EuroTimes Oct 2019 | Vol 24 Issue 10

SPECIAL FOCUS CATARACT & REFRACTIVE

October 2019 | Vol 24 Issue 10 STRATEGIC PLAN

2025

The The evolution evolution of of

ophthalmic ophthalmic

Imaging CORNEA | CONGRESS REVIEW | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY | OCULAR

Faros MAKING THE DIFFERENCE WITH LEADING INNOVATION ™

Precision and efficiency in eye surgery

NEW Not available for sales in the US

with active infusion (GFI) available soon

The Faros surgical platform enables cataract, vitrectomy and glaucoma surgery of the highest level while constantly remaining comfortable and intuitively operable. The reliable flow control makes the surgeon’s work even easier and safer than before. In addition, the Faros impresses with versatility, innovative technologies, exceptional functionality and ease of use. → Available as an anterior platform or as a combined anterior/posterior platform → Cutting-edge dual-pump system with flow and vacuum control with its unique SPEEP Mode™ → Proven easyPhaco® technology → Continuous Flow Cutter for traction-free vitreous body removal Make the difference – with the new Faros: www.oertli-instruments.com

EYE SURGERY. SWISS MADE .

P.21

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Ria Pollock Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org

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

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

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

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

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

ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

CONGRESS REVIEW

CATARACT & REFRACTIVE

21 Five-year plan announced

4 EuroTimes looks at the

22 Pearls for Young

evolution of ophthalmic imaging

8 Anterior segment

imaging for cataract and refractive surgery

10 How to minimise

and manage posterior capsule tears

11 A new approach for

MSICS in hard cataracts

12 Lens options abound for presbyopic patients

13 Intracameral injections

can help stop anterior chamber bleeding

14 What IOL would you choose for your own surgery?

15 JCRS highlights

CORNEA 17 Gene editing for

inherited dystrophies

18 Tissue engineering for

severe trophic corneal ulcer

20 Gene therapy for anterior As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between February and December 2018 was 48,900

segment disease

www.eurotimes.org

P.42

at 37th Congress of the ESCRS

Ophthalmologists

23 Congress news highlights

24 Congress picture gallery 26 EURETINA is the world’s largest retina meeting

27 EuCornea goes from strength to strength

28 Highlights from

Glaucoma Day and WSPOS Subspecialty Day

RETINA 29 The gut microbiome and the eye

30 Ophthalmologica highlights

31 Recognising floaters as a disease

GLAUCOMA 32 Should intraocular

pressure be measured around the clock?

PAEDIATRIC OPHTHALMOLOGY 36 The challenge of uveitis in children

37 When to operate in

paediatric cataract

OCULAR 39 Tear biomarkers may help

in diagnosing Alzheimer’s

REGULARS

40 Gender inequality

in ophthalmology

42 Travel 45 Industry News 46 ESCRS Academy 47 Calendar

33 Phacoemulsification as glaucoma treatment

34 Slowing progression by blocking cellular proteins

EUROTIMES | OCTOBER 2019

2

EDITORIAL A WORD FROM NINO HIRNSCHALL MD, PHD

GUEST EDITORIAL

Ophthalmic imaging New innovations expand technical possibilities

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

EUROTIMES | OCTOBER 2019

I

am delighted to be asked to write this guest editorial for this issue of EuroTimes, which has a special focus on cataract and refractive surgery. The cover story for this issue takes an in-depth looking at the evolution of ophthalmic imaging.

Ophthalmologists have at their fingertips an impressive array of imaging tools for diagnosing disease, guiding interventions and documenting progress after treatment. These tools are a key part of everyday cases, particularly cataract and refractive surgery, corneal transplantation, keratoconus detection and progression and ocular surface disease evaluation.

The level of detailed information provided by optical biometry, aberrometry, OCT imaging, Ophthalmologists keratometry and others have at their continues to increase.

While new and improved fingertips an imaging techniques impressive array undoubtedly provide of imaging tools more information, questions remain about for diagnosing how much of an effect disease, guiding this might have on patient interventions outcomes, and in which and documenting cases the cost of adding expensive new equipment progress after can be justified. treatment.

EuroTimes takes a look at recent innovations in anterior segment imaging now in the clinic as well as ongoing research into novel imaging technologies that could provide a better understanding of fundamental questions still remaining about problems such as negative dysphotopsia and corneal ectasia.”

As well as our cover story, which deals with these new and exciting developments in imaging, there’s also an interesting article by my colleague Soosan Jacob, which takes a detailed look at various options available for anterior segment imaging in cataract and refractive surgery.

We have also just returned from a very successful Congress of the ESCRS in Paris, and in this issue you can see some of the highlights of the meeting including reports from presentations, award winners and picture galleries.

Dr Nino Hirnschall, VIROS – Vienna Institute for Research in Ocular Surgery, Hanusch Hospital, Vienna, Austria

YOUR NAVIGATING PARTNER IN OPHTHALMOLOGY

www.ziemergroup.com

The FEMTO LDV Z8 and the GALILEI G4 are CE marked and FDA cleared. For some countries, availability may be restricted due to regulatory requirements. Please contact Ziemer for details.

4

SPECIAL FOCUS: CATARACT & REFRACTIVE

The The evolution evolution of of

ophthalmic ophthalmic

Imaging EuroTimes takes a look at recent innovations and novel technologies and their impact on anterior segment imaging.

Sean Henahan reports

F

rom the earliest days of the first ophthalmoscope, ophthalmologists have had an advantage over most other specialties in their ability to see inside the body to evaluate the fundus and other ocular structures of their patients. Indeed, the ophthalmoscope, described by Hermann Helmholtz in 1851, is still part of regular practice, and the concepts of magnification and illumination EUROTIMES | OCTOBER 2019

continue to be the basis of most imaging technologies now in use.

Ophthalmologists currently have at their fingertips an impressive array of imaging tools for diagnosing disease, guiding interventions and managing outcomes. These tools are a key part of everyday practice in anterior segment surgery, particularly cataract and refractive surgery, corneal transplantation, keratoconus, glaucoma and ocular surface disease.

Imaging of the anterior segment has

evolved significantly over the past decade.

The technology has improved in many areas including resolution, acquisition time, speed of acquisition, better output maps etc notes Soosan Jacob MD, FRCS, Director and Chief, Dr Agarwal’s Refractive and Cornea Foundation, Chennai, India. “In addition, the ability to image more accurately the anterior and posterior surface as well as layer imaging in the form of epithelial mapping have improved the ability to understand the cornea

SPECIAL FOCUS: CATARACT & REFRACTIVE better. Integration of better software, calculations, nomograms and predictors also help us to analyse corneal maps better,” she told Eurotimes.

KERATOCONUS SCREENING AND DIAGNOSIS Screening for corneal ectasia in general and keratoconus in particular is one of the biggest challenges facing clinical ophthalmology. The nature of the cornea leads to unexpected outcomes in refractive and keratoplasty surgeries even when the procedures seem to have gone well. This is attributable to variations in the biomechanical properties of individual corneas and inadequacies in the ability to diagnose ectasia in the early stages.

Screening at the primary level includes slit-lamp evaluations and corneal topographic imaging. Corneal specialists can then call on many imaging options including optical coherence tomography (OCT) such as the Visante (Carl Zeiss Meditec), Scheimpflug imaging with Oculus Pentacam HR and Placido Disk keratography (Oculus Keratograph) to evaluate the anterior and posterior surfaces of the eye as well as the pachymetry.

More recently, the ORA ocular response analyser (ORA Reichert) and the Corneal Visualisation Scheimpflug Technology (Corvis ST) have entered the arena. Both of these use a puff of air to evaluate the biomechanical properties of the cornea. Researchers are still working to translate data provided by these systems into useful diagnostic values.

“I think epithelial mapping with either OCT or very high-frequency (VHF) digital ultrasound (Artemis, ArcScan) would be of help in screening for keratoconus. We also have tools that have been added to imaging technologies such as indices and screening tests such as the BAD D value, Corvis Biomechanical Index (CBI), Tomographic Biomechanical Index (TBI). Devices based on biomechanical properties still have a far way to go before being able to be translated into perfect accuracy for each patient every time, but if perfected, can become an invaluable tool,” commented Dr Jacob.

While these instruments are invaluable for cornea specialists, none of them can provide a reliable diagnosis of keratoconus for the simple reason that there is currently no consensus on how

best to classify and predict ectasia. The best-known classification systems are the Amsler-Krumeich and Collaborative Longitudinal Evaluation of Keratoconus (CLEK), but neither are considered to be the perfect solution.

In the search for a more accurate screening technique, Seok Hyun Yun PhD and colleagues at Harvard University Medical School, Cambridge, USA, are using a non-invasive technique known as Brillouin microscopy imaging. This technique utilises a low-power near infrared laser to determine the mechanical compressibility of tissue, otherwise known as the longitudinal modulus, by analysing the return signal spectrum. Brillouin imaging maps small frequency changes, known as Brillouin frequency shifts, in order to create a 3D scan of the cornea.

Early research findings are promising.

Clinical studies have revealed significant differences in the elastic properties of normal corneas compared to those diagnosed with mild and severe keratoconus. Brillouin imaging studies have also demonstrated biomechanical changes after corneal collagen crosslinking treatment in keratoconus patients.

The technique has also been used to image the crystalline lens and the sclera.

Research with Brillouin microscopic imaging is furthest along in the area of keratoconus diagnostics. Dr Yun believes that the technique should become clinically useful in the not-too-distant future.

“Our data warrant further clinical validation. A promising next step is to derive metrics that combine the biomechanical data with morphological features and establish the clinical benefits – sensitivity and specificity – over current morphology-only diagnostic criteria,” Dr Yun told Eurotimes.

Beyond applications in keratoconus diagnostics, Dr Yun believes Brillouin microscopy has potential applications in many areas of ophthalmology, including cataract and refractive surgery, noting that this imaging technique has the potential to predict the refractive changes in the cornea after corneal incisions and post-LASIK more accurately.

Dr Yun and colleagues built the instruments and the related software used in his research in his lab at Harvard Medical School. He is also the medical research director of start-up company Intelon Optics, which hopes to commercialise a Brillouin eye scanner product.

I think epithelial mapping with either OCT or very high-frequency (VHF) digital ultrasound (Artemis - ArcScan) would be of help in screening for keratoconus Soosan Jacob MD, FRCS

INTRAOPERATIVE OCT? Optical coherence tomography imaging is now used in virtually every aspect of ophthalmology, from detailed studies of the optic nerve and retina to guiding femtosecond laser-assisted cataract surgery, corneal surgery and even submicron analysis of ocular surface disease.

Intraoperative imaging has become a useful tool for many cataract and refractive procedures. Intraoperative OCT is now finding a place in anterior segment surgery.

However, the best use of this approach, particularly in the area of corneal transplantation, is still being debated.

Nino Hirnschall MD, PhD, FEBO, Vienna, Austria, and Massimo Busin MD PhD, University of Ferrara, Italy, discussed the pros and cons of intraoperative OCT for corneal transplantation in a EuroTimes Eye Contact interview (available at eurotimes.org).

Dr Hirnschall noted that the visualisation provided by intraoperative OCT could allow Descemet’s membrane endothelial keratoplasty (DMEK) to be performed in an eye with a cloudy cornea, where otherwise Descemet’s stripping automated endothelial keratoplasty (DSAEK) would be needed by default.

Intraoperative OCT can also identify the remnants of Descemet’s membrane, allowing complete Descemet’s removal in both DMEK and DSAEK. This is important because the detachment rate is higher if the graft is placed on top of remnants of Descemet’s membrane. There is also published clinical research indicating that the improved visualisation provided by intraoperative OCT could mean less graft manipulation time, and so less endothelial cell loss. OCT also aswsures proper graft orientation.

Professor Busin, a high-volume corneal surgeon, is not convinced.

“In my field of corneal transplantation I feel that intraoperative OCT is really not that useful, and doesn’t justify the expense. It has two main limitations – it only gives small slices, and you have to scan the whole surface yourself. It is difficult to see what you are looking for.

Plus, it moves while you are using it and is very awkward to use. It is difficult to obtain useful information that you can use to adjust your surgery,” he said.

Dr Hirnschall noted that during both DMEK and DSAEK, intraoperative OCT enables identification of fluid in the donor-graft interface and of graft adherence. For deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty procedures, intraoperative OCT gives surgeons exact information about trephination depth and, during DALK, it can guide cannula depth when creating the big bubble.

Dr Busin commented that there are techniques besides OCT that surgeons use to determine DMEK graft orientation, EUROTIMES | OCTOBER 2019

5

6

SPECIAL FOCUS: CATARACT & REFRACTIVE including by looking through the microscope. If still uncertain, other practical and less expensive approaches include the handheld slit beam, an S or F stamp, the Moutsouris sign or endoillumination.

Dr Jacob agrees that although intraoperative OCT is proving useful for certain corneal surgeries such as DMEK or pre-Descemet’s endothelial keratoplasty (PDEK), where it can help identify graft orientation, there are other ways to accomplish this accurately with other techniques such as the endoilluminator-assisted DMEK or PDEK described by her.

“Intraoperative OCT may also help identify fluid in the interface,” she said.

However, with the air pump-assisted technique, again described by her, interface fluid can be decreased in these surgeries so that confirmation with i-OCT would not be required. In DALK too, although it has been similarly claimed to be of benefit, an experienced surgeon can generally make do well without the aid of intraoperative OCT. “Current disadvantages of intraoperative OCT such as additional time taken, the need to constantly keep focusing the scan exactly on the area of interest in the x,y and z axes, rapid shifting of focus on eye movements, inversion of the image as well as of course, the additional cost involved make it less practical,” she commented.

DISCOVERING THE BASIS OF DYSPHOTOPSIA Even as IOL designs continue to improve and biometry and improved surgical techniques evolve, dysphotopsia remains the leading cause of patient dissatisfaction after uncomplicated cataract surgery.

While the glare and halo symptoms of positive dysphotopsia are believed to be attributable to square-edged IOL design, the causes of negative dysphotopsia are less well understood. Negative dysphotopsia presents as persistent dark shadows in the patient’s peripheral visual field even after an uneventful cataract surgery.

With support from an ESCRS clinical research award, Jan-Willem Beenakker PhD and colleagues at the Leiden University Medical Centre in the Netherlands are conducting a study known as vRESPOND, (Virtual REfractive Surgery for the Prevention Of Negative Dysphotopsia), the goal of which is to uncover the pathological origin of negative dysphotopsia.

The researchers are using advanced magnetic resonance imaging (MRI) techniques and other imaging modalities to make models to study the exact path of light through the eye. They are using the imaging data to build personalised threedimensional models that link the optical characteristics of negative dysphotopsia with patients’ subjective complaints.

Dr Beenakker notes that conventional EUROTIMES | OCTOBER 2019

We have found significant differences in the anterior chamber configuration of patients with and without negative dysphotopsia Jan-Willem Beenakker, PHD optical techniques used to measure distances in the eye have significant systematic errors for off-axis measurements due to refraction. Since MRI is not affected by refraction it can be an important tool to study the retinal shape. However, the sensitivity of MRI to eye-motion has limited these evaluations to two-dimensional or low-resolution three-dimensional studies. The Leiden team has developed a method that takes advantage of advances in high field MRI to quantify full three dimensional images.

“The acquisition of the data has been finished and a large part of the data have been analysed. We have found significant differences in the anterior chamber configuration of patients with and without negative dysphotopsia.

These findings provide the first clinical confirmation of earlier ray-tracing studies on the relation between the angle kappa and negative dysphotopsia,” Dr Beenakker told Eurotimes.

The novel, patient-specific, 3D eye models provided by this study should prove useful for many different future applications in refractive surgery, enabling innovative clinical solutions for diseases that affect the quality of vision, he predicted.

OBJECTIVE BASIS OF SUBJECTIVE COMPLAINTS Related research is being conducted in Portugal by Joaquim Murta MD, PhD, Miguel Castelo Branco MD, PhD, and Andreia Rosa MD, PhD, in the department of ophthalmology, University of Coimbra. With support from another ESCRS clinical research award, the Neuroadaptation after Cataract and Refractive Surgery Study, or NECSUS, is carried out jointly by the Universities of Coimbra and Maastricht.

It is set to study the occurrence of patient-reported subjective difficulties and neuroadaptation after cataract surgery with different IOLs (multifocal, monofocal and extended depth of focus lenses) and levels of adaptation, using functional magnetic resonance imaging (fMRI). A group of unhappy multifocal IOL patients expecting explantation surgery will also be included.

Prof Murta notes that positive dysphotopsia, in the form of glare, haloes and starbursts, remains an important cause of dissatisfaction after cataract surgery. Moreover, these unwanted effects are considered to be limiting

the more widespread use of multifocal intraocular lenses.

In a pilot study funded by ESCRS in 2016 it was shown, for the first time, an association between patients’ reported subjective difficulties and fMRI outcomes, independently of optical parameters and psychophysical performance.

The increased activity of cortical areas dedicated to attention, learning and cognitive control and to task goals probably represent the beginning of the neuroadaptation process to multifocal intraocular lenses. Thus was demonstrated a positive change in brain activity months after surgery, accompanying clinical improvement.

