EuroTimes June 2021, Volume 26 Issue 6

Research Education Innovation

ESCRS’s vision is to educate and help our peers excel in our field. Together, we are driving the field of ophthalmology forward.

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

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Circulation Manager

Angela Morrissey

Contributing Editors

Howard Larkin

Dermot McGrath

Roibeard Ó hÉineacháin

Contributors

Maryalicia Post

Leigh Spielberg

Gearóid Tuohy

Priscilla Lynch

Soosan Jacob

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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.

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patients

18 The Law of Life Dr Aaron Donnelly’s shortlisted essay for the John Henahan writing prize

19 JCRS Highlights

20 What a difference a year makes: Dr Stuart Guthrie’s shortlisted essay for the John Henahan writing prize

CORNEA

22 Good long- to mediumterm visual outcomes with DSEK and DMEK

23 A new limbal stem cell transplant technique appears to be safe and effective

24 The definition of dry eye disease continues to evolve

25 Optimal dry eye management in cataract surgery requires a well thought out strategy

Included with this issue...

MEDICAL EDITORS

MIGS update

The popularity of minimally invasive glaucoma surgery has risen

It is with great pleasure that I am writing this editorial for the June issue of EuroTimes, which has a special focus on Glaucoma.

Glaucoma is the second most common cause of blindness worldwide and as ophthalmologists we are constantly searching for new procedures to tackle the condition

In our cover story, we focus specifically on MIGS and we examine how the popularity of minimally invasive glaucoma surgery has risen dramatically over the past few years

As with all procedures, we need to exercise caution with this procedure. As compared with trabeculectomy, the reasons for the success of MIGS are the low variability of the surgical protocols, the more comfortable postoperative period, the quick recovery of vision, the supposed lower incidence of complications. We should also note that the reported complications may be the same as those of trabeculectomy when a sudden drop in IOP takes place. On the other hand, MIGS appears to lower IOP at a lesser extent and for a shorter time than trabeculectomy. It is much too early to draw conclusions and precise indications; however, MIGS might change glaucoma surgery from a single and sometimes dramatic procedure into multiple yet safer procedures titrating intraocular pressure.

It must also be pointed out that MIGS is an expensive procedure and may not be available to all surgeons. In my own country, Italy, MIGS is rarely reimbursed in public hospitals but this situation may change in future years. If the reimbursement situation can be changed, I believe MIGS will be the standard of care. The short surgical times in the procedure will also allow more surgeries, thus facing the increase in the demand for glaucoma care due to the increased life span of an increasingly older European population.

In this issue of EuroTimes, you can also look at other developments in the treatment of glaucoma.

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)

Dr Soosan Jacob has written an excellent article on the different MIGS techniques and also the devices that are currently available for surgeons who choose to practice MIGS. We also have a very interesting commentary from Dr David Garway-Heath, who notes that the next 40 years are likely to see advances in the diagnosis of glaucoma using technologies that are now in their infancy.

I am sure you will enjoy reading this month’s magazine and urge you, your families, colleagues and friends to stay safe.

In our cover story, we focus specifically on MIGS and we examine how the popularity of minimally invasive glaucoma surgery has risen dramatically over the past few years

Emanuel Rosen Chief Medical Editor

José Güell

Roberto Bellucci

Thomas Kohnen

Dr Roberto Bellucci is Consultant Eye Surgeon at St Anna Hospital, Brescia, Italy

Paul Rosen

MIGS & Cataract Surgery

The ultimate marriage of convenience?

Continuing innovation in the field of MIGS should further increase its usage and potential. Priscilla Lynch reports

Glaucoma treatment is essentially a race against time; lowering intraocular pressure (IOP) to slow down progression in order to preserve quality of vision.

While eye drops remain first-line glaucoma treatment, followed by trabeculoplasty, to reduce IOP and protect the optic nerve, the popularity of minimally invasive glaucoma surgery has risen dramatically over the past few years.

“As compared with trabeculectomy, the reasons for its success are the low variability of the surgical protocols,

the more comfortable postoperative period, the quick recovery of vision, the supposed lower incidence of complications,” commented Professor Roberto Bellucci MD, Italy. “However, the reported complications may be the same as those of trabeculectomy when a sudden drop in IOP takes place. On the other hand, MIGS appears to lower IOP at a lesser extent and for a shorter time than trabeculectomy.”

