EuroTimes Vol 24 Issue 12 Dec 2019 | Vol 25 Issue 1 Jan 2020 by EUROTIMES

SPECIAL FOCUS BEST OF THE BEST 37TH CONGRESS OF THE ESCRS

Dec 2019 | Vol 24 Issue 12 Jan 2020 | Vol 25 Issue 1

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Content Editor Aidan Hanratty Senior Designer Lara Fitzgibbon Designer Ria Pollock Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

3 Remembering Wolfgang Haigis (1947-2019)

SPECIAL FOCUS

THE BEST OF THE BEST

4 Key opinion leaders

discuss their highlights from the 37th Congress of the ESCRS in Paris, France

6 Thinking outside the box: this year’s Binkhorst Medal Lecture

7 Best video aided by

amusing and illustrative animations

20 Prof Béatrice CochenerLamard reflects on her time as ESCRS President

21 Small changes in power

calculations can improve toric lens performance

success for innovation prize winner

13 Animal eyes and

defocus curves win poster prizes winner focuses on clinical and scientific research

17 Personal perspectives

on exciting presentations

18 Robust ethical guidelines needed for using artificial intelligence

37 There is potential for

false positives in early diagnosis

38 A new study on

26 A high-flying dogfight of

OCULAR

keratoconus in paediatric patients

cataract and glaucoma phaco instructors from across the globe

28 Device offers new

12 Online sales key to

customised treatment can be improved

23 JCRS highlights 24 Managing co-existing

10 This year’s Henahan

Prize-winning essay

36 Current approaches to

PAEDIATRIC OPHTHALMOLOGY

clinic may help patients and surgeons

CORNEA

history of cataract surgery

GLAUCOMA

22 Streamlining the cataract

8 Heritage Lecture tracks

16 Peter Barry Fellowship

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

CATARACT & REFRACTIVE

www.eurotimes.org

approach amid shortage of corneal grafts

29 Examining newer

contact lens designs for keratoconus

30 Dealing with the

potentially fatal necrotising fasciitis

31 Age-related changes

40 Low-voltage electric

shocks can have lasting effects

REGULARS 41 Books 42 Practice Management 43 Travel 44 Hospital Diary 45 Random Thoughts 46 Society News 47 Calendar

can have a major effect on vision

32 An interview with incoming EURETINA President Prof Frank G. Holz

33 Success with gene

therapy offers reasons to be optimistic

35 Artificial intelligence

will soon revolutionise diagnosis and treatment

Supplement December 2019/ January 2020

Presbyopia & Toric IOL Correction: Keys to Success with Multifocal & EDOF IOLs

A Cataract Surgeon’s Guide to iStent inject W Improving Outcomes and Quality of Life in Cataract Patients with Mild-to-Moderate Open-Angle Glaucoma

Ocular Surface Disease Diagnosis & Management: Putting current and emerging treatment options into practice Sponsored by Supplement December 2019/ January 2020

Included with this issue... IOLs and OSD Education Forum Supplements Glaukos Supplement EUROTIMES | DECEMBER 2019/JANUARY 2020

EDITORIAL A WORD FROM BÉATRICE COCHENER-LAMARD MD, PhD

GUEST EDITORIAL

Inspiring a new generation It is important for the society to innovate and fine-tune its mission

Béatrice Cochener-Lamard

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 | DECEMBER 2019/JANUARY 2020

s President of the ESCRS, it was my great honour to welcome friends and colleagues from Europe and across the globe to the 37th Congress of the ESCRS in Paris, France. In this special edition of EuroTimes we look at some of the highlights of the Congress, which, as always, featured an excellent scientific programme. I was also honoured to announce the new five-year strategic plan for the society at the Opening Ceremony of the Congress. As I mentioned in my speech at the Opening Ceremony, it is important for the society to innovate and fine-tune its mission to better serve its members through high-quality clinical research and education. 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. We also plan to position the ESCRS as an independent platform to share the latest scientific results and clinical knowledge, to promote research and to provide I was also honoured education, thereby to announce the new supporting our members in continuing their five-year strategic professional development plan for the society and delivering the best at the Opening possible eye care. The plan will focus on Ceremony of the five principal areas: the Congress members, research and education, partnerships, representation of interests and organisation and finance. I am confident that with the wealth of talent we have in the Society we can implement this plan with imagination and confidence and inspire a new generation of cataract and refractive surgeons to serve the Society and the wider ophthalmic community. I have been honoured to serve the members for the last two years as President of the ESCRS. In January 2020, my successor, Professor Rudy MMA Nuijts, will take over as the Society’s President. I would like to thank the Board and Executive of the Society and all ESCRS members for supporting me during my time as President and wish Rudy my very best wishes and support as he takes on this great office.

Béatrice Cochener-Lamard is the President of the ESCRS and Professor and Chairman of the ophthalmology department at the University Hospital of Brest, France

OBITUARY

Wolfgang Haigis PhD 1947-2019 An Appreciation Oliver Findl MD, Secretary of the ESCRS, pays tribute to Wolfgang Haigis, who passed recently

I remember him being a very good teacher with the gift of being able to explain complex ideas in a manner that was easy to absorb...

Amsterdam

2020 3-7 October RAI Amsterdam

38th Congress of the ESCRS

s a physicist working at the University of Wurzburg, Germany, Wolfgang Haigis always tried to bring the mathematics of power calculation closer to medical doctors. Oliver Findl He will primarily be remembered as the developer of the Haigis Formula, which was conceived after years of research and mathematical deliberations and which has been used by eye surgeons all over the world for the benefit of their patients. Also, the Haigis-L formula was used for calculating appropriate IOL power in patients who have previously undergone refractive laser surgery for myopia. I remember him being a very good teacher with the gift of being able to explain complex ideas in a manner that was easy to absorb for his students and followers. He would put up slides with a lot of formulae and then try to make us understand what they were about. He taught at many courses over the years at ESCRS and elsewhere and was a renowned expert in ultrasound biometry. Later, when optical biometry came to the market, he was instrumental in optimising the IOL constants, using the User Group for Laser Interference Biometry website, which allowed us to use that data to get good results. Wolfgang Haigis PhD I would meet him on a regular basis after we developed optical biometry in Vienna. We met at a lot of meetings and at the IOL Power Club of which he was a founding member. We used to have long discussions about all kinds of issues and I knew him as somebody who had strong opinions but was always open to new ideas. I can remember there was one instance many years ago when I was a second-year resident and I produced the first paper on optical biometry. He was chairing the session and was very critical at the time. I was very young and he was a very experienced biometrist, but he was still welcoming and open. We are going to miss him and on behalf of everybody in the ESCRS I would like to pass on my sincere sympathies and condolences to his wife Katharina and his son Michael. Oliver Findl

www.escrs.org

SPECIAL FOCUS: BEST OF THE BEST

Innovative content and interactive formats elevated the 37th Congress of the ESCRS in Paris. Howard Larkin reports

ne of the more unusual events at the 37th Congress of the ESCRS in Paris involved some 2,000 ophthalmologists standing in unison for a course of stress-relieving breathing exercises led by Denmark’s Stig A Severinsen MsC, PhD. “These are very simple breathing techniques you can use the next day. It was amazing to see EUROTIMES | DECEMBER 2019/JANUARY 2020

from the podium,” said Oliver Findl MD, of Hanusch Hospital, Vienna, Austria, who co-chaired the “Surgeons Under Stress” main symposium following the Congress’s opening ceremony and Binkhorst Medal Lecture on Sunday morning. Relaxed surgeons help relax patients and vice versa, and that makes surgery less stressful for both, according to anaesthesiologist Andrew Presland FRCA,

of Moorfields Hospital, London, UK. Counselling patients in advance about exactly what they can expect in terms of pain and what they will experience can improve cooperation and outcomes. Quantitative research by Stefan Palkovits MD, also of Hanusch Hospital, showed stress during cataract surgery peaks at cracking the nucleus and declines as phacoemulsification concludes. “You

SPECIAL FOCUS: BEST OF THE BEST know that once you have the crack you are stood out this year, Prof Kohnen said. programme, said Soosan Jacob MS, nearing the end,” Dr Findl explained. Other “It’s more the format that attracts people; FRCS, DNB, of Dr Agarwal’s Group of presenters addressed effectively managing the freedom of information, unlimited Eye Hospitals, Chennai, India. She cited stressful complications, including use of spaces in Europe and it is easy to talks from the International Society of capsulorhexis run-outs, constricted pupils fly.” The society’s emphasis on creating Refractive Surgery symposium. and wobbling lenses. interactive experience is also a big factor, Brad Randleman MD spoke on Yet practical as such guidance can be, drawing 9,550 ophthalmologists and Brillouin microscopic studies of corneal it took some work convincing the 14,000 attendees overall, he added. biomechanics that demonstrated Congress Programme Committee Similarly, because of the successful the effectiveness of contact lensto tackle surgeon stress, Dr pilot approach of Free Paper Forum assisted corneal cross-linking Findl said. That the Committee initiated by Prof Cochener in 2018, this for treating thin corneas. approved and attendees year the model was generalised to all Scott MacRae discussed embraced it demonstrates free paper sessions, which were held in a femtosecond lasers to induce the value surgeons find in the large room with several sessions running refractive index changes in innovation, practicality and concurrently, with observers listening the cornea, and Dr Jacob rigour that have become the with wireless headphones. This allows presented her own research on hallmark of ESCRS meetings. smaller groups that encourage more corneal allogenic intrastromal Béatrice Cochener-Lamard “It’s not just about interaction, and allows listeners to easily ring segments to replace MD, PhD technology and technique, move from one session to another, an synthetic materials. but about doctors. Most of the approach piloted last year in Vienna, Dr Other cutting-edge papers outcome is connected to the behaviour Findl noted. “With smaller groups people Dr Jacob noted include a report on the of surgeons managing surgery. It is a nice feel more free to interact. There were a vRESPOND study that attempted to trace way to think about it; it is different and lot more questions and an interactive the path of light in patients with very successful,” said Professor Béatrice atmosphere and vibe.” negative dysphotopsias and create Cochener-Lamard MD, PhD, of the The Members’ Lounge was a virtual refractive surgery University of Brest, France. another popular feature application to treat it. The debuted in Paris. “It was NECSUS study aimed to quite nice to sit and have identify IOL characteristics CUTTING-EDGE SCIENCE a coffee. It was a very nice that may trigger Excellent research is another reason atmosphere and a welcome neuroadaptation. Gene why many surgeons consider the ESCRS addition,” Dr Nuijts said. therapy for hereditary diseases meetings among the best in the world, It might even boost and tumours, and corneal said Professor Rudy MMA Nuijts MD, membership, said Dr Findl, endothelial cell regeneration Rudy MMA Nuijts PhD, of Maastricht University, the who was pleasantly surprised for Fuchs’ dystrophy or MD, PhD Netherlands. “People are very sensitive to by its success. bullous keratopathy were other the quality of what is being conveyed on As President of the ESCRS in 2018 promising technologies presented. the podium and we stand out there.” and 2019, Dr Cochener-Lamard set out The 2019 Binkhorst Medal Lecture on to make the ESCRS more interactive, INTERACTIVE EXPERIENCE innovation by Israel’s Ehud Assia MD is she said. In addition to the lounge and Monday’s main symposium on artificial a good example, Prof Nuijts said. In it, free paper format changes the society intelligence drew another big crowd, and Dr Assia described fixating an intraocular has bolstered online and social media was another example of innovation, Prof lens to the sclera combining the Yamane offerings to engage younger members. Cochener-Lamard said. “I confess that technique with a Prolene 6-0 suture. “It’s A new two-level grant programme was it was challenging to demonstrate to the nice to see what has changed.” initiated to provide smaller sums for new ESCRS Board that AI, which is a current For IOLs, new randomised trials suggest researchers and larger awards supporting hot topic in the world, had reached a level that new extended range of vision lens major projects. of maturity sufficient in Ophthalmology may provide better intermediate vision Prof Cochener-Lamard looks forward to to be the subject of a symposium; and using an elegant wavefront approach that seeing the ESCRS increasing engagement without a doubt the meeting was a great does not create the optical disturbances with developing nations to provide more success. Besides getting the science, it seen with many multifocal and even education and collaboration through brought in how AI may change treatments extended depth of focus lenses. “If true, international partners. She also hopes and patient management and the job of this is a whole new area of IOLs opening the society will continue refining meeting being a doctor.” up,” Dr Nuijts said. programmes based on experience and Compelling as new The depth and variety of the four main member insights. research is, it’s not the only symposia, the four research symposia and Above all, Prof Cochener-Lamard reason the Paris meeting the debate format Journal of Cataract hopes the ESCRS will continue to foster and Refractive Surgery symposium solidly a vital and supportive community to anchor the scientific programme, said further advance the field and its goals. Professor Thomas Kohnen MD, PhD, “Besides science we are making great FEBO, of Goethe University, Frankfurt, relationships with people. Friendship is Germany. “If you look at these nine you in there.” get the whole story.” The greater freedom European surgeons have to test new devices means more cutting-edge research is on hand than at some meetings in the USA, Prof Kohnen added. Instructional courses also are rigorously evaluated and updated. “If they are not working, they are out. Several courses have evolved over the years.” Collaboration with other international societies further strengthened the Paris

With smaller groups people feel more free to interact. There were a lot more questions [at the Free Paper Forum] and an interactive atmosphere and vibe Oliver Findl MD

Oliver Findl: oliver@findl.at Beatrice Cochener-Lamard: beatrice.cochener@ophtalmologie-chu29.fr Thomas Kohnen: Kohnen@em.uni-frankfurt.de Rudy Nuijts: rudy.nuijts@mumc.nl Soosan Jacob: dr_soosanj@hotmail.com EUROTIMES | DECEMBER 2019/JANUARY 2020

SPECIAL FOCUS: BEST OF THE BEST

Thoughtful innovation Advancing medical science through creative thinking. Dermot McGrath reports

he 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 Ehud Assia MD in his Binkhorst Medal Lecture, delivered at the 37th Congress of the ESCRS in Paris, France. “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, Prof 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 Prof 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 Prof Assia, noting that there are now more than 10 million patents in the United States alone and the number continues to increase every year. Prof Assia’s own research has sought to develop new surgical devices and technologies by considering issues from different angles and with a non-conventional view. One such example is the side-view technique that Prof Assia developed with Dr David Apple as a new method for studying the anterior chamber anatomy in post-mortem eyes. The problems encountered by lens subluxation, usually managed by capsulestabilising devices such as Cionni Ring and its modifications or capsule hooks, also prompted Prof Assia to develop an alternative approach using a capsular anchor (Hanita Lenses). The anchor comprises a central rod placed in front Ehud Assia MD of the anterior capsule and two lateral prongs placed under the anterior capsulorhexis edge, with the tips of the prongs extending to the capsule equator to provide localised support. A new second-generation version of the anchor is currently under development, he said. Prof Assia cited yet another example of innovation, which came from dealing with small pupils during cataract surgery. Instead of iris hooks or iris-expanding rings such as the Malyugin Ring, he proposed a pupil expander that uses two spring-loaded devices inserted through 1.1mm sideport incisions opposite each other to create a rectangular pupil opening and facilitate surgery. Dr Assia devoted the greater part of his lecture to his research efforts to improve fluidics during phacoemulsification, with an emphasis on maintaining corneal endothelial safety. “There is so much more than we can do to improve phaco fluidics if we are prepared to just think unconventionally about the problems involved,” he said.

