Noecker: noeckerrj@gmail.com Jeffery Kammer: jeffrey.kammer@vanderbilt.edu EUROTIMES | JULY/AUGUST 2018
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GLAUCOMA
Prevalence of dry eye with glaucoma Survey examines link between ocular surface disease and topical regimens. Roibeard Ó hÉineacháin reports
T
he Fast Assessment of Ocular Surface Trouble (FAST) survey is providing insights into the prevalence of ocular surface disease in glaucoma patients and the impact it has on treatment and compliance, said Marta MisiukHojło MD, Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland. “Despite its common prevalence, ocular surface disease remains an uncommonly recognised condition in glaucoma. It is well known that ocular surface disease may compromise the tolerability of topical therapy and may induce a decrease in compliance that may impact treatment efficacy leading to a risk of visual loss,” Prof Misiuk-Hojło told the 13th European Glaucoma Society Congress in Florence, Italy.
FAST STUDY
See into the future of eye surgery and patient care.
Belong to something inspiring. Join us. www.escrs.org
The FAST study is a multi-centre international retrospective survey being carried out in six European countries, namely Belgium, France, Italy, Spain, Poland and the United Kingdom. Ophthalmologists participating in the study complete the FAST questionnaire during routine general consultations to identify the risk factors and evaluate the possible OSD symptoms and ocular signs of patients treated by preserved and preservative-free eye drops. In its current form, the FAST questionnaire consists of 14 questions, divided into two parts, to collect data from the patient’s interview and the clinical examination. Data collected includes the year of the glaucoma or ocular hypertension diagnosis, the type of IOP-lowering eye drops used and whether or not it contains preservatives. Prof Misiuk-Hojło presented the results from the first 928 glaucoma/OHT patients surveyed. The average time since their diagnosis of glaucoma or ocular hypertension diagnosis was 8.4 years, with 59.7% of patients diagnosed for more than five years.
EYE DROP TREATMENT The use of preserved glaucoma eye drop treatment was high – 68.7% versus 31.4% preservative free. Some 16.4% of patients were treated with at least one preserved treatment at the time of the visit. Nearly two-thirds of patients presented at least one risk factor for ocular surface disease, and more than 30% had stopped using a preservativecontaining drop due to intolerance. The symptoms experienced by patients receiving preservative-free drops were generally on the absent or mild end of the scale. There were significant differences between the prevalence of ocular symptoms between preserved and the preservative-free groups. “These new results offer interesting insight into the prevalence of OSD and the risk factors. After the graded response model analysis, the final validated version of the fast questionnaire will be a useful tool for ophthalmologists in daily practice to assess patients at risk of ocular surface disease,” Prof Misiuk-Hojło concluded. Marta Misiuk-Hojło: misiuk55@wp.pl
EUROTIMES | JULY/AUGUST 2018
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 K.K. Nischal UK/USA
Registration, Hotel Bookings & Programme Information
www.wspos.org
Supported by
Friday 21 September Lunchtime Symposium Boxed Lunch Included
Integrated Intraoperative OCT in Paediatric Ocular Surgery
50
PAEDIATRIC OPHTHALMOLOGY
Nystagmus treatments Many treatment options are available for nystagmus, but it is best to start early. Soosan Jacob MD reports
E