MIGS can essentially be defined as any procedure, generally angle and outflowbased, wherein there is minimal risk of hypotony or other sight-threatening

complication, explained Dr Brandon Baartman MD, US, an anterior-segment and glaucoma specialist and expert on MIGS.

“Broadly speaking, it’s considered as a bridge between drops and more invasive, traditional surgery like filters or trabeculectomy. However, as glaucoma specialists have become more comfortable working in the angle and seeing the results of MIGS procedures, we have begun to see a shift to earlier procedural treatment of glaucoma. Even selective laser trabeculoplasty (SLT), with the results of the LiGHT trial (Gazzard

G et al 2019), has become somewhat of a first-line therapy for newly-diagnosed glaucoma patients.”

There is now an array of MIGS devices available, as surgical techniques and approach have also refined.

“As for the type of implant, I think all of them work properly and are able to decrease IOP,” said Dr Bellucci. “In some patients a second or a third implant might be required, as it commonly happens for cardiovascular stents. We should get familiar with one or two different types of implants, as it might be difficult to deal with many of them: they are not intraocular lenses and require more time for us to learn what and when, and to evaluate our personal results.”

Dr Baartman said that current MIGS devices such as the “iStent and iStent inject (Glaukos), Kahook Dual Blade (New World Medical), OMNI (SightSciences), Hydrus (Ivantis), and Xen (Allergan) have excellent data behind them and I believe have ushered in the era of treating glaucoma earlier, often times coupled with cataract surgery”.

THE PERFECT COMBINATION

Combining MIGS with cataract surgery makes perfect sense: two conditions can be treated using just one incision, leading to a dramatic improvement in patient vision, consistent lowering of IOP and easing of medicine burden with the removal of drops; a particularly important consideration given the age profile of these patients. Furthermore, glaucoma cases are continuing to rise in line with the growing, ageing population in Western countries and inadequate surgeon numbers. So could MIGS and cataract surgery be the ultimate marriage of convenience? Possibly, according to many in the field. However, when to use MIGS and in whom remains a key question, as it is not the answer for all glaucoma cases.

“One procedure that deviates a bit from the definitive MIGS, but I think of in the same vein, is endocyclophotocoagulation or ECP, which can be used at the time of cataract surgery, with other MIGS devices or in a standalone fashion in pseudophakic patients in order to hopefully delay or avoid entirely the future need for

traditional incisional glaucoma surgery,” outlined Dr Baartman. “In short, MIGS is most useful when employed earlier in the disease process in attempt to delay need for additional surgeries.”

Dr Bellucci currently uses MIGS only in pseudophakic eyes or in association with cataract surgery, and only when the target pressure is above 12mmHg. “Two good examples are high myopia with IOP elevation, and late IOP rise after posterior vitrectomy. I still use trabeculectomy in advanced glaucoma cases, but do prefer MIGS in late-stage glaucoma, where trabeculectomy might resolve in blindness. At present I offer MIGS to pseudophakic patients requiring prostaglandins to control their IOP, to avoid the late anatomical impairment and discomfort of the ocular surface,” said Dr Bellucci.

COST CHALLENGE

However, one of the biggest challenges for further widespread adoption of MIGS appears to be financially related, depending on the healthcare system of individual countries.

Cost is a limiting factor in public hospitals in Italy, where MIGS is rarely reimbursed, Dr Bellucci acknowledged.

“In the US, there may be some limitations, based on insurance reimbursement, on which device might be used in which scenario, but data suggests that even as standalone procedures, and sometimes even in phakic patients, these procedures can be safe and effective at controlling IOP and reducing medication burden [thus being cost-effective],” commented Dr Baartman.

STANDARD OF CARE?

So is MIGS the future standard of care, in a healthcare culture driven by making surgery as minimally invasive as possible, against the background of ever-growing demand, a shortage of surgeons and the projected global rise of glaucoma cases?

Yes, according to Dr Bellucci: “I believe MIGS will be the standard of care if the cost problems will be solved. It is important to understand that with MIGS, glaucoma surgery is transitioning from a single event into a surgical protocol that can include two or three surgeries. By

decreasing IOP in steps we will probably avoid the complications associated with sudden IOP drop, and will be able to titrate surgery over the entire life span of the patient. In addition, the short surgical times will allow more surgeries, thus facing the increase in the demand for glaucoma care due to the increased life span of an increasingly older European population.”