In order to come up with new ideas and innovations we often need to think differently

EUROTIMES | DECEMBER 2019/JANUARY 2020

Courtesy of Ehud Assia MD

The Tri-MICS technique and Active Fluidics

He noted, for example, that phaco surgery depends largely on fluid irrigation and maintaining the volume of the anterior chamber and intraocular pressure, usually with a passive irrigation of fluid (BSS) delivered through the machine handpiece. “This has not changed in the last 50 years since the early days of phacoemulsification. And it works well in keeping a stable anterior chamber and intraocular pressure, but only as long as the phaco tip is in the eye. Once we pull the tip out, the pressure drops and the chamber can collapse until we reinsert the irrigation line to re-establish the pressure,” he said, Maintaining a stable anterior chamber and IOP during surgery requires continuous irrigation throughout surgery, said Prof Assia. He proposed that this separate irrigation line would be the sole fluid source for the surgery which could be performed through a 1mm incision when 1mm IOLs eventually become available, he added. “My idea was to identify a method for maintaining steady pressure throughout surgery, independent of the phaco handpiece, and utilising an automated pump to achieve continuous active maintenance of anterior chamber pressure,” he said. Such an approach combines the advantage of active fluidics and the stability of an anterior chamber maintainer and works well with Prof Assia’s novel three-port mini-incision phaco technique (Tri-MICS). Prof Assia also proposed using a diluted viscoelastic substance, instead of BSS, to give “slow motion” protection to the endothelium. “This would provide a comfortable surgical environment with low turbulence to protect the corneal endothelium. The advantage is that it its use would not be restricted to phacoemulsification but could also be used in vitreoretinal or glaucoma surgery as required,” he said. The new diluted viscoelastic substance could also incorporate ascorbic acid as a non-toxic free radical scavenger to protect against corneal endothelial damage caused by ultrasound energy-generated free radicals. “Phaco energy generates free radicals that initiate the process of apoptosis and programmed cell death. We have carried out extensive animal studies that show that free radical scavengers added to the phaco fluid may protect cells from chemical damage,” he said. Ehud Assia: assia@netvision.net.il

SPECIAL FOCUS: BEST OF THE BEST

New twists on old techniques Overall winner of ESCRS Video Competition used amusing and illustrative animations. Roibeard Ó hÉineacháin reports

he overall winner of this year’s ESCRS Video competition was Chandrashekar Balachandran, Australia, for “The DMEK kite”. Accompanied throughout by amusing and illustrative animations, the presentation describes a new technique for improving the surgeon’s control in placing the donor tissue in Descemet’s membrane endothelial keratoplasty (DMEK) procedures. It involves using a novel Descemet’s punch for creating Descemet’s button with a 1.0mm by 3.0mm tail and a 7.0mm diameter centre. The graft is pulled through the eye by its tail, which is left in place in the corneal incision during the opening and unrolling, centring and air-bubbleassisted placement of the tissue.

throughout the centuries”. His video highlights the development of the art of anatomical illustration and its contribution to the growth of scientific understanding and surgical practice in ophthalmology. Robert Osher, USA, received second prize for “The zonular challenge: history and evolution” and Lional Raj Daniel Ponniah, India, received third prize for “Herbal Magic – A Superluminal Anesthetic Ethnomedicine”.

INNOVATIVE

Tushya Om Parkash was awarded first prize in the Innovative category for “Outcome of pupillary zone sparing partial corneal epithelium debridement for collagen cross linking (C3R) in keratoconus”. It describes outcomes with a new collagen crossDIFFICULT AND linking (CXL) method designed to achieve the pain reduction and more SPECIAL CASES rapid visual rehabilitation of epiLucio Buratto, Italy, took first prize on CXL, yet maintain the superior in the Difficult and Special Cases Overall winner Chandrashekar Balachandran efficacy of conventional epi-off CXL. category for “Cataract surgery in eyes Timothy Page, USA, received second with previous radial keratotomy”. In the prize for “Make the Turn without the Burn: A Critical Analysis video he provides tips on the precautions necessary to achieve of CTR Insertion and a Novel Injector System to Reduce CTR optimal visual results and avoid dehiscence of the radial Complications”. keratotomy. Fathy Morkos, Italy, received second prize in the same category SCIENTIFIC for “Vision Rescue in an Eye Scheduled for Evisceration”. Amar Agarwal, India, received third prize for “Ocular masquerades”. Sheetal Brar, India, received first prize for “Boost that SMILE: Enhancing the “WOW” factor with Small Incision Lenticule Extraction”. The video describes the theory and practice of EDUCATIONAL optimising femtosecond laser settings and lenticule extraction In the Educational category, Jiří Cendelin, Czech Republic, in SMILE® procedures in order to provide patients with more won first prize for “Cataract surgery in case of damaged or lost predictable postoperative refractive correction and a more rapid capsular bag”. Using a large eye model and surgical videos, Dr Cendelin demonstrates the use of scleral tension rings, equatorial VISUAL RECOVERY iris hooks, iris-fixated IOLs and scleral fixation of IOLs in eyes with compromised or absent capsular bags. Diana Carmen Dragnea, Romania, received second prize for Vasavada Shail, India, received second prize in the Educational “In vitro evaluation of the Feasibility of Slit-lamp Nd:YAGcategory for “Posture perfect: ergonomics for the ophthalmic laser Descemetorhexis”. surgeon”. Third prize went to Hisaharu Suzuki, Japan, for “Creation and Evaluation of Complication Models Using Slit RESIDENT IN TRAINING Side View Cataract Surgery”. Jerónimo Riera, Argentina, received first prize in the Resident in Training category for “How do we mark the eye for HISTORICAL a successful Toric IOL alignment in just one step”. Rahil In the Historical category, Georgios Balanikas, Greece, took Chaudhary received second prize for “Posterior Polar Cataractfirst prize for “Imaging and depiction in ophthalmology how to be safe as a resident”. EUROTIMES | DECEMBER 2019/JANUARY 2020

SPECIAL FOCUS: BEST OF THE BEST

The road to modernity Transforming cataract extraction from couching to the world’s most frequent surgery. Howard Larkin reports

edical regulation stretches back in history preceding cataract surgery said Prof Spalton (Emeritus Professor of Ophthalmology, King’s College, London) in his introduction to the 2019 ESCRS Heritage Lecture “The Origins of Cataract Surgery”. The Code of Hammurabi, written in Mesopotamia, 1750 BC, lays down both a scale of fees and penalties too. “…if a physician open a tumour (over the eye) with an operating knife and saves the eye, he shall receive ten shekels…… if the physician makes a large incision with the operating knife and kills him or open a tumour with the operating knife and cut out the eye, his hands shall be cut off.” It has been suggested that the ‘tumour’ might mean a pterygium, if so there was a strong disincentive to be a corneal surgeon in the days of ancient Mesopotamia. The development of cataract surgery reflects the advances in the understanding of the eye. References to ocular surgery date back to antiquity and EUROTIMES | DECEMBER 2019/JANUARY 2020

couching cataracts – pushing the lens into the vitreous cavity to restore light perception – probably started in India some where about 1000–600 BC. The technology was probably introduced into Europe by the conquests of Alexander the Great (300 BC) and was the only treatment available until the introduction of extracapsular surgery by Daviel in 1745. Couching was performed in ancient Greece from about 300 BC, but early accounts of ocular surgery confuse corneal and lenticular pathologies and reflect no understanding of anatomy – Galen placed the lens anatomically in the centre of the eye and thought the lens was the organ of visual perception so that the eyes were thought to light up the world like car headlights, the extramission theory of vision. Prof Spalton explained “if you need the lens for visual perception, you were never going to take it out”. Instead, the ancient Greeks thought a cataract was a ‘hypochyma’, a dried up fluid lying in front of the lens and behind the iris. The ideas of Galen and Celsius

dominated thinking for 1,500 years. Celsius made the important observation that no perception of light was a bad prognostic indicator for surgical success. Another interesting observation was that Galen observed that “a goat suffering from hypochyma saw again when it fell and a thorn pierced its eye”, and it is interesting that a similar procedure – needling – was still the treatment of choice for congenital cataract when Prof Spalton was a resident at Moorfields in the 1970s, almost 2,000 years later. By the 1500s there was still no understanding of the anatomy of the eye, its optics or the lens as the location of the cataract and it wasn’t until the taboo on human dissection started to be relaxed in the 16th Century that fundamental breakthroughs in understanding the anatomy and physiology of sight finally cleared the way for development of cataract surgery.

UNDERSTANDING THE LENS Vesalius in Padua published his major work on human anatomy (De Humani

SPECIAL FOCUS: BEST OF THE BEST Corporis Fabrica; on the fabric of the human body) in 1543. He incorrectly still showed the lens as being at the centre of the eye but also showed that it was not the organ of perception. Bartisch in 1583 published the first textbook on ophthalmic surgery, at his own expense, with beautiful but gruesome detailed drawings of surgical procedures; he was trained by barber surgeons noting in the forward that “as he could not afford to go to school or university he had to restrict himself to surgery”! Forty years later Felix Platter’s anatomy placed the lens close to its true position and he identified the retina as the organ of visual perception. In 1619, Christophorus Scheiner accurately placed the lens and opened the sclera to observe the image on the retina. Kepler was the father of modern optics, and in 1603 published his monumental book Astronomiae Pars Optica. He recognised the ocular image was projected inverted on the retina but the solution of this was of no interest to him as it was not optical – he was clearly a very focused individual – merely observing “that the image is corrected in the hollows of the brain by the activity of the soul”. Identification of the lens as the cataract surprisingly came rather later by Rolfinck in 1656 and confirmed in 1705 when Brisseau couched a soldier’s eye. He subsequently died and Brisseau extracted the lens, offering conclusive proof that the lens is the source of the cataract, Prof Spalton said. Throughout this time couching was performed by itinerant surgeons such as the notorious ‘Chevalier’ John Taylor. He trained at St Thomas’ Hospital and travelled throughout Europe self styling himself as the oculist to the Pope and European royalty. Notably, he blinded Bach and possibly Handel too. It was said

of him “bombast, effrontery, dishonesty, ignorance – all these qualities Taylor showed in perfection”. Another interesting aside was that Rembrandt too painted a picture of Tobias and the angel operating on his father’s eye – careful study of which suggests that Rembrandt had watched couching surgery.

BIRTH OF MODERN CATARACT SURGERY Against this background, the French surgeon Jacques Daviel (1693–1762) started to limit his practice to the eye in 1728, claiming to have performed more than 2,000 operations by 1737. In 1745 he opened the cornea of a patient with a curved needle and scissors to remove lens fragments and blood from a failed couching attempt, and the patient could immediately distinguish objects, though the eye was lost to infection. Two years later, Daviel performed a couching procedure on M Garion, a wig maker. He was unable to depress the lens and decided to operate as he had done on the previous patient, publishing an account in 1753. By 1756 Daviel reported 434 extractions with 88% “success”, a marked improvement over couching. All procedures were done of course without anaesthetic, leading Daviel to observe: “Stabilisation is a problem… There is general unsteadiness of the globe from the influence of the mind on the organ about to be injured.” A remarkable turn of phrase, Prof Spalton commented. The popularity of lens extraction and its requirement for quick and accurate surgery led to a blossoming proliferation of keratomes, specula and other instruments, while controversy swirled over whether couching or lens extraction was best. Refinements from

many surgeons accelerated through the 19th Century, Albrecht von Graefe being a notable contributor, and there are many instruments that are similar to what we use today. The invention of cocaine for topical anaesthesia by Dr Karl Koller in Vienna in 1884 was a major contribution that did much to rapidly advance surgery. While the extracapsular technique pioneered by Daviel and continuously improved was safe and relatively easy, it was limited to mature cataracts and subject to secondary membrane development and inflammation. Through the first half of the 20th Century it gave way to intracapsular techniques that, while more technically challenging and requiring larger incisions, were suitable for less mature cataracts. Pioneering advances included manual expression of the lens by Col Henry Smith in India, alpha chymotrypsin to dissolve zonules by Jose Barraquer and cryoextraction by Krawicz and Kelman. However, it was the invention of the intraocular lens by Sir Harold Ridley followed by phacoemulsification by Charles Kelman that made cataract surgery the most widely performed and highly successful procedure it is today. Many surgeons made great contributions, but Daviel was the first of the four great pioneering surgeons followed by von Graefe, Ridley and Kelman, David Spalton concluded, but we have run out of time and the story of their contributions will have to be the subject of a Heritage Lecture another day. The complete lecture is available on ESCRS on Demand on the ESCRS website. David Spalton: profspalton@gmail.com

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A Symbiotic Relationship In his winning essay for the 2019 John Henahan Prize, Dr Luke Sansom reflects on the journey he and his family have taken over the years of his career

â&#x20AC;&#x153;I

want to quit!â&#x20AC;? A look of bemusement came across the face of my supervisor as I told him of my intentions toward the end of my first year in ophthalmology training. It was a moment I had rehearsed in my head for some months and I was clear about two things, I hated ophthalmology and I wanted out. Or so I thought. This may not be the opening paragraph one might expect for an essay on balancing family life and ophthalmology. I must explain the journey that got me to this point, what happened and where I am today. Following specialty recruitment applications, I was incredibly fortunate to receive a national training post in ophthalmology. The post did however require me to move my wife, young son and baby daughter across the country, far from friends, family and familiarity. When we moved, we found the local schools were full, with no places for miles around, and the house we had rented turned out to be small and dated, and we quickly learnt it was cold, mould-ridden and noisy too. We ended up having to register with a local fee-paying school at the cost of nearly one third of my annual take home pay, ouch! My wife

EUROTIMES | DECEMBER 2019/JANUARY 2020

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was miserable, having left her friends and support network behind. I was working long days, with lengthy commutes on public transport. The school fees made it financially unviable to run a car. I was also often working extra shifts in the emergency department to generate extra money. Family life was at a low point, we had little money and even less time to spend together, happiness was very much at a premium. Surely work could provide me with some relief and form of escape from the pressures of family life. It seemed not. My new colleagues were all welcoming,

kind and supportive and without Thankfully my supervisor them I’m sure I would have tried listened to me and encouraged to quit sooner still. Despite me to give it more time. I their efforts I found the work reluctantly agreed. I was glad very challenging. There I did. My wife and I set to was new equipment, new work trying to transform terminology and new diseases our family life. We managed to learn, and fast. I was finding to move to a lovely house, cataract surgery hard, really hard. get my son into an excellent Operating was the one thing I had Luke Sansom state school and we started making enjoyed the most during my medical friends locally. We had a little more time training, but here I was hating every together and most importantly filled that minute and struggling terribly. Each day I time with the fun, love and happiness that felt like I was drowning in new challenges, we had been so desperately missing. unable to ever catch my breath. I could see I still work long hours, have long my trainee colleagues were excelling, where commutes and cover unsociable oncalls I very clearly was not. and inevitably miss out on family events. I had the job that I had so My family accept that I might not always desperately always wanted, so be there, but when I am home, they know why was I so dissatisfied and that I am theirs and theirs only. From unmotivated. I had convinced playing football in the garden after an myself that I’d be much exhaustingly long day, skipping breakfast happier doing something to instead plait my daughter’s hair to look else and that quitting was ‘just like Rapunzel’, or getting up early my best option. After after a busy weekend oncall to take the a protracted period kids out so that my wife can have a few of reflection, I came child-free hours to see her friends. These to realise that I was so small acts of effort, love and kindness are unhappy in my work the glue that bond our family together because my family felt and provide each of us with a stable base stressed, unsupported to go forward and achieve our goals. and disillusioned. I I did ultimately stay in ophthalmology blamed myself and training and I could not be happier. These I felt a great sense are my reflections on balancing a career in of guilt. Moreover, ophthalmology and family life and how in I hadn’t been this symbiotic relationship things can go there to support very wrong, but how we owe it to ourselves, them through their to our families and to our patients to find struggles. The times I that balance. My greatest failing was not was home, I often felt realising soon enough the monumental so fatigued from the role my family play in making me fulfilled, stresses of my working day that I was happy and resilient and the vital importance unable to give them the attention and this has in all aspects of my life. love that they so desperately craved. I felt that if I couldn’t properly care for Dr Sansom is a Specialty Trainee at the my own family how could I reasonably York Teaching Hospital NHS Foundation be expected to care for my patients or Trust, Yorkshire, UK anyone else.

CALL FOR ENTRIES

JOHN HENAHAN

PRIZE 2020

Young ophthalmologists are invited to write a 900-word essay on

“Will Clinicians Be Replaced By A Robot To Perform Cataract Surgery?” The prize is a travel bursary worth €1,000 to attend the 38th Congress of the ESCRS in Amsterdam,The Netherlands

CLOSING DATE FRIDAY 29 MAY 2020 Entries to be sent to: henprize@eurotimes.org For further information visit: www.escrs.org

EUROTIMES | DECEMBER 2019/JANUARY 2020

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SELLING

consultations online

Innovations prize winner enters a new market. Aidan Hanratty reports

ometimes inspiration can come from the strangest places. Julien Buratto met a grandmother who lived near him who was looking after her daughter’s children in a playground. Distracted for a moment, she lost sight of her grandson and entered panic mode, thinking of every possible negative outcome. He was still playing happily, but his grandmother was shaken. It was later determined that she had cataract, for which she had a successful surgery. Speaking at the ESCRS Practice Management and Development Programme at the 37th Congress of the ESCRS in Paris, France, Buratto, Operation Manager at the Neovision Cliniche Oculistiche, Milan, Italy, described a situation where many grandparents look after their grandchildren while their own children work. The New York Times calls this “intensive grandparenting”: “It refers not to a particular number of hours, but to a commitment to providing regular child care, often accompanied by housekeeping or other tasks,” wrote intensive grandparent Paula Span in June 2019. Buratto then cited a statistic that in Italy, 47 children are injured every day by television tip-overs. Some 72% of emergency department visits due to these tip-overs are by children younger than five years old. With failing eyesight a potential risk for lost or injured children, it is imperative that older family members get adequate eye care. But who is taking care of the grandparents? Buratto said that it’s not as simple as suggesting to grandparents that they should see a doctor. Instead, he and his team at the Neovision clinic wanted to provide a service that was: easy to buy and easy to pay; easy to book; one that should be a cuddle, not a military order; and that should look serious and professional. They developed a packet that included a card with vision and cataract information as well as a phone number to make a consultation – since those of the baby boomer generation are more likely to want to speak to a real person, rather than going online to make appointments. They then sold this online at amazon.it. Citing pioneering research scientist Everett Rogers and his diffusion of innovations theory – which broke people down into the categories of innovators, early adopters, early majority, late majority, and laggards – Buratto noted that the Neovision clinic was the first to provide a medical service on Amazon. Stories about the package went viral in Italy, with the Italian Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri (the professional body for the medical profession) summoning the practice for further information about their sales. Buratto was keen to stress that the packet, Julien Buratto

Medicine is not something that is frozen and cold, it must be sensitive to people’s emotions

EUROTIMES | DECEMBER 2019/JANUARY 2020

Courtesy of Julien Buratto

Julien Buratto (top); the gift pack as sold on Amazon

which includes the price of a consultation, is not discounted. It’s not their goal to drive down prices, but rather to encourage people to care for their loved ones. “Medicine is not something that is frozen and cold, it must be sensitive to people’s emotions,” he said. With almost half the audience vote, this project was the clear winner of the Inaugural Innovation Prize, which came with a €1,500 bursary to attend the 38th Congress of the ESCRS in Amsterdam, The Netherlands in October 2020. Julien Buratto: julien.buratto@neovision.eu

SPECIAL FOCUS: BEST OF THE BEST

ESCRS 2019 Poster Prize Winners Posters were judged on originality, scientific quality, relevance to clinical practice and presentation Emilio Torres-Netto MD

irst, second, and third prizes for the best cataract and refractive posters were awarded on Sunday afternoon during the Video Awards Session. The posters are judged based on originality, scientific quality, relevance to clinical practice and presentation.