arly intervention is key to optimal treatment of nystagmus, emphasised Richard Hertle MD in a keynote lecture at the World Congress of Paediatric Ophthalmology and Strabismus in Hyderabad, India. Dr Hertle is a world-renowned expert on nystagmus based at Akron Children’s Hospital, Ohio, US. He explained that nystagmus is a neuro-developmental disorder of the ocular motor system that generally starts as an acquired condition at 4 weeks to 3 months of age. Patients often have dynamic vision that changes with anxiety, sleep, medications, state of attention etc. It also differs when checked monocularly versus binocularly and it is therefore important to assess binocular vision. In addition to eye movement recordings that are crucial for a thorough understanding, all patients should get OCT, visual fields, visually evoked potential, contrast sensitivity, photography and electroretinogram tests for assessing the afferent system, he said. Infantile nystagmus is caused by an abnormality occurring during a sensitive period of visual development. About 75-85% of patients with infantile nystagmus syndrome have associated ocular pathology, much of which is amenable to treatment. He stressed that similar to amblyopia, it is important to treat nystagmus early when the developing visual system is the most plastic. A disruption in neural communication between the developing afferent and efferent systems secondary to eye or other ocular motor pathology is the root cause of infantile nystagmus syndrome. This communication can sometimes be restored early as in early cataract surgery for congenital cataracts, which is responsible for visual pathway
Richard Hertle
delays with resultant disruption in neural afferent-efferent communications and subsequent nystagmus. Optical treatment in the form of contact lenses and glasses are almost as powerful as surgery but are underused, he said. High ametropia should be treated. Among medications, baclofen is generally well tolerated in children and very useful in the up to one-third of patients, who have an additional component of periodicity to their infantile nystagmus syndrome. Eye muscle surgery is an effective treatment in patients with infantile nystagmus and serves three purposes; to improve an anomalous eye position (strabismus), to improve anomalous head position (eccentric null zones) and, to improve the nystagmus (beat-to-beat foveation, waveform and extent and breadth of the null zone). The cutting of the eye muscles at their insertion on the globe (enthesis) with original insertion site reattachment eye muscles improves nystagmus and gives better visual function.
The current hypothesis is that cutting newly discovered proprioceptive entheseal nerve endings sends signals to the brain, which, in turn “re-boots” the ocular motor system, thus improving the nystagmus. Dr Hertle hopes that his work in this area will help stimulate research on medications that act on these nerve endings, such as his research with topical brinzolamide. Research by him and others has shown significant improvement in waveform characteristics and visual acuity using this topical glaucoma medication. He also described a nine-operation algorithm for surgical treatment of nystagmus, which produced improvement in multiple measures of visual function (acuity, contrast sensitivity, gaze-dependent vision, visual recognition time) in almost all patients. Between one and three lines of optotype visual acuity improvement occurred in 75% of patients using the PEDIG protocol, binocularly with best correction in place. Richard Hertle: rhertle@chmca.org
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52
EUROPEAN BOARD OF OPHTHALMOLOGY
Gordana Sunaric Mégevand, President of the EBO
EBO exam puts candidates through their paces 651 candidates from 28 European countries took part in this year’s examination. Dermot McGrath reports
T
he best and brightest of Europe’s young ophthalmologists gathered in May in Paris for the annual European Board of Ophthalmology diploma (EBOD) examination. First held in Milan in 1995, the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices. The high participation rate of recent years shows no sign of abating, with 651 candidates from 28 European countries taking part in this year’s comprehensive examination. “This year’s pass rate was 90%, so we are
EBO honours renowned Italian ophthalmologist The renowned Italian ophthalmologist Costantino Bianchi was posthumously honoured at the European Board of Ophthalmology (EBO) Diploma Award Ceremony as the recipient of the Peter Eustace Medal for his contribution to ophthalmic education in Europe.