The NECSUS study aims to extend this knowledge by comparing different IOL designs and evaluating functional connectivity among visual and attentionrelated areas, especially in patients in which neuroadaptation failed to occur.

Information produced by this research should provide valuable knowledge leading to the identification of therapeutic targets, as well as IOL characteristics that are more likely to trigger neuroadaptation circuits effectively. Hopefully, this could lead to practical clinical applications for better medical and surgical outcomes, notes Prof Murta.

IMAGING THE FUTURE When asked what she would you like to see in imaging technology that would help in day-to-day clinical work in the future, Dr Jacob commented: “Among other things, I would anticipate greater use of artificial intelligence and greater accuracy in layer-by-layer analysis. We need better devices to measure corneal biomechanics reliably. We need a greater understanding of the eye’s refractive mechanisms for extremely accurate IOL power measurements, especially in aberrated and post-surgical corneas. I also hope we will see microscopic-level imaging of the trabecular meshwork and outflow pathways in the glaucoma area.”

Soosan Jacob: dr_soosanj@hotmail.com Seok Hyun Yun: syun@mgh.harvard.edu Massimo Busin: mbusin@yahoo.com Jan-Willem Beenakker: j.w.m.beenakker@lumc.nl Joaquim Neto Murta: jmurta@netcabo.pt

INTRODUCING

EVOLVING DESIGN. ADVANCING PREDICTABILITY. Featuring a wide flange at its base, the new precision-engineered iStent inject® W Trabecular Micro-Bypass System is designed to optimise stent visualisation and placement, enhance procedural predictability, and increase confidence.

Glaukos.com | +1.949.367.9600

INDICATION FOR USE. The iStent inject ® W is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject ® W can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and / or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. © 2019 Glaukos Corporation. Glaukos and iStent inject are registered trademarks of Glaukos Corporation. PM-EU-0050

8

SPECIAL FOCUS: CATARACT & REFRACTIVE

Imaging in cataract & refractive surgery There are a range of options available for the assesment and measurement of the anterior segment.

Soosan Jacob MD reports

U

nlike physicians who often have to take educated guesses to formulate even a provisional diagnosis, ophthalmologists are blessed in having a transparent cornea that allows direct visualisation of pathology preoperatively and the actual surgical field postoperatively. However, there are still situations where we, like our medical and surgical counterparts, have to depend on other modalities for additional information. This article deals with anterior segment imaging in cataract and refractive surgery.

Anterior segment optical coherence tomography (ASOCT): Described in 2000, OCT can be used to image ocular tissues right from cornea to retina.

Dedicated anterior segment units, combined units as well as posterior segment units with accessories that allow anterior segment scanning are available.

OCT may be time domain, spectral domain or swept source – the latter two take up to 100,000 scans/second with resolution of 1-10 microns. Imaging is based on grade of tissue opacity. Ciliary body and retro-iridal structures, however, cannot be imaged.

Advantages include fast scanning, high resolution, wide applicability and noncontact testing. Linear scans, raster scans, three-dimensional scans and pachymetric maps are obtained.

ASOCT has numerous uses – pachymetric and epithelial thickness maps can help decide for or against refractive surgery in patients with suspicious topography. Depth of scars is assessed for performing phototherapeutic keratectomy or for deciding between LASIK and photorefractive keratectomy.

LASIK flap thickness and residual bed thickness help decision-making in enhancement surgeries.

EUROTIMES | OCTOBER 2019

Use of imaging in keratoconus: A,B: Preoperative evaluation – axial curvature map on the Pentacam® (A); Point Spread function seen on Zywave® aberrometry map (B); C: Slit-lamp photography showing cornea after CAIRS (Corneal Allogenic Intrastromal Ring Segments) implantation; D: ASOCT image showing CAIRS segments in situ

The LASIK flap, SMILE® cap, any interface debris, epithelial ingrowth, infiltrates, fluid collection etc. can all be analysed. OCT is also useful for post-surgical evaluation of anterior and posterior chamber phakic IOLs. In glaucoma, it helps assess angle anatomy, occludability, physiological changes to light/medication or

accommodation, diagnosis of narrow angles and plateau iris, assessment of post-laser or post-surgical changes, postoperative bleb morphology, position of tubes, shunts and MIGS devices.

Prior to premium IOL implantation, posterior segment OCT helps rule out macular pathology. ASOCT also helps postoperatively in diagnosing Descemet’s

SPECIAL FOCUS: CATARACT & REFRACTIVE detachments, IOL position, tilt, centration, assessment of zonulopathy, posterior capsular opacification etc.

Ultrasound biomicroscopy (UBM): Invented in 1990, this uses B-scan mode ultrasonography, has tissue penetration of about 5mm and resolution of 25 microns.

It is extremely useful when retro-iridal and sulcal areas, zonules, periphery of capsular bag, IOL haptics and ciliary body need imaging. It can also be used to assess angle and other anterior segment structures.

However, an immersion technique, need for an experienced examiner, supine position testing, changes in angle anatomy in supine position etc are disadvantages.

Topography and tomography: Topographic devices assess only the anterior corneal surface whereas tomographic devices such as Pentacam® (Oculus Inc), Orbscan® (B&L), Sirius® (CSO) and Galilei® (Zeimer) assess anterior and posterior corneal surfaces, anterior chamber, iris and lens. These are invaluable for patient assessment before cornea- and lens-based refractive surgeries such as SMILE, LASIK and phakic IOL. They help in screening; planning of refractive surgery; evaluation of postrefractive surgery patient; evaluation and treatment of keratoconus, post-LASIK ectasia, irregular corneas, corneal scars, corneal transplants etc.

They are used for planning Intra Corneal Ring Segments as well as CAIRS (Corneal Allogenic Intrastromal Ring Segments) implantation in patients with keratoconus. Difference maps are used for evaluating progression or treatment effect.

Phakic IOL software in Pentacam® can simulate lens position preoperatively.

For cataract surgery, net corneal power can be measured to calculate IOL power in patients with previous corneal surgery. Axial length may be measured by Pentacam® AXL and used for IOL power calculation with inbuilt software.

Toric IOL planning, assessment of posterior corneal astigmatism, measurement of corneal higher- and lower-order aberrations including

spherical aberration, grading of lens opacity and lens thickness before cataract surgery are all possible.

Pentacam®, Cassini® (i-Optics), OPDScan III® (Nidek), Aladdin® (Topcon) can all be integrated with the Lensar® femtosecond laser cataract platform to accurately perform arcuate incisions and to create anterior capsular nubs for toric IOL alignment. Corrected IOP measurements, corneal white to white, pupil size and angle kappa, densitometry values for lens and cornea, glaucoma screening – evaluation of angle and anterior chamber anatomy are other features. Topolyzer® (Alcon) gives Zernicke and Fourier analysis and pupil centroid shift and is used for topographyguided LASIK. Scheimpflug imaging is also used by Corvis® ST (Oculus) to record corneal reaction to a defined air pulse to measure IOP, pachymetry and biomechanical corrected IOP. Corvis Biomechanical Index and Tomographic Biomechanical Index (with Pentacam) are also calculated.

Slit-lamp photography: This is becoming popular as tele-ophthalmology takes root. Choices include high-end slitlamp integrated cameras with dedicated software or simple mobile phone camera fixed to the ocular of any slit-lamp via an adapter to click images that can then be transmitted via internet.

Epithelial mapping: Detailed measurements of corneal epithelium over the entire cornea are presented as epithelial maps that help analyse and differentiate between pseudo- and true form fruste keratoconus and to detect sub-clinical keratoconus in patients with apparently normal topographic maps. It is a useful tool for refractive surgery candidates, patients with keratoconus and other causes of irregular corneas. It helps understand epithelial remodelling as a cause for postLASIK regression and helps plan any corrective refractive surgery. Mapping may be done using OCT RTVue® (Optovue) or very high-frequency (VHF) digital ultrasound Artemis® (ArcScan).

Wavefront imaging: Aberrometers measure the wavefront of the eye, map them and give an assessment of higherand lower-order aberrations. They measure total eye aberrations and help in separating lenticular from corneal aberrations. They are useful in assessing refractive surgery candidates, planning wavefront-guided LASIK and for evaluating keratoconus and other causes of irregular corneas.

Premium IOLs may cause visual dissatisfaction in patients with irregular or post-refractive surgery corneas and preoperative aberrometry is useful to avoid such situations. Intraoperative aberrometry is also possible and helps in IOL power selection, toric IOL selection and placement, placing limbal-relaxing incisions etc and is especially useful in post-refractive surgery patients. Software can help compare pre-, intra- and postoperative data to allow constant improvement.

Tear film imaging and Meibography: OCT, fringe interferometry and other techniques are used to image the tear film and its layers. This is useful for diagnosis and management of dry eye disease. Tear meniscus height, non-invasive tear breakup time and blink rate can also be measured. Meibography uses infrared illumination to evaluate Meibomian gland function, density and anatomy as well as capture images for patient education and documentation.

In vitro confocal microscopy (IVCM): Microscopic imaging of living cornea by IVCM without damaging tissue is used to diagnose Acanthamoeba keratitis, keratoconus, dry eyes etc, and to monitor response to therapy and surgery.

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

Convenient Web-Based Registry

Cataract, Refractive and Patient Reported Outcomes in One Platform

Join

the EUREQUO Platform

Track

your Surgical Results

www.eurequo.org

The patient-reported outcome is linked to clinical data in EUREQUO. This enables better knowledge of indications for surgery and offers a tool for clinical improvement work based on the patients’ outcome.

EUREQUO is free of charge for all ESCRS members

EUROTIMES | OCTOBER 2019

9

10

SPECIAL FOCUS: CATARACT & REFRACTIVE

Posterior capsule tears Precautions may avoid tears, but be prepared to manage them.

Howard Larkin reports

C

apsulorhexis tears and posterior capsule breaks Dr Tipperman advised taking the time to get a pair of good can be minimised using good surgical technique forceps rather than pushing through and try to manage. and precautions in high-risk patients. When they “The road to ruin is paved with good intentions,” he said. do occur, however, surgeons should be prepared In the event of radial tears, Dr Tipperman also advised to manage them, presenters told the ASCRS releasing the capsule and repositioning the forceps to tear ASOA 2019 Annual Meeting in San Diego, USA. centrally. If the tear extends past the iris, he recommends Recent literature puts the overall rate of posterior using hooks to get a better view, which may allow capsule breaks at about 3.2%, though some large completion of a circular capsulotomy. series show rates below 1.0%, said Thomas Kohnen When the tear cannot be recovered, converting MD, PhD, professor and chair of the department to a can-opener capsulotomy is an option, Dr of ophthalmology at Goethe University, Frankfurt, Tipperman said.

Germany. That’s down from 8.4% from the can“Remember, these were done for years with excellent opener capsulotomy era and 4.8% in the early years results.” of capsulorhexis.

However, a can-opener capsulotomy is at risk for And while some surgeons use femtosecond additional radial tears, so the lens should be prolapsed lasers to reduce posterior breaks, recent studies out of the bag before phacoemulsification, if possible.

Thomas Kohnen MD, PhD show no differences overall between laser-assisted The can-opener also may render the capsule unsuitable and manual cataract procedures done by experienced for in-the-bag lenses, so sulcus fixation of a three-piece surgeons. lens may be necessary.

Occasionally, posterior capsule breaks are associated with the cataract itself, as with primary holes from posterior polar MANAGING POSTERIOR BREAKS cataracts, Prof Kohnen noted. Other risk factors include Capsule ruptures during lens removal are potentially disastrous, male gender, pseudoexfoliation, diabetes and renal failure, so Prof Kohnen said. surgeons should take precautions with these patients. Most “The biggest goal is to keep the nucleus from diving into often, though, posterior capsule breaks are caused by surgery, the vitreous.” This can be done by deepening the irrigation and may occur at any point in surgery, including during bottle to increase pressure, applying viscoelastic in front of and lens removal, cortex aspiration and intraocular lens (IOL) behind the core to avoid lens posterior dislocation and protect implantation, he added. the endothelium during lens removal. Should the lens drop

AVOIDING AND RECOVERING FROM RADIAL TEARS Posterior ruptures are often preceded by radial tears during capsulorhexis, Prof Kohnen said. These can be minimised by starting the capsulorhexis toward the centre of the anterior capsule and tearing outward in a spiral that intersects itself at the desired diameter. Should a radial tear begin, the capsulotomy may be recovered by picking it up from outside the tear and bringing it back toward the centre, rather than trying to continue the tear from the inside out.

Understanding why radial tears occur is important to managing them, said Richard Tipperman MD, of Wills Eye Hospital, Philadelphia, USA. Causes include difficulty initiating the tear, poor visualisation due to white cataracts, small pupils, young patients and calcified capsules, each requiring its own approach.

Flat anterior chambers can create abnormal vector forces that push tears in unpredictable directions, as do forceps with tips that Thomas Kohnen MD, PhD don’t quite line up.

...Occasionally, posterior capsule breaks are associated with the cataract itself, as with primary holes from posterior polar cataracts

EUROTIMES | OCTOBER 2019

into the vitreous, pars plana vitrectomy likely will be required to remove it.

“It’s not a good idea to try to remove it from the anterior,” Prof Kohnen cautioned.

For tears during cortex aspiration the question is whether the vitreous membrane is intact. If so, the tear should be extended into a round opening to prevent the radial tear from extending further to the periphery, which may make it impossible to implant a lens in the bag, Prof Kohnen said. Any vitreous entering the anterior segment must be removed using anterior vitrectomy.

Posterior tears during lens implantation may be recovered with the lens implanted in the bag if there is enough residual capsule to support it, Prof Kohnen said. This involves carefully removing any vitreous behind the lens.

How an IOL should be implanted after a capsule rupture depends on the condition of the capsular bag, Prof Kohnen added. It may be possible to place a lens in a bag with a posterior tear if there is enough support. If the rhexis is not torn, an optic capture in the capsulorhexis with haptics in the sulcus may be possible.

If the bag will not support a lens, a sulcus placement may be necessary, Prof Kohnen advised. Avoid placing single-piece IOLs in the sulcus to avoid future iris chafe and pigment dispersion, which may lead to glaucoma.

In cases of lost zonules, open the sulcus ciliaris with viscoelastic, retract the iris and position haptics away from the foramen in case of rhexis rupture, he advised.

Thomas Kohnen: Kohnen@em.uni-frankfurt.de

SPECIAL FOCUS: CATARACT & REFRACTIVE

Option for MSICS in hard cataracts Lens segmentation device allows smaller incisions for removing hard cataracts. Howard Larkin reports

ARTIFLEX

®

M

10

0

170

160

15 0

14 0

50

60 70

110

80

100 80

100

90

90

0 12

110

70 50

0 13

60

40

14 0

It’s time to experience the ONLY foldable Toric IOL that absolutely does not rotate.

30

20

10

0

170

160

15 0

With dense lenses one of the most difficult parts is the posterior plaque

40

30

20

0 12

REUSING THE DEVICE The Minicap MSICS procedure Dr Crandall described involves inserting the miLOOP device into the capsular bag beneath the capsulotomy edge, using the thumb slider to expand the loop in the iris plane, then pushing it peripherally and rotating the loop to surround the nucleus in the sagittal plane. Retracting the loop with the thumb slider pulls the filament through the cataract, cutting it in two.

The segments are then prolapsed into the anterior David A Crandall MD chamber and extracted using a lens loop or simcoe I/A cannula. A foldable lens can then be inserted without enlarging the incision.

Dr Crandall, of the Henry Ford Health System in Detroit, USA, noted that the miLOOP device is labelled for single use in developed countries, but can be sterilised with spirits and reused at least 50 times.

“They are very durable,” he said.

Dr Crandall advised mastering the miLOOP in softer cataracts where the loop passing behind the nucleus can be seen as well as felt before attempting dense cataracts, where it must be done by feel alone. He also advised using a second instrument to prevent the nucleus from prolapsing during segmentation, and to complete segmentation as the loop may not completely separate the fragments. Viscoelastic is used to open the capsular bag for loop insertion and to protect the cornea during segmentation.

Iris Fixated Toric PIOLs

0 13

anual small-incision cataract surgery (MSICS) is widely used in resource-limited areas because it is faster, less expensive and less dependent on modern infrastructure and external supplies than phacoemulsification.

Even in developed countries it can be the preferred choice for patients with very dense cataracts or compromised corneal endothelium because it eliminates the risk of ultrasound.

However, removing very hard cataracts whole with MSICS can require a scleral incision of up to 8.0mm with a trapezoidal profile that widens about 25% toward the anterior chamber.

While often self-sealing, such large incisions may increase leakage and infection risk as well as postoperative astigmatism.

Using a miLOOP device to cut the lens nucleus in half in the capsular bag can reduce MSICS incision size to 4.0mm-to-5.0mm, David A Crandall MD told the ASCRS ASOA 2019 Annual Meeting in San Diego, USA. The device, which consists of a retractable nitinol loop that ensnares the lens nucleus, is also useful for segmenting cataracts to reduce ultrasound in phaco procedures, he added.

“With dense lenses one of the most difficult parts is the posterior plaque, and you are guaranteed to make it all the way through the lens.”