Dr Baartman also agrees. “Yes, I believe it may be the future standard of care. As mentioned above, I believe we have seen a shift in how we think about, talk about, and manage glaucoma patients, with an emphasis on earlier procedural treatment. Rarely do I see patients in our referral centre on four bottles of ineffective medications to control IOP, and instead, I am seeing these referrals at two bottles and need for additional control with MIGS or SLT. I have appreciated this practice pattern change because it limits drops burden for patients and preserves optionality, both in additional surgical procedures and available medications should additional control be necessary in the future.

“MIGS also has the benefit of being a class of treatments that are generally straightforward in postoperative management and low in complication profile, such that they can often have fewer postoperative visits and return more quickly to their routine glaucoma follow-up schedule.”

There is also continuing innovation in the field of MIGS, which should further increase its usage and potential. “I am looking forward to an expanded arsenal of MIGS treatment options including devices deploying greater numbers of stents (iStent infinite, Glaukos) and even additional subconjunctival MIGS devices in the pipeline (PreserFlo, Santen). I also believe the melding of medication and procedure in the form of sustained drug delivery is a future category of its own we can be excited about,” concluded Dr Baartman.

Roberto Bellucci: roberto.bellucci52@gmail.com

As compared with trabeculectomy, the reasons for its success are the low variability of the surgical protocols the more comfortable postoperative period, the quick recovery of vision, the supposed lower incidence of complications

Roberto Bellucci MD

Two good examples are high myopia with IOP elevation, and late IOP rise after posterior vitrectomy

Roberto Bellucci MD

Everything you need to know about MIGS

Minimally invasive glaucoma surgery comes with major advantages for surgeon and patient alike. Soosan Jacob, MS, FRCS, DNB reports

The management of glaucoma has taken a subtle shift in the recent past with the advent of minimally invasive glaucoma surgery (MIGS). MIGS has become an option for mild-to-moderate glaucoma when more invasive surgeries such as trabeculectomies and tube shunts carrying a higher risk of complications are viewed with some hesitancy. The minimal dissection required, relatively easy learning curve, ability to be easily incorporated by cataract surgeons into their practice, easy and beneficial combination with cataract surgery and relative lack of major complications are significant advantages.

MIGS may be indicated for different purposes – for IOP control, to decrease dependence on medications or to avoid side-effects associated with glaucoma medications. MIGS surgeries such as trabecular bypass devices have high safety and modest efficacy whereas those using subconjunctival filtration have high efficacy but can be associated with higher risk of complications.

The ab interno approach of most MIGS leaves the conjunctiva intact, thus allowing future glaucoma surgeries that may be required. Acceptance of many of these procedures by insurance providers has also helped make this a popular method for treating glaucoma, especially when coexistent with cataract. MIGS is however, generally not used in patients with advanced disease, previous filtering surgeries, angle closure glaucoma etc.

MIGS may be performed using specific implantable devices or by using special techniques and instruments/ machines. The various MIGS procedures use one of different mechanisms for IOP lowering –increasing trabecular outflow or bypassing trabecular meshwork, suprachoroidal drainage, subconjunctival filtration or decreased aqueous production.

Trabecular bypass devices are especially commonly used in combination with cataract surgery for patients with co-existing cataract and early-tomoderate glaucoma as ease of surgery, quick recovery, safety and efficacy make

it an attractive solution despite being less effective than traditional glaucoma surgeries. They are, however, not effective if the episcleral venous pressure is raised.

MIGS DEVICES

i-Stent (Glaukos Corp): This is an FDAapproved trabecular bypass device that is placed ab interno through a clear corneal incision into the Schlemm’s canal. It is a heparin-coated, nonferromagnetic, surgical grade titanium stent less than 1mm in length with a pointed tip that is self-retaining once implanted through the

trabecular meshwork into the Schlemm’s canal. Two stents are reported to give greater IOP reduction than one. The i-Stent Inject via a single entry, delivers two pre-loaded trabecular micro-bypass stents to be implanted two-to-three clock hours apart. These devices are preferred to be placed in areas with the highest density of collector channels thereby targeting a large aqueous vein, generally in the infero-nasal quadrant of the eye.