EUROTIMES | JULY/AUGUST 2018
happy to see that the high standards continue to be maintained and we congratulate all of those candidates who took part this year,” said Gordana Sunaric Mégevand MD, FMH, PhD FEBO, President of the European Board of Ophthalmology. Candidates who succeed in passing the examination receive an EBO certificate and earn the right to use the title “Fellow of the European Board of Ophthalmology (FEBO)” after their name. Dr Sunaric Mégevand paid special tribute to the 308 examiners from 27 countries who put the candidates through their paces over the two days of the examinations. “The EBO is very grateful and deeply appreciative to all examiners for their commitments and efforts in advancing
“Dr Bianchi sadly passed away last year but his legacy in terms of his achievements in Italian and European ophthalmology will continue to inspire those who follow in his footsteps,” said Gordana Sunaric Mégevand, President of EBO. Born in Bergamo in 1940, Dr Bianchi began his career in ophthalmology after graduating in medicine from the University of Milan in 1969. He established his own eye clinic in Milan and established a national and international reputation for his research in refraction, tear film diagnosis and as a developer of instruments for corneal topography. From 1985 to 2005, he served as professor of
training and education in Europe,” she said. Beginning next year, EBO will introduce an awards system in recognition of the examiners’ contribution to the exam, said Dr Sunaric Mégevand. Those examiners who have participated in six exams will receive a silver pin, with gold and platinum pins awarded for nine and 12 exams respectively. Dr Sunaric Mégevand also thanked the French Society of Ophthalmology (SFO), which hosts the exam every year in conjunction with its annual meeting, as well as Théa Laboratories for their active support over many years. The EBO exams this year also included the first ever subspecialty paediatric and strabismus examination, with seven candidates from four countries taking part. EBO now validates several subspecialty examinations, including glaucoma since 2015 and cataract and refractive since 2017, with more expected to follow in the near future. “The exam is primarily intended for those who have recently completed one year of fellowship training in strabismus and paediatric ophthalmology or equivalent training, have gained in addition two-tothree years’ clinical experience and are starting independent practice,” explained John Sloper, President of the European Strabismological Association. Seven candidates have taken the exam, and five have passed successfully. The 2018 Peter Eustace Medal, in recognition of service to the cause of European ophthalmic education, was awarded posthumously to the Italian ophthalmologist Costantino Bianchi. The merit and contribution of Dr JeanPaul Dernouchamp to the development of the EBO was also posthumously acknowledged. A former secretary general of the UEMS, Dr Dernouchamp passed away late last year. This year, Estelle Neiter from France received the Alan Ridgway Award for best multiple choice questions (MCQs) result, while the award for Best Overall EBOD outcome went to Nikolaus Luft from Germany.
ocular pathology at the Optometry Institute in Lombardy, followed by a stint at the University of Siena from 2005 until shortly before his death. Dr Bianchi was an active member of several scientific societies in Italy and abroad, serving as Italian delegate to the Ophthalmic section of the European Union of Medical Specialists (UEMS) from 2000 and Italian delegate to the EBO from 2000 to 2008. As well as being the lead author of many peer-reviewed publications, Dr Bianchi was founder and director of the ocular microsurgery magazine Viscochirurgia, and went on to edit several ophthalmological publications during his long and distinguished career.
EUROPEAN BOARD OF OPHTHALMOLOGY
A solid basis for my future career Nikolaus Luft, Germany, Overall Winner EBOD Examination 2018
Nikolaus Luft
My main motivation in taking the EBO exam was to immerse myself more in clinical ophthalmology. I believe obtaining the FEBO degree shows a fair amount of dedication towards best clinical practice. I think the written exam was challenging as the timeframe for answering 250 questions was a bit
short. However, I appreciated the format that allows you to abstain from answering a question if you are not sure and do not get penalised. The oral exams were overall very fair, in some cases there even emerged interesting discussions from colleague to colleague about particular cases. I would strongly encourage residents to take the plunge and register for the exam as it really puts
you in a position where you have to devote yourself to the full spectrum of ophthalmology – from anatomical fundamentals and pharmacology to current treatment guidelines. I believe this gives you a very solid basis for wherever your future career in ophthalmology will take you. Currently I am about to finish my training at the University Eye Hospital in Munich, where my next big challenge will be to master the hurdles of cataract surgery.
More self-confident about my knowledge Estelle Neiter, France, Winner of the Alan Ridgway Award 2018 It was really important for me to take the EBO examination because it represents an internationally recognised assessment of general knowledge in ophthalmology, and because it is a beautiful example of
European cooperation. I’ll always remember the EBO exams as a rewarding experience. I couldn’t honestly imagine winning any award, because I actually studied with both the Kanski textbook and my nine-month-old baby on my knees! It makes me feel more self-confident about
my knowledge in ophthalmology and reassures me that it really is possible to combine successfully professional and personal goals. In the future I would like to continue working at the University Hospital in Nancy, France, and try to always keep my knowledge up-to-date.