REFRACTIVE

First prize in the refractive category was given to Emilio TorresNetto MD, Switzerland, for his poster “Stromal bed smoothness after excimer laser surface ablation as a key element for the expression of inflammatory genes”. The poster presented findings from a study conducted in animal eyes that identified expression of inflammatory genes following PRK performed with a standard versus low fluence ablation. Ablations were done using technology based on a three-dimensional fullerene model to smooth the stromal bed. The results showed that the optimisation of new algorithms or energy settings allowed for reduction of the inflammatory response after refractive laser surgery. In addition, Dr Torres-Netto concluded that postoperative corneal smoothness appears to be the key factor in regulating the inflammatory response. Yuka Horigome MD, Japan, received the second prize for refractive posters for his presentation of a “Novel technique of intrascleral IOL fixation with intraoperative adjustment of refraction”.

Daniel Chang MD

Third prize went to Zhou Jihong, MD, China, for the poster “Clinical outcomes of a large sample after small-incision lenticule extraction and femtosecond laser-assisted in situ keratomileusis for myopia by generalised linear mixed models (GLMM) analysis”.

CATARACT First prize for cataract posters was awarded to Daniel Chang MD, USA, for his poster “Visual outcomes and defocus curve profile of a next-generation diffractive presbyopia-correcting intraocular lens”. The poster presented defocus curve and visual acuity outcomes from a multi-centre randomised study that included 148 patients bilaterally implanted with the TECNIS Synergy IOL or the +3.25D TECNIS Multifocal IOL. The surgeries were performed at 12 centres across the United States. The study found that the Synergy IOL maintained excellent continuous vision up to 33cm with distance vision better than 1.0 (20/20). Compared with the multifocal IOL, the TECNIS Synergy provided both better DCIVA and had a better range of vision. Second prize for cataract posters went to Grzegorz Labuz, MD, Germany, for his poster describing “Laboratory assessment of the effect of spectral filters on the optical performance in an extended-depth-of-focus intraocular lens”. Arthur Cummings, Ireland, received the third prize for his work addressing the question “Does an objective evaluation of patients’ daily life influence surgeon selection of presbyopia-correcting IOLs?” EUROTIMES | DECEMBER 2019/JANUARY 2020

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Keratoconus: Current Management and Future Perspectives

Chairpersons: M. El Bakkali MOROCCO S. Morselli ITALY

Chairpersons: M. Busin ITALY M. Harouch MOROCCO

saturday 22 February

SUNDAY 23 February

11.30 – 13.00

High Tech Eye Tech Chairpersons: T. Kohnen GERMANY M. Shafik Shaheen EGYPT

Cataract Surgery: Approaching Difficult Cases Organised by the Young Ophthalmologists Committee Chairpersons: S. Palkovits AUSTRIA C. Pedrosa PORTUGAL

Other Sessions Friday 21 February

Saturday 22 February

Basic Optics Course

Cataract Surgery Didactic Course Part 2

Catract Surgery Didactic Course Part 1

Cornea Didactic Course

ESCRS/EuCornea Cornea Day

Free Paper Session

Free Paper Sessions

Near Live Surgery Session

Pan Arab Refractive Council Symposium

Moderated Poster Session

Refractive Surgery Didactic Course Part 2

ESONT Didactic Programme for Ophthalmic Nurses & Technicians

What is New in My Practice to Make My Patients Happier? l

Instructional Courses

Moderated Poster Session

Refractive Surgery Didactic Course Part 1

Young Ophthalmologists Programme

Sunday 23 February l

SAMIR / Pan Arab Refractive Council Symposium Ocular Surface Disease in 2020

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he winner of the 2019 ESCRS Peter Barry Fellowship Grant was Dominika Wróbel-Dudzińska. The Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. 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. Dr Wróbel-Dudzińska, who works in the Department of Diagnostic and Microsurgery of Glaucoma in Lublin, Poland, received the Fellowship from ESCRS President Béatrice CochenerLamard at the Opening Ceremony of the ESCRS Congress in Paris, France. “Being an ophthalmologist has been my dream since childhood but I began to think Dominika Wróbel-Dudzińska deeply about ophthalmology after Student Exchange Scholarship in the Ophthalmology Department at the Federal University of Santa Catarina in Florianopolis, Brazil; in 2007,” said Dr Wróbel-Dudzińska. “In 2010 I started my ophthalmology residency and a postgraduate programme at the Medical University of Lublin. Since that time, I have been giving lectures and classes in Polish and English with medical students at the Medical University of Lublin,” she said. “Moreover, I conducted clinical and scientific research to establish genetic risk factors in the occurrence of normal tension glaucoma, in contrast to open-angle glaucoma, that was the topic of my PhD dissertation. “Nowadays, apart from working in the clinic, I additionally conduct scientific work: ‘Genes polymorphism’s affecting the structure Dominika Wróbel-Dudzińska and functions of corneal endothelial cells in patients with Fuchs’ dystrophy’ and ‘Efficacy of platelet-rich plasma in the treatment of ocular surface diseases’. In 2013, Dr Wróbel-Dudzińska was selected as an SOE Observership grant recipient. She completed her fellowship in Vissum Corporacion Clinic in Alicante. “I had a great time there, gaining the experience and practice, learning from the best. I was able not only to look at the procedures but also actively participate in some of the surgeries. This was the first place of my contact with refractive surgery,” she said. Dr Wróbel-Dudzińska said that after receiving the fellowship she was eager to undertake various clinical duties to extend her knowledge in diagnosing, evaluating and managing patients with various ophthalmology disorders.

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A potpourri of hot topics Experts pick out the Best of the “Best”. Cheryl Guttman Krader reports

SCRS Chairpersons Oliver Findl MD and Boris Malyugin MD, PhD, highlighted some of the most interesting videos, posters, free papers, and symposia presentations from the 37th Congress of the ESCRS in Paris. Together with panelists comprised of key opinion leaders, they offered their personal perspectives about the ideas and findings contained in the selections.

VIDEO HIGHLIGHTS Two videos presented by Ehud Assia MD in his Binkhorst Lecture were reviewed. One of the videos demonstrated a portable operating theatre that can be erected at remote sites in underdeveloped countries. The structure keeps the patient’s head and surgical staff in a clean environment, separated from the outside world. A second video presented the adjustable flange technique, which is Dr Assia’s modification of the flanged IOL fixation technique for managing a dislocated IOL. Descemet membrane endothelial keratoplasty (DMEK) was the topic for two videos. They included “The DMEK Kite”, which showed a technique for improving surgeon control over graft orientation, unrolling and positioning. “In vitro evaluation of the feasibility of slit-lamp Nd:YAG laser descemetorhexis” described experiments testing different Nd:YAG settings for scoring Descemet’s membrane at the beginning of the surgery. Cataract surgery was the focus for several of the videos discussed during the session. They included “Make the turn without the burn: a critical analysis of CTR insertion and a novel injector system to reduce CTR complications”. This video described predictable cardinal movements of the capsular tension ring (CTR) that indicate uncomplicated insertion, reviewed the advantages of a suture-guided CTR insertion technique, and presented a suture-guided CTR platform that is in development as a preloaded delivery system.

The video “Creation and evaluation of complication models using slit side view cataract surgery” reported on use of the slit side view technique to gain understanding of anterior chamber dynamics as the foundation for conducting safe surgery. A video titled “Winnie the Pooh gets stuck in a hole, how do his friends get him out of there?” provided tips for managing the situation where the IOL gets stuck in the incision during insertion. The video “Posture perfect: ergonomics for the ophthalmic surgeon” provided advice for enhancing comfort and efficiency in the operating room. It highlighted the ergonomics of an ideal surgeon’s chair and simple exercises for safeguarding health.

BEST PRESENTATIONS Presentations that were chosen as “the best of the best” included several cataract surgery free papers and posters. Among them was “Cataract surgery for late in-the-bag IOL dislocation: longterm visual outcome in a randomised clinical trial – lens repositioning vs lens exchange”. The study found that the ab externo scleral suture loop technique for repositioning and IOL removal followed by replacement with an iris-claw IOL were associated with similar visual acuity and safety outcomes after two years. “Novel technique of intrascleral IOL fixation with intraoperative adjustment of refraction” showed how cutting the haptics to change haptic length during flanged IOL fixation altered refraction. The paper “Comparative efficacy of Barrett True-K IOL power calculation with and without measured posterior corneal astigmatism” found that in patients with a history of refractive surgery and no available history, particularly previous myopic eyes, use of direct posterior corneal astigmatism measurements and the Barrett True-K formula provided greater accuracy than other available formulas. A free paper and a poster presenting

findings from studies of two presbyopiacorrecting IOLs that will be coming to market were also highlighted because of the interest these new technologies will hold for surgeons. “Clinical outcomes of a new extended-vision intraocular lens in the United Kingdom” reported on the AcrySof IQ Vivity Extended Vision IOL. “Visual outcomes and defocus curve profile of a next-generation diffractive presbyopia-correcting intraocular lens” summarised study data on the TECNIS Synergy IOL. The paper “Inducing a trifold conformation in Descemet’s membrane endothelial keratoplasty using small paired radial incisions” was also selected as a “best of the best”. The author demonstrated how creating paired radial incisions in the DMEK graft encouraged a wide triple scroll conformation that is favorable for unfolding and worked better using younger donor tissue (age ≤65 years). Another DMEK paper presented “Risk factors associated with high endothelial cell density decrease after DMEK”. It concluded that to reduce the risk of high endothelial cell loss, DMEK surgeons should avoid graft detachments, do continuous postop screening to ensure early detection of potential complications, and consider surgical intervention before eyes with Fuchs’ endothelial corneal dystrophy reach an advanced stage. Two presentations from the main symposium “Surgeons Under Stress” were also considered the “Best of the Best”. They included the talk “Understanding Stress”, given by internist Michaela Bayerle-Eder MD that presented the physiological and medical consequences of stress and featured videos of surgeons discussing how they deal with stress. The presentation “Relaxing the surgeon: Stress control for your next surgery”, given by Stig A Severinsen PhD, also included some simple strategies for dealing with stress.

EUROTIMES | DECEMBER 2019/JANUARY 2020

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Ethics and artificial intelligence The need for an ethical approach to AI applications highlighted. Dermot McGrath reports

ith artificial intelligence (AI) applications impacting on practically every facet of daily life – including healthcare and ophthalmology – the need for robust ethical guidelines to shepherd its use has never been greater, according to Barry O’ Sullivan PhD. “As Steven Croft, the Bishop of Oxford, has said: ‘This is a critical moment. Humankind has the power now to shape AI as it develops. To do that we need a strong ethical base: a sense of what is right and what is harmful in AI’,” he told delegates attending the 37th Congress of the ESCRS in Paris, France. Prof O’ Sullivan, Professor of Constraint Programming at University College Cork, Ireland, said that while AI had immense potential for making a positive contribution to human productivity and well-being, it also carried significant risks that everyone should be aware of. “Because AI is so powerful there is massive responsibility that comes with it. It is a technology which we should not anthropomorphise like in Mary Shelley’s Frankenstein. Essentially, AI can do no more than what we train or teach it to do. So we need to understand its key limitations, especially in a field such as ophthalmology, when we are dealing with people’s health and possibly even their lives,” he said. Prof O’ Sullivan emphasised that AI is not really about emulating human intelligence but should be considered more as a set of techniques that performs specific tasks in a narrowly defined area.

“Based on a dataset an algorithm can be built that can perform as well as a human expert, but the disadvantage is that the AI application will know nothing at all about the domain in which it is working. So while it might be able to screen for retinal disease it knows nothing about the concept of an eye or a human being,” he said. Clinicians also need to be aware of the potential for bias when developing an AI application. “One can influence the machine by not selecting appropriate training examples or omitting certain details, and this will have a devastating impact when the machine is deployed,” he said. He encouraged delegates to look at the work of the European Commission’s High-Level Expert Group on Artificial Intelligence, which has produced an ethics code for AI in Europe. The code emphasises the need for a humancentric approach that will give rise to “trustworthy” AI, which incorporates key criteria such as accountability, data governance, human oversight, non-discrimination, respect for human autonomy, privacy, robustness, safety and transparency. Prof O’ Sullivan said that interested parties could also contribute directly to the AI debate by participating in the European AI Alliance, a forum to discuss all aspects of AI development and its impacts and provide input to inform future policy.

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CATARACT & REFRACTIVE

A wonderful adventure Béatrice Cochener-Lamard talks to Dermot McGrath about her experience as President of ESCRS as she approaches the end of her term in office It is almost two years now since you became President of the ESCRS. How has the experience been for you overall? Has it turned out as you imagined it might be? I confess that I put all my heart and energy into the work, giving me the impression that time has passed very quickly and will not be enough to accomplish all the projects that have sprouted, but most probably my close entourage would answer you that this mission has taken most of my time. This is undoubtedly a wonderful adventure and I confirm that it is a privilege and an honour to serve as President of this beautiful society that is ESCRS. I saw it as a duty to maintain our position as an academic leader in the world, to best meet the expectations of our members, and to continue to integrate innovations, develop research and charity activities, and to maintain our friendship and partnership with the international Societies. But above all on a personal level, this presidency has given me the opportunity to meet the exceptional people that the board brings together, to develop a sincere and lasting friendship with the ESCRS Board and to build strong links with the very effective Agenda team that assists us on a daily basis. It is indeed the woven human bond that remains the primary and enduring value. What innovations or changes in the ESCRS have you initiated or helped to initiate in your two years as president? It would be pretentious to take credit for the developments that have been observed over the past two years, because each president follows in the footsteps of the previous one and does his or her best to continue on the path set. Moreover, he or she fulfils this task not alone but with the support of the ESCRS Board and the Agenda Communications team. That being said, I would like to mention the main projects that have emerged under my initiative: the establishment of a strategic plan defining the main lines of EUROTIMES | DECEMBER 2019/JANUARY 2020

podcast. In partnership with academic societies in various countries around the world, we are increasing the number of Academies dedicated to teaching organised by the Education Committee chaired by the past President, currently David Spalton. Most importantly, we have increased the number of scholarships offered to trainees. In the field of research, two levels of grants have been structured with a multicentre project focused on a public health theme or a search for scientific evidence on a current practice (funded up to €750,000) and individual projects by young doctors under 45 years of age, exploring innovations (funded up to €50,000).

Béatrice Cochener-Lamard

development to be achieved over the next five years, the establishment of free paper forums to create a more open, intimate and rewarding space for this presentation format; this in support of the success we had recorded around presented posters and the poster village. The introduction of the tracking badge is also part of our concern to better identify the interests of our participants. The possibility this year of identifying oneself with one's badge is intended to meet the soon-to-be-generalised need to identify one’s individual activities and collect CME points, while respecting GDPR rules. Research and training are very important. Talk about the recent initiatives in these areas. We continued our support for young ophthalmologists, by focusing, beyond the specific programme dedicated to them at conferences, on optimising our website and our presence on social media. Thus, the content of symposia, surgical videos, interviews with experts and the followup of the multi-sponsored educational programme are available online or even

Finally, as one term of office ends, a new one begins. What are your feelings as you look forward to 2020? Bringing the ESCRS winter meeting to Marrakech in February 2020 is a very personal initiative. We had never been to this part of the world before, although we have regular members from the Maghreb and Middle East countries. I hope that this congress will be a great success. In 2020, we will also have the great pleasure of welcoming our new President Rudy Nuijts, whom the whole world knows and whose taste for perfection, scientific rigour and transparency, guarantees us that he will make a magnificent President. Good luck to him in writing a beautiful new page for ESCRS.