Adequate skills in intraoperative gonioscopy and visualisation of the angle are important in successful placement of

Various minimally invasive glaucoma surgery (MIGS) devices are seen – Trabecular bypass devices: iStent (a) and Hydrus (b); Subconjunctival filtration devices: Xen Gel stent (c), InnFocus microshunt (d); Suprachoroidal shunts: iStent Supra (e)

the iStent. Placement is easier in patients with wide open angles, pigmented trabecular meshwork and in those without systemic or local conditions that preclude proper positioning of the eye and head. It is easier to place after removing the cataract as the anterior chamber is deeper.

Hydrus microstent (Ivantis Inc): This is also a trabecular bypass device with an 8mm long curved nitinol body that has windows for aqueous outflow and is implanted via a pre-loaded injector. It acts by providing intra-canalicular scaffolding to a quadrant of the Schlemm’s canal. It dilates the canal four-to-five times and prevents collapse of Schlemm’s canal secondary to elevated IOP. As it is placed over a larger area of Schlemm’s canal, targeted placement is less crucial.

Suprachoroidal Shunts: The iStent Supra (Glaukos Corp) is a 4mm tube made of polyethersulfone and titanium that is placed ab interno and drains into the suprachoroidal space. The Gold Shunt (SOLX Inc) and the STARflo ((iSTAR Medical) are ab externo supraciliary implants placed under scleral flaps.

Sub-conjunctival filtration devices: The XEN gel stent (AqueSys Implant) and the InnFocus Microshunt (InnFocus) use Newtonian fluid dynamics and the Hagen–Poiseuille equation to eliminate clinically significant postoperative hypotony. An area of virgin conjunctiva should be chosen. Though biocompatible and resistant to neovascularisation and fibrosis, they are generally used together with anti-metabolites like 5-FU or Mitomycin-C. The XEN gel stent is 6mm long and available with different internal lumen diameters. It is made of porcine collagen-derived gelatin cross-linked with glutaraldehyde and comes pre-loaded for implantion ab interno or via conjunctival

dissection. The InnFocus Microshunt is made of SIBS (synthetic polymer of poly(styrene-block-isobutylene-blockstyrene)). It is an 8.5mm long, flexible tube with 70 micron lumen that is inserted into the AC under a scleral flap. Tiny fins on either side prevent migration. It may be used for moderate-to-advanced glaucoma and is as effective as trabeculectomy.

MIGS TECHNIQUES

Trabectome [NeoMedix]: This uses a handpiece with irrigation, aspiration and electrocautery modes to perform about 60-to-120 degrees of ab interno trabeculotomy and removal of a strip of trabecular meshwork (TBM) and inner wall of Schlemm’s canal. Inadequate IOP lowering may occur since flow is not established all around. In addition, the trabeculotomy may close or may be limited by inherent episcleral venous pressure and Schlemm’s canal resistance.

Gonioscopy-assisted transluminal trabeculotomy (GATT)/ ab interno canaloplasty (ABiC): GATT creates a 360-degree trabeculotomy/viscodilatation using an ab interno approach thereby avoiding some of the disadvantages of the ab externo technique. The iTrack microcatheter (Ellex) or a 5-0 nylon/ prolene suture is passed through the Schlemm’s canal 360 degrees circumferentially via an internal goniotomy incision. GATT utilises a 360-degree trabeculotomy by tightening the suture/ microcatheter while ABiC relies on 360 degrees viscodilatation. To avoid false passages, the iTrack has an illuminated tip to guide the catheter. If prolene suture is used, its leading edge is rounded out with low-temp cautery.

Excimer laser trabeculostomy: Using a goniolens or endoscope, a fibre-

optic delivered 308-nm xenon chloride excimer laser is used to create between four and 10 small ostia through the trabecular meshwork, juxtacanalicular trabecular meshwork and the inner wall of Schlemm’s canal. The non-thermal approach prevents scarring and resultant closure of the ostia.

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 minimising damage. High-intensity focused ultrasound (Eye Tech Care) is also available.

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

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New EGS guidelines

The 5th Edition of the European Glaucoma Society (EGS) guidelines, released at the 14th EGS Congress, provides answers to key questions regarding the diagnosis and management of glaucoma based on the most up-to-date evidence, reports guidelines editor Augusto Azuara-Blanco PhD, FRCS(Ed), FRCOphth, Clinical Professor of Ophthalmology, Queen’s University Belfast, UK.