Estelle Neiter
Healthy competition allows us to evolve Pedro Morais De Almeida Aguiar Coelho, Portugal, Joint Overall Second Place 2018
Pedro Morais De Almeida Aguiar Coelho
Although the ophthalmology residency training in Portugal requires the realisation of a final examination, I decided to take the EBO exam in order to evaluate my preparation in relation to colleagues from all over
Europe. A medical career is based on constant evaluation between peers and I believe that healthy competition allows us to evolve. It is an additional help if in the future I intend to work abroad. The exams gave me the satisfaction of demonstrating the quality of training in ophthalmology that exists in Portugal. It was quite a positive
experience. I would recommend residents to take the EBO examination, especially in countries that do not require final exams to end residency training. The study that is necessary to be successful will surely be helpful in clinical practice. In the near future I plan to attain a fellowship abroad, preferably in cornea and ocular surface.
A well structured and organised examination James Vassallo, Malta, Joint Overall Second Place 2018
James Vassallo
The EBOD is the exit exam recommended in my country in the final year of training. Being able to complete it over one day is very convenient. Obtaining the FEBO usually serves as the springboard for one to progress to the next stage of one's professional development. The candidates feel significant pressure on the day of this exam
as it is the culmination of many years of training. The last few months of preparation are intense but ultimately hard work usually pays off. One has to be careful with the negative marking in the written part. The examiners in the viva voce manage to put you at ease, and build up the questions in a way that is similar to how one would manage a patient in real life with complimentary images. I would encourage other trainees
to consider applying for the EBOD as it is the only single exam that can provide one with a widely recognised qualification that certifies the acquisition of the fundamental concepts across all topics. It also allows one to eventually sit for an EBO subspecialty exam. After finishing my training, I want to be involved in teaching and research, and pursue my special interests to a greater depth.
EUROTIMES | JULY/AUGUST 2018
53
OUTLOOK ON INDUSTRY
55
Making a difference
F
rom an idea that first saw the light of day back in the 1990s, Infinite Vision Optics (IVO), a privately-held company headquartered in Strasbourg, France, believes the time is now right for cataract patients to benefit from its adjustable intraocular lens technology. “It has been a long time coming from the initial concept, but sometimes the best ideas take time in terms of clinical and manufacturing development. We are at an exciting phase of our development and I am confident that the process will further accelerate from this point forward,” said Carsten Laue PhD, Chief Executive Officer and the main driving force behind IVO. Incorporated in 2010, IVO has built its company around the concept of an adjustable IOL developed by Theodore P. Werblin MD, PhD, a practising ophthalmic surgeon and associate clinical professor of ophthalmology at the University of Virginia in Charlottesville, USA. Dr Werblin is still actively advising the company. Unlike currently available intraocular lenses, IVO’s lens system, dubbed PreciSight, offers a life-long solution to vision correction made possible by proprietary technology. The IVO lens system comprises two components – a base lens that serves as a docking station, and an easily accessible front lens that can be exchanged. This system allows the front lens to be adjusted throughout the patient’s lifetime.
FLEXIBLE APPROACH Dr Laue is convinced that the technology offers many advantages to surgeons and their patients. “Our system allows the surgeon to implant a precise, individualised, vision-correcting lens without changing the workflow in the operating room. The system can address all degrees of near-sightedness, farsightedness, astigmatism and presbyopia. The docking system also means that there is
no need for a full lens explantation in the event of postoperative refractive surprises or other issues with quality of vision. We only need to replace the front lens with a significantly reduced risk of capsular bag damage and additional costs that that entails,” he said. Although other strategies may be employed to avoid full lens explantation, such as postoperative adjustment by UV light on special silicone lenses or the use of two independent lenses, none of the current systems combines small incisions, the perfect optical alignment and reversibility associated with IVO’s docking lens system, adds Dr Laue. “Our approach is minimally invasive, and only applied to those patients who really need it. The front lens is made of hydrophilic material, which is flexible and small enough to be removed through the original incision. Furthermore, the ease of exchange of the front lens does not seem to change with the time in the eye, and we are about to generate long-term data to confirm this,” he said. From the development of a prototype lens in 2008 and 2009, the company’s development has accelerated rapidly since 2015, explains Dr Laue. “In the last three years we have developed the manufacturing process and have got clinical studies with key clinical reference centres up and running to prove that the concept works. The initial results have been very promising, as reported at the ESCRS meeting in Lisbon in 2017, with an update at ASCRS in Washington DC in 2018. The lens has now been implanted
Our system allows the surgeon to implant a precise, individualised, vision-correcting lens without changing the workflow in the operating room Carsten Laue PhD
Picture by Dr Harvey Uy
Infinite Vision Optics (IVO) believes the time is right for cataract patients to benefit from its adjustable intraocular lens technology. Dermot McGrath reports
A PreciSight lens as seen by slit-lamp examination
in over 100 eyes and studies are ongoing. We also recently received the European CE-mark approval for PreciSight, which is a key milestone in getting the system into the market and making it available for European patients,” he said.