Treat Astigmatism with confidence: P NO POSTOP ROTATION P ONE SIZE FITS ALL P PERFECT AXIS ALIGNMENT

COMPREHENSIVE PLATFORM MANAGEMENT ASTIGMATISM

David A Crandall: DCranda1@hfhs.org EUROTIMES | OCTOBER 2019

11

12

SPECIAL FOCUS: CATARACT & REFRACTIVE

Presbyopia treatment options increasing Patients the winners in relentless race for progress.

Dermot McGrath reports

A

dvanced intraocular lens IOLs began with bifocals with variable technology and surgical additions, and all available in toric version, techniques have significantly as a key refinement when we know that improved postoperative the achievement of emmetropia is required visual outcomes in recent with multifocal IOLs. Then came trifocal years, with surgeons now able to offer lenses that added intermediate vision a wide array of potential solutions enhancement to both elementary tailored to the specific refractive distances at far and near, and needs and lifestyles of their come also in toric version.. patients, according to Béatrice The latter have proven the Cochener-Lamard MD, PhD. most popular in Europe, said “We are very lucky to be Prof Cochener-Lamard. ophthalmologists at a time More recently, the EDOF of major advances in optics lenses have brought some new and IOL technology,” she told features into play, providing a Béatrice Cochener-Lamard delegates attending her keynote range of visualisation rather than MD, PhD lecture ‘From premium to a single focal point and offering EDOF IOLs: Race for progress’ at the some degree of spectacle independence by European Society of Ophthalmology improving near and intermediate vision (SOE) meeting in Nice, France. with minimal impact on distance. Actually, “The progress in optics in recent years allows “EDOF” design one goal for different efficient compensation of accommodation concepts : extended focal zones, asphericity loss. Trifocal lenses have emerged as the modulation, pinhole. She added that clear winners in Europe for presbyopia these lenses are also more “forgiving” for correction for multitasking patients, and the remaining refractive error than multifocal new extended depth-of-focus (EDOF) lenses IOLs, minimising haloes and glare and also offer a compelling compromise that may reducing contrast sensitivity loss at distance. extend the number of patients and surgeons “What all this technology equates to interested in these solutions,” she said. is that these IOLs are very well adapted In a wide-ranging lecture focusing on for ‘social vision’, to enable people to recent developments in “premium” lens accomplish tasks such as computer work, designs, Prof Cochener-Lamard said that cooking, shopping, playing games, and today’s surgeons can choose from an everoutdoor activities. This is apparent when increasing array of "advanced" monofocal, we study the binocular defocus curve multifocal and extended depth of focus IOL in a dome-shaped EDOF lenses that options to meet their patients’ needs. they perform particularly well at these She said that progress over the past intermediate distances,” she said. decade has been particularly noteworthy in Compared to earlier multifocal lenses, the terms of presbyopia-correcting IOLs, with EDOF lenses generate a high degree of patient the emergence of concepts designed to satisfaction, noted Prof Cochener-Lamard. compensate for the loss of accommodation, “We have carried out several comparative when we are still looking for a true studies of these diffractive lenses at our accommodative IOL, that could restore clinic in Brest and the patient satisfaction accommodation. was consistently high for all the IOLs that “The race for progress has focused we studied. I think the fact that these IOLs on two priority objectives: to offer deliver good quality of vision, maintaining spectacle independence by restoring contrast sensitivity and with a very low effective vision at all distances while incidence of optical phenomena such as optimally respecting the quality of vision, haloes and glare, accounts for the high particularly in terms of contrast vision percentage of satisfied patients,” she said. and night driving,” she said.

The key to obtaining optimal outcomes The range of diffractive multifocal with EDOF IOLs, and indeed other EUROTIMES | OCTOBER 2019

It is vital to select patients who are motivated and have reasonable expectations, who understand the compromises involved and who aren’t looking for perfection Béatrice Cochener-Lamard MD, PhD.

multifocal lenses, lies in careful patient selection, education and counselling, advised Prof Cochener-Lamard.

“It is vital to select patients who are motivated and have reasonable expectations, who understand the compromises involved and who aren’t looking for perfection. It is important to discuss with them issues such as neuro-adaptation, dependence of surrounding light conditions, degradation of night vision, and the risk of certain sideeffects before the surgery,” she said.

Surgeons should avoid implanting these lenses in patients with ocular diseases such as glaucoma, maculopathy, corneal abnormalities, moderate amblyopia, strabismus, ocular surface disease or poor binocular vision.

With uptake of multifocal IOLs still representing only about 4-to-5% of the total global IOL market, Prof CochenerLamard said that a lot of work needs to be done to educate ophthalmologists and the wider medical community of the potential benefits of these lenses.

“There are a lot of factors holding back the market, often based on fears related to complications experienced with older models, but which are no longer an issue with today’s lenses,” she concluded.

SPECIAL FOCUS: CATARACT & REFRACTIVE

Stopping anterior chamber bleeding Intracameral phenylephrine found to have benefit in small case series.

Cheryl Guttman Krader reports

I

ntracameral injection of phenylephrine appears to be an effective treatment for stopping intraoperative anterior chamber bleeding, reports Mukhtar Bizrah, MD, FRCOphth.

At the 2019 meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada, Dr Bizrah, Cornea fellow and senior resident, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, England, reported success using this approach in three patients.

The experience, which involved injection of 0.3mL of undiluted 2.5% phenylephrine, is also summarised in a published paper Dr Bizrah co-authored with Melanie C Corbett, MD, FRCS, FRCOphth (Ophthalmol Ther.

2019;8(1):137-141).

“To our knowledge, this is the first report of intracameral injection of phenylephrine to successfully stop anterior chamber bleeding during surgery.”

Intraocular bleeding during anterior segment surgery creates a challenging situation for the surgeon because it can obscure visualisation, and if it is not controlled, it can lead to intraoperative and postoperative complications. Intervention by tamponade using viscoelastic, air or saline can sometimes fail to control significant bleeding, or it might provide only a temporary fix with the bleeding restarting following further intraocular manoeuvres, he explained.

Furthermore, the increase in IOP that occurs with tamponading can cause pain for patients being operated on under topical anaesthesia, as well as optic nerve damage in patients with very advanced glaucoma, said Dr Bizrah.

All three patients in the case series were undergoing cataract surgery and one was having a combined procedure with suprachoroidal stent (CyPass Micro-Stent) insertion. All patients had received topical phenylephrine preoperatively for pupil dilation administered as drops or as the fixed combination phenylephrine/tropicamide conjunctival insert (Mydriasert). All cases were performed with irrigation solution containing 0.1% adrenaline.

In all cases, the bleeding stopped completely within 30-to60 seconds after the phenylephrine injection, and the surgery was completed successfully without any further bleeding.

Postoperative follow-up showed no eyes developed hyphaema.

Dr Bizrah said that the efficacy of the intracameral phenylephrine in these eyes that received phenylephrine previously by topical and irrigating solution containing adrenaline may be explained by the more potent vasoconstrictive effect of a high concentration of phenylephrine when injected intracamerally at the time of the bleeding.

“One patient who was at risk for intraoperative floppy iris syndrome had also received intracameral phenylephrine at the start of surgery. Bleeding only stopped when phenylephrine was re-injected 15-to-20 minutes later when iris bleeding started. The efficacy of the intracameral injection of phenylephrine may therefore be due to a direct vasoconstrictive effect on the exposed bleeding vessel,” he noted.

Discover a New World New Features!

Biomechanical Comparison Display Unique: Stress-strain curves Biomechanical assessment after LVC Glaucoma screening software

OCULUS Corvis ® ST Novel diagnostic solutions based on corneal biomechanics Biomechanical assessment before refractive surgery has been essential since the introduction of the Tomographic Biomechanical Index.

The Corvis® ST software now includes novel features that open up the field for further applications such as laser vision correction and corneal crosslinking.

A new revolutionary glaucoma screening software completes the update.

www.cornealbiomechanics.com

Follow us!

Mukhtar Bizrah: m.bizrah@doctors.org.uk EUROTIMES | OCTOBER 2019

13

14

SPECIAL FOCUS: CATARACT & REFRACTIVE

Ophthalmologist, treat thyself Study examines preferences of ophthalmologists for their own procedures. Dermot McGrath reports

NUMBER 1!

83% of readers are satisfied or very satisfied with EuroTimes

Reach

48,900

*

*Average net circulation for the 10 issues circulated between 1 February 2018 to 31 December 2018.

See www.abc.org.uk Results from the

EuroTimes Readership Study 2017

W

hen it comes to choosing anaesthesia, intraocular lens type and other key aspects of cataract surgery, what would ophthalmologists choose for their own cataract procedures and how would their choices compare to actual real-world practices?

The answer, according to a study presented by Raphaël Barugel MD at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris, France, is that the majority of ophthalmologists would prefer manual phacoemulsification under sedation with a monofocal hydrophobic implant targeting emmetropia and with the use of a prophylactic intracameral antibiotic.

“There were some interesting findings, particularly the high percentage of ophthalmologists who said that they would select a multifocal lens for their own surgery, which is at variance with the very small number of multifocal IOLs that are actually implanted every year in France,” he said.

Dr Barugel’s study was based on 264 responses to a questionnaire distributed to ophthalmologists in France between November 2017 and May 2018. The questionnaire comprised 14 questions relating to the key steps of cataract surgery including choice of implant (monofocal/multifocal, white/yellow filter, hydrophobic or hydrophilic), targeted refraction, anaesthesia, antibiotic prophylaxis and surgery type (manual or femto-cataract). Respondents were also asked about their type of practice and the volume of cataract surgeries, if any, that they performed every year.

In terms of preferred IOL, 74% of respondents said they would choose a monofocal implant for their own surgery, while 25% said that they would opt for a multifocal lens.

“When we look at real-world practice, we see that only around 5% of IOLs implanted in 2016 were multifocal implants so there is quite a large discrepancy there between what ophthalmologists would choose for themselves compared to what they actually implant for their patients,” he said.

Almost 91% of respondents said they would prefer standard manual phacoemulsification to femto-cataract. Of those 8.8% who would opt for a femto-cataract procedure, some 46% preferred a multifocal IOL, compared to 23% for those who selected manual surgery. Over half (55%) of respondents said they would choose intraoperative sedation, and 83% said they would request intracameral antibiotic prophylaxis.

Dr Barugel noted that the preferences expressed by the ophthalmologists were usually in line with the precepts of evidence-based medicine (i.e. preference for hydrophobic versus hydrophilic lens material) while the choices were more nuanced when debate was still ongoing (i.e. choice of white or yellow filter IOLs).

While the study had clear limitations, Dr Barugel added that it would nevertheless be interesting to perform similar studies for other aspects of ocular surgery, in particular refractive surgery, in order to shed some light on preferred treatments for presbyopia where multiple options are currently available to patients.

Raphaël Barugel: rbarugel@yahoo.fr

EUROTIMES | OCTOBER 2019

SPECIAL FOCUS: CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 9 MONTH: SEPTEMBER 2019

REDUCING ENDOPHTHALMITIS WITH MOXIFLOXACIN Intracameral moxifloxacin prophylaxis significantly reduces postoperative endophthalmitis rates in various types of cataract surgery, including those with complications such as posterior capsule rupture (PCR), a study of more than two million cases indicates. That data came from a retrospective multi-centre clinical registry of 10 regional Aravind Eye Hospitals in India. The majority of these patients had manual small-incision cataract surgery (MSICS), with private patients having phacoemulsification surgery with a foldable IOL, and a few patients requiring manual extracapsular cataract surgery.

Patients receiving moxifloxacin prophylaxis had an injection of 0.1mL containing 0.5mg of moxifloxacin into the anterior segment at the end of surgery. The was associated with a significant decline in the endophthalmitis rate, from 0.07% to 0.02%. This was independently significant for phacoemulsification and for MSICS. A Haripriya et al., JCRS, “Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: Results from 2 million consecutive cataract surgeries”, Volume 45, Issue 9, 1226-1233.

TORIC ALIGNMENT WITHOUT MARKING Conventional corneal marking can lead to postoperative toric intraocular lens misalignment. Researchers evaluated the OPMI Lumera 700 microscope and CALLISTO eye cataract surgery for toric IOL alignment in 50 eyes of 50 patients. The image-guided system enabled “easy and exact toric IOL alignment”. The absolute difference between the aimed toric IOL axis and the positioned toric IOL axis after the IOL implantation was 0.52 ± 0.56 degrees (range 0.01 to 2.76 degrees). RM Varsits et al., JCRS, “Evaluation of an intraoperative toric intraocular lens alignment system using an image-guided system”, Volume 45, Issue 9, 1234-1238.

USING PREDICTION ERRORS TO IMPROVE RESULTS The primary limitation of intraocular lens power formulas today is the accurate prediction of the effective lens position (ELP). Formulaspecific adjustments based on the prediction error (PE) of the first eye in cataract surgery can produce more accurate prediction of the ELP in the second eye, new research suggests. A retrospective study analysed 139 patients in Australia and 605 patients in the UK who underwent delayed sequential bilateral cataract surgery. The prediction error was determined by comparing postoperative subjective refraction with the predicted postoperative refraction calculated by the Barrett Universal II, Hoffer Q, Holladay I, and SRK/T formulas. Adjustment coefficients were derived for each formula and applied to the second eye’s IOL calculation. Separately, patient-specific optimised IOL constants were derived from the first-eye PE and applied to the second-eye calculation. Second-eye refinement via either method improved the percentage of patients achieving the refractive target with their second eye. A Turnbull et al. JCRS, “Using the first-eye prediction error in cataract surgery to refine the refractive outcome of the second eye”, Volume 45, Issue 9 1239-1245.

The editors of the JCRS extend congratulations to the annual award winners!

2018 OBSTBAUM AWARD BEST ORIGINAL ARTICLE

Surgical Management of Negative Dysphotopsia Samuel Masket, MD, Nicole R. Fram, MD, Andrew Cho, BS, Isaac Park, BA, Don Pham, BS J Cataract Refract Surg 2018; 44:6–16

2018 ROSEN AWARD BEST TECHNICAL ARTICLE

Streamlined Method for Anchoring Cataract Surgery and Intraocular Lens Centration on the Patient’s Visual Axis Vance Thompson, MD J Cataract Refract Surg 2018; 44:528-533

JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | OCTOBER 2019

15

11th EuCornea Congress

AMSTERDAM 2 – 3 October 2020 RAI Amsterdam, The Netherlands

www.eucornea.org

CORNEA

Gene editing for dystrophies Pursuit of a novel, highly specific, personalised strategy.

Cheryl Guttman Krader reports

A

new personalised CRISPR gene-editing approach could offer a new avenue in the treatment of inherited corneal dystrophies, according to research reported at the 2019 annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada.

The majority of inherited corneal dystrophies, including transforming growth factor-β-induced (TGFBI) corneal dystrophies, are caused by dominant-negative mutations.

In the case of TGFBI corneal dystrophies, more than 70 different TGFBI mutations have been described to date.

Successful gene therapy for such genetic diseases where haploinsufficiency is not an issue requires a mutant allelespecific silencing approach, with one guide specific for each mutation.

Having shown that “conventional” CRISPR/Cas9 gene editing is able to target less than half of the TGFBI mutations and also lacks sufficient specificity to secure gene editing of the mutant allele only, researchers at Ulster University, Northern Ireland, and Avellino Labs, California, US, went on to develop a novel allele-specific CRISPR approach to target all TGFBI mutations.

M Andrew Nesbit, PhD, Senior Lecturer in Molecular Biology at the Biomedical Sciences Research Institute, Ulster University, Coleraine, Northern Ireland, described the work being carried out by the Ulster team and discussed its broader application to autosomal dominantly inherited genetic diseases.

The research is being led by Professor Tara Moore, Professor of Personalised Medicine, Ulster University. Their approach is a “catch all” or “all in one” method in which a dual cut is made at two sites that flank a number of mutations.

“With this approach we are able to provide Avellino Labs, our industrial partner, with a more commercially realistic approach to gene therapy with a significantly reduced number of guides requiring regulatory approval and clinical trial authentication.

Through our continued research efforts, we are now able to simultaneously target a number of mutations with one therapeutic guide,” Dr Nesbit explained.

Applying the technique on the DNA of a patient with R124H Avellino corneal dystrophy showed it provided efficient and specific gene editing. Looking at how well the dual-cut approach worked, the researchers found it could make deletions as large as tens of kilobases. Yet the results indicated that even with the allele-specific method, special care needs to be taken to avoid potential off-target effects.

Use of the CIRCLE-seq technique to define the on- and offtarget effects of the editing showed that the on-target site was detected with a high read count in all samples. However, a number of potential off-target sites were also identified, some of which were confirmed in the patient’s cell line.

“We believe, however, that our dual-cut CRISPR mutation deletion approach will minimise these risks because it requires cutting of two nearby sites before any gene editing takes place,” Dr Nesbit said.

CRISPR-Cas9 uses the CRISPR-associated protein 9 enzyme to snip complementary strands of DNA, allowing for very specific gene editing. CRISPR is an abbreviation for clustered regularly interspaced short palindromic repeats.