...this presidency has given me the opportunity to meet the exceptional people that the board brings together Béatrice Cochener-Lamard MD, PhD

CATARACT & REFRACTIVE

Toric IOL calculations Improve outcomes by using exact vergence and total SIA to calculate toric power. Howard Larkin reports

The Next Generation

or the median cataract surgeon implanting toric IOLs, 75% of cases end up within ±0.5 dioptres of the residual astigmatism target. But wherever you fall on the toric outcomes bell curve, Jack T Holladay MD, MSEE, believes you can improve your toric lens performance 10% by making two changes in IOL power calculations. First, switch from an IOL power calculator using a fixed constant for determining vergence to one that uses exact vergence for the spherical equivalent (SEQ) power and residual astigmatism of the toric lens to be implanted, Dr Holladay, of Baylor College of Medicine, Houston, USA, told the 2019 ASCRS ASOA Annual Meeting in San Diego, USA. Constant vergence calculators use the same ratio (1.46) for the toricity of the IOL to the keratometric astigmatism regardless of lens SEQ, while the actual IOL toricity required drops as SEQ increases, throwing off power calculations for most lenses, Dr Holladay explained. For example, a constant vergence ratio of 1.46 calls for 3.0D toricity for 2D of corneal astigmatism for lenses ranging from 10 to 34D SEQ – 3D of toricity is only correct for a 22D SEQ lens, but undercorrects a 10D SEQ lens by 0.5D, and overcorrects a 34D SEQ10 lens by 0.6D. An exact vergence calculator changes the ratio based on IOL SEQ, reducing one significant source of toric lens power error, Dr Holladay said. Exact vergence calculators include the AMO Express, the Alcon Holladay Toric Calculator and the Holladay IOL Consultant (http://www.hicsoap.com/).

THE ROLE OF TOTAL SIA In 2012, research by Douglas Koch MD and colleagues on posterior corneal astigmatism (PCA) found that, on average, using anterior Ks alone underestimates total corneal astigmatism by 0.22D at 180° meridian, and exceeded 0.5D in 5% of eyes. This led to more accurate toric IOL calculations, but still misses some factors influencing total surgically induced astigmatism (SIA), Dr Holladay said. So, Dr Holladay set out to develop a new approach based on optics that determines directly total SIA by subtracting pre-surgery Ks from post-surgery measured refractive astigmatism using non-toric IOLs. This accounts for all factors, including differences in measured keratometric versus actual corneal refractive astigmatism, actual versus aggregate PCA values, and even lens tilt and decentration. Data from clinical trials of non-toric IOLs implanted using a 2.5mm temporal incision showed that post-op total SIA vectors correlated consistently with the axis and magnitude of the pre-op steepest K, Dr Holladay said. Applying a formula based on this relationship retrospectively significantly increased toric IOL power prediction accuracy, bringing residual astigmatism below 0.25D for most cases (Holladay J, Pettit G. JCRS 2019;45:272-283). “Since the goal is minimum long-term residual astigmatism, remember one more thing,” Dr Holladay concluded. Astigmatism drifts about 0.25D against-the-rule each decade, so a small amount of with-the-rule is desirable immediately after surgery.

NEW Pentacam® AXL Wave The first device to combine Scheimpflug Tomography with Axial Length + Total Wavefront + Refraction + Retroillumination The new Pentacam® AXL Wave is a reliable partner for your refractive and cataract practice, creating the best prerequisites for surgery, based on pre-op metrics, and providing post-op measurements for reliable monitoring, in just one device ! With high-end hardware and software for optimum treatment and satisfied patients, the new Pentacam® AXL Wave makes no compromises on quality.

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Jack Holladay: holladay@docholladay.com EUROTIMES | DECEMBER 2019/JANUARY 2020

CATARACT & REFRACTIVE

Streamlining the cataract clinic Lean principles are essential to meeting increased demand for cataract surgery. Roibeard Ó hÉineacháin reports

he coming decades will see a massive increase in the demand for cataract surgery, but a streamlined approach integrating electronic patient management systems with both health system administration and modern diagnostic technology may lighten the burden, according to speakers at a symposium at the Annual Conference of the Irish College of Ophthalmologists in Galway, Ireland. Cataract surgery accounted for 82% of all ophthalmic procedures between 1991-2001 and the requirement for cataract surgery is projected to more than double over the next 20 years, said Paul Mullaney FRCOphth, Sligo General Hospital, Sligo, Ireland. “We are going to be inundated with the coming tsunami and we will need more resources, but we have to be sure that we are using the resources maximally and that’s where lean principles come in,” said Dr Mullaney, whose ophthalmology team won the prestigious Irish Health Service Executive’s National Health Service Excellence award in 2016.

THE MEANING OF LEAN He outlined a number of measures that have improved performance at his clinic. The process begins prior to referral, whether by optometrists or medical ophthalmologists, when patients should undergo measurement of refraction and IOP and fundus examination. Once a patient has been referred for cataract surgery their details are entered into an electronic patient record (EPR) housed on a hospital server linked to peripheral clinics and optometric centres. During the preoperative assessment period patients are listed for surgery based on severity of symptoms and clinical findings. They then receive information including a brief explanation of procedure and major possible complications such as endophthalmitis, surgical mishap and, where relevant, retinal detachment. He emphasised that patients should not be cleared to progress to surgery until all EUROTIMES | DECEMBER 2019/JANUARY 2020

relevant issues determined during clinic assessment are resolved. But once a patient is cleared they should be ready for surgery – there should be no cancellations on the day of surgery. He noted that newer technologies are becoming available that can greatly enhance efficiency in cataract surgery. They include surgical microscopes that enable surgeons, while they operate, to see machine settings, anatomical landmarks and other important data, all provided from the wirelessly connected EPR. Although they are expensive, the very newest devices can be leased at a much lower cost through managed service contracts. An additional advantage is that, in the event of a machine breaking down, the company is obliged to replace it with a newer model. “The culture you need to promote is one of getting the maximum out of your resources safely and effectively and also finding ways to improve that service. You need organisational support with all hospital departments, The department has to sell itself constantly internally and externally with maximised outcomes bringing in revenue,” Dr Mullaney added.

GETTING THE RIGHT ETHOS

effective surgery, according to Paul Barrington Chell FRCS, Ophthalmologica Consulting, formerly clinical director of Head and Neck Surgery at Worcestershire Royal Hospital, Worcester, UK, a unit recognised for efficient surgery. “It’s about setting an ethos where everything is going to be clean and sterile and friendly and the receptionist looks up when you walk through the door. If you get the ethos right and you get the staff right everything will go well for the patients,” Dr Chell noted. Nurses in a cataract clinic must be multiskilled and able to take on the whole range of preoperative, surgical and postoperative tasks involved in assisting the patient’s journey from their entry to the clinic to their discharge. Furthermore, all team members should be involved in planning of services. Teams must understand social versus business language, he stressed. It is also important to take human factors into consideration. Performing too few surgeries will result in the surgical team not having enough regular practice, yet performing too many surgeries can also reduce performance levels, through sheer fatigue and other factors affecting concentration and alertness, Dr Chell said.

A professional ethos and a focused approach in the cataract clinic environment are key to efficient and

Paul Mullaney: Paul.mullaney@hse.ie Paul Barrington Chell: paul.chell@virgin.net

CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 11 MONTH: NOVEMBER 2019

UPRIGHT PHACO SURGERY A new slit-lamp-based technique allows phacoemulsification surgery to be performed on patients who until now had been refused for cataract surgery. The new technique enabled surgeons to perform phacoemulsification on four eyes of two patients, who were sitting in a strictly upright position, by using a slit lamp rather than an operating microscope. The surgeon sits on the other side of the slit lamp, facing the patient, and operates via a temporal corneal incision. Both patients achieved a corrected distance visual acuity of 20/20 in both eyes. This approach could prove useful in patients unable to lie flat, including those with orthopnea, spinal deformity or Ménière's disease. M Muraine et al., “Face-to-face phacoemulsification using a slit lamp in patients who are unable to lie flat”, Volume 45, #11, 1535-38.

LONG-TERM ICL RESULTS Phakic IOL implantation offers a treatment option for high myopia that preserves accommodation and spares the cornea. The implantable collamer lens (ICL, STAAR Surgical) is a posterior chamber pIOL that first appeared in 1993. The V4 model of the ICL was introduced in 1998 to address some issues encountered with the original version. Little is known about the long-term visual outcomes and anatomic effects of the V4 ICL. A new retrospective study of 110 eyes of 60 patients showed that the lens provided long-term stability and good refractive outcomes at the 10-year mark. Mean spherical equivalent was -0.65 ± 1.09D 10 years postoperatively. The mean vault height was 562.4 ± 175.9μm six months postoperatively, decreasing to 352.9 ± 171.8μm at 10 years. Lens opacities developed in 21 eyes (12.1%) during the 10-year follow-up. The mean vault in the lens opacity group was significantly lower than in the clear lens group after four years. No patient who had ICL implantation when they were 30 years or younger developed lens opacity or required phacoemulsification. The study found no significant decrease in endothelial cell density or increase in intraocular pressure over time. JH Choi et al., “Ten-year clinical outcomes after implantation of a posterior chamber phakic intraocular lens for myopia”, Volume 45, #11, 1555-61.

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

COMPARING DEFOCUS CURVES Researchers evaluated the defocus curves of four presbyopiacorrecting IOLs in a prospective clinical study. The four IOLs provided equally good corrected distance visual acuity (VA). The EDOF IOL yielded slightly better distance-corrected intermediate VA, but provided worse distance-corrected near VA than the other IOLs. That finding was clinically relevant, and a lower percentage of patients in the EDOF group achieved spectacle independence. Only the panfocal IOL gave better distance corrected intermediate VA at 50cm. M Böhm et al., “Defocus curves of 4 presbyopia-correcting IOL designs: Diffractive panfocal, diffractive trifocal, segmental refractive, and extended-depth-of-focus”, Volume 45, #11, 1625-36. JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | DECEMBER 2019/JANUARY 2020

CATARACT & REFRACTIVE

C ATA R ACT and MIGS

Part three in our series on everything you ever wanted to know about management of co-existing cataract and glaucoma. Soosan Jacob MD reports

nvasive glaucoma surgeries such as trabeculectomy, tube shunts and non-penetrating glaucoma surgeries have traditionally been reserved for patients with moderate-to-advanced glaucomas because of greater risks associated with them. Mild glaucoma is generally treated with medications or lasers, though poor compliance to medications, toxicity of preservatives and costs have always been issues. For cataract patients with co-existent early-to-moderate glaucoma, minimally invasive glaucoma surgery (MIGS) is an option that has recently become more and more popular as despite lesser efficacy compared to traditional glaucoma surgeries, high safety profile is an advantage. Other advantages include ease and minimally traumatic nature of surgery, early recovery, relative lack of major complications, possibility for effective and long-lasting IOP control with decreased number of medications together with ability to incorporate these techniques easily into one’s cataract practice. Inclusion of many MIGS procedures under insurance has also gone towards making this a popular glaucoma treatment, especially when coexistent with cataract. MIGS includes implants, devices and techniques. Most use an ab-interno conjunctiva- sparing approach, thus leaving virgin conjunctiva for any future glaucoma surgeries if required. Some, however, do affect the conjunctiva, such as the Aquesys Xen implant. MIGS can be classified depending on their mechanism of action:

I. INCREASED TRABECULAR OUTFLOW/ TRABECULAR BYPASS:

iStent (Glaukos Corp): This is a selfretaining, heparin-coated titanium stent with a pointed tip that penetrates through the trabecular meshwork for implantation EUROTIMES | DECEMBER 2019/JANUARY 2020

MIGS is however, generally not used in patients with advanced disease, previous filtering surgeries, angle closure glaucoma etc. into the Schlemm’s canal. Though overall mean IOP was similar to a control group at 24 months, there appears to be some benefit of stent implantation. Implantation of two stents was reported to give a 43% reduction in mean intraocular pressure (IOP) to 14.6mmHg up to 36 months’ follow-up. The infero-nasal quadrants have a higher density of collector channels and may be preferred for implantation. The iStent Inject delivers with a single entry, two pre-loaded trabecular micro-bypass stents that can be implanted two-to-three clock hours apart. The Hydrus microstent (Ivantis Inc) is an 8mm long curved device made from nitinol that is implanted via a pre-loaded injector. It provides an intra-canalicular scaffold to one quadrant of the Schlemm’s canal, dilates the canal by four-to-five times the natural width and prevents collapse of Schlemm’s canal secondary to elevated IOP. The device has windows that allow aqueous outflow. A prospective, multi-centre, randomised controlled trial comparing one Hydrus device versus two iStents (COMPARE study) reported the Hydrus group to have a greater reduction in mean IOP than the iStent group (-1.7 vs. -1.0mmHg), though not reaching statistical significance. The Hydrus group showed superiority in certain other parameters as well. The Trabectome (NeoMedix) performs an ab interno trabeculotomy and removes a strip of trabecular meshwork (TBM) and inner wall of Schlemm’s canal. The handpiece has irrigation, aspiration and electrocautery modes. A 60-to-120degree ablation is generally performed. Advantages include conjunctival sparing,

reasonable efficacy, absence of bleb and ability to combine with cataract surgery. Disadvantages include lack of flow all 360 degrees around, closure of the trabeculotomy, limitation by inherent episcleral venous pressure and Schlemm’s canal resistance. Gonioscopy-assisted transluminal trabeculotomy (GATT)/ ab interno canaloplasty (ABiC): This ab interno technique has eliminated many of the disadvantages of ab externo trabeculotomy while retaining advantages of a 360-degree trabeculotomy/viscodilatation. Either the iTrack microcatheter (Ellex) with a 250-micron diameter or a 5-0 nylon/ prolene suture, the leading edge rounded by low temperature cautery, is advanced through the Schlemm’s canal 360 degrees circumferentially via an internal goniotomy incision. Viscodilatation (360 degrees) is performed in ABiC while suture/the microcatheter is tightened to create a 360-degree trabeculotomy in GATT. The illuminated tip of the iTrack helps guide the catheter reliably. Excimer laser trabeculostomy is performed with a goniolens or endoscope and uses a fibre-optic-delivered 308‑nm xenon chloride excimer laser to create multiple (four-to-10) small ostia through the trabecular meshwork, juxtacanalicular trabecular meshwork and the inner wall of Schlemm’s canal via a non-thermal approach to improve outflow. It uses a clear corneal incision, sparing conjunctiva, thus minimising healing response that could otherwise close the ostia.

CATARACT & REFRACTIVE

II. SUPRACHOROIDAL SHUNTS: The iStent Supra (Glaukos Corp) is a 4mm tubular device made of polyethersulfone and titanium with a 160–170mm lumen. It also drains into the suprachoroidal space and is inserted ab interno. The Gold Shunt (SOLX Inc) and the STARflo (iSTAR Medical) are ab externo supraciliary implants placed under scleral flaps.

Minimally invasive glaucoma surgery (MIGS) can work via four mechanisms – increasing trabecular outflow, sub-conjunctival filtration, supra-choroidal drainage or decreasing aqueous production

III. SUB-CONJUNCTIVAL FILTRATION: Two devices – the XEN gel stent (AqueSys Implant) and the InnFocus Microshunt (InnFocus) are available for subconjunctival filtration. They are designed using Newtonian fluid dynamics and the Hagen–Poiseuille equation to eliminate clinically significant postoperative hypotony. Both have high biocompatibility and resist neovascularisation and fibrosis. However, both are generally used together with anti-metabolites like 5-FU or Mitomycin-C. The XEN gel stent is made of soft, non-inflammatory porcine collagen-derived gelatin cross-linked with glutaraldehyde. It is 6mm in length and comes pre-loaded in three different internal lumen diameters – 140, 63 and 45 microns. It is implanted either completely ab interno or with conjunctival dissection. The InnFocus Microshunt is an 8.5mm long, flexible tube with a 70-micron lumen made of SIBS (synthetic Poly(Styrene-block-IsoButylene-

block-Styrene)). It is inserted into the AC under a scleral flap and tiny fins on either side prevent it from migrating. It may be as effective as trabeculectomy and thus may be used for moderate-to-advanced glaucoma.

IV. DECREASED AQUEOUS PRODUCTION: Endocyclophotocoagulation decreases aqueous production and has been combined with phacoemulsification since 1995.