The large team involved in the new guidelines included Carlo Traverso (co-Editor) and EGS past-president Ted GarwayHeath, as the ultimate decision makers as well as a guidelines committee, the EGS executive committee, researchers experts in evidence synthesis particularly the collaboration with the US branch of Cochrane Eyes and Vision (CEV-US), as well as a patients representative organisation, Glaucoma UK.

those where the benefit-risk ratio may be less clear.

Part I also includes a new section on ‘Things to avoid (choosing wisely)’ with brief but important messages, and sections on patients’ concerns and communication, epidemiology of glaucoma, overview of landmark studies and a concise section describing cost-effectiveness considerations.

Part II is similar to a text book and consists of three chapters: the first is on patient examination, the second on classification and terminology and the third on treatment options.

As illustrations of the type of recommendations and qualifying remarks included in the new guidelines, Prof Azuara-Blanco highlighted an example of one the 16 key questions, namely question number 10, which asks, “what is the most effective medical treatment, and what is the first-choice medication for open angle glaucoma?”

The guidelines’ response is that prostaglandin analogues are the most effective medication and are usually recommended as the first-line treatment for open angle glaucoma. The guidelines class the evidence as high for IOP reduction but very low for other outcomes. However, they also include the comment that other factors may need to be taken into consideration before prescribing the treatment, such as possible adverse effects, co-morbidities, systemic therapy, adherence, patient preferences, life expectancy, cost and availability. Of note, the new EGS guidelines recommends laser trabeculoplasty as a first option for initial treatment of open angle glaucoma and laser trabeculoplasty, at least as good as initial medical treatment.

Augusto Azuara-Blanco PhD, FRCS(Ed), FRCOphth

The new EGS guidelines consist of two parts. Part I includes a new section that addresses 16 key questions in glaucoma management identified by the guidelines committee, with evidence-based recommendations and discussions. To answer these key questions, the guidelines team performed an overview of 4,451 systematic reviews to identify those evaluating technologies and treatments for glaucoma. From these they derived 49 high-quality and reliable systematic reviews. They graded the level of evidence, e.g., considering risk of bias, inconsistency of results and imprecision. They also graded the strength of recommendations, with “strong” signifying benefits well-proven and highly recommended, and “weak” signifying

In the section on “Things to avoid”, Prof Azuara-Blanco, highlighted two recommendations he regards as particularly important. The first is that glaucoma diagnosis should not be based on optical coherence tomography alone. The second is that lowering IOP to just below 21mmHg is inadequate in cases of advanced glaucoma. IOP in the low teens or below is necessary.

The new EGS guidelines provide an update on best practices in glaucoma diagnosis and management. Roibeard Ó hÉineacháin reports

Keep learning. Whenever, wherever.

The first is that glaucoma diagnosis should not be based on optical coherence tomography alone

AI & Robotics in healthcare

The Next Generation

Artificial intelligence and robotics have the potential to completely transform healthcare, but there are a number of caveats that require consideration as the new technologies are increasingly introduced into medical practice and into patients’ lives, according to Marco Lorenzi PhD, Epione Research Group, Inria Sophia Antipolis, University of Côte d’Azur.

“The speed at which AI products have gained FDA approval and entered the market has doubled over the past two years. In fact, the market for AI is to be in the hundreds of billions of dollars by 2026,” Dr Lorenzi told the 14th European Glaucoma Society Congress.

ALLEVIATING PRESSURE

The COVID-19 pandemic is further accelerating the AI revolution because of its potential contribution to telemedicine and drug discovery. The use of robots to deliver care in hospitals is also under development as a means of alleviating the pressure on hospital personnel and reducing the risk of infections. AI is also being used in finding cases with smartphone tracing apps.

The new applications of AI pertaining to glaucoma management primarily involve radiology and image analysis, the area where deep learning is most applicable. He noted that he and his associates are developing software to harness AI in the analysis and integration of very complex data in order to predict visual function scores from optical coherence tomography (OCT) imaging. AI can also be used in combination with special attachments for smartphones as a form of portable fundoscopy.