M Andrew Nesbit: a.nesbit@ulster.ac.uk EUROTIMES | OCTOBER 2019

17

18

CORNEA

A L LO G E N E I C tissue engineering Corneal transplant alternative shows promise in initial clinical trial.

Cheryl Guttman Krader reports

A

fibrin-agarose-based anterior lamellar corneal substitute is a feasible and safe treatment for severe trophic corneal ulcer or its sequelae, and preliminary data also show some encouraging signals of efficacy, reported researchers at the annual meeting of the Association for Research and Vision in Ophthalmology (ARVO), in Vancouver, Canada.

A phase IIA clinical trial finished the follow-up of the first five patients who received the fibrin-agarose-based substitute, enrolled at different centres in Spain. Now, a comparative study is under way that is randomising patients 2:1 to receive the bioengineered corneal substitute or an amniotic membrane transplant, reported Miguel González-Andrades MD, MSc, PhD. “Treatment for corneal blindness today is similar as in 1905, when the first human penetrating keratoplasty was performed.

However, there is a lack of corneal donors, a lack of corneal transplantation readiness and inability to successfully perform the transplantation in certain severe cases for which the procedure has a poor prognosis. It is in this context that more than 10 years ago, we set out to develop a corneal substitute,” explained Dr González-Andrades, Maimonides Biomedical Research Institute of Córdoba and Reina Sofia University Hospital, Córdoba, Spain.

Dr González-Andrades worked on the development of the bioengineered implant during his Ophthalmology residency and PhD training in the Tissue Engineering Group of the University of Granada, Granada, Spain. The bioengineered graft material is manufactured at the GMP facility of the Cell Production & Tissue Engineering Unit at the University Hospital Complex of Granada.

It is prepared by co-culturing allogeneic human corneal epithelial cells on top of a fibrin-agarose scaffold and allogeneic human corneal fibroblasts within the scaffold. The clinical trial is promoted and coordinated by the Andalusian Network of the Design and Translation for Advanced Therapies.

The implantation procedure involves Miguel González-Andrades MD, MSc, PhD

Visual acuity improved in two patients, and hopefully we will be better able to evaluate change in visual acuity in future phases of the study

EUROTIMES | OCTOBER 2019

removal of the damaged tissue after partial trephining of the recipient cornea. The stromal substitute is sutured into place with 10-0 nylon.

Eligibility criteria for the clinical trial required that patients have stage 3 Mackie corneal ulcers not responding to conventional medical treatment or sequelae from a previous stage 3 Mackie corneal ulcer, such as stromal fibrosis or corneal thinning, that had no effective therapeutic alternative.

Stromal involvement not reaching the Descemet membrane was another inclusion criteria.

Dr González-Andrades said that the five patients enrolled in the first phase all had mild-to-moderate limbal stem cell deficiency, corneal fibrosis, light perception visual acuity and retinal and/or optic nerve disease.

Safety evaluation is the main focus of the study.

Therefore, the five patients were sequentially enrolled at an interval of at least 45 days, and the trial protocol incorporated strict stopping rules that considered various adverse events and complications.

“There were no corneal infections, graft-related inflammation, rejections or detachments,” reported Dr González-Andrades.

There was good integration of the transplanted tissue in all eyes. The scaffold degrades after a few months, and in vivo confocal microscopy imaging performed after it disappeared identified stratified metaplastic epithelium in all cases and keratocytes in the stroma in some eyes.

Clinical evaluation was performed using the Sotozono Eye Complications Grading System. Dr González-Andrades reported that the mean total score was significantly improved from baseline at three, six, 12 and 24 months. Component scores showed all patients had improvements in superficial punctate keratopathy and conjunctival hyperaemia, and some patients showed improvements in corneal epithelial defect, neovascularisation, opacification and keratinisation.

The study also evaluated corneal and conjunctival staining using the SICCA ocular staining score. The results showed a global improvement during follow-up with a benefit that was statistically significant at 24 months. Assessments of lacrimal gland and tear function using a Schirmer test and tear break-up time showed no change.

Subjective data were collected via a questionnaire, and the patients’ responses showed improvement in symptoms, particularly pain. In addition, all patients said that they would be willing to repeat the transplantation procedure.

Dr González-Andrades noted that the severity of the initially enrolled cases preclude using visual acuity to assess efficacy.

“Visual acuity improved in two patients, and hopefully we will be better able to evaluate change in visual acuity in future phases of the study,” he said.

Miguel González-Andrades: mgandrades@gmail.com

SmartSight: level up your vision.

Minimally invasive for maximum delight.

SCHWIND SmartSight® • Intelligent eye tracking for maximum safety • Cyclotorsion compensation for effective treatment • Improved eye comfort through innovative patient interface geometry • Fast achievement of good vision through smooth lenticular surface • High flexibility through compact design

SCHWIND SmartSight® is the most advanced minimally invasive femtosecond laser procedure without a flap. This innovative refinement of lenticule extraction combines maximum safety with highly predictable vision outcomes. Intelligent eye tracking with pupil recognition and cyclotorsion compensation enable very easy and precise centring.

The curved patient interface substantially reduces pressure on the eye during positioning, for more patient comfort. The compact design and user-friendly operation provide maximum flexibility and allow very efficient corneal surgery workflow.

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

EUROTIMES | OCTOBER 2019

20

CORNEA

Anterior segment gene therapy Achievements in the laboratory create optimism for clinical translation.

Cheryl Guttman Krader reports

G

ene therapy has been successful in preclinical studies as intervention for various conditions affecting the anterior segment, and the results hold promise for clinical application in the future, reported Alexander V Ljubimov PhD at the 2019 Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada.

Providing an overview of gene therapy for anterior segment disease, Dr Ljubimov described research using various vectors and focusing on a growing number of molecular targets. He noted that current trends include the prevalence of topical gene administration and increasing use of nanocarriers for gene delivery. Gene-editing techniques for inherited diseases are also emerging as a gene therapy variant that is beginning to be applied to corneal dystrophies.

“There is a race to translate these systems to the clinic and to obtain FDA approval,” said Dr Ljubimov, Director, Eye Program Board of Governors Regenerative Medicine Institute, and Professor of Biomedical Sciences and Neurosurgery, Cedars-Sinai Medical Centre, University of California Los Angeles School of Medicine, Los Angeles, USA. The ease of access to target tissues and the availability of a variety of diagnostic tools that can be used for monitoring outcomes make gene therapy an attractive therapeutic option for diseases affecting anterior segment structures. Currently, progress is being made with gene therapy for diseases affecting the cornea, conjunctiva, lacrimal glands and trabecular meshwork.

“Gene therapy has been successfully tested in various model systems and in animals using various viruses for delivery as well as using plasmids, microRNA, self-delivery siRNA and nanoconstructs. Administration routes have included topical, intrastromal, subconjunctival and anterior chamber injections.

Of course, non-invasive delivery with topical administration represents the ideal scenario,” said Dr Ljubimov.

CORNEAL GENE THERAPY Dr Ljubimov’s research focuses on corneal gene therapy and he devoted a portion of his talk to describing the work being done in his laboratory to address corneal epithelial wound healing problems in patients with diabetes.

Based on the identification of various molecular alterations in diabetic corneas, Dr Ljubimov and colleagues developed adenovirusbased gene therapy approaches targeting those abnormalities and tested them in both cultured human diabetic limbal epithelial cells and in a human diabetic corneal organ culture system. He reported the best results were achieved with a triple combination approach that was designed to silence matrix metalloproteinase-10 and cathepsin F and upregulate c-met proto-oncogene.

“The combination gene therapy essentially normalised epithelial healing time as well as the expression of several putative epithelial stem cell markers,” he said.

Although the expression of transgenes was not negatively impacted using the combination approach, toxicity was EUROTIMES | OCTOBER 2019

encountered in stem cell-enriched cultures. To overcome that problem, an alternative treatment was designed using a non-toxic nanopolymer that had covalently attached antisense oligonucleotides inhibiting cathepsin F and microRNA-4093p, which suppresses c-met expression.

Results of experiments using the latter approach showed that wound healing was accelerated in both the cultured cell system and whole diabetic corneas. In addition, restoration of the expression of putative stem cell markers – keratin 15, keratin 17 and ABCG2 transporter – was documented with immunostaining and Western blots. “Now we hope to expand the approach to target additional markers and perhaps explore combination therapy,” Dr Ljubimov said.

Gene therapy with delivery of the β-glucuronidase gene has been successful for ameliorating mucopolysaccharidosis type VII. Researchers have also used decorin, Smad7, BMP7 and c-met genes, antisense to opioid growth factor receptor gene, and an inhibitor of microRNA-146a to alleviate scarring and burn injury and to enhance wound healing.

Gene therapy is also being investigated for its potential to improve corneal graft survival with approaches that include silencing or upregulating certain interleukin genes or transfer of the Bcl-xL gene to reduce apoptosis that is associated with graft failure.

Herpes simplex virus (HSV) keratitis is another target for corneal gene therapy research. Studies have been done targeting HSV glycoprotein genes, inflammatory mediators and degradation of the HSV genome.

In addition, pathologic corneal neovascularisation has also been successfully reduced through transduction of s-Flt-1, Flt23K, pigment epithelium-derived factor, endostatin genes and microRNA-204.

OTHER ANTERIOR SEGMENT TARGETS Gene therapy approaches that have been successful in the laboratory for counteracting conjunctival scarring include those that increased expression of Smad7, PPARγ and the dominant negative mutant for p38MAP kinase. Gene therapy directed at the lacrimal gland is being studied as a possible treatment for dry eye disease. Alleviation of dry eye symptoms has been demonstrated using adenoviral-based gene therapy targeting TNF-α inhibitor, and interleukin-10 gene therapy was shown to improve signs of Sjögren’s syndrome. In addition, increased tear production has been achieved using nanoparticle delivery of the MUC5AC gene.

Gene therapy for glaucoma is focusing on increasing outflow facility through the trabecular meshwork, and research in this area includes attempts to increase expression of cyclooxygenase-2, prostaglandin F synthase and matrix metalloproteinase-3. In addition, CRISPR/Cas9-based gene editing in a mouse model of myocilin-associated glaucoma was shown to knockdown expression of the mutant myocilin gene and reduce IOP. Ljubimov@csmc.edu: Ljubimov@csmc.edu

ESCRS PARIS REVIEW

Béatrice Cochener-Lamard at the official Opening Ceremony of the 37th Congress of the ESCRS

ESCRS five-year strategic plan

T

he phenomenal success of the ESCRS has been built on a culture of innovation and a desire to keep pace with the evolving needs of its members, said ESCRS President Professor Béatrice Cochener-Lamard.

Announcing the launch of a five-year strategic plan at the Opening Ceremony of the 37th Congress of the ESCRS, Prof Cochener-Lamard said it was important for the society to innovate and fine-tune its mission to better serve its members through high-quality clinical research and education.

“This aspiration is captured in the vision statement of our strategic plan, which states that by 2025 we want the ESCRS to be the leading community and trusted source for science, education and professional development in the fields of cataract and refractive surgery,” she told the 37th Congress of the ESCRS in Paris, France.

The other key component of the strategic plan is the mission statement, which will position the ESCRS as “an independent platform to share latest

scientific results and clinical knowledge, to promote research and to provide education, thereby supporting our members in continuing their professional development and delivering the best possible eye care”, she said.

The plan will focus on five principal areas, said Prof Cochener-Lamard: the members, research and education, partnerships, representation of interests and organisation and finance.

“We are here to serve you, the members, and promote a European vision of a Society that we can all participate in for the ultimate benefit of our patients,” she said.

Prof Cochener-Lamard said that the ESCRS is currently providing funding of €4 million for a wide variety of research projects in cataract and refractive surgery, with two new projects approved this year.

BINKHORST MEDAL LECTURE President Cochener-Lamard presented the Binkhorst Medal to Ehud Assia MD, at the Opening Ceremony.

The capacity to “think outside the box” and not be afraid to challenge conventional thinking represents a powerful means to advance medical science and has been the creative starting point for many key innovations in cataract surgery, said Dr Assia.

“In order to come up with new ideas and innovations we often need to think differently, to approach things from a different perspective or in an unconventional way so that we can see things that we have not imagined or thought of before,” he said.

In a wide-ranging lecture, Dr Assia spoke about the power that comes from challenging conventional thinking and how this approach directly led to his own various innovations in the field of cataract surgery.

Innovation is a continuous and ongoing process, said Dr Assia, citing the amusing quote of the Commissioner of the United States patent office Charles Holland Duell, who in 1889 stated that “everything that can be invented has been invented”.

“I think he got that one wrong,” said Dr Assia, noting that there are now over 10 million patents in the United States alone and the number continues to increase every year.

ESCRS HERITAGE LECTURE Professor David Spalton delivered the second ESCRS Heritage Lecture at the Congress.

Prof Spalton’s lecture focused on the origins of cataract surgery, taking delegates on a journey through ancient Egypt, classical Greece, ancient Rome and the medieval period right up to the advent of extracapsular surgery in the 18th Century.

He revealed the trials, tribulations and triumphs of cataract surgery as practised through the ages, describing a rich tapestry of medical history interwoven with characters such as Galen, Kepler, Rembrandt and many others.

At the end of the lecture Prof Spalton received the ESCRS Heritage Lecture Trophy from Prof Cochener-Lamard.

PETER BARRY FELLOWSHIP The winner of the ESCRS Peter Barry Fellowship Grant was Dominika WróbelDudzińska.

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

EUROTIMES | OCTOBER 2019

21

22

ESCRS PARIS REVIEW

David Spalton delivering the 2019 ESCRS Heritage Lecture

The Origins of Cataract Surgery Some of the delegates and presenters who attended the Young Ophthalmologists Programme

Pearls for YOs

O

ne of the highlights of the 37th Congress of the ESCRS was the day-long Young Ophthalmologists Programme, Starting Phaco.

The Programme was chaired by Oliver Findl, Simonetta Morselli, Filomena Ribeiro and Kaarina Vannas.

The Programme started with Paul Rosen MD, who spoke about preparing for the first operation, while Nino Hirnschall MD, PhD, advised attendees on what one needs to know in the field of biometry.

Richard Packard MD, FRCS, FRCOphth, introduced ideas around OVD and viscoelastics, while Nic Reus MD, PhD, covered capsulorhexis and hydrodissection.

Brendan Strong from the ESCRS introduced the Society’s iLearn platform, an online learning resource that is free for members and offers more than 30 hours of interactive and accredited elearning content. Mor Dickman MD, PhD, spoke about the value of registries such as the ESCRS-sponsored EUREQUO. Larry Benjamin FRCS(Ed) FRCOphth DO, and Oliver Findl, MD, FEBO, spoke about different aspects of phacoemulsification, while Filomena EUROTIMES | OCTOBER 2019

Ribeiro MD, PhD, FEBO, offered wisdom in inserting intraocular lenses.

Dr Findl, Secretary of the ESCRS and Chairperson of the Young Ophthalmologists Committee, said that the environment of this session encouraged interaction and discussion. “A lot of questions arise. And I think these are questions which are relevant to everybody who learns cataract surgery.”

He commended the bravery of young surgeons who show videos of procedures where they run into difficulty, be they normal or extraordinary cases. “Because we all essentially make the same mistakes.

And we all run into these problems at some point. You get different tips from different panellists. And I think it’s very instructive, and probably the best way to learn in this kind of format,” he added.

The Young Ophthalmologists also had a session on Cataract Surgery: Learning From Our Mistakes, which featured video-based didactic lectures.

This included sessions on Getting the crack, Avoiding a posterior capsule tear, How to approach PEX patients, How to handle IFIS and small pupils, Doing the first anterior vitrectomy and Which IOL now.

I

f a physician … open a tumour (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels…”

– Code of Hammurabi, Mesopotamia, 1750 BCE References to cataracts and ocular surgery date back to antiquity, and couching cataracts – pushing the lens out of the capsular bag to restore light perception – has been practiced the world over. But breakthroughs in understanding the anatomy and physiology of sight in the 16th and 17th Centuries paved the way for Jaques Daviel to perform his first successful cataract extraction in 1747, said David Spalton FRCS, FRCP, FRCOphth at the ESCRS Heritage Lecture 2019 “The Origins of Cataract Surgery”.

Using instruments remarkably similar to today’s, by 1756 Daviel reported 434 extractions with 88% successful, a marked improvement over couching, Dr Spalton said. Refinements accelerated through the 19th Century, with development of foundational surgical techniques by Albrecht von Graefe, and anaesthesia. Invention of the intraocular lens by Sir Harold Ridley and phacoemulsification by Charles Kelman MD were the other two key developments that made cataract surgery the most widely performed and highly successful procedure it is today.

“Many surgeons have made great contributions, but Daviel was the first of the four great pioneering surgeons,” Dr Spalton concluded.

ESCRS PARIS REVIEW

Congress News AI is the way of the future

A

rtificial intelligence is improving the precision of intraocular lens (IOL) power calculations and is the future, Damien Gatinel MD, France, told the Journal of Cataract and Refractive Surgery Symposium ‘Controversies in Cataract and Refractive Surgery’ session.