POSITIVE FEEDBACK With patient recruitment for clinical studies of the lens still ongoing, Dr Laue said that the initial feedback from surgeons has been largely positive. “We are lining up requests from surgeons in Europe to implant the lens now that we have received the CE mark. We have also had many requests for us to supply a multifocal optic for the system. This is our next priority and the development of the multifocal version is now well advanced,” he said. In terms of marketing, Dr Laue believes that it would be a mistake for the company to focus only on the functional aspect of the PreciSight technology. “I prefer to talk in terms of patient groups rather than function and technology, because at the end of the day if there is no perceived benefit for the patient then the lens will not make it. It needs to demonstrate real advantage to the patient beyond the fact that it is ‘exchangeable’. “The patient that will benefit most from our lens is one that has a high likelihood of vision problems after cataract surgery – i.e. patients with irregular corneas, keratoconus, or post-LASIK patients. That’s already a huge market and that’s where I think we can make a real difference,” he concluded. EUROTIMES | JULY/AUGUST 2018
INDUSTRY NEWS
INDUSTRY
NEWS
Premium OCT system
NIDEK has launched the RS-3000 Advance 2 Optical Coherence Tomography. “This premium OCT system incorporates a scanning laser ophthalmoscope (SLO) and is designed for comprehensive imaging and analysis of the retina and glaucoma,” said a company spokesman. Faster scanning speed allows rapid image acquisition, decreasing patient chair time and increasing clinical efficiency, according to Nidek. Higher scanning speeds also reduce artifacts due to fixation loss, resulting in better image quality. “The suite of features incorporated in the RS-3000 Advance 2 represents a comprehensive solution to detect retinal pathology and glaucoma.” said Motoki Ozawa, president of NIDEK. “We will continue to provide eye care professionals with complete solutions for their diverse needs,” he said. www.nidek.com
COMMUNITY INITIATIVE
MICROSECOND PULSING
Santen Pharmaceutical launched its first regional community initiative, ‘10,000 Hours’, at the World Ophthalmology Congress in Barcelona, Spain. This initiative will enable Santen staff to volunteer for nongovernment organisations (NGOs) and advocacy groups in eye health and vision impairment. During WOC, Santen also made a donation to One Dollar Glasses, a charity that has developed a method of providing spectacles to those who cannot otherwise afford them. “Santen is passionate about improving the lives of the patients we serve,” said Shigeo Taniuchi, President and Chief Operating Officer of Santen Global. www.santen.com/en/
OD-OS has released a comprehensive software update for the unique computer-guided Navilas 577s Laser System. “New functionalities make the tissuefriendly treatment of retinal diseases using navigated microsecond laser pulses more intuitive, predictable and reproducible,” said a company spokesman. “Since the launch of the compact Navilas 577s Laser System, we have seen true excitement from retinal experts in the market. We’re glad that we have brought a new paradigm of retinal laser care to routine use in many renowned clinics and private practices worldwide,” said OD-OS Managing Director Dr Winfried Teiwes. www.od-os.com
European Union Web-Based Registry The aim of the project is to build a common assessment methodology and establish an EU web-based registry and network for academics, health professionals and authorities to assess and verify the safety quality and efficacy of corneal transplantation.