Micropulse cyclodiode laser (Iridex) uses ultra-short energy bursts, allowing tissue to cool between pulses thus minimizing damage. High-intensity focused ultrasound (Eye Tech Care) may also be used for decreasing aqueous production. 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

EU-CC-NP-0014

EUROTIMES | DECEMBER 2019/JANUARY 2020

CATARACT & REFRACTIVE

Top Gun phaco showdown

Cataract surgery pearls from the world’s best phaco instructors. Howard Larkin reports

ven the sunniest cataract extraction can turn suddenly cloudy when a detached Wieger’s ligament unexpectedly allows aspiration of the posterior capsule. That’s when it’s time to soar back into the blue with a posterior continuous curvilinear capsulorhexis (CCC), Boris Malyugin MD, PhD, Moscow, Russia, told the Top Gun session at the ASCRS ASOA 2019 Annual Meeting in San Diego, USA. “Whoops, I did it again,” quipped Dr Malyugin, who represented ESCRS under the call sign “Danger Zone-ules” in this high-flying dogfight of phaco instructors from across the globe. The first step to successful recovery is to leave the irrigation probe in place and fill the anterior chamber with viscoelastic, Dr Malyugin said. This makes the tear visible for evaluation. If the anterior hyaloid membrane is intact, any vitreous that appears to prolapse often can be pushed back with additional visco. “This is a very important procedure to keep the vitreous stable and located behind the posterior capsule.” The posterior tear can then be converted to a CCC using micro-forceps, he explained. To minimise stress on the capsule and zonules, Dr Malyugin recommended injecting the intraocular lens into the anterior chamber rather than the capsule, then inserting the haptics into the capsule one at a time. “These gentle manoeuvres help keep the vitreous in place to avoid any herniation.” Remove the viscoelastic and you’re done. “If everything is done properly you will have a very nice result,” Dr Malyugin concluded.

SEALING CORNEAL INCISIONS The key to sealing corneal incisions after surgery is creating self-sealing incisions in the first place, said Soon-Phaik Chee FRCSEd, FRCOpth, Singapore. To avoid leaks, side-port incisions should be longer than they are wide, and main clear corneal incisions with a ratio of length to width of 4:5 to 3:5 have long been shown to seal better than incisions that are closer to square (Ernest PH et al. J Cataract Refract Surg 1994;20:626-629), she noted. More recently, trapezoidal incisions that are wider internally than externally have been shown to seal better, said Dr Chee, representing APACRS under call sign “Phaiko Savant”. “This allows you to move your instruments around without stretching [the incision].” On closure, seal the side port by stroking the incision while maintaining irrigation. Use irrigation infusate to hydrate the main incision and simply massage externally to seal it without need for Boris Malyugin MD, PhD injecting additional BSS.

This is a very important procedure to keep the vitreous stable and located behind the posterior capsule

EUROTIMES | DECEMBER 2019/JANUARY 2020

Boris Malyugin MD, PhD

MILOOP FOR HARD CATARACTS Dense cataracts got you frustrated? Just loop it, said Mitchell P Weikert MD, Houston, USA, representing ASCRS as “Cyclops – so my patients don’t have to be”. Staining is the first step to successfully using the miLoop device (ZEISS) for segmenting the nucleus, said Dr Weikert. “Even if you have a decent red reflex, with these dense cataracts you want to be able to see the capsule when you are passing your loop around.” A good-size, round capsulorhexis is worth a little extra time to mark and carefully execute, Dr Weikert said. “If I’m going to err, it’s going to be a little bit on the larger side.” Complete hydrodissection is essential both to free the nucleus to spin and create enough room for the loop to get behind it, he added. It’s important to understand how the snare extends, first toward the surgeon and then away, and its angulation to safely deploy along the anterior surface of the crystalline lens. The snare should slide under the stained capsule edge, extended under the capsule, and rotated posteriorly to ensuring the instrument is properly inserted. As you rotate the snare around the lens it will be a little delayed, so go past the midpoint and then back to ensure it is centered. Constrict the snare slightly to grab the nucleus, and use a second instrument to prevent the distal nucleus edge from rising as you close the snare, segmenting the lens, Dr Weikert advised. “I like to do two passes to quarter the lens. You can even do more if you want to,” Dr Weikert said. The greatest advantage is the complete absence of posterior leathery attachments that can substantially increase phaco time and fluid usage. Applying additional viscoelastic to protect the endothelium throughout nucleus removal helps produce clear corneas on day one, he concluded. Boris Malyugin: boris.malyugin@gmail.com Soon-Phaik Chee: chee.soon.phaik@singhealth.com.sg Mitchell P Weikert: mweikert@bcm.edu

ESCRS

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• Subscription to Journal of Cataract & Refractive Surgery • Access to ESCRS Grants, Bursaries and Research Awards

Join today. www.escrs.org

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CORNEA

Innovative implant Implant replacing 200-700 microns of cornea could reduce global blindness. Howard Larkin reports

ith approximately 30 million people affected by unilateral corneal blindness and 10 million people by bilateral corneal blindness, corneal opacity is the third leading cause of blindness worldwide. Yet fewer than 200,000 corneal grafts are available annually, meaning less than 1% of patients can receive corneal transplantation. Use of the penetrating Boston keratoprosthesis is also limited by the need for donor tissue and the risk of severe complications. A recently developed non-penetrating keratoprosthesis could break this mismatch of tissue supply versus demand, Yichieh Shiuey MD told the innovators session at the ASCRS ASOA 2019 Annual Meeting in San Diego, USA. “It is my sincere hope that this and other technologies will finally be able to rid the world of the scourge of corneal blindness.”

OFFICE PROCEDURE Compared with penetrating alternatives, the minimally invasive KeraKlear (KeraMed) offers easier implantation, equal or better visual outcomes and lower risk of complications, including extrusion, endophthalmitis and glaucoma, said Dr Shiuey, who is KeraMed’s founder and CEO, and the device’s inventor. Unlike PK and the Boston K-PRO, KeraKlear can be implanted in any clean environment such as an office or laser suite and does not require a trained cornea

Courtesy of Yichieh Shiuey MD

A patient with a corneal scar

The same patient following implantation of the KeraKlear

transplant surgeon or a sterile, specially equipped operating room. The flexible device is placed through a circular 3.5mm partial-thickness incision into a uniform 8.0mm corneal pocket, and can replace 200-to-700 microns of diseased corneal tissue. A femtosecond laser is usually used to cut the pocket and semi-automated pocket-making devices may be used where lasers are not available. However, manual dissection is not a viable option because the human hand cannot create a uniform depth pocket, Dr Shiuey said.

Unlike corneal transplantation, vision improves immediately after surgery with the KeraKlear, and vision is stable within one-to-two months, he added. To date, no patient receiving the implant has experienced endophthalmitis, retroprosthetic membrane or increased intraocular pressure or glaucoma. Extrusion, corneal melting and non-endophthalmitis infection rates were also similar or lower than penetrating alternatives. A separate published study of 15 patients reported similar results (Alió JL, et al. Br J Ophthalmol. 2015;99:1483-1487). The KeraKlear device is commercially available outside the USA, and recruitment for a FDA clinical trial is currently under way at Harvard University, Duke University, University of California, Irvine and the Cincinnati Eye Institute.

GOOD OUTCOMES In a 50-month follow-up of 26 cornea blind patients implanted with KeraKlear, 92% achieved 20/200 or better vision. This level of visual acuity was as good or better than several Boston K-PRO studies and was also similar to the outcomes of several PK studies, Dr Shiuey reported.

Yichieh Shiuey: shiuey@yahoo.com

European Union Web-Based Registry

ECCTR is co-funded by Co-funded by the Health Programme of the European Union

EUROTIMES | DECEMBER 2019/JANUARY 2020

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.

www.ecctr.org

CORNEA

Contacts for keratoconus New options may better meet diverse patient needs. Howard Larkin reports

igid gas-permeable (RGP) designs remain the most popular contact lenses for moderate keratoconus patients. However, newer designs may offer better comfort and reduced complication risk, Kathryn A Colby MD, PhD, told the 10th EuCornea Congress in Paris, France. She recommended collaborating with contact lens experts, educating patients that fitting takes time and patience and keeping up with new technologies to better meet individual patient needs. Toric soft lenses are the most comfortable option, but are only suitable for mild cases, said Dr Colby, who is Professor and chair of ophthalmology and visual science at the University of Chicago, USA. For moderate cases, RGPs are currently the first line of treatment. In the past, RGP lenses were fitted “flat”, bearing on the apex of the cone. This was comfortable for patients, but increased corneal complications, including swelling, staining and scarring, Dr Colby said. Today’s “three-point touch” approach has minimal apical contact, a low vault and minimal peripheral touch. It provides stable vision and allows tear exchange with minimal chronic damage to the corneal epithelium. Rose K is the most common RGP lens, Dr Colby noted. It is customisable, well-tolerated, widely available and relatively inexpensive. The K2 version features an aspheric design to reduce spherical aberrations, a larger optical zone to reduce glare and haloes in low light and a steepened inferior quadrant for a more stable fit. The K2 XL is a larger diameter “semi-scleral” design that can be used in post-graft eyes, with a customisable edge lift to protect the ocular surface.

11th EuCornea Congress

AMSTERDAM 2 – 3 October 2020

RAI Amsterdam, The Netherlands www.eucornea.org

COMBINATION LENSES Less common are piggyback lenses, which mount an RGP on a soft base. This can increase comfort and makes the design suitable for use with inferior or marginal cones, Dr Colby said. However, it also means patients must care for two types of lens. “We have a hard enough time getting them to take care of one type of contact lens,” she commented. Hybrid lenses are similar to piggyback lenses, but in a single piece, though these can be slippery, making them difficult to handle, Dr Colby said. Scleral lenses vault higher, improving comfort, but require saline to insert. The PROSE lens is customisable to accommodate cones, but is expensive and not available everywhere. “Ever-expanding contact lens options are available and most patients can be fit successfully,” Dr Colby said. However, patients should be counselled that achieving a good fit often requires several tries. Patience and help from a contact lens specialist are very useful, she added. Kathryn Colby: kcolby@bsd.uchicago.edu

Ever-expanding contact lens options are available and most patients can be fit successfully Kathryn A Colby MD, PhD

EUROTIMES | DECEMBER 2019/JANUARY 2020

CORNEA

Necrotising fasciitis Manchester oculoplastic and orbital specialists clinicians are dealing with a rising incidence of periocular necrotising fasciitis. Roibeard Ó hÉineacháin reports

ith a higher incidence of necrotising fasciitis than elsewhere in the UK, ophthalmologists at the Manchester Royal Eye Hospital have become all too familiar with periocular manifestations of this disfiguring and potentially fatal bacterial infection. Compromised immunity resulting from alcohol excess, intravenous drug abuse, malnutrition, homelessness, immunosuppressive medications and trauma are major predisposing risk factors. However, the exact cause of the apparent increase in the Manchester catchment area are not fully obvious, Mr Micheal O’Rourke FRCSI(Ophth), FEBO, PhD, oculoplastic and orbital fellow, told the Annual Conference of the Irish College of Ophthalmologists in Galway, Ireland. Good outcomes can be achieved with prompt diagnosis and early treatment while planning immediate surgical debridement, he said. Mr O’Rourke presented a retrospective series of six patients with periocular necrotising fasciitis managed by the oculoplastic and orbital service at the Manchester Royal Eye Hospital in the previous 12 months. This series represents

data accumulated by fellows at the unit in this time period including Ms Egle Rostron, Ms Varajini Joganathan, Mr Ate Altenburg and Mr Micheal O’Rourke under the consultant care of Mr Aruna Dharmasena, Mr Paul Cannon, Ms Anne Cook, Mr James Laybourne and Mr Saj Ataullah. The patients included five men and one woman with a mean age of 43 years. The most obvious predisposing factor was immune stress and compromise. One 37-year-old male patient who consumed excessive alcohol and previously used intravenous drugs was also seropositive for hepatitis C. Another 36-year-old male patient had self-discharged Micheal O’Rourke FRCSI(Ophth), FEBO, PhD with facial trauma the day prior to requiring readmission. The series also included a 30-year-old homeless alcoholic patient and another homeless man with bipolar schizophrenia. Another patient was a 60-year-old male who had diabetes and was receiving steroids for vasculitis. Pathogens identified from swabs and blood cultures include group A-β haemolytic Streptococcus in four cases, Staphylococcus in one and one case was culture negative. The onset of symptoms was rapid in all patients. Five required immediate admission to the intensive treatment unit and emergency surgical debridement. The mean number of procedures was 4.3 including debridement and reconstructions, with some patients still undergoing complex reconstructions. There were no mortalities, which is likely attributable to early and intensive management achieved. Necrotising fasciitis is a serious bacterial infection that spreads rapidly along fascial planes with high morbidity and mortality. The reported incidence of periocular necrotising fasciitis is 0.24 cases per 1,000,000 per annum in the UK. The Greater Manchester Area has a population of 2.55 million; the six cases reported during this one-year study period therefore represents an annual incidence of 2.35 cases per million, nearly 10 times higher than the reported UK average. In response to the increased incidence of the condition, local management guidelines have been designed to improve patient care. The guidelines emphasise early recognition of the characteristic signs and symptoms of this condition in predisposed patients, prompt intravenous administration of broad spectrum antibiotics, repeat debridements as necessary until perfused viable tissue is reached and delayed reconstruction in collaboration with other facial surgeons including maxillofacial surgeons and ENT surgeons.

Good outcomes can be achieved with prompt diagnosis and early treatment while planning immediate surgical debridement

Michael O’Rourke: maorourk@tcd.ie, micheal.orourke@mft.nhs.uk EUROTIMES | DECEMBER 2019/JANUARY 2020

CORNEA

How ageing can affect the cornea Wide-ranging therapeutic consequences of corneal ageing. Dermot McGrath reports

ge-related changes in the cornea and ocular surface tissues have a major effect on vision and should be taken into account in many aspects of everyday clinical practice, according to Antoine Rousseau MD. “Ageing affects us all but we don’t always consider the direct impact it has on the cornea and the wide-ranging therapeutic consequences relating to the process of ageing in the eye,” he told delegates attending the 10th EuCornea Congress in Paris. Defined as an age-dependent or age-progressive decline in intrinsic physiological function and loss of adaptation, ageing affects the structure and function of the eye in multiple ways, said Dr Rousseau of Kremlin-Bicêtre Hospital in Paris. Corneal biomechanics, permeability and astigmatism, for example, are all impacted by the passage of time. The ageing eye is also more susceptible to the damaging effects of ultraviolet radiation. The cornea and the lens absorb most UV-B rays, while UV-A radiation penetrates through the stroma and induces reactive oxygen species, which can lead to oxidative stress, inflammation and cellular damage, explained Dr Rousseau. In terms of structural changes in the eye, some studies have shown a decrease in mid-peripheral and peripheral epithelial thickness over time, while there appears to be no correlation between stromal thickness and age. By contrast the epithelium basement membrane thickens over the course of a lifetime and the risk of dystrophy increases with age. Corneal nerve density has also been shown to decrease with age, said Dr Rousseau. Ageing also plays a role in diseases such as Fuchs’ endothelial corneal dystrophy. Although the actual mechanism of cell loss is unknown, it has been hypothesised that UV-A may promote reactive oxygen species accumulation and oxidative stress with implications for cell survival and functionality. Corneal permeability also increases with age, although the exact reason for this is still not fully understood. “It is a matter of debate but we do know that ocular penetration is increased with age and should be taken into account when prescribing topical drugs to our patients,” he said. Ageing should also be taken into account by glaucoma specialists because corneal biomechanics change with age and can have an impact on the intraocular pressure. “It is not easy to correlate this in clinical practice but we should at least keep it in mind,” said Dr Rousseau. Ageing also needs to be taken into account after cataract surgery, with particular regard to epithelial defects in patients with basement membrane dystrophy. Age-related changes in corneal astigmatism may have consequences for the predictability of toric IOLs and need to be considered in long-term planning for the patient, he concluded. Antoine Rousseau MD

Ageing affects us all but we don’t always consider the direct impact it has on the cornea...