Dr Gatinel spoke in favour of using AI technology, specifically deep learning to create adaptive algorithms, for IOL power calculation formulas, adding that we now have access to tremendous amounts of high-quality data and storing Damien Gatinel, MD and analysing it is becoming faster and cheaper.

Dr Gatinel outlined positive data results on a new AI-based formula that he was involved in developing himself – PEARL-DGS, which was developed using optical and machine learning modelling to predict the effective lens position (ELP) and adjust for extreme biometric values.

The study results for PEARL-DGS compare favourably to classical formulas, and it is good for short and long eyes and complicated cases, including those with previous corneal refractive surgery, he reported.

The more information you get, the more refined the algorithm becomes, Dr Gatinel explained, noting that there was a significant improvement when doing second eye calculations.

Concluding, Dr Gatinel said the IOL calculation community needs a comprehensive “hold-out” data set, independently comparing all existing formulas, across the various eye types and complications, to determine the best options.

Optical modelling for negative dysphotopsias

R

esearchers appear to have moved towards a hypothesis that explains negative dysphotopsias perceived by some pseudophakic patients, but more work is needed to fully understand the aetiology of these bothersome dark shadows, said Michael J Simpson, PhD. Speaking during a Clinical Research Symposium on “Understanding and Dealing With Dysphotopsias”, Dr Simpson discussed work he has been doing with ray-tracing to help characterise the mechanism underlying negative Michael J Simpson, PhD dysphotopsias and the challenges for developing a better understanding.

He explained that with large visual angles, “vignetting” of light at the edge of an IOL is likely to be the primary cause of negative dysphotopsias that are perceived with a small pupil.

“The main image goes dark in the periphery with a small pupil, and light can also miss the IOL. As the pupil opens, the shadow effect rapidly disappears, and this sensitivity to pupil size may explain why patients find the phenomenon bothersome,” said Dr Simpson, an optics expert from Arlington, Texas, USA. Looking ahead, he noted that elucidating the cause of negative dysphotopsias will require research to fill gaps in data on its related parameters.

Far peripheral vision has been a neglected topic, and information is needed on pupil diameters, visual angles and specific IOL design characteristics associated with the dark shadows, said Dr Simpson.

Balancing life and ophthalmology

W

orking and looking after a family can be challenging at the best of times, but for young ophthalmologists in training it can be an especially daunting task.

‘How To Balance Ophthalmology And Family Life’ was the title of this year’s John Henahan Prize, which attracted more than 61 entries, one of the highest number of entrants since the competition was launched in 2008.

The judges had a difficult task in making their choice but in the end, they decided that the outstanding essay was written by Dr Luke Sansom.

Luke Sansom Dr Sansom studied medicine at the University of Leeds, United Kingdom, and is an ST5 Ophthalmology specialist trainee in the Yorkshire and Humber deanery.

He received a travel bursary worth €1,000 to attend the 37th Congress of the ESCRS and a special trophy was presented to him at the Video Awards Session.

Emanuel Rosen, chief medical editor of EuroTimes and chairman of the judging panel, said all the submissions were of the highest quality and selecting an overall winner was extremely difficult.

“Dr Sansom described, in an entertaining manner, the difficulties of combining the physical and mental decisions that were necessary to do justice to the requirements of learning ophthalmology with all that entailed with the needs of his wife and his young family transplanted into a new and initially difficult environment,” said Dr Rosen.

EUROTIMES | OCTOBER 2019

23

24

PARIS PICTURE GALLERY

PICTURE GALLERY

EUROTIMES | OCTOBER 2019

PARIS PICTURE GALLERY

PICTURE GALLERY

EUROTIMES | OCTOBER 2019

25

26

EURETINA PARIS REVIEW

Caroline Klaver

Smokers unaware of risks to eyes

EURETINA president Sebastian Wolf addressing delegates at the Opening Ceremony of the 19th EURETINA Congress

World’s largest retina meeting

S

ebastian Wolf, president of EURETINA, told delegates attending the 19th EURETINA Congress in Paris that EURETINA now holds the title of largest retina meeting in the world.

“The success of the annual Congress has been remarkable; EURETINA today holds the title of largest retina meeting in the world.

And with more than 6,800 in attendance in Paris, including more than 5,600 delegates, I am delighted to announce that this 19th Congress is also the largest in the history of the Society,” said Prof Wolf.

Prof Wolf said the significance of EURETINA runs far beyond the success of its annual meetings.

“This year we organised, with the help of the Czech Society, a successful educational Winter Meeting in Prague, while next March we look forward to bringing the Winter Meeting to Vilnius, Lithuania,” he said.

Prof Wolf said education has always been high on the agenda for the society, both in its meeting and online endeavours.

“This year the society took a major step by EUROTIMES | OCTOBER 2019

investing heavily in research and opening two funding calls in the field of research.”

The introduction of the EURETINA Retinal Medicine Clinical Research Funding Call provides grant opportunities to EURETINA members of up to €300,000, said Prof Wolf.

Additionally, EURETINA teamed up with Fight for Sight to establish a call for funding of up to €2 million for clinical research projects, to address the best treatment option for sub-macular haemorrhage caused by AMD, a major unanswered question in retina.

“Once again, an external team of expert judges was established to review applications, from which a clear winner was identified. I am delighted to announce the winning applicant as Professor Timothy Jackson, of King’s College London (KCL).”

Prof Wolf concluded his speech saying that the Congress was a culmination of the efforts of each chairperson, speaker and delegate, who had travelled to be at the Congress.

P

atients seem more likely to consider the risk of blindness as a better reason to quit smoking than the risk of dying,” said Professor Caroline Klaver, Rotterdam University Medical Center, the Netherlands. “And yet, many smokers are not aware of their habit’s risk of eye disease, so I believe it is our responsibility as ophthalmologists to inform them.”

Dr Klaver addressed delegates during the EURETINA session on the epidemiology of retinal disease at the 19th Annual EURETINA Congress at the Palais des Congrès in Paris, France.

Smoking is known to significantly increase the risk of retinal arterial branch occlusions eightfold.

The risks of developing both neovascular AMD and geographic atrophy, as well as Graves’ orbitopathy, optic neuropathy, intermediate uveitis and dry eye are also increased in smokers.

SYNERGISTIC EFFECT “The synergistic effect of smoking and genetic risk is particularly strong,” said Dr Klaver, increasing the risk by about 50% compared to non-smokers.

The risks to eye health can even start before birth: maternal smoking during pregnancy increases the risk of strabismus in offspring by 50%, although the pathogenesis is unknown.

“Despite these risks, only about 40% of eye patients who smoke are aware of smoking-related eye diseases,” she said, citing a study performed by the UK National Health Service.

EUCORNEA PARIS REVIEW

10th EuCornea Congress

EuCornea President Jesper Hjortdal and Poster Winner Lional R. Daniel Ponniah

Antimicrobial implants study Jesper Hjortdal, President of EuCornea, speaking at the Opening Ceremony

EuCornea is getting stronger

T

he EuCornea Congress is going from strength to strength every year, with approximately 600 delegates attending this year’s event, the Opening Ceremony heard.

Welcoming delegates to the 10th EuCornea Congress in Paris, France, EuCornea President Jesper Hjortdal MD said there was a choice of excellent educational sessions for those attending.

“We are delighted to host a joint session in collaboration with The Cornea Society, an update on ectatic diseases. As another new initiative, a limited number of wetlab courses on DMEK surgery led by Dr Federico Badala and our faculty colleagues will also be available,” he said during the Opening Ceremony.

Dr Hjortdal said that EuCornea was very pleased once again to partner its annual meeting with the 37th Congress of the ESCRS and the WSPOS Subspecialty Day. As part of this collaboration, a combined EuCornea/ESCRS Symposia took place on the topic of “Cataract Surgery in Eyes with Diseased Corneas”.

Dr Hjortdal also drew attention to the Congress update on the work of the European Cornea and Cell Transplantation Registry (ECCTR), a European Consortium that aims to build an EU webbased registry in the field of cornea. 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 in ophthalmic surgery.

He also reminded delegates to check out the latest copy of JEuCornea, the journal of the EuCornea, noting that it was open for article submissions.

Finally, he thanked all organisers, chairpersons and speakers for their invaluable role in creating such a highcalibre scientific programme for the 10th Congress.

Finishing his speech, Dr Hjortdal introduced the EuCornea Medal Lecturer, Sadeer B Hannush MD, USA, who spoke on the topic of “Clinical Corneal Research: Why It Is Important to Get Involved”.

“A

novel in situ sustained release drug delivery system for infective keratitis” was the topic of this year’s EuCornea Congress Winning Poster in Paris.

Poster winner Lional R. Daniel Ponniah MD, Dr Agarwal’s Eye Hospital, South India, outlined findings from his prospective interventional non-comparative clinical trial, which demonstrated the efficacy of implantable intracorneal sustained-release antimicrobials in posterior corneal infections and abscesses.

Cases with posterior corneal infections were enrolled, while implantable antimicrobials were used in the interface during therapeutic lamellar keratoplasties too.

A deeper corneal plane was fashioned either manually or by femtosecond lasers with one-to-two incisions, through which antimicrobial implants were positioned.

Results were analysed using daily anterior segment optical coherence tomography and slit lamp photography.

Implants (n=16) were removed between three-to-five days after surgery and were re-implanted if required (n=2).

Analysis showed that significant levels of antimicrobials were reached in less than eight hours after implantation, and prolonged release was noted after 72-to-96 hours.

In all cases the infections were resolved.

Dr Ponniah concluded that the newer in situ sustained-release drug delivery system showed an optimal therapeutic effect in deep corneal infections in terms of prolonged corneal contact time, enhanced ocular bioavailability, patient compliance and reduced surface toxicities.

EUROTIMES | OCTOBER 2019

27

28

WSPOS & GLAUCOMA DAY PARIS REVIEW

WSPOS

ESCRS/EGS Glaucoma Day 2019

SUBSP ECIALT Y DAY

Paolo Nucci

Francisco Goñi

Diagnosing glaucoma

Cataract surgery & aniridia

ttentive evaluation of the optic disc provides invaluable information for diagnosing glaucoma, but establishing a diagnosis of glaucoma based on optic disc appearance usually requires the combination of different signs, said Francisco Goñi MD at the ESCRS/EGS Glaucoma Day meeting.

Dr Goñi discussed how to recognise typical optic disc features in early disease. However, he showed how various “typical” features can lack specificity for glaucoma and thus the need to place individual findings in the context of a complete examination.

“When a sign is detected, search carefully for other signs,” said Dr Goñi, Barcelona, Spain.

To evaluate the optic disc, he recommended that the examination be performed through a dilated pupil and before knowing findings from IOP measurement and OCT imaging.

“If you know the patient’s IOP and OCT, you will be biased to judge the optic disc,” he explained. Then, clinicians should follow a systematic approach, and they should always compare the appearance of the optic disc between eyes.

ood outcomes are difficult to achieve when performing cataract surgery in eyes with aniridia, said Paolo Nucci MD at the WSPOS Subspecialty Day. He noted that cataracts typically develop in aniridia in patients at an age when the requirement for good vision is at its greatest, around the age people are learning to drive. However, in his experience, only a minority of cases will benefit from such procedures.

Both conventional phacoemulsification and femtosecond laserassociated cataract surgery are highly problematic in anridia patients due to corneal opacity and weak zonules. In addition, the irregularity of the cornea makes it difficult to achieve a perfect capulorhexis, said Prof Nucci, Director, University Ophthalmology Clinic, of San Giuseppe Hospital in Milan, Italy.

He added that capsular tension rings are not useful in eyes with aniridia because the zonular weakness in eyes with the condition extends the entire perimeter of the capsular bag.

A

Pearls and pitfalls Both computerised perimetry and structural tests are sensitive for detecting early glaucoma, but there is potential for false positives with each. Speaking at the ESCRS/EGS Glaucoma Day meeting, Anders Heijl MD discussed considerations for building certainty when diagnosing glaucoma.

Patient age and IOP are two meaningful factors to think about, said Dr Heijl, Lund University, Malmö, Sweden. “It is rather unlikely that young patients with a low IOP have glaucoma,” Dr Heijl said.

To avoid being misled by false positives with functional testing, clinicians should look to see if early apparent field loss is reproducible. When reviewing the OCT printout, the potential for mass significance should be considered, and structural findings should always be consistent with functional findings.

He concluded by cautioning against making uncertain glaucoma diagnoses, noting the potential harm.

EUROTIMES | OCTOBER 2019

G

Aniridia and keratopathy Speaking during the WSPOS Subspecialty day, Neil Lagali PhD, Institution for Clinical and Experimental Medicine, Linköping University, Sweden, said that research is continuing to reveal the multifaceted nature of aniridia-associated keratopathy (AAK).

He noted that AAK is a condition that leads to progressive opacification of the ocular surface, which in most cases leads to corneal opacification. It is difficult to treat with keratoplasty because of the associated high risk of graft rejection.

In addition, inflammatory mediators play a role. A study that he and his associates conducted showed tear film activation of six different immunomodulators and reduced levels of IL1-RA. He added that genotype testing is critical for prognosis of AAK. Some 70% of cases with PTC/CTE mutations are progressive, leading to eventual conjunctivalisation of the entire cornea and the 10% with chromosomal deletions have an aggressive phenotype at young age. On the other hand, the 10% of patients with the PAX6 non-coding mutations have a mild, non-progressive phenotype, as is the case with the 10% with missense mutations.

RETINA

Gut reaction Research suggests that a healthy gut microbiome correlates with healthy eyes.

Roibeard Ó hÉineacháin reports

W

estern lifestyles are leading to an infancy and trials of interventions in humans have up to now increasing incidence of diabetes. Poor involved only small numbers of patients. However, it is a nutrition is contributing to an unhealthy reasonable hypothesis that microbiota-driven disease may be gut microbiome, with loss of microbial associated with eye conditions, said Sinead Corr PhD, Trinity diversity. This in turn may be contributing College Dublin, Dublin, Ireland. to poor ocular health. This can have serious long-term The dysbiosis of the gut microbiome that is associated with consequences for vision, according to speakers at a symposium obesity and diabetes may also contribute to diabetic retinopathy. held at the Annual Conference of the Irish Society of The well-established role of diet in the prevention of Ophthalmologists in Galway, Ireland. age-related macular degeneration (AMD) also points Since the beginning of the industrial revolution, to a potential role of gut biome imbalance in that social progress has meant that fewer people are condition. In addition, around 10% of IBD cases are dying from communicable diseases and more people accompanied by manifestations in the eye such as are instead dying of non-communicable diseases. uveitis and conjunctivitis.

Such diseases primarily include cancer, diabetes In regard to AMD, she noted that studies using a and cardiovascular diseases. There is much research mouse model of the disease have shown that animals that implicates lifestyle choices and poor diet in all receiving oral antibiotics and germ-free mice had a these conditions. The accompanying adverse changes reduced disease severity. Furthermore, in mice fed a Monique Hope-Ross to the gut microbiota may be one of the mechanisms high-fat diet and patients with AMD there are increased FRCP, FRCS, FRCOphth implicated in the development of these diseases, said phylum amounts of Firmicutes species, but reduced Monique Hope-Ross FRCP, FRCS, FRCOphth, UK. Bacteroides species, and a lower number of fatty-acid digesting “Diet is not only a means of preventing disease, it is also bacteria. Gut microbiome dysbiosis may contribute to elevated a way of treating disease,” she added. This has now formerly complement levels and chronic overactivation of complement entered clinical practice, where low-carbohydrate programmes cascade, Dr Corr said. for people with diabetes are showing remission of diabetes.

She noted that obesity has reached epidemic proportions in UNBALANCED GUT MICROBIOME modern industrialised societies around the world, where an Research has also shown that autoimmune uveitis has a gut estimated 55% of people are overweight. Diet affects the microbial signature associated with disease severity of gut microbiome and so-called western diets with high uveitis in mice and that oral antibiotics reduce severity, proportions of refined carbohydrates and fast foods while germ-free mice are protected from the condition. have adverse effects on the gut microbiota.

An unbalanced gut microbiome may provoke or

worsen autoimmune uveitis, in that the microbiota activate T cells, which migrate to the eye and react to As an extreme example, Dr Hope-Ross cited the case retinal proteins, she said. of a celebrated young Chinese man who attained a The ocular surface appears to have its own weight of 175kg on a diet that consisted primarily of microbiome, Dr Corr noted. In 2009, the Bascom fast food. In addition, he had a voracious appetite, which Palmer Eye Institute, University of Miami, Florida, Sinead Corr PhD he could never satisfy. An analysis of his gut microbiome initiated the Ocular Microbiome Project. The researchers revealed that it was composed of predominantly one species, found that eyes with infections of the cornea had reduced compared to the average of 1,500 species in healthy people. An bacterial diversity. expert in obesity and the microbiome moved him to a plantShe noted that manipulation of the gut microbiome can, in based diet; not only did he lose weight, but his microbiome experimental settings, reduce and eliminate the gut’s response greatly increased in bacterial diversity and he was not hungry to inflammatory stimuli. It may therefore also be possible to all the time. improve disease resistance by manipulating the ocular biome.