Join
the ECCTR Registry
Track
your Surgical Results
www.ecctr.org ECCTR is co-funded by Co-funded by the Health Programme of the European Union
EUROTIMES | JULY/AUGUST 2018
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↙
The International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology will take place in Munich
CALENDAR
LAST CALL
JULY
31st APACRS Annual Meeting
19–21 July Chiangmai, Thailand www.apacrs2018.org
AUGUST
Baltic Eye Surgeons Talk Show Vol. 6 24–26 August Rigas Jurmala, Latvia balticeye2018.com
SEPTEMBER
ALACCSA-R LASOA
6–8 September Santiago, Chile www.alaccsasantiago2018.com
18th EURETINA Congress
OCTOBER
NEW
6th Egyptian Vitreoretinal Society (EGVRS) Training School 4–6 October Alexandria, Egypt www.egvrs.org
20–23 September Vienna, Austria www.euretina.org
NEW
9th EuCornea Congress
8–11 October Munich, Germany www.echography.com
21–22 September Vienna, Austria www.eucornea.org
International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology
2018 WSPOS Subspecialty Day
Ophthalmic Imaging: from Theory to Current Practice
21 September Vienna, Austria www.wspos.org
12 October Paris, France www.vuexplorer.com/en/congres
36th Congress of the ESCRS
AAO Annual Meeting 2018
22–26 September Vienna, Austria www.escrs.org
27–30 October Chicago, USA www.aao.org
DECEMBER
NEW
Arab International Ophthalmology Congress
7–8 December Dubai, UAE www.menaophthalmologycongress.com
The 2018 EURETINA, EuCornea and ESCRS Congresses will take place in Vienna
EUROTIMES | JULY/AUGUST 2018
59
60
CALENDAR
The 2019 EURETINA, EuCornea and ESCRS Congresses will take place in Paris
2019
APRIL
FEBRUARY
23rd ESCRS Winter Meeting 15–17 February Athens, Greece www.escrs.org
NEW Snowmass Retina & Eye 2019 25 February – 1 March Colorado, USA www.snowmasscme.com
NEW International Meeting of the Egyptian Vitreoretinal Society (EGVRS) 10–12 April Cairo, Egypt www.egvrs.org
9th EURETINA Winter Meeting 1–2 March Prague, Czech Republic www.euretina.org
SEPTEMBER
WSPOS Subspecialty Day
13–16 June Nice, France www.soevision.org
13 September Paris, France www.wspos.org
SEPTEMBER
37th Congress of the ESCRS
19th EURETINA Congress
MAY
14-18 September Paris, France www.escrs.org
5–8 September Paris, France www.euretina.org
ASCRS•ASOA Symposium and Congress
MARCH
JUNE
SOE Congress 2019
OCTOBER
10th EuCornea Congress
3–7 May San Diego, USA www.ascrs.org
AAO Annual Meeting
13–14 September Paris, France www.eucornea.org
12–15 October San Francisco, USA www.aao.org
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23rd ESCRS Winter Meeting
ath ens
In conjunction with the 33rd HSIOIRS International Congress
15 â&#x20AC;&#x201C; 17 February 2019 Megaron Conference Centre, Athens, Greece
www.escrs.org
Workshop 26.10.2018 – AXIS Workshop Advanced 30.11.2018 – AXIS Workshop for Young Ophthalmologists
VENUE: Alcon Experience Center (Barcelona, Spain) COURSE LEADERS:
1. Prof. J. Murta, Portugal 2. Dr. K.G. Gundersen, Norway 3. Dr. H. Carreras, Spain 4. Dr. N. Pesztenlehrer, Hungary 5. Dr. A. Dmitriew, Poland 6. Dr. B. Galan, Romania
DESCRIPTION: From a discussion on general Astigmatism Management and Surgical Planning Pearls, to a thorough review of the new Online Toric Calculator and powerful New Theories in Corneal Astigmatism, join Session One for some of the latest developments in Astigmatism Management. Session Two features tips and pearls on managing surgical variables, along with insightful clinical cases and post-op assessments showcasing ORA®. Moving through New Patient and Pre-Op Data, to Post-Op Reviews and powerful reporting features, join Session Three for an insightful discussion on how to maximize the many facets of the AnalyzOR® within the practice. Get first-hand experience with the latest cataract refractive Alcon technologies at the VerionTM 3.1 and ORA® VLynk® Hands-on Session. For more information and course registration, contact your local Alcon representative.
© 2018 Novartis 6/18
18-MK-AXIS-001-JAD-EU