EUROTIMES | DECEMBER 2019/JANUARY 2020

RETINA

A vision for the future The new EURETINA President Frank G. Holz MD outlines his plans for his term of office. Dermot McGrath reports

resh from another record-breaking annual congress in Paris, the European Society of Retina Specialists will be ramping up its efforts to promote science, research and education in the field of retina over the next few years, according to Frank G. Holz MD, the newly incumbent President of EURETINA. Taking the reins of the Society from outgoing President Sebastian Wolf MD, Professor Holz said that he is keen to build on the sterling work of his predecessors in serving the interests of EURETINA’s growing membership and the wider retinal community. “Priorities for my term of office include further development and improvement of the yearly main congress and to promote Frank G. Holz MD knowledge sharing among retina specialists. Addressing the needs and expectations of younger ophthalmologists is of high importance also for the future care of patients with retinal diseases. I will particularly support and strengthen all endeavours of the Young Retina Specialists (YOURS) group under the EURETINA umbrella and will continue to support the successful observership grants,” he told EuroTimes. Supporting research will also constitute a main priority for EURETINA under Prof Holz’s leadership. “In 2020 we will again run a EURETINA Retinal Medicine Clinical Research Funding call to fund specific research projects. Then in 2020 the EURETINA-funded trial on management of submacular haemorrhage in AMD will be initiated. Finally, we plan to develop and offer a special European Board of Ophthalmology (EBO) retina exam, and thus support our subspecialty,” he said. Prof Holz sees plenty of other challenges on the horizon for EURETINA, in particular the demographic time-bomb of Europe’s ageing population, which will place unprecedented strain on healthcare services in the coming years. “We have to anticipate the growing number of patients who will need special care. At the same time, the number of ophthalmologists is not increasing in Europe. So, we need solutions to assist specialists and save time on tasks that can be delegated,” said Prof Holz. Artificial intelligence (AI) is one possible avenue to lessen the burden on retinal experts in the future, he suggested. “With AI applications we can analyse digital images faster. For instance, screening OCT-B scans for retreatment decisions can be time-consuming and AI can accomplish this in much shorter time frames. We must ensure that patients have access to these developments as soon as possible. Bottlenecks in this respect for reimbursement also need to be addressed. Easy access to education materials will also be key and EURETINA is engaged actively in various developments in this regard,” he said. As Prof Holz sees it, research funding will remain a key priority, both through the EURETINA Retinal Medicine Clinical Research EUROTIMES | DECEMBER 2019/JANUARY 2020

Funding Call and through advocacy at a European level. “The aim of our efforts is to gain better access to EU research funding, which plays a growing role besides national funding. The Macustar study, for instance, is currently the only funded ophthalmological project in the context of the IMI2 European programme. It is noteworthy that it is a retina project in intermediate AMD, looking at the development of novel clinical endpoints for clinical trials in patients with a regulatory and patient access intention,” he said. Prof Holz also sees scope for EURETINA to support pivotal randomised clinical trials to answer key questions relating to clinical practice in the field of retina. “We have just selected the recipient of the grant for a trial on management of submacular haemorrhage secondary to AMD. This will be large-scale prospective randomised trial, which will be realised with a grant of over €2 million from EURETINA. We intend to fund more projects of similar scope in the future,” he said. The beating heart of EURETINA’s success remains its annual congress, which attracted nearly 6,000 delegates to the last meeting in Paris, said Prof Holz. “It has become the major international meeting in Europe that focuses on retinal diseases with the most prominent and outstanding experts across the entire spectrum of retinal topics. The balanced mix of educational formats works very well. Attendees receive information on new developments that also impact on their clinical management of patients. There is also practical guidance based on consensus papers developed by EURETINA,” he said. In fact, the continued growth of the Society means that the format of a joint annual meeting with the ESCRS needs to be revisited in the future, said Prof Holz. “The collaboration with ESCRS has worked wonderfully well over the past four joint congresses and we have enjoyed a very positive engagement with ESCRS during that time. Both societies have experienced tremendous success during this period and, as a result, Amsterdam 2020 will be the last of these joint meetings. Both congresses attract an increasing number of attendees so a combined meeting would be too large in the future, with a very limited number of possible venues that could accommodate such numbers,” he concluded. Frank G. Holz is Professor and Chair of the Department of Ophthalmology at the University of Bonn, Germany. He trained at the University of Heidelberg, Germany, and completed a fellowship at Moorfields Eye Hospital, London, UK. He is a board member of the German Ophthalmological Society as well as a member of the European Academy of Ophthalmology, the Macula Society and is editor-in-chief of Der Ophthalmologe

RETINA

Gene therapy progress Optimism for studies of gene therapy of choroideremia and X-linked retinitis pigmentosa. Leigh Spielberg MD reports

Surgeons prepare to inject a viral vector into the back of the eye

for specific several genes such as RP2 and OFD1, family trees must be consulted. “In choroideremia, potential patient’s female family members can be screened for carrier status. A ‘typical’ female carrier has had slightly reduced vision since childhood, a mother with poor night vision and a great grandfather who had gone blind due to what was (mis)diagnosed as glaucoma,” he explained, noting that one must be absolutely certain that the phenotype observed in the clinic is caused by the genetic abnormality discovered in the lab, otherwise there will, of course, be no effect. Choroideremia is in many respects the ideal model for gene therapy in other retinal diseases. These diseases require early intervention before the onset of visual loss, as it is much easier to prevent a retina from degenerating, via gene therapy, than to reconstruct it once the damage has been done. Considering the success of the current studies, Dr MacLaren was justifiably optimistic about the future of gene therapy for choroideremia. Big pharma has been taking note of the gene therapy successes. Spark’s LUXTURNA, the first gene therapy for retinal degeneration, paved the way with its approval, but the reimbursements for novel gene therapies are still unclear and payment terms will need to be determined. In contrast to the relatively slow progression of choroideremia, X-linked retinitis pigmentosa is characterised by its

Courtesy of Robert E. MacLaren FRCOphth, FRCS

arly clinical results with gene therapy for choroideremia and X-linked retinitis pigmentosa suggest there is reason to be optimistic about this therapeutic approach to genetic retinal disease, according to Robert E. MacLaren FRCOphth, FRCS, speaking at the 19th Annual EURETINA Congress in Paris, France. Dr MacLaren, University of Oxford, presented an update on the current state of the art during a session on the present and future of retinal gene therapy. Choroideremia is an X-linked recessive chorioretinal dystrophy caused by REP1 protein deficiency, which usually begins with an impairment of night vision and leads to constriction of the peripheral visual field, progressing from annular scotomas to concentric visual field loss. It is characterised by progressive degeneration of the choroid, retinal pigment epithelium and retina. The choroideremia phenotype is driven by the RPE degeneration. Evidence that it occurs secondary to RPE cell death was revealed when a dominant mutation in RPE65 identified by whole-exome sequencing was shown to cause retinitis pigmentosa with choroidal involvement. Dr MacLaren first reviewed the technical details of gene delivery for retinal disease. “The procedure starts with a vitrectomy to gain access to the retina. Intraoperative OCT is then used to guide a measured subretinal injection of balanced salt solution into the potential space between retina and RPE. This detaches the retina, allowing for subsequent subretinal injection of 0.1ml of viral vector suspension into the BSS-bleb,” he explained. But how high should the vector concentration be? “The dosing of gene therapy is still relatively unexplored. A suboptimal dose of the vector leads to insufficient numbers of transfused cells, which will die due to the natural history of the disease. However, a toxic dose can also lead to cell death,” said Dr MacLaren. Finding just the right concentration is needed, and dosing strategies will be the focus of later studies, he added. He explained that in the meantime, finding patients can be challenging, because the genetics of retinal degenerations aren’t always very straightforward. For example, in a case of X-linked retinitis pigmentosa, with more than 100 retinal degeneration genes to analyse and exome sequencing negative

The right eye of a patient with X-linked retinitis pigmentosa

rapid disease progression. Most commonly caused by mutations in the retinitis pigmentosa GTPase regulator (RGPR) gene, X-linked retinitis pigmentosa is also a target of gene therapy. “The goal is to express RPGR in the photoreceptors,” said Dr MacLaren. “The first human RPGR gene therapy was performed in Oxford Eye Hospital in 2017,” with promising results. As with choroideremia, the treatment is delivered via an adeno-associated virus (AAV) vector, which is nonenveloped and thus is less likely to induce an inflammatory response. As for the extraocular safety of gene therapy, there are a lot of data suggesting that both shortand long-term results are safe. Robert MacLaren: enquiries@eye.ox.ac.uk EUROTIMES | DECEMBER 2019/JANUARY 2020

Euretina Congress Amsterdam

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RETINA

Unlocking the potential of artificial intelligence The potential applications of AI are wide-ranging. Priscilla Lynch reports

phthalmology is leading the way in unlocking the potential of artificial intelligence (AI) in the medical arena, and AI will very soon revolutionise the way patients are diagnosed and treated, according to one of the pioneers in the field. Pearse Keane MD, FRCOphth, Consultant Ophthalmologist at Moorfields Eye Hospital, UK, has led the development of a groundbreaking AI algorithm that applied novel deep learning technology to clinically heterogeneous three-dimensional macular optical coherence tomography (OCT) scans. The resulting algorithm was able to recommend the correct referral decision for more than 50 sightthreatening retinal diseases with 94% accuracy, matching or exceeding worldleading ophthalmologists in a proof-ofconcept trial. Having published the data in Nature Medicine in 2018, Dr Keane is keen to see the findings implemented in real life, and hopes that a clinical model can be ready within the next couple of years.

WIDE-RANGING POTENTIAL But that is only the beginning – the potential applications of AI in ophthalmology are wide-ranging and will one day assist in screening and triaging as well as diagnosing, treating and predicting outcomes in

I firmly believe for AI to be successful in medicine and a specialty like ophthalmology, it has to be driven by healthcare professionals Pearse Keane MD, FRCOphth

I think we need to balance enthusiasm and excitement for these new technologies with caution. They do have the potential to be transformative but there are lots of ways they may not work or go astray Pearse Keane MD, FRCOphth

patients in everyday clinical practice, Dr Keane, who will address the 2020 Spark Summit in Dublin on the topic of AI in medicine, contended. “Despite all the hype around AI, it does have the potential to transform healthcare. Ophthalmology is going to be the first of all the medical specialties to be fundamentally transformed using AI and I am very excited about that,” he told EuroTimes. “I firmly believe for AI to be successful in medicine and a specialty like ophthalmology, it has to be driven by healthcare professionals. I think if you empower ophthalmologists, we’ll come up with hundreds of applications for AI systems and be able to assess them.” Furthermore, ophthalmology could be “an exemplar” for other medical specialties in the development, validation, implementation and adoption of AI, Dr Keane said. “So in other words, an exemplar in terms of identifying cases where AI can add value to patients, clinicians and healthcare institutions; and in setting up infrastructure where AI can aggregate and curate data for the development of AI systems; as well as the validation of these systems through randomised clinical trials that will properly demonstrate these things work and are safe and effective and bring benefits to patients.”

“I think we need to balance enthusiasm and excitement for these new technologies with caution. They do have the potential to be transformative but there are lots of ways they may not work or go astray. We can still be enthusiastic but at the same time demand very high standards before we use them on patients.” One of the key potential barriers is suspicion that AI could eventually replace clinicians or operate independently without oversight. “Nobody is going to be replaced and no one is suggesting that we just let these systems loose on patients to do very important things such as decide whether they need an injection or surgery without a doctor/healthcare professional being in the loop. So the technology is still very young and we are trying to find the areas which can bring the best benefits for patients,” Dr Keane said. He emphasised that AI will be just another, albeit very useful, tool for clinicians, against a background of everincreasing demand for services. “Given how busy we are now and will continue to be, everybody recognises that this is not a luxury to develop these technologies; it is a necessity.”

REPLACING THE DOCTOR?

The second HSE Spark Summit will take place in the Convention Centre Dublin, Ireland, on February 13 and 14, 2020.

Dr Keane acknowledged that rolling out AI in medicine will have to be done in an incremental, evidenced-based manner.

For more information visit https://www.sparksummit.ie EUROTIMES | DECEMBER 2019/JANUARY 2020

GLAUCOMA

I N D I V I D UA L I S I N G

glaucoma patient care

More tools needed to optimise therapeutic tailoring. Cheryl Guttman Krader reports

lthough guidelines from around the world provide general advice on glaucoma management for populations of patients, their recommendations are not geared for individualised decision-making for each patient, notes Fotis Topouzis, MD. Speaking at the ESCRS/EGS Glaucoma Day meeting in Paris, France, Dr Topouzis discussed current approaches to matching therapeutic strategies to individual glaucoma patients and outlined a path for improving customised treatment in the future. Reviewing prospective clinical trial data on progression rates associated with various treatment strategies, Dr Topouzis brought forth the drawbacks of following a standard approach to care, but also the limitations of the current approach to an individualised regimen based on target IOP. “We saw in the Early Manifest Glaucoma Trial (EMGT) and in the United Kingdom Glaucoma Treatment Study (UKGTS) that a standard approach with less aggressive treatment would probably result in many patients being under-treated. Therefore, one would ask why not be on the safe side and treat everyone more aggressively?” said Dr Topouzis, Professor of Ophthalmology, Aristotle University of Thessaloniki, Greece. “According to results from the Collaborative Initial Glaucoma Treatment Study, the answer to that question is that aggressive treatment would result in overtreatment for many glaucoma patients. In addition, data from the EMGT and UKGTS show strikingly that many glaucoma patients do not progress when left untreated.” Dr Topouzis reminded clinicians that as stated in the EGS guidelines, the goal of glaucoma treatment is to maintain the patient’s visual function and quality of life at a sustainable cost. In addition, every treatment is associated with cost and sideeffects that affect quality of life. “Increasing treatment increases sideeffects leading to an increased impact on quality of life. Therefore, we need to be balanced in our decisions at the individual level,” said Dr Topouzis. For now, customised treatment depends on setting a target IOP and reaffirming its appropriateness through continued EUROTIMES | DECEMBER 2019/JANUARY 2020

We need to know the stage that is tolerable because quality of life may be affected even at an earlier stage of damage Fotis Topouzis, MD

follow-up. Multiple factors are considered when establishing the target, including the stage of glaucoma damage, the patient’s life expectancy, the level of untreated IOP, additional risk factors (e.g., central corneal thickness, presence of pseudoexfoliation) and rate of progression. Rate of progression, however, cannot be used as a parameter when first initiating therapy. There are also challenges for assessing progression in clinical practice and a need to better understand how different rates of progression impact individual patients. Dr Topouzis explained that in patients who are slow progressors, a larger number of visual fields are needed to detect progression in a given time frame. As described in a paper by Chauhan et al. (Br J Ophthalmol. 2008;92(4):569-573), six visual field examinations should be performed in the first two years to rule out the presence of rapid progression (≥-2 dB/year) and establish a good baseline. “Obtaining that many visual fields is difficult, but even if it was feasible, it seems inadequate for detecting slower rates of progression that would result in visual impairment or blindness during lifetime in the majority of patients,” said Dr Topouzis. Explaining his comment, Dr Topouzis presented findings from a study conducted to provide information on the maximum tolerable rate of progression to avoid visual impairment and blindness in patients with open-angle glaucoma (Br J Ophthalmol. 2018;102:916-921). The analysis, which included data from participants in the crosssectional, population-based Thessaloniki Eye Study, found that the maximum tolerable rate of glaucoma progression to avoid blindness was <-2 dB/year in 72.4% of patients. Therefore, currently our best tools, methods and proposed strategies aiming to detect fast progressors (-2dB/year or faster)

seem inadequate to detect slower rates of progression that would result in visual impairment or blindness during lifetime in the majority of patients.

NEEDS FOR THE FUTURE To be able to individualise therapy based on rate of progression, there is a need for better understanding of the stage of visual field damage that has to be prevented. “We need to know the stage that is tolerable because quality of life may be affected even at an earlier stage of damage,” Dr Topouzis explained. Then strategies and tools for calculating tolerable rates of progression for the individual patient are needed, fast progressors need to be defined at the individual level according to their tolerable rate of progression, taking into account life expectancy, stage of damage and other factors, and next strategies and tools to identify fast progressors are needed. Potential tools in the era of precision medicine include the identification of biomarkers for fast progression, risk alleles for glaucoma onset and progression and biomarkers for guiding angle-based surgery approaches and efficacy. Reviewing the status of these, Dr Topouzis said there is limited knowledge regarding risk factors and biomarkers for fast progression. Genetics is a promising pathway for the future, and methodologies are being developed to evaluate aqueous humour dynamics to obtain information for planning and monitoring the response to surgery. “Ideally, we need a calculator for glaucoma progression and fast progression similar to what we have for ocular hypertension and that potentially integrates genetic information,” he said. Fotis Topouzis: ftopou12@otenet.gr

GLAUCOMA

Recognising early glaucoma

CO NE NT W EN T

Diagnosis hinges on understanding of risk factors and test interpretation. Cheryl Guttman Krader reports

oth computerised perimetry and structural tests are sensitive for detecting early glaucoma, but there is potential for false positives with each, cautioned Anders Heijl MD at the ESCRS/EGS Glaucoma Day meeting in Paris, France. Dr Heijl, Lund University, Malmö, Sweden, discussed considerations for building certainty when diagnosing glaucoma. For example, patient age and IOP are two meaningful factors to think about. He illustrated his point with findings from a prediction model based on the population screened for the Early Manifest Glaucoma Trial. “It is rather unlikely that younger patients with low IOP have glaucoma. Our suspicion should be much higher in older patients and with higher IOPs,” Dr Heijl said. When glaucoma is suspected, documentation of corresponding structural or functional damage is necessary to establish the diagnosis. Looking at perimetry, clinicians need to differentiate glaucomatous field loss from cataract-related defects. Cataract results in a diffuse loss of threshold sensitivity and progressive cataract leads to darker greyscale maps. Glaucomatous visual field loss is primarily localised, resulting in field defects with shape. A diffuse loss component develops in later stages, and with Anders Heijl MD progression defects deepen and even more importantly increase in area. “Very early glaucomatous field loss, however, is often visible only in the probability maps, not in the greyscale maps, but is still diagnostic if confirmed in a second or third tests,” said Dr Heijl. He cautioned that pre-perimetric glaucoma is a “rather risky diagnosis”, which should be avoided, and noted that false positive diagnoses are common in normal subjects with large discs.