At the opposite extreme are the Hadza people in northOne approach is to apply commensal bacteria directly to central Tanzania, modern-day hunter gatherers whose way the surface of the eye. In one study involving seven patients, of life is likely similar to the ancestral culture of all of treatment with probiotic lactobacillus acidophilus eye drops humanity. Death from non-communicable diseases is rare in for four weeks resulted in a modest reduction in signs and this indigenous ethnic group. Their diet is composed entirely symptoms of conjunctivitis. of plants that they obtain through foraging and hunting such Another approach is to treat the eye indirectly by improving as wild berries, tubers, honey and wild meat, when available. the gut biome. In a study involving 62 patients, oral Their gut microbiome has the greatest bacterial diversity of any administration of lactobacillus over a period of eight weeks population anywhere. appeared to alleviate eye fatigue caused by blue light exposure.

Dr Hope-Ross noted that some species of bacteria appear to “Where we go next with microbiome research is to determine be especially beneficial to health. However, in order to thrive the specific impacts of individual microbiota, elucidate the in the gut, they need a hospitable environment, which in turn mechanisms that mediate microbe-host interaction and apply depends on a healthy diet and other lifestyle factors. that knowledge to therapeutic aims,” Dr Corr concluded.

There are very few studies concerning the impact of the microbiome and ocular disease. Although some observations Monique Hope-Ross: monique.hopeross@icloud.com have been made, this area of research is very much in its Sinéad Corr: corrsc@tcd.ie

EXTREME EXAMPLE

EUROTIMES | OCTOBER 2019

29

30

RETINA

th

Euretina Congress Amsterdam

1–4 October 2020

RAI Amsterdam, The Netherlands Instructional Course & Symposium Submission Deadline: December 20 2019

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 242 ISSUE: 3

META-ANALYSIS CONFIRMS ANTI-VEGF EFFICACY FOR BRANCH RETINAL VEIN OCCLUSION A new meta-analysis appears to confirm the comparable safety and efficacy of anti-VEGF therapies for patients with cystoid macular oedema (CME) secondary to branch retinal vein occlusion (BRVO). The meta-analysis included a total of 1,236 eyes from 22 studies randomised controlled trials with aflibercept, bevacizumab and ranibizumab. It showed that anti-VEGF treatment demonstrated an overall mean improvement in BCVA at 12 months of 14 letters (p<0.001) and a reduction in central foveal thickness of 228 µm (p<0.001). In addition it showed that the 12-month gains at 12 months were maintained to month 24, with a mean gain of 12.5 letters (p<0.001), as was the reduction of CFT (238µm, p<0.001). No cases of endophthalmitis or glaucoma were reported in any study. The authors suggest that randomised controlled trials are needed to compare the efficacy of the different ant-VEGF agents. K Spooner et al, “Current Outcomes of Anti-VEGF Therapy in the Treatment of Macular Oedema Secondary to Branch Retinal Vein Occlusions: A MetaAnalysis”, Ophthalmologica 2019, Volume 242 Issue 3.

GLOBAL STRATEGY SUGGESTED FOR EARLIER INTERVENTION IN DIABETIC RETINOPATHY

www.euretina.org

This month’s issue includes the text of the 2018 EURETINA Lecture, which calls for a paradigm shift in the management of diabetic retinopathy with the accent on early intervention. Noting that diabetic retinopathy is the leading cause of blindness in working-aged adults and that diabetes is projected to affect 642 million adults by 2040, with 75% residing in low- and middleincome countries, the authors suggest that newer strategies like telemedicine and artificial intelligence should be developed to intervene with secondary and primary prevention measures in a multi-pronged whole-of-society approach at regional and national levels. TY Wong et al, “Strategies to Tackle the Global Burden of Diabetic Retinopathy: From Epidemiology to Artificial Intelligence”, Ophthalmologica 2019, Volume 242 Issue 3.

ROBUST EVIDENCE NEEDED FOR GENETIC TESTING AND GENE THERAPY FOR HEREDITARY RETINOPATHIES This month’s issue also includes the text of the Ophthalmologica Lecture delivered at the 18th EURETINA Congress. The lecture discusses the barriers that remain to translate gene testing for monogenetic hereditary retinal diseases into a clinically useful tool.

The author stresses the importance of precisely and consistently capturing phenotypic information, including natural history data, in order to accelerate the implementation of clinical genetic interventions. PI Sergouniotis, “Inherited Retinal Disorders: Using Evidence as a Driver for Implementation”, Ophthalmologica 2019, Volume 242, Issue 3.

Ophthalmologica is the peer-reviewed journal of EURETINA

EUROTIMES | OCTOBER 2019

RETINA

Vitrectomy for Myodesopsia Vitreous floaters – from ‘nuisance to disease’.

Dermot McGrath reports

W

hile ophthalmologists have not always fully appreciated the extent to which vitreous floaters may severely impact on the quality of life of their patients, that perception is finally changing thanks to research efforts to define objective and quantitative metrics of vitreous structure and visual function in patients suffering with floaters, according to J. Sebag MD, FACS, FRCOphth, FARVO. “The real question in considering vitreous floaters is whether this is a nuisance or a disease. If you ask the patients it is clearly a disease. Studies have shown that the negative impact of vitreous floaters is considered by patients to be equivalent to age-related macular degeneration and greater than glaucoma and diabetic retinopathy,” said Dr Sebag in the inaugural Robert Machemer Lecture delivered at the European Society of Ophthalmology (SOE) meeting in Nice, France.

Dr Sebag added that patients bothered by vitreous floaters are willing to accept a 7% risk of blindness and exchange one out of 10 years of their remaining life just to be rid of their floaters. Despite the deleterious impact that floaters have on a patient’s quality of life, the medical profession continues to downplay or dismiss their significance, said Dr Sebag, who is Senior Research Scientist at the Doheny Eye Institute/UCLA, Professor of Clinical Ophthalmology at the Geffen School of Medicine, UCLA, and Founding Director of the VMR Institute for Vitreous Macula Retina.

“A typical doctor will say that it is a nuisance – there is no tear or hole in the retina, so just deal with it. Because of this prevailing attitude, we have not met the needs of our patients suffering from vitreous floaters,” he said.

He added that the root of the “callous attitude” of physicians to floaters stems from the absence of objective clinical indices of structural and functional abnormalities with which to define it. To address this gap, Dr Sebag and co-workers have worked to develop specific indices such as contrast sensitivity function

(CSF), quantitative ultrasound and floaterspecific visual function questionnaires in order to define Vision Degrading Myodesopsia as a disease.

“I’ll be the first to admit that ‘visiondegrading myodesopsia’ does not exactly roll off the tongue, but it sounds like a disease and I think psychologically that is the first step in beginning the process of getting doctors to accept vitreous floaters as a disease,” he said.

Floaters most commonly occur in middle age due to age-related changes in vitreous structure and light scattering by the posterior vitreous cortex after collapse of the vitreous body during posterior vitreous detachment (PVD), explained Dr Sebag.

“The most common event in the life of the human vitreous is PVD and there are two critical components for a PVD: you have to have liquefaction of the gel but also weakening of the vitreoretinal adhesion to allow the collapse of the vitreous body. Both of these events are required in tandem for an innocuous PVD to occur,” he said.

In younger patients, floaters are most often due to myopic vitreopathy, a worrying fact given the worldwide epidemic in myopia, said Dr Sebag.

“This is a real problem because studies have estimated by the year 2050 there will be almost 5 billion people in the world with myopia. If myopic vitreopathy plays an important role in disturbed vision then we need to pay attention to that because it will be a growing problem,” he said.

An increasingly common treatment option for floaters has been Nd:YAG laser vitreolysis, which is largely ineffective, said Dr. Sebag.

Although further study is warranted, a Cochrane Database Review in 2017 concluded that there are no clinical

J. Sebag MD, FACS, FRCOphth, FARVO

studies proving efficacy of YAG laser vitreoylsis and other scientific papers show only a limited success rate in a small minority of patients “This is probably because Nd:YAG photodisruption does not ablate. It takes large particles and renders them smaller and the net effect may not be improvement in vision and account for the disappointing results we have seen in the scientific literature,” he said.

Limited vitrectomy is currently the most effective treatment for severe floaters, said Dr Sebag, who recently published a case series of 195 eyes of 145 patients with good outcomes.

“It normalises contrast sensitivity function and improves patients’ well-being with few short-term complications and even fewer long-term ones,” he concluded.

Thus, greater efforts should be made to listen to patients more attentively when they complain of vitreous floaters, to further study the disease scientifically and to develop new methods to cure the condition safely. Only then will we have achieved what Dr Sebag described as the goal of modern Medicine: “To help people die young... as late in life as possible.”

(– Dr Ernst Wynder, American Health Foundation) J. Sebag: jsebag@VMRinstitute.com EUROTIMES | OCTOBER 2019

31

32

GLAUCOMA

Diurnal IOP Is monitoring 24-hour fluctuations useful for managing glaucoma?

Howard Larkin reports

T

hanks to new technology including home tonometers and contact lens sensors, monitoring intraocular pressure (IOP) around the clock is getting easier. But while circadian IOP fluctuation has been known for more than a century, what role does it play in glaucoma progression? And can monitoring it help guide treatment?

In a playful boxing-themed debate, two heavyweight experts squared off over these serious questions at the Glaucoma Subspecialty Day of the 2019 ASCRS ASOA Annual Meeting in San Diego, USA.

IOP VARIATION MATTERS Arguing for 24-hour IOP monitoring, Ike K Ahmed MD of the University of Toronto, Canada, presented a case of open-angle glaucoma progressing despite office-measured IOPs consistently in the mid-teens. Home tonometry revealed frequent lateevening spikes above 30mmHg in one eye and wide variations in both. Based on this additional information, Dr Ahmed performed a MIGS procedure to reduce peak IOP and fluctuations.

“Measuring IOP only in office hours is highly likely to miss the

Ready when you are.

• EBO – ESCRS Examination • iLearn • On Demand • Media Player • Cataract Tutorial Group • Landmark Journal Articles • Case Studies • Course Handouts • ESCRS Study Portals (PREMED, Endophthalmitis) and more...

Continue your education all year

with our new range of online resources

Visit education.escrs.org

EUROTIMES | OCTOBER 2019

patient’s peak pressure, which is where conventional thinking is where the damage occurs,” Dr Ahmed said.

Studies suggest that peak IOP occurs between 9:30pm and 7:00am in 75% of patients, and detecting these higher pressures often leads to therapy changes. Wider IOP fluctuation is associated with greater risk of ocular hypertension progressing to glaucoma, higher risk of glaucoma progression and greater visual field loss, Dr Ahmed noted.

Similarly, two large studies, the Collaborative Initial Glaucoma Treatment Study (CIGTS) in 2011 and the Advanced Glaucoma Intervention Study (AGIS) in 2004, found IOP fluctuation a stronger independent predictor of visual field progression than mean IOP. Dr Ahmed allowed that other large studies, including the Early Manifestation Glaucoma Trial (EMGT) in 2007, did not find IOP fluctuation a significant factor. However, this may be because the EMGT patients’ IOP was not as well controlled as in AGIS and CIGTS, suggesting fluctuation may be a bigger problem in treated eyes with lower pressures.

Diurnal IOP variation can help determine how invasive a procedure is needed for patients progressing at apparently “normal” pressures, Dr Ahmed said.

“If glaucoma is progressing at 12, are the pressures fluctuating or is it really progressing at 12? If they are fluctuating [into the high teens or more], we don’t need to aim for a pressure of 8, we may aim for 12 and have it consistent.

“On the other hand, if someone has low teens and they don’t fluctuate much, that’s when we pull out the big guns like trabeculectomy” to achieve stable single-digit pressure.

“It’s 2019. Let’s think of IOP of more than a single office measurement. Peak IOP and fluctuations are useful in glaucoma management,” Dr Ahmed concluded.

IOP VARIATION IS NORMAL Arguing against diurnal monitoring, Douglas J Rhee MD of Case Western Reserve University in Cleveland, USA, noted that wide second-to-second IOP variation is normal, increasing nearly 10mmHg from position changes and up to 60mmHg in forced blinking. If IOP variation caused glaucoma, this physiological variation would make it much more common.

Dr Rhee found the literature unconvincing. Only four published studies have examined circadian IOP fluctuation without an associated intervention, and all were retrospective comparisons that did not establish causality, he noted. In addition, several large studies, including the European Glaucoma Prevention Study (EGPS), EMGT and the Ocular Hypertension Treatment Study (OHTS), found no connection between progression and IOP variation.

Perhaps more importantly, diurnal IOP variability increases with higher mean IOP, Dr Rhee pointed out (Zeimer RC. Ch 21, Shields, Ritch and Krupin. Mosby 1996). “Variation is just a marker for mean IOP.” However, inter-visit IOP variation is important because it often indicates a treatment failure that should be addressed, Dr Rhee said.

Lastly, if IOP variation were the cause, trabeculectomy, which virtually eliminates it, would be curative, Dr Rhee argued. But it’s not, especially if it doesn’t achieve low pressure.

“Too high is too high,” Dr Rhee concluded. And the audience agreed; Dr Rhee was judged to have won the debate.

GLAUCOMA

Phaco over trab or shunt for PACG Cataract extraction may be better first surgical option than trab or tube.

Howard Larkin reports

A bright vision on illumination

T

he proven success of phacoemulsification in treating primary angle closure (PACG) makes cataract surgery a better first-line surgical treatment choice than trabeculectomy or tube shunts with their related complication risks, Reay H Brown MD told the Glaucoma Subspecialty Day at the ASCRS ASOA Annual Meeting, in San Diego, USA. “This is very evidence based. Phaco is an effective glaucoma treatment in all stages of angle closure – early or late, IOP normal or high, cataract or clear lens, even with angles closed for years,” said Dr Brown, of Atlanta, USA. Dr Brown’s experience with phaco for angle closure dates back more than a decade, when he treated a 47-yearold woman with multiple iridotomies and angles closed for six years on maximum medications. With her intraocular pressure (IOP) spiking to 31mmHg and nerve cupping in the right eye, a glaucoma specialist recommended trabeculectomy.

Dr Brown tried clear-lens cataract surgery and goniosynechialysis instead.

Today, the patient’s IOP runs in the teens with no meds and 20/20 vision.

“It’s like she doesn’t even have glaucoma. She’s much better off without a Reay H Brown MD tube or trab,” he said.

The case was among those he submitted for an early case series demonstrating the potential of cataract surgery as a PACG treatment (Brown et al. JCRS 2014; 40:840-841). The EAGLE study confirmed the concept, recommending clear-lens extraction as a first-line option for treating PACG (AzuaroBlanco et al. Lancet 2016; 388:1389-1387).

It’s like she doesn’t even have glaucoma.

She’s much better off without a tube or trab

WHEN TO CONSIDER PHACO Poor IOP control on multiple medications is a good indication that surgery may be needed, particularly if pilocarpine is one of the meds, Dr Brown said.

“Chronic pilocarpine is … nature’s way of telling you that you need to do cataract surgery,” he noted.

Long-term pilocarpine can result in small, fibrotic pupils, Dr Brown noted. However, such cases can be successfully managed with careful pupil expansion and devices including iris hooks and the Malyugin ring, he said.

Ultra-shallow anterior chambers may be the most difficult challenge in angle-closure phaco, Dr Brown said. In cases where the chamber is too shallow or the pupil touches the cornea, about five seconds of dry pars plana vitrectomy can deepen the chamber enough for cataract extraction.

“It may take all of our surgical skills, but most of the time the cataract surgery is routine. The main challenge is not how [to surgically treat PACG] but why and when,” Dr Brown concluded.

Directional Chandelier system delivers illumination where you need it

Directional function Patent Pending

29G Spotlight Directional Chandelier A new generation chandelier with major improvements in functionality and ease of use.

• Directional Chandelier system designed to enhance illumination control • Wide view fiber tip for global endo-illumination • Easy insertion and fixation of the fiber with 29G valved entry system • 29G minimal invasive incision

bvimedical.com

vitreq.com

Reay H Brown: reaymary@comcast.net EUROTIMES | OCTOBER 2019

33

34

GLAUCOMA

Slowing glaucoma progression Blocking connexins in retinal astrocytes may help protect the optic nerve.

Howard Larkin reports

A

growing body of research suggests that connexin 43 (Cx43), a transmembrane cellular protein that facilitates chemical signalling between cells, may play an important role in glaucoma progression.

Blocking its effects in injured and diseased retinal tissues may slow neurodegeneration, Helen Danesh-Meyer MBChB, MD, PhD, told the Glaucoma Subspecialty Day at the 2019 American Society of Cataract and Refractive Surgery Annual Meeting in San Diego, USA. Recent insights into the role of astrocytes and Cx43 in creating an environment that perpetuates neurodegeneration could revolutionise the understanding of glaucoma, possibly answering questions including why it often progresses even in eyes with well-controlled intraocular pressure (IOP), said Dr Danesh-Meyer, who is Sir William and Lady Stevenson Professor of Ophthalmology at the New Zealand Eye Centre, Auckland, NZ. “We’ve been focused on the retinal ganglion cell in our glaucoma research. …

To take glaucoma treatment to the next step we need to consider the environment, the astrocytes that surround RGCs,” Dr Danesh-Meyer said.