STRUCTURAL EVALUATION Although OCT can be both sensitive and specific for diagnosing glaucoma, because of the large amount of data on an OCT printout, clinicians must beware of the potential for mass significance. “There are many analyses in the OCT printout, and it is very likely that at least one will be significant even if the subject is perfectly normal,” Dr Heijl said. He presented examples of false OCT flags in normal eyes and cited a paper discussing “red disease” that emphasised the importance of correlating findings from structural and functional tests along with the common occurrence of OCT segmentation/image acquisition errors. Dr Heijl also cautioned against diagnosing glaucoma when uncertainty exists, noting the potential harm. “Receiving a diagnosis of glaucoma reduces quality of life and can lead to problems with anxiety and fear of blindness. Patients with suspect or uncertain glaucoma should usually be followed, but should usually not receive a diagnosis or be treated,” Dr Heijl said.

A library of symposia, interviews, video discussions, supplements, articles and presentations Spotlight on: 

Toric IOLs and Presbyopia



Glaucoma



Ocular Surface Disease



Corneal Therapeutics

Visit forum.escrs.org for details

Anders Heijl: anders.heijl@med.lu.se EUROTIMES | DECEMBER 2019/JANUARY 2020

PAEDIATRIC OPHTHALMOLOGY

Paediatric keratoconus Large hospital-based series describes incidence and multiple features. Cheryl Guttman reports

new prospective, observational study has provided a wealth of information on the incidence, clinical features, comorbidities and management outcomes of keratoconus in paediatric patients, said Meenakshi Ravindran MD. Dr Ravindran, Aravind Eye Hospital, Tirunelveli, India, reported the data and compared them with previously published data at the World Society of Paediatric Ophthalmology & Strabismus Subspecialty Day in Paris, France. The study identified patients aged 5 to 18 years seen between December 2016 and April 2017, with a diagnosis of keratoconus suspect, forme fruste keratoconus, early keratoconus or keratoconus having six months' follow-up. It found a 0.27% incidence of keratoconus among all paediatric patients (50/18,684 patients) and that the paediatric patients accounted for 21.93% of all patients with keratoconus (50/228). “In their retrospective study, El-Khoury et al. reported these parameters to be 0.53% and 2.96%, respectively,” Dr Ravindran said. Other endpoints were analysed for 70 eyes of 38 patients. The most common clinical features were scissoring (71%) and Fleischer’s ring (58%), while Vögt striae was seen in 38% of

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...

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Visit education.escrs.org EUROTIMES | DECEMBER 2019/JANUARY 2020

Courtesy of Meenakshi Ravindran MD

Follow-up results of BCVA after surgical intervention

eyes. “Similar results have been noted by Sharma et al.,” Dr Ravindran said. A history of vernal keratoconjunctivitis (VKC) was present in 50% of eyes, and there were no statistically significant differences in scanning slit topography (Orbscan II) parameters comparing eyes with and without VKC. Eye rubbing, bilateral disease, and mixed-type VKC were associated with more severe keratoconus. “The lack of differences in topographic parameters between eyes with and without VKC is in contrast to a report by Taneja et al. The same authors also reported significant differences in topography only in the 3mm zone values comparing eyes with mixed and palpebral types of VKC,” Dr Ravindran said. Within the Aravind Eye Hospital series, higher percentages of eyes that were recommended for surgical intervention at follow-up had adverse topographic parameters than those not so advised. Surgery was recommended for 52 eyes. Corneal cross-linking was mostly advised and was performed in 42 eyes. Six eyes had deep anterior lamellar keratoplasty (DALK). “CXL stabilised BCVA (see above), refraction and topographic parameters, and the visual outcomes were comparable to those of patients who had DALK. Our study indicates that DALK is an appropriate alternative to penetrating keratoplasty,” Dr Ravindran said. She noted that the study has several limitations, including short recruitment and follow-up periods. In addition, the numbers of patients and their preoperative characteristics differed among the three surgical intervention groups. “Therefore, the groups are not readily comparable. Furthermore, details of postoperative complications could not be assessed,” Dr Ravindran said. Meenakshi Ravindran: drmeenakshi@aravind.org

Our study indicates that DALK is an appropriate alternative to penetrating keratoplasty Meenakshi Ravindran MD

WCPOS V | 2020 5th World Congress of Paediatric Ophthalmology and Strabismus 2–4 October 2020 | RAI Amsterdam, The Netherlands

Keynotes Friday 2 October 2020 David Mackey

AUSTRALIA

Non-Strabismus Keynote Lecture Genes and Environment: Towards Personalised Prevention of Myopia in Children

Saturday 3 October 2020 Burton Kushner

USA

Strabismus Keynote Lecture Forty-Five Years of Studying Intermittent Exotropia — What Have I Learned

Sunday 4 October 2020 Marie-José Tassignon

BELGIUM

Kanski Medal Lecture A Thing of Beauty is a Joy Forever

Key Dates

Abstract Submission Open

JANUARY 2020 Registration opens for WCPOS V (5th World Congress of Paediatric Ophthalmology and Strabismus)

FRIDAY 28 FEBRUARY 2020 Abstract Submission closes for Free Papers, Posters & Video Competition

FRIDAY 2 – SUNDAY 4 OCTOBER 2020 WCPOS V (5th World Congress of Paediatric Ophthalmology and Strabismus)

www.wspos.org

OCULAR

Shocking convergence Low-voltage shock leaves lasting visual effects. Aidan Hanratty reports

38-year-old male with no past medical history presented one week following a low-voltage alternating current injury, said orthoptist Eamonn Nugent. Contact to the electrical source lasted approximately four-to-five seconds and entered via his right hand, Mr Nugent told the Annual Conference of the Irish College of Ophthalmologists. The patient’s chief ocular complaints were vertigo and horizontal diplopia, as well as difficulty reading and in recognising faces. He also suffered right-sided muscle weakness, muscle spasms, headaches and self-reported psychological changes. His visual acuity was 6/9 in both eyes, with no relative afferent pupillary defect, no lens opacities and with normal anterior and posterior segments. An orthoptic exam showed orthophoria, but motility testing showed bilateral restrictions of upgaze and convergence was defective at 15cm. MRI and CT scans yielded no significant findings, and OCT results were unremarkable. “As a differential diagnosis of this patient, the bilateral restrictions of upgaze and the convergence being defective does suggest the dorsal midbrain region has been affected,” said Mr Nugent. Furthermore, functional overlay could not be ruled out. EUROTIMES | DECEMBER 2019/JANUARY 2020

CONVERGENCE EXERCISES In an attempt to relieve the convergence insufficiency, the patient was given reading glasses, and three-times-daily dot card convergence exercises were prescribed. Eight weeks later convergence improved to 12cm, but the patient continued to have restriction of upgaze. He also said that he could see cars but no one inside them and had continued to have difficulty recognising faces. The patient also reported a complete change in character, adding that he felt like a 70-year-old man and suffered from depression and severe fatigue. He also became unemployed. The patient requires frequent therapeutic monitoring, as the literature suggests that changes following electric shocks can take between days and years to manifest. “Interestingly, the retina and optic nerve are known to have a higher electric

resistance in comparison to other areas, so this may be another reason for why they've been spared in this case,” said Mr Nugent. Subsequent electro-diagnostic testing may yet give more information about the patient’s retinal function, he added. While electric injuries are uncommon, they can have a devastating impact on patients. According to Mr Nugent, most of the literature is focused on high-voltage or lightning-strike-type injuries, especially within ophthalmology, so this case shows the damaging effects of even a low-voltage injury. “We need to implement further frequent therapeutic monitoring for this patient and we also made sure there was onward referral to neurology and medical psychology,” said Mr Nugent, acknowledging the various symptoms the patient has been suffering. Eamonn Nugent: nugentorthoptics@gmail.com

As a differential diagnosis of this patient, the bilateral restrictions of upgaze and the convergence being defective does suggest the dorsal midbrain region has been affected Eamonn Nugent

BOOK REVIEWS

PUBLICATION RETINAL DETACHMENT SURGERY & PROLIFERATIVE VITREORETINOPATHY

LEIGH SPIELBERG MD Books Editor

BOOK

EDITORS CYNTHIA TOTH AND SALLY ONG PUBLISHED BY ELSEVIER

PUBLISHED BY SPRINGER

INPUT FROM SURGEONS AROUND THE WORLD

Reviews PUBLICATION HANDBOOK OF PEDIATRIC RETINAL OCT & THE EYE-BRAIN CONNECTION

EDITORS ULRICH SPANDAU, ZORAN TOMIC AND DIEGO RUIZ-CASAS

First of its kind in imaging study

“The eye is an approachable part of the brain.” This quotation is the premise on which half of the subject matter of this handbook is based. The other premise, that optical coherence tomography (OCT) can be used to help diagnose causes of reduced visual acuity not only in adults, but also in children and even infants, forms an intriguing introduction to this 330-page handbook. The Handbook of Pediatric Retinal OCT & the Eye-Brain Connection (Elsevier), edited by Cynthia Toth and Sally Ong, might be the first of its kind. Professor Toth has been imaging infants for more than 15 years, and has published extensively on the subject, sharing her insights on OCT for retinopathy of prematurity, nystagmus and ocular albinism, among others. The first part of the handbook introduces paediatric retinal OCT imaging, informing the reader on how to organise the logistics of such imaging and how to analyse the resulting scans. Because paediatric retinas are not simply smaller versions of the adult structure, section 2 delves into “Age-dependent Features & Common Abnormalities”. Examples include a fascinating discussion of foveal development from 30 weeks of gestation to childhood and a surprisingly large range of vitreoretinal abnormalities. After having covered the practical matters of OCT imaging and interpretation, the authors turn to the specific diseases that will be encountered in clinical practice. What does Best disease look like on OCT in a six-year-old girl? How about FEVR in a fiveyear-old? It’s all here. Each disorder is illustrated by the highest-quality OCT scans and ancillary imaging, mostly courtesy of the Duke Imaging Center. What about the eye-brain connection? “Pediatric intermediate uveitis may be rarely associated with multiple sclerosis,” and “Torpedo maculopathy has been reported in one patient with tuberous sclerosis” are some examples. This handbook is intended for retinal specialists, ambitious paediatric ophthalmologists and ophthalmology departments in hospitals with referral centres for neonatal intensive care and/or complex paediatric disease. With its highly organised structure and clear overview of rarer retinal disease, it can also help the ready study for large examinations.

A SUMMARY OF 77 IMPORTANT TRIALS “Do you always have the latest evidence-based medicine at your fingertips?” This is the challenge posed by Current Clinical Evidence in Ophthalmology (Kugler), edited by Drs Roberts, Gale & Martin. This book summarises 77 important trials in ophthalmology, offering all the information needed for a clinician to make informed decisions. Organised by subspecialty (anterior segment, glaucoma, retina, neuro-ophthalmology and paediatric ophthalmology), each section includes the studies judged by the editors to be the most PUBLICATION CURRENT CLINICAL EVIDENCE relevant at this time. Each study is summarised on two pages, with information such as IN OPHTHALMOLOGY study design, evidence level, aims, methods, results, weakness and “key EDITORS messages” provided. HARRY W ROBERTS, JESSE The book was designed for busy clinicians and trainees GALE, KEITH R MARTIN sitting specialist examinations, and could certainly be useful for EUROTIMES | MONTH YEAR PUBLISHED BY KUGLER ophthalmology researchers.

“Retinal detachment has always been a dramatic and terrifying experience for the patient and a source of frustration for the surgeon,” writes Relja Zivojnovic in this book’s foreword. Retinal Detachment Surgery and Proliferative Vitreoretinopathy (PVR): From Scleral Buckling to Small Gauge Vitrectomy (Springer), edited by Ulrich Spandau, Zoran Tomic and Diego Ruiz-Casas, tackles this pathology systematically. Starting with an introduction to PVR, preoperative assessment and surgical technique, the book then progresses to “Special & Advanced Cases” and postoperative care. For Part VI, the editors received input from VR surgeons around the world regarding how they would tackle specific challenging cases. This 400-page handbook, intended for VR surgeons and fellows, finishes with video cases.

PUBLICATION INNOVATIVE APPROACHES IN THE DELIVERY OF PRIMARY & SECONDARY EYE CARE EDITORS ROHIT C KHANNA, GULLAPALLI N RAO, SRINIVAS MARMAMULA PUBLISHED BY SPRINGER

TAKING A STEP BACK FOR A BROADER VIEW Innovative Approaches in the Delivery of Primary & Secondary Eye Care is part of Springer’s Essentials in Ophthalmology series. Rather than reiterating the specifics of pathology and treatment, this book takes a step back for a broader view. Topics include “Expanding & Optimizing Human Resources for Eye Care,” “Affordability & Financing for Eye Care” and several chapters on “Innovative Approaches in the Delivery of Eye Care”. This book shows that medical skills are necessary but not sufficient for the delivery of care, and is intended for hospital directors, ophthalmologists in underserved regions and anyone responsible for organising care efficiently, particularly at scale.

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

EUROTIMES | DECEMBER 2019/JANUARY 2020

PRACTICE MANAGEMENT

Mike Malley (left) and Amanda Cardwell Carones (below), speaking at the ESCRS Practice Management Masterclass

Driving revenues

Building a patient-centric ophthalmic practice that maximises profitability. Colin Kerr reports

elegates at the 37th Congress of the ESCRS in Paris, France, attended a highly interactive and didactic workshop-based course led by Amanda Cardwell Carones, Managing Director of CARONES Vision and founder of Eligite SRL, and Mike Malley, President and Founder of CRM Group. In the session devoted to ‘Building A Patient-Centric Ophthalmic Practice That Maximises Profitability’, Carones and Malley challenged surgeons to assess their effectiveness in various aspects of their clinics. This included physician time management; practice profit margins; patient education processes; premium services planning; staff conversion training; practice culture commitment; exit-strategy evaluation; staff incentive strategies; maximising surgeon production; and costs controls. Malley began the session with a question for the audience: “What factor most interferes with your success?” Attendees answered waiting times, expenses for acquiring new technologies, form completion and appointment schedules. The experts helped to address these pain points with what they referred to as the “ophthalmic holy grail”, best summarised with a quote by Amazon founder, Jeff Bezos: “When you reduce friction and make something easy, people do more of it.” EUROTIMES | DECEMBER 2019/JANUARY 2020

By pushing care to the lowest provider level, surgeons can maximise their time seeing the right kind of patients... Mike Malley

DRIVING REVENUES Carones then went on to discuss the most effective way of driving revenues by converting more patients to premium procedures and adjusting the practice flow. She said: “Stop penalising premium patients who come in willing to spend their money. Streamline the flow of these patients and improve their educational process, rather than having them lose confidence in the practice and the surgeon.” Pushing patient care to the lowest provider level was another key takeaway from the session. Malley explained: “As reimbursement continues to drop – and the shortage of ophthalmologists continues to rise – it is imperative for surgeons to understand the value of their time and how it relates to the bottom line. By pushing care to the lowest provider level, surgeons can maximise their time seeing the right kind of patients in the clinic, and spending the rest of their time in the OR!” The session ended with a summary

of the ‘best patient-centric approach’ and alluded to the “hyper-sensitivity of patients” considering ocular surgery. A famous quote by Maya Angelou, expressed this point: “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.” Malley and Carones urged practice managers to pay closer attention to their clinics from the patient’s perspective, to ensure all staff are aware of their contribution and role in the care of the patient, to involve the patient’s family when possible. Carones concluded with the statement: “A medical practice can say what they want about who they think they are and what they think they deliver... but patients will believe what they actually experience.” Amanda Cardwell Carones: acarones@carones.com Mike Malley: Mike@RefractiveMarketing.com

EXPLORING MARRAKECH

Mezze salads at Le Trou Au Mur restaurant, Marrakech

MARRAKECH

TO NOTE ... Courtesy of www.secondhalftravels.com

SALADS ON HAND FOR VEGETARIANS, THOUGH WATCH OUT FOR STOCKY TAGINE Although Moroccans in general may not understand vegetarianism, vegetarians won’t go hungry in Marrakech, especially if they like salads. Classic offerings include ’zaalouk’, made of eggplant, tomato and garlic, and Tk’touka: bell peppers, tomatoes and spices. Chopped cucumbers and tomatoes with a vinaigrette dressing will probably be available, too, along with lentils and white kidney beans in a tomato sauce. Hot main meals may include vegetarian tagine: potatoes, carrots, chickpeas, and onions or other vegetables in season and vegetarian couscous, made by steaming semolina above vegetables. However, know that both couscous and tagines are often cooked with meat stock and may simply have had the meat taken out to fill the ‘vegetarian’ order. Oil used in fried foods may have been used to cook meat.