CHANGING THE NEURONAL ENVIRONMENT Astrocytes surround axons throughout the optic nerve head and make up much of the neuroglia, which is thought to persist as neurons die in glaucoma, possibly explaining the “floor effect” in nerve fibre layer thinning seen in advanced cases. Astrocytes support cellcell communication, microenvironment control, “glio” transmitters, neuroplasticity, neuroinflammation and long-range information exchange.

In their normal physiological state, astrocytes communicate in part by passing chemical and electrical signals across cell gap junctions bridged by bundles of six Cx43 molecules known as connexons.

Connexons in adjoining cells dock with each other, forming channels that open to EUROTIMES | OCTOBER 2019

allow chemical signalling while undocked connexon hemichannels remain closed, Dr Danesh-Meyer explained.

In a pathological state the situation is reversed, Dr Danesh-Meyer noted. In addition to stressing neurons and RGCs, trauma, ischaemia and mechanical stress, including high IOP, activate astrocytes.

This causes their gap junction channels to disassociate and close, and opens undocked hemichannels, releasing signalling compounds, notably adenosine triphosphate (ATP), into the extracellular space. Extracellular ATP further stresses neurons and RGCs, and activates astrocytes resulting in astrocytosis in a self-reinforcing cycle.

Dr Danesh-Meyer and colleagues demonstrated the relationship between optic nerve injury and astrocytosis in a rat model of acute injury. Elevating IOP to 120mmHg for 60 minutes followed by reperfusion of the retina increased Cx43 protein associated with astrocytosis (Danesh-Meyer et al. Brain 2012; 135:506-520).

The evidence is strengthened by postmortem studies of glaucomatous human eyes, in which increased astrocyte activation and upregulation of Cx43 were found in the laminar cribrosa and retina compared with controls (Ker NM et al. J Clin Neuroscience.

2011; 18:102-108).

“Stress on the retina, whether it is an optic nerve crush or ischaemia or glaucoma or diabetic retinopathy, produces astrocytic activation that seems to occur following injury,” Dr Danesh-Meyer said.

“Leaky” Cx43 channels are also associated with non-ocular neuropathies, including Alzheimer’s (Frontiers in Cellular Neuroscience. 27 July 2015), as well as stroke, trauma, infection and chronic conditions such as Huntington’s disease, Parkinson’s, MS, epilepsy and migraine, she noted.

HELPFUL OR HARMFUL?

So the question becomes: Is Cx43 and astrocyte activation neuroprotective or harmful? Dr Danesh-Meyer’s research suggests the latter.

Following up her study of retinal damage to rats, administering a Cx43 hemichannel

Stress on the retina, whether it is an optic nerve crush or ischaemia or glaucoma or diabetic retinopathy, produces astrocytic activation that seems to occur following injury Helen Danesh-Meyer MBChB, MD, PhD blocker reduced vessel leakage and significantly reduced RGC loss seven and 21 days post-ischaemia (p<0.05) (DaneshMeyer et al. Brain 2016).

“This can lead to neurorescue, which suggests Cx43 and astrocyte activation is a negative process that leads to perpetuation of damage.”

A study using a Cx43 antisense compound in an animal spinal crush study reinforces the evidence, showing less scarring, inflammation and astrocytic activation, leading to improved motion in treated subjects (Mol Cell Neurosci 2008; 39:152-160).

Future research should focus on the role of connexins in chronic versus acute glaucoma, and in humans rather than animals. Whether treatment is effective when the disease process is well advanced or mild, and whether down regulation of hemichannel opening can be combined with other neuroprotective strategies are key unanswered questions, Dr DaneshMeyer said.

“We’ve focused on the neuron. Perhaps we’ve neglected the environment in which that neuron lives.”

Helen Danesh-Meyer helendm@gmail.com

36

PAEDIATRIC OPHTHALMOLOGY

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

2–4 October 2020 RAI Amsterdam, The Netherlands www.wspos.org

Treating uveitis in children Many challenges of diagnosis and treatment of paediatric uveitis.

Dermot McGrath reports

R

apid diagnosis and swift intervention with targeted treatments is essential to reduce the risk of vision-threatening complications in cases of paediatric uveitis, according to MarieHélène Errera MD, PhD. “These cases in children are typically chronic and may result in substantial ocular complications and vision loss if they are not diagnosed and treated appropriately,” she told delegates attending a World Society of Paediatric Ophthalmology and Strabismus (WSPOS) symposium held during the European Society of Ophthalmology (SOE) meeting in Nice, France.

The differential diagnosis of paediatric uveitis is extensive, noted Dr Errera, associate professor of ophthalmology at UPMC Eye Center, Children’s hospital Pittsburgh and at the University of Pittsburgh School of Medicine, Pennsylvania, United States.

As in adult patients, it is important to identify infectious versus non-infectious uveitis as well as anatomic location, since that will have a bearing on prognosis and treatment strategies, she said.

“Of non-infectious causes, juvenile idiopathic arthritis (JIA) is the most common systemic association of paediatric uveitis and accounts for between 35% and 60% of uveitis cases in children,” she said.

Pars planitis is another common idiopathic intermediate uveitis, which predominantly affects children and adolescents, and accounts for up to 28% of paediatric uveitis cases.

“Complications to watch for with pars planitis include cataract, cystoid macular oedema, vitreous opacities, glaucoma, retinoschisis, retinal detachment, epiretinal membrane and optic disc oedema.”

Other autoimmune causes of paediatric uveitis include juvenile sarcoidosis and Blau syndrome, which may also present with joint and eye involvement. Both of these conditions usually present with granulomatous ocular inflammation and can have posterior segment involvement, which is not normally found in JIA-related uveitis, she added.

Toxoplasmosis, caused by the parasite Toxoplasma gondii, is the most common cause of posterior uveitis in children and adults, said Dr Errera. It is normally unilateral and ocular manifestations include retinochoroiditis and retinal vasculitis, which can be challenging to diagnose and treat.

Sarcoidosis, a rare disease characterised by the formation of granulomas in different tissues and organs throughout the body, presents in two distinct forms in children.

“In children under the age of 5 there are usually three features present – a rash, arthritis and uveitis. In older children, the lungs, lymph nodes and eyes are affected,” she said.

Tubulointerstitial Nephritis and uveitis (TINU) is rare and possibly underdiagnosed. It presents as a sudden-onset bilateral AU in older children to young adults.

Topical corticosteroids such as prednisolone or dexamethasone remain the first-line treatment for both acute and chronic anterior uveitis, said Dr Errera, while in severe cases immunosuppressive and biological agents may be used.

The use of anti-TNF treatments such as adalimumab and infliximab may also be proposed in JIA-related uveitis refractory to conventional therapy, but also tocilizumab, abatacept and rituximab, concluded Dr Errera.

Marie-Hélène Errera: erreram@upmc.edu

EUROTIMES | OCTOBER 2019

PAEDIATRIC OPHTHALMOLOGY

Cataract in children Choosing to operate in cases of paediatric cataract depends on a range of factors. Aidan Hanratty reports

W

riting in 1982, Noel Rice and David Taylor said that “bilateral congenital cataract is the most common cause of potentially treatable blindness in infancy”. That remains the case, according to Chris Lloyd MD, who was speaking at the Annual Conference of the Irish College of Ophthalmologists in Galway, Ireland.

Studies have suggested that the incidence of cataract in infants is about 2.5 per 10,000, increasing to about 3.5 per 10,000 by the age of 15. Cataract is not a diagnosis, however, said Dr Lloyd, who is Consultant paediatric ophthalmologist at Great Ormond Street Hospital for Children in London, UK. “Cataract is derived from the Greek word for waterfall, and it tells you there’s a whitish opacity in the lens. But the severity of the opacity can vary,” he said.

“Prolonged early monocular visual deprivation in infancy causes irreversible neurological changes – you develop an abnormal lateral geniculate nucleus and an abnormal occipital cortex,” said Dr Lloyd. Early intervention – of some kind – is therefore crucial.

The density of the cataract will determine whether it requires conservative management or surgical intervention, and studies have shown that with surgery, results were best where children with unilateral cataract had surgery by six-to-eight weeks, while in the bilateral group results were best at eight-to-10 weeks (Birch et al, J AAPOS. 2009 Feb; 13(1): 67–71).

GOLD STANDARD

Lensectomy – removing the lens without inserting an implant lens – remains the gold standard procedure for young infants, said Dr Lloyd, who expressed uncertainty about the benefit of implanting intraocular lenses in infants. “Infant eyes are small, they have a hypoplastic and vascular iris, they’ve got an immature trabecular meshwork, the anterior chamber is shallow, and the eyes are floppy – the sclera is not rigid.”

Studies such as the IOLunder2 and the Infant Aphakia Treatment Study (IATS) suggest that visual acuity results were not significantly different between patients that received a lens and those that did not. There were, however, more reoperations in the implant group, while strabismus was slightly increased in children that received contact lenses.

If a child is put to sleep, Dr Lloyd is adamant that the anaesthetic not be wasted. Checking intraocular pressure, corneal diameters, B-scan ultrasonography, pachymetry, keratometry, biometry – are all things that should be done while the opportunity is there. In children under 5, a surgical posterior capsulorhexis and anterior vitrectomy is essential: “If you don’t do this, the visual axis will opacify within weeks and you’ll end up having to come back to carry out a YAG or a surgical capsulotomy.”

Where lenses are required, allowances must be made for myopic shift related to growth of the eye, and Dr Lloyd recommends a table produced by Dr Scott McClatchey from San Diego that helps calculate appropriate IOL power.

GLAUCOMA ANALYSIS GCL & RNFL

HEMISPHERE GANGLION ANALYSIS

STRUCTURE AND FUNCTION REPORT

ANGIO OCT

FULL AUTO

BIOMETRY OCT

The World’s fastest OCT The World’s first OCT Biometry The World’s first OCT Topography State-of-the-art Glaucoma analysis

manufacturer of the fi rst Spectral Domain OCT in the world

EUROTIMES | OCTOBER 2019

37

J IN US

MAY 13 – MAY 19 2020 ASCRS Annual Meeting May 15 – May 19 Boston, MA Coinciding with World Cornea Congress VIII May 13 – 15 Featuring ASCRS Subspecialty Day (Refractive, Glaucoma) May 15

Hear what others have to say about their recent ASCRS Annual Meeting experiences: “The 2019 ASCRS meeting was the highlight of my work year. I came home energized by so many great ideas on how to better treat patients and how to strengthen my practice,” Dr. John Hovanesian

“I truly believe a significant value derived from the meeting this year is how many different avenues for education of new techniques/technologies were at the 2019 meeting. From lectures, wet labs, peer to peer opportunities; so many other creative ways so that each attendee can learn the way they do best,” Dr. Zaina Al-Mohtaseb

“There’s new technology and new advancements in surgery presented every year,” Dr. Deborah Ristvedt

“With so many educational options to choose from, I’m overcome with “FOMO” at the ASCRS Annual Meeting,” Dr. David Chang

OCULAR

Diagnosing Alzheimer’s Study explores potential for assaying biomarkers in tears.

Cheryl Guttman Krader reports

T

ear biomarkers could prove useful as a diagnostic tool for Alzheimer’s disease, suggests a pilot trial conducted at Maastricht University. The research was presented by Marlies Gijs PhD, at the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada.

“Tears are known to contain thousands of molecules and specific biomarkers in tears have been identified for ocular, systemic, and neurologic diseases, but so far no one has looked for tear-specific biomarkers for Alzheimer’s disease,” said Dr Gijs, a postdoctoral researcher in the School for Mental Health and Neuroscience, Maastricht University Medical Centre, the Netherlands.

“Although Alzheimer’s disease is commonly viewed as a disorder of the brain, more and more it is being regarded as a systemic disease with dysfunctions in peripheral tissue and also the eye.”

Dr Gijs said that retinal nerve fibre layer thinning and changes in retinal vasculature are the best known ocular components of dementia. In addition, amyloid plaques have been detected in the eye and the amyloid precursor protein has been shown to be expressed by the acinar cells of the lacrimal gland and secreted into tears.

To look for tear biomarkers of Alzheimer’s disease, the study analysed levels of total-tau and amyloid-β Marlies Gijs PhD 42 (Aβ42) in samples collected using Schirmer strips. The study included 34 subjects who represented four subgroups: persons with Alzheimer’s disease, persons with mild cognitive impairment, persons with subjective cognitive impairment, and age-matched healthy controls.

Dr Gijs reported that the concentration of total-tau increased with increasing dementia severity and that the concentration of Aβ42 decreased as dementia severity increased.

A receiver operating characteristic curve analysis was also done to explore the performance of the two parameters for discriminating between healthy and diseases states, and the results were compared with those achieved using total-tau and Aβ42 levels in cerebrospinal fluid (CSF). The results showed that tear total-tau and Aβ42 each had reasonable discriminatory power – area under the ROC curve values were 0.81 and 0.725, respectively, and higher than those found using the CSF. “We are now planning a larger study with 305 patients to validate our pilot results that suggest a relationship between tear biomarkers and the severity of dementia,” said Dr Gijs.

“Our study also shows that tear biomarkers provide valuable information for non-ophthalmic conditions. That is why at the University Eye Clinic at Maastricht, we collect all Schirmer tear strips.”

Our study also shows that tear biomarkers provide valuable information for non-ophthalmic conditions

Marlies Gijs: marlies.gijs@mumc.nl EUROTIMES | OCTOBER 2019

39

40

GENDER BALANCE

Gender inequality in ophthalmology Improving women's experiences in the workplace improves life for everyone. Sorcha Ní Dhubhghaill and Diana Carmen Dragnea report

“A

re women actually upset they get paid 77 cents for every dollar a man gets, or that they get paid in change?”

– Adam Carolla, Comedian

Jokes aside, women make up more than 70% of the healthcare workforce and the proportion of women to men entering medical school is now approximately 50:50. While almost half of the assistant professors in the US are women, only about a third of full professors and even fewer (15%) heads of department are women.1 Women are also less likely to write journal articles, to be on editorial boards or to be speakers at top-level conferences.

While ophthalmology may not be the worst offender, the data from the EBO-ESCRS examination serves as an example from our own field. This subspecialist exam is geared towards accrediting experts in the field of cataract and refractive surgery but only 8% of successful candidates carrying the FEBOS-CR title are women.2 This drop-out phenomenon has been described as the “leaky-pipeline”, where the gender balance at entry level

Jokes aside, women make up more than 70% of the healthcare workforce and the proportion of women to men entering medical school is now approximately 50:50 EUROTIMES | OCTOBER 2O19

Myself, I was once asked if I would be diminishes as you climb the career ladder.3 While some of the leaky pipeline effect free to babysit for a consultant surgeon. can be attributed to time, assuming that There was no question of asking my two the incoming candidates will start to shift male colleagues present. the balance, this has not occurred at the We also sometimes feel the need to pace expected and the gender imbalance at minimise our femininity to fit in. Shorter the uppermost levels remain. haircuts, avoiding skirts and dresses Are women less capable or less in favour of power suits and adopting ambitious than their male counterparts? A colder, harsher personalities are often Canadian study showed that postoperative used as coping methods in a less than surgical outcomes are slightly better for welcome environment.7 If women cannot be themselves female surgeons.4 While I do not think that this and bring their own approach should be interpreted as women to the job, the whole idea of being better surgeons, it does diversity is lost. help debunk the myth that Another huge challenge women make worse surgeons. is addressing mid-career So, if the talent and dropout during a woman’s capacity is there, where and childbearing years. Asking why do we lose the women in a woman what her family ophthalmology? plans are during a job When we think about gender interview is not permitted but Sorcha Ní Dhubhghaill inequality in any profession, we some employers still ask about tend to focus on a number of problems it either directly or indirectly. areas such as payment, treatment at And even those who don't might be work, responsibilities, mentorships and considering it in the background. opportunities for career progression.

One (female) employer admitted to Regarding pay, a statement from the us that when given the choice of two Association of Women Surgeons reported candidates with equal qualifications, she that at the current rate that we will not chose the male because he would not take reach parity in wages until the year 2152.5 maternity leave in the near future. This Women earn approximately 90% of what can often put a woman into a position of a man earns until the age of 35, after choosing between her surgical career or which the gap significantly widens. her family plans.

Transparency in the remuneration The reality is that, while maternity process can be effective in balancing the leave is disruptive to service provision, scales as women tend to accept what they it comes with a lot more advanced are offered rather than negotiating and warning than other forms of medical pushing for more. leave, and perhaps we can work towards Treatment at work can be a trickier a flexible solution to manage it without issue to tackle. Every woman in medicine putting our mother-surgeons on a lower will have multiple anecdotes to attest to career track. a time when they were asked to perform There is hope though. Role models, tasks that would never be asked to a man.6 mentors, institutions and professional

GENDER BALANCE

When we think about gender inequality in any profession, we tend to focus on a number of problems areas such as payment, treatment at work, responsibilities, mentorships... societies can all participate in improving of alumni to help women in their midthe situation. Fortunately, there is no lack career, preparing to take the next step up. of female role models in ophthalmology.