RESTRICTED BUT NOT PROHIBITED The licence to sell alcohol in Marrakech is prohibitively expensive; most smaller restaurants can’t afford it. That doesn’t necessarily mean they don’t serve it – a quiet request to the waiter, if you’re dining out of sight of passers-by, may result in the discreet appearance of wine or beer. While Muslims do not drink alcohol, allowance is made for the tastes of foreigners. Restaurants catering to tourists will usually serve both imported and locally produced wines. There’s a more restricted range of beers, but cocktails and ‘mixology’ flourish. There are a couple of cocktail bars in Marrakech, the first and most famous being Le Baromètre in Gueliz. Dinner (and tapas) served every evening except Sunday, reservations advised at +212 5243-79012. No website.

BRING A TASTE OF MOROCCO HOME TO YOUR FRIENDS AND FAMILY Proof that visitors to Marrakech find the tastes and smells of local food irresistible can be found in the number of cooking schools that flourish in the city. Invest a couple of hours learning to recreate something you’ve enjoyed and you have a souvenir that will give pleasure to yourself and those at your kitchen table. The Viator listing of cooking courses offers a remarkable 62 choices; some include shopping for the ingredients, others entail a day out of the city. Any of one of them provides a great introduction to the spices and skills intrinsic to Moroccan cuisine. Browse the list https://www.viator.com/Marrakech-tours/ Cooking-Classes/d5408-g6-c19

Taste of Marrakech Delegates can start looking forward to some marvellous meals in Morocco. Maryalicia Post reports. Getting ready for Marrakech? In addition to experiencing a range of exotic sights and sounds, you can anticipate some memorable tastes as well. Start with breakfast. Of course, you could choose to have a continental breakfast of croissant, juice and coffee. But at least once, experience a classic Moroccan breakfast based on bread – several kinds of bread – served with honey, fruit, goat cheese and sometimes a runny egg and olives. Add a semolina pancake, enjoy an orange juice and mint tea. You won’t have to eat again until dinner. If you should want lunch, however, visit the Amal Center, a non-profit association that offers paid internships, literacy programmes and culinary training to disadvantaged women. The restaurant is one of the main fundraising initiatives of this worthy foundation. The menu features less common Moroccan dishes such as fish balls, Moroccan tortilla and calamari salad. Payment is by cash only. Details and booking at amalnonprofit.org Open daily 12pm-4pm. Dinner time is where the Moroccan table really shines. Candles on the table and stars in the sky add the glitter; the Moroccan cuisine does the rest. If you’re ready for a top-of-the-line experience at top-of-the-line prices, you are ready for the famous Le Jardin at the Royal Mansour. Chef Yannick Alléno, who has two three-starred Michelin restaurants

to his name, offers sharing plates that include fish and slow-roasted meats along with ‘fire-cooked’ plates such as fried eggplant with orange-blossom honey and picanha beef. royalmansour.com Open daily, reservations essential. For an excellent meal on a more casual level, one of the best addresses in Marrakech is a restaurant called Le Trou Au Mur; this particular ‘hole in the wall’ is attractively decorated with local crafts and modern furniture and is located in a small riad in the medina. Choose a table in the air-conditioned restaurant or on the rooftop terrace. Specialities include mechouai – slow-roasted leg of lamb prepared in their clay oven – and ‘family recipes’ as well as the usual tagines and couscous. Closed Tuesday. The website is letrouaumur.com For a meal that skilfully combines the tastes of East and West, book a table at La Palette Restaurant. In this attractive contemporary setting, a very accomplished young chef pulls out all the stops to ensure you have a meal to remember, whether you crave a simple steak or a Moroccan speciality. There’s a good wine cellar with a range of red and white Moroccan wines along with imported bottles. La Palette is located in the Gueliz area, not far from the huge shopping centre Carre Eden. The restaurant is closed Sunday. https://www.lapalette-restaurant.com/ EUROTIMES | DECEMBER 2019/JANUARY 2020

HOSPITAL DIARY

Wine in paradise Wine and ophthalmology have a lot in common, writes Leigh Spielberg MD

hat is during a water break, halfway the #1 through my tennis lesson, that red grape my instructor said: “After this variety in lesson, I’m off to the wine shop to Italy, as measured by total wine prepare for tonight. I’m hosting production?” I asked, as the nine this month’s wine club meeting other members took their seats, and I have some wines to buy and pen and paper in one hand and material to study.” a Chianti in the other. “Tell me more,” I said. The first Friday of the month I realised then and there that had finally arrived, and for us, wine was something that could that means: Wine Club. The 10 be learned and studied, just like of us were enjoying the bright, ophthalmology, just like retinal warm, long evenings typical of surgery. It was something that Belgium’s summer. could be read about, discussed, Yes, I know, Belgium is welland experienced. There are known as a beer country, from objective facts, like which grapes common pints like Stella Artois are used to make Brunello di to alcoholic powerhouses like Montalcino, and what causes a Duvel and on to the trappists retinal detachment. And then like Chimay and the nearlythere are subjective, debatable impossible-to-get-your-handsaspects, like whether a big on, medal-winning Westvleteren. Brunello is better than a bold But for wine-lovers, Belgium Bordeaux blend, or which is paradise. Although very multifocal IOL might be best little wine is produced here, it suited for a particular patient. is a huge importer with a long I also realised that it would take history of wine knowledge and time and dedication to develop excellent connections to the best the knowledge necessary to make vineyards worldwide. Belgium it all worthwhile. Just drinking was the first international market it wouldn’t be enough. Reading for French wines from Burgundy and talking about it would be In both ophthalmology and wine, and Bordeaux. Its per-capita necessary. It would have to knowledge and surgical skills can be consumption of Champagne is become a certain state of mind. the highest in the world. And No problem, I thought. Isn’t this supplemented by listening to lectures because it isn’t a producer itself, how we all learned how to become and taste-test videos online we are not beholden to wines ophthalmologists? By reading, from a specific country or region. observing and trying for ourselves. Belgian importers have their pick In both ophthalmology and of the lot. wine, knowledge and surgical skills can be supplemented by So, there we were, in David Van Grembergen’s back yard. Just listening to lectures and taste-test videos online. I have watched like a subspecialty day within a big conference, each Wine Club literally hundreds of surgical videos about everything from how meeting has a particular theme. Tonight’s was “Italian reds”. best to save a lost capsulorhexis to how best to peel a tricky The four possible answers for the #1 red grape variety were diabetic membrane. Needless to say, the internet is full of great Montepulciano, Sangiovese, Negroamaro and Primitivo. It was my videos made by wine professionals on how to taste, differentiate quiz, so I knew the answer, and it was fun to see my fellow cluband, most importantly, enjoy wine. members trying to figure out the right answer based on what they And so, the 10 of us in our Wine Club take our hobby (semi-) had read and drunk over the past few years. seriously: we purchase, prepare, plan and PowerPoint our way to Wine, like uveitis, seems unknowable until you really get into proficiency in Pinotage, Pinot Noir and Primitivo. it. Like many people, I found the sheer volume of information Of course, wine-tasting will always remain a hobby for me, regarding wine to be overwhelming. Even just the terminology can rather than a full-time job. Few people will be coming to me for be intimidating, involving so many countries, regions, climates, wine advice, and no one will ever pay me for a second opinion terroirs, growers, vintages, grape varieties and blends, not to on what to serve with dinner. But I know that it will become, just mention ageing and food pairing. like photography, skiing, writing, reading, parenting and, yes, And then comes the subjective information. There is a lot of ophthalmology, a lifelong passion from which I will always derive objective information to be had, but once the wine is poured a great deal of satisfaction. and consumed, we all seem to step into a realm of individual The quiz was finishing up, the sun was going down and Galileo’s interpretation and idiosyncratic discussion. great quote came to mind: Wine is sunlight, held together by water. But, at a certain point, I figured that if other people could come Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent to know wine, and enjoy it more because of this knowledge, why University, Belgium couldn’t I? And so I recently set out to get to know wine. It was Illustration by Eoin Coveney

EUROTIMES | DECEMBER 2019/JANUARY 2020

RANDOM THOUGHTS

An innovator and role model EuroTimes Executive Editor Colin Kerr remembers Sir Harold Ridley and a momentous moment for the ESCRS The end of every year is a time for reflection, for looking forward to a new year and looking back on the year gone by. Some people will look further back, maybe to a previous decade or a decade before that. So as we say goodbye to 2019 and look forward to 2020, let’s go back a little further, to 1999. This was a momentous year for the ESCRS and in particular for the then president Thomas Neuhann MD, who presented Sir Harold Ridley with the Grand Medal of Merit in Vienna in 1999. The story behind that great event is recounted by Dr Neuhann in an extract from European Society of Cataract & Refractive Surgeons – A History (Gill & McMillan 2013).

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

he 50th anniversary of the intraocular lens accorded me the extraordinary privilege of honouring Harold Ridley,” he says. “The occasion deeply touched my heart. His IIIC had been more a conspiratorial circle than a society and now, the whole thing having come of age, the ESCRS was a well-regarded worldwide society and lens implantation is learned in residency. And he had lived to see that happen.” It was on that occasion that Dr Neuhann came up with the idea of the Grand Medal of Merit, to be an extraordinary distinction not to be awarded every year but just when there is an outstanding personality. “And I had the honour to present the first Grand Medal to Harold Ridley,” he says. “It is unusual for an eye doctor like myself to feel the breath of history. That was one of those rare moments.” Dr Neuhann met Harold Ridley on the 40th anniversary of the IOL in the US, before meeting Sir Harold Ridley again on the occasion of the 50th anniversary. “It was not long after that,” says Dr Neuhann, “that I realised that every country in the world had paid respect to him with the exception of Great Britain, I still have to laugh that I had the courage — some might even call it arrogance — to write to the Right Honourable Mr Tony Blair, prime minister to the Queen. I proposed Ridley for the honours list of the following year, pointing out we were lucky he had lived over 90 years, and urging that he be paid the honour that was due while he was still alive. “I learned after some time, that he got his knighthood. Ridley was a role model to me, scientific yet practical and with the courage of his convictions: Ridley stood his ground through all the bitter moments of disrespect, which as we know today was not proof that his invention was unworthy — but said more about the limited intellectual capacity of his critics. His set an example which can serve as an inspiration: while you should always be open to learn you are on the wrong side, as long as no one has a better argument — stick to your convictions.” Thomas Neuhann MD

It is unusual for an eye doctor like myself to feel the breath of history. That was one of those rare moments

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MEETING UPDATE

Research and reconstructions Prof Madeleine Zetterberg describes the Swedish Opthalmological Society’s annual meeting

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

aymond Douglas, of the Cedars-Sinai Medical Center, Los Angeles, an authority in orbital, oculoplastic and reconstructive surgery, spoke on groundbreaking research that led to the development of IGF1-receptor antagonist therapy against thyroid eye disease. Soosan Jacob gave a keynote lecture on complex reconstructions combining various anterior segment surgeries. She also spoke on her innovations such as PEARL Inlay for Presbyopia, CAIRS for keratoconus and Paperclip capsule stabiliser for subluxated cataracts. A session on retinopathy of prematurity (ROP) was a highlight. Andreas Stahl, University Medical Center, Greifswald talked about the CARE-ROP study, a randomised multi-centre study investigating optimal dosing of Ranibizumab in ROP. He shared his experience as member of steering-committees in several renowned ROP-studies such as PRIDE- and RAINBOW-studies and as initiator of German national ROP-register. Gerd Holmström, Uppsala Hospital, Sweden, demonstrated the importance of national patient registries, in this case SWEDROP, where 10-years’ outcome (n=10,000) resulted in improved outcomes and decreased screening visits. Aldina Pivodic, Sahlgrenska Academy, Gothenburg, reported an individualised prediction model (www.digirop.com) for developing sight-threatening ROP with 100% sensitivity and high specificity developed using SWEDROP data (n=7,900). Lotta Gränse, Lund University Hospital, demonstrated the impact of using Retcam images for screening and during laser treatment (performed close to the ridge and only two disc diameters wide) to minimise ROP recurrence. Ann Hellström, Queen Silvia Children’s Hospital, Gothenburg, discussed risk factors and preventive measures for ROP, highlighting the importance of personalised oxygenation, nutritional components such as breast milk, Omega-3 and Omega-6 fatty acids as well as the effects of fetal blood components such as fetal haemoglobin, growth factors and haematopoietic stem cells on ROP. Other topics discussed included TB-uveitis, minimally invasive glaucoma surgery (MIGS), orbital tumours, thyroid eye disease, corneal surgery etc. Other highlights included an honorary lecture by Kristina Tornqvist about changes in care for the visually disabled over the past 100 years, as well as the annual SOE lecture for the most accomplished clinician/ researcher with a promising future, which was delivered this year by David Epstein from St Erik’s Eye Hospital / Karolinska Institute. From an interview with Soosan Jacob MD If you want to share your society news with EuroTimes, mail Colin Kerr, Executive Editor, EuroTimes at colin@eurotimes.org

EUROTIMES | DECEMBER 2019/JANUARY 2020

...highlights included an honorary lecture by Kristina Tornqvist about changes in care for the visually disabled...

CALENDAR

↙

LAST CALL

DECEMBER 2019 World Eye and Vision Congress 9–10 December Abu Dhabi, UAE https://eye.conferenceseries.com/

The 24th ESCRS Winter Meeting will be held in Marrakech, Morocco

2020 FEBRUARY

FEBRUARY

All India Ophthalmology Conference 2020

24th ESCRS Winter Meeting

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

6th Annual Congress on Controversies in Ophthalmology Asia-Australia (COPHy AA) 14–15 February Bangkok, Thailand http://cophyaa.comtecmed.com/

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

MARCH Frankfurt Retina Meeting 2020 14–15 March Mainz, Germany www.eckardt-frankfurt.de

34th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 19–22 March Athens, Greece https://www.hsioirs.org/en/ 34th-international-congress-ofhsioirs-19-22-march-2020/

10th EURETINA Winter Meeting 20–21 March Vilnius, Lithuania www.euretina.org

11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU) 26–28 March Lisbon, Portugal http://cophy.comtecmed.com/ The 11th Annual Congress on Controversies in Ophthalmology: Europe (COPHy EU) will be held in Lisbon, Portugal

EUROTIMES | DECEMBER 2019/JANUARY 2020

CALENDAR

APRIL

The AAO Annual Meeting 2020 will take place in Las Vegas, USA

NEW 18th Congress of the Black Sea Ophthalmological Society 24 –26 April Tbilisi, Georgia www.bsos-tbilisi2020.org

MAY NEW ARVO 2020

3–7 May Baltimore, USA www.arvo.org/annual-meeting/

SFO 2020 Congress

9–12 May Paris, France https://www.sfo.asso.fr/

World Cornea Congress VIII

13–15 May Boston, USA www.corneasociety.org

ASCRS•ASOA Symposium and Congress

JUNE

SEPTEMBER

OCTOBER

20th EVRS Meeting 2020

5th International Glaucoma Symposium

38th Congress of the ESCRS

June 11–14, Stockholm, Sweeden http://www.evrs.eu

15–19 May Boston, USA www.ascrs.org

World Ophthalmology Congress (WOC)

18th SOI International Congress

26–29 June Cape Town, South Africa http://woc2020.icoph.org

27–30 May Milan, Italy https://www.congressisoi.com

JULY

EyeAdvance 2020

XXI International Congress of the Brazilian Society of Ophthalmology

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

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

14th EGS Congress

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

ASRS 2020

23–28 July Seattle, USA www.asrs.org

Euretina

Winter Meeting

Vilnius 20–21 March Radisson Blu Hotel Lietuva, Lithuania Registration & Hotel Bookings available at www.euretina.org EUROTIMES | DECEMBER 2019/JANUARY 2020

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

OCTOBER 20th Euretina Congress 1– 4 October Amsterdam, The Netherlands www.euretina.org

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

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

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

NOVEMBER AAO Annual Meeting 2020

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

100th SOI National Congress

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

38th Congress of the ESCRS

Amsterdam

2020 3-7 October RAI Amsterdam

www.escrs.org

YOUR NAVIGATING PARTNER IN OPHTHALMOLOGY

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