On a larger scale, national programs From ESCRS President Béatrice like the Athena SWAN encourages Cochener-Lamard and and recognises the institutions former President Mariethat take on the cause of José Tassignon, to tireless gender balance in science, educators like Soosan technology, engineering, Jacob and the inventor of mathematics and medicine.8 Societies have their own the YAG laser for posterior parts to play. The Association capsulotomy, Daniele Aron of Research in Vision and Rosa, to name a few.

Ophthalmology (ARVO) There are so many has a programme known inspirational women in Diana Carmen Dragnea as Women in Eye and Vision our field and it is our job to Research (WEAVR) that arranges meetings, celebrate them and continue their work. workshops and mentorship programs for The University of Glasgow recently women in our field. Some travel fellowships launched a new initiative called now add additional funding for childcare to “Developing Female Medical and encourage mothers to attend the conferences Academic Leaders Scholarship that will help forward their careers.

Programme”, and Drexel University in At the end of the day, rights for women the US offers the Executive Leadership are just rights in general and achieving a in Academic Medicine (ELAM), which work-life balance is not just for the ladies. provides training and a support network

All families are unique and should be able to make choices that fit them best.

Flexible hours, job-sharing as well as maternity and paternity leave for partners and adoptive parents would help not only keep talented women working but the homestead ticking over too.

1. Year of reckoning for women in science.

The Lancet 2018:531.

2. FEBOS-CR successful candidates. https://education.escrs.org/ fellows-by-year/.

3. Krishnan N, Szczepura, A. The glass cliff effect for women in STEM. The Lancet 2018;391:2320-1.

4. Wallis CJ ea. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study.

BMJ 2017;10.

5. AWS. Womensurgeons.org.

6. Bellini M, et al. A woman’s place is in theatre: women’s perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group BMJ Open 2019:e024349.

7. Breaking the barriers. Eurotimes 2017.

8. Khan H, Moosajee M. Facing up to gender inequality in ophthalmology and visual science. Eye 2018;32:1421-2.

Please visit us at the American Academy of Ophthalmology in San Francisco Booth #2339 (South Hall)

EU-CC-NP-0014

EUROTIMES | OCTOBER 2019

41

42

EXPLORING MARRAKECH

The famous Jemaa el-Fnaa marketplace

MARRAKECH

3

FOR ...

THE LAST STORYTELLERS: TALES FROM THE HEART OF MOROCCO In 2008, UNESCO recognised Jemaa el-Fnaa as the first “Masterpiece of the Oral and Intangible Heritage of Humanity”. Storytellers have been entertaining here since the city was founded in 1070. Fascinated by the elderly men who carry on a dying tradition Richard Hamilton, the radio and television journalist, was moved to preserve this ancient art. Tracking down the last of the traditional storytellers, he produced a collection of 36 of the folk tales and fables they tell, along with the backgrounds of the storytellers themselves. Readers of this book, though they may not understand Darija Arabic, the storyteller’s language, will have some understanding of the dynamics at play as they watch the storytellers at work on Jemaa el-Fna.

By Richard Hamilton. Paperback and Kindle Editions from Amazon.

MOROCCO: A CULINARY JOURNEY… A celebration of the wide range of exotic flavours and cooking styles of Morocco. Whether you have yet to meet these dishes and are curious, or have enjoyed them on a visit to Morocco and seek to replicate them in your own kitchen, this book will inspire you. Some 80 recipes including those with Berber influences or hints of Spain, from tagines to street food, from appetisers to desserts, it’s all here – complete with enticing photos of markets and street scenes. By Jeff Koehler. Available in hardcover and Kindle versions from Amazon.

LORDS OF THE ATLAS The dramatic story of the rise and fall of the Glaoua clan, which ruled Morocco from 18931956, is traced in this acclaimed book. The story starts with Madini and T’hami El Glaoui – the sons of a Moroccan caïd and an Ethiopian concubine; they surged to power and enormous wealth at the end of the 19th Century, a time when the country was still trapped in a feudal past. Madini died in 1918, but his brother T’hami continued to enjoy a life of unimaginable splendour and unchallenged cruelty. His social circle included Winston Churchill, Colette and Charlie Chaplin, all of whom were T’hami’s guests in Marrakech. In 1953, T’hamil had his enemies’ heads impaled on his gates; only three years later, his rule collapsed.

It’s an epic story played out against a background of Marrakech and the now-ruined castles of the High Atlas. The book is illustrated with fascinating photographs. By Galvin Maxwell. Paperback and Kindle Editions from Amazon.

EUROTIMES | OCTOBER 2019

Marvellous Morocco A long list of highlights awaits delegates travelling to Marrakech. Maryalicia Post reports

I

n the 19th and 20th Centuries, the mild winter climate of L’Hivernage attracted wealthy residents of Marrakech; in this area near the foot of the Atlas Mountains they passed the winter season in luxurious comfort. Today, elegant new buildings such as the Palais de Congrès, along with the old villas and palm-lined roads, contribute to its ‘gardens and glamour’ ambience. A casino, nightclubs and fine restaurants add to the appeal.

Charm of a different sort is just a short taxi ride away. The ancient souks and narrow alleys of old Marrakech, its maze-like ‘medina’, are a living relic of an important 14th-Century town. Embellished with new museums and incredible gardens, a visit to this quarter of the Red City is an experience to remember. But hire a guide. I don’t mean one of the street guides who are drawn to tourists like ants to a picnic (and who will guide you first to their uncle’s shop) but one recommended by your hotel or a reliable service like Tours by Locals. With a proper guide, you’ll avoid getting hopelessly lost in the old town, have friendly assistance with shopping and get back to your hotel or the conference centre on schedule.

What to see? Out of a fairly long list, five highlights: The world-famous Jemaa el-Fnaa, the “square of trespassers”, has been the heart of the city for 950 years. Lively from dawn to long after dark, it’s at its peak around sunset when food sellers start setting up stalls. Populated by acrobats, musicians, dentists, snake charmers, storytellers and pickpockets, you will love it or hate it but you won’t be indifferent.

Exotic souks that begin at the edge of Jemaa el-Fnaa. Enjoy bargaining for

souvenirs, from jewelled sandals to iguana skins. https://visitmarrakech.com/discovermarrakech/art-of-living/souks Le Jardin Majorelle; a two-and-ahalf-acre complex housing the Berber Museum, the Islamic Art Museum of Marrakech and the Musée Yves Saint Laurent. Majorelle, with its fountains and collection of cacti, is open every day.

Book online to avoid discouraging queues. www.jardinmajorelle.com/en Maison de la Photographie is a small, interesting museum of street and portrait photographs, open daily from 9.30 to 19.00. http://www.maisondelaphotographie.ma/ Experience a Riad, a traditional Moroccan house built around a central courtyard with fountain or pool and a rooftop terrace. Many have been converted into memorable hotels. The list of the world’s top 25 Small Hotels 2019 included Riad le Clos des Arts (http://www. leclosdesarts.com) and Riad Kaiss (http:// www.riadkaiss.com).

A traditional Moroccan Riad

38th Congress of the ESCRS

Amsterdam

2020 3-7 October RAI Amsterdam

Instructional Course Submission Deadline 31 October 2019

www.escrs.org

Seeing more with the first digital microscope.

ZEISS ARTEVO 800 The first digital ophthalmic microscope brings a new era in visualization for greater certainty in surgery. ZEISS optics and the expansive possibilities of digital imaging enable you to see even more with greater comfort thanks to DigitalOpticsâ&#x201E;˘, AdVisionâ&#x201E;˘ and Cloud Connectivity. zeiss.com/artevo800

INDUSTRY NEWS

RingJect

™

Preloaded Capsular Tension Ring in a single use injector

INDUSTRY

NEWS

Newly patented technology

VSY Biotechnology’s invention, the Rotaryjet Preloaded Injector containing an accessory system for the storage and injection of an intraocular lens, has been registered by the European Patent Institute (EPI). This newly patented technology minimises the use of viscoelastic material in intraocular lens implantation and provides ultimate ease of use.

“The features of the Rotaryjet enable ophthalmologists to perform cataract surgeries quickly and safely. Rotaryjet offers ease of use with its specially designed lens-folding system. In this manner, cataract surgeries can be performed without having to place the lens into the injector. The aim is to reduce the humaninduced error ratio during the lens’s preparation before the surgery and to reduce the duration of the surgery by facilitating the procedure,” said a VSY spokesperson. https://www.vsybiotechnology.com/

MODEL FOR SUCCESS Around 1,200 AMARIS excimer lasers have been installed in 100 countries so far, according to Schwind. “SCHWIND users have performed more than six million treatments with AMARS technology to date. With 3.1 million treatments (52%), LASIK performed with a femtosecond laser or a microkeratome is the most frequently chosen method

by SCHWIND users since the introduction of the AMARIS,” said a Schwind spokeswoman.

Of these, 1.3 million treatments were performed as FemtoLASIK. The touchless TransPRK/ SmartSurf ACE procedure is also enjoying growing demand. https://www.eyetech-solutions.com/en

MULTIMODAL PLATFORM NIDEK CO., LTD has launched the Mirante Scanning Laser Ophthalmoscope.

“The Mirante is the ultimate multimodal fundus imaging platform that combines highdefinition SLO and OCT with ultra-wide-field imaging,” said a company spokesperson.

“The ultra-wide-field modalities of colour, FA, ICG and Retro mode allow detailed evaluation of pathologies from the fovea to the extreme periphery. The Mirante achieves a wider view of the retinal structure and vasculature with unparalleled clarity,” the spokesperson added. www.nidek.com

Action retraction mechanism for total control

CTR is extremely flexible

Long, small tip especially convenient in case of deep set eyes

Prepositioned and self-loading CTR

FDA

approved

97.70% IOL centration at 12 months*

• Management of weak zonulas • Capsular bag stabilization

* Interim Results of the United States Investigational Device Study of the Ophtec Capsular Tension Ring.

Francis W. Price et al. Ophthalmology 2005 Mar;112(3):460-5

EUROTIMES | OCTOBER 2019

45

46

ESCRS NEWS

ESCRS

NEWS

Some of the speakers and moderators at the ESCRS Academy in Warsaw

ESCRS Academy visits Warsaw Keep learning.

Stay relevant.

Learn online in your own time, with self-paced and assessed ESCRS iLearn courses on: ∙ Cataract Surgery ∙ Cornea ∙ Refractive Surgery ∙ Visual Optics

Learn more at http://elearning.escrs.org EUROTIMES | OCTOBER 2019

The ESCRS Academy in Warsaw took place during the three-day 50th Jubilee Congress of Polish Ophthalmologists.

This year’s Congress was presided over by Professor Iwona Grabska-Liberek and was also the 111th anniversary of the establishment of the Polish Ophthalmological Society.

The ESCRS Academy shared best practice in “Challenges in Cataract Surgery” and was split into two sessions. The first, moderated by Profs Wojciech Lubiński and Ewa Mrukwa-Kominek, featured Prof Iva Dekaris presenting on cataract surgery in corneal disease, Prof Thomas Kohnen on cataract surgery and glaucoma and Paul Rosen on the problems of cataract surgery in diabetic eyes.

The second session was moderated by Profs Edward Wylęgała and Marcin Stopa, with Prof David Spalton discussing cataract surgery and pseudoexfoliation with a great video on an “unforgettable” cataract surgery, Dr Roberto Bellucci on IOL calculation post-refractive surgery and myself, Alex Day, on issues surrounding cataract surgery in keratoconic eyes.

Overall, the Congress was a great experience and opportunity to discuss practice and challenging cases and the hospitality and kindness of the Polish organisers made us all feel exceptionally welcome. Alex Day, Moorfields Eye Hospital, is Associate Professor UCL Institute of Ophthalmology, London, UK

LEARNING OPTIONS ON THE ESCRS PLAYER Eye Contact is a series of interviews that are recorded at ESCRS Congresses and posted on the ESCRS Player.

They feature key opinion leaders discussing the latest research, techniques and approaches when it comes to the diagnosis and treatment across the full spectrum of ophthalmology.

These interviews also explore controversies and debates in the field.

The ESCRS Player also features Videos of the Month, where doctors introduce outstanding videos submitted to the ESCRS Video Competition throughout the year. There is also an online museum, looking at ophthalmology throughout history, as well as instructional courses and a dedicated section showing techniques performed and described by experts

CALENDAR

The 11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU) will take place in Lisbon, Portugal

NOVEMBER 33rd European Ophthalmology Congress

DECEMBER

LAST CALL

OCTOBER 2019 32nd APACRS Annual Meeting 3–5 October Kyoto, Japan apacrs2019.org

Ophthalmic Imaging: from Theory to Current Practice

4 October Paris, France https://www.vuexplorer.com/en/congres

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

EVER 2019

17–19 October Nice, France www.ever2019.org

↙

↙

14–15 November Madrid, Spain https://ophthalmologycongress. ophthalmologyconferences.com/

World Eye and Vision Congress

5–6 December Abu Dhabi, UAE https://eye.conferenceseries.com/

MARCH NEW 34th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

FEBRUARY

19–22 March Athens, Greece https://www.hsioirs.org/en/ 34th-international-congress-ofhsioirs-19-22-march-2020/

All India Ophthalmology Conference 2020

10th EURETINA Winter Meeting

13–16 February Gurugram, India https://aios.org/aioc2020.php

20–21 March Vilnius, Lithuania http://www.euretina.org/vilnius2020/

6th Annual Congress on Controversies in Ophthalmology Asia-Australia (COPHy AA)

11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU)

2020

14–15 February Bangkok, Thailand http://cophyaa.comtecmed.com/

24th ESCRS Winter Meeting Marrakech

26–28 March Lisbon, Portugal http://cophy.comtecmed.com/

MAY

21–23 February Marrakech, Morocco www.escrs.org

SFO 2020 Congress

MARCH

World Cornea Congress VIII

NEW Frankfurt Retina Meeting 2020

14–15 March Mainz, Germany www.eckardt-frankfurt.de

9–12 May Paris, France https://www.sfo.asso.fr/ 13–15 May Boston, USA www.corneasociety.org

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

EUROTIMES | OCTOBER 2019

47

48

CALENDAR

MAY

The 38th Congress of the ESCRS, 20th Euretina Congress, 11th EuCornea Congress and WCPOS V will each take place in Amsterdam, the Netherlands

18th SOI International Congress 27–30 May Milan, Italy https://www.congressisoi.com

EyeAdvance 2020

29–31 May Mumbai, India https://www.eyeadvance.org/

14th EGS Congress

May 30–June 2 Brussels, Belgium https://www.eugs.org/eng/default.asp

JUNE 20th EVRS Meeting 2020 June 11–14, Stockholm, Sweeden http://www.evrs.eu

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

JULY NEW XXI International Congress of the Brazilian Society of Ophthalmology

SEPTEMBER

OCTOBER

NOVEMBER

NEW 5th International Glaucoma Symposium

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

AAO Annual Meeting 2020

4–5 September Mainz, Germany https://glaucoma-mainz.de/

OCTOBER

2–4 July Rio de Janeiro, Brazil https://sistemacenacon.com.br/site/ sbo2020/mensagem

20th Euretina Congress

ASRS 2020

11th EuCornea Congress

23–28 July Seattle, USA www.asrs.org

1– 4 October Amsterdam, The Netherlands www.euretina.org 2–3 October Amsterdam, The Netherlands www.eucornea.org

TH

Euretina

Winter Meeting

Vilnius 20–21 March | Lithuania

www.euretina.org

EUROTIMES | OCTOBER 2019

2– 4 October Amsterdam, The Netherlands www.wspos.org

38th Congress of the ESCRS

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

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

100th SOI National Congress

25–28 November Rome, Italy https://www.congressisoi.com

24th ESCRS Winter Meeting

M arrakech

In conjunction with SAMIR (Moroccan Society of Implant & Refractive Surgery)

21 – 23 February 2020 Mövenpick Hotel Mansour Eddahbi & Palais des Congrès, Marrakech, Morocco

Abstract Submission Deadline 31 October 2019

www.escrs.org

THE ULTIMATE EXPERIENCE OF CONTROL AND CLARITY Clareon® AutonoMe™. Automated delivery of unsurpassed clarity.§,1-4

Introducing the Clareon® IOL with the AutonoMe™ automated, disposable, preloaded delivery system. With its intuitive, ergonomic design, the AutonoMe™ delivery system enables easy, single-handed control of IOL advancement and preserves incisions as small as 2.2 mm.1,5-8 Preloaded with the Clareon® IOL, it delivers a new monofocal lens with an advanced design and unsurpassed optic clarity.1-4,9-12

Talk to your dedicated Alcon representative to learn more about Clareon® AutonoMe. TM

1. Clareon® AutonoMe™ Directions for Use. 2-12. Alcon Data on File.

§Based on aggregate results from in vitro evaluations of haze, SSNGs and glistenings compared to TECNIS§§ OptiBlue§§ ZCB00V (Abbott), TECNIS§§ ZCB00 (Abbott), Eternity Natural Uni§§ W-60 (Santen), Vivinex§§ XY-1 (HOYA) and enVista§§ MX60 (B&L; Bausch & Lomb). §§Trademarks are the property of their respective owners.

© 2017 Novartis 11/17 GL-CAM-17-MK-0486-EU