This new reality brings several challenges that have yet to be solved. For example, most of the potential applications of AI and robotics in healthcare have not been adequately validated for adoption into general use, Dr Lorenzi noted. He cited a study showing that robotic laparoscopic hernia repair had the same outcome as standard surgery, but at an increased operating room duration and also increased cost.

BIAS IN TRAINING DATA

Another of the main issues that AI has to face is the issue of bias in the training data. A highly publicised example was the Amazon.com Inc.’s finding that their automatic recruitment algorithm was preferentially selecting men’s curricula vitae (CVs) because they had been trained on a data set composed mostly of men’s CVs and therefore identified being male as a positive feature.

And finally, there are many privacy and security issues involved with the use and sharing of big data and the ethical questions around of providing or selling patients’ data to third party AI companies. Dr Lorenzi noted that he and his associates are working on a new type of AI paradigm, called federated learning, that will allow the sharing of knowledge while preserving privacy.

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AI’s potenital must be tempered by freedom from bias and protection of privacy. Roibeard Ó hÉineacháin reports

Future glaucoma diagnostics

The next 40 years are likely to see advances in the diagnosis of glaucoma using technologies that are now in their infancy, said Prof David F. GarwayHeath MD, FRCOphth, Moorfields Eye Hospital and Glaucoma UK Professor of Ophthalmology, University College London, London, England.

“The future is exciting, with advances in miniaturisation and mobile technology, advances in perimetry and imaging, machine learning to better interpret the data from these devices, and also in developing biomarkers to identify patients who have glaucoma or who are more susceptible to glaucoma,” Prof Garway-Heath told the 14th European Glaucoma Society Congress.

He noted that records going back 30 years show a consistent pattern of a portion of glaucoma cases being missed until they are at a late stage of disease, demonstrating the need for better case-finding technologies. The case-finding approaches now under investigation include innovations in both structural and functional measurements.

For example, perimetry is likely to improve because research has shown that modulating the size of stimuli used in perimetry devices can increase the specificity of the devices in identifying glaucoma and reduce the need for re-testing. One new means of measuring functional changes now being tested is the recording of patients’ gazing patterns, for which glaucoma patients have characteristic differences compared to those with healthy eyes.

There is also a new portable hand-held binocular OCT device that is now undergoing trials at Moorfields and other centres. The current advances in software processing for imaging devices are also likely to continue, enabling the visualisation of the optic nerve in exquisite detail. The coming decades are also likely to see more precision in the correlation between structural changes in the optic nerve and functional changes in glaucoma. In addition, there is now a camera attachment for mobile phones which allow imaging of the fundus.

“Combined with machine learning and artificial intelligence it may be possible to identify obvious glaucoma in individuals with simple imaging with mobile phones in the future,” Prof Garway-Heath said.

Other approaches include the use of biomarkers, that might enable the detection of glaucoma with a blood-test. Frans Grus MD and his associates in Mainz Germany have shown that it is possible to identify glaucoma patients based on their antibody profile with high sensitivity and specificity. Other biomarker strategies under development include new means of detecting mitochondrial dysfunction as a biomarker for glaucoma susceptibility, and metabolic imaging, with two-photon imaging with an ultrafast pulsing laser which can target particular molecules in the retina, Prof Garway-Heath said.

Current research foreshadows future technologies for glaucoma diagnosis. Roibeard Ó hÉineacháin reports

...it may be possible to identify obvious glaucoma in individuals with simple imaging with mobile phones in the future

Prof David F. Garway-Heath MD, FRCOphth

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Uncooperative patients

There are a range of physical, psychological, sensory and cognitive factors that can contribute to a patient’s inability to cooperate during a cataract procedure. A compassionate but objective approach is necessary to achieve the best results, advises Zaid Shalchi MD, Windsor, UK.

“All patients want to cooperate; they want a good outcome and they want their surgery to be successful. They want to make their surgeon’s life easier. It’s all about trying to understand why they can’t cooperate and what you can do to help them,” he said during the 25th ESCRS Winter Meeting.

He noted that blaming non-cooperative patients makes the surgeons themselves become the victim, which is quite disempowering. Instead, surgeons should approach such patients the same as they would a surgical difficulty. For example, in the case of an eye with a small pupil one would not blame the patient for the problem. Rather, more typically one would assess the problem and decide on a course of action on that basis. In the case of small pupil, that would most likely be the placement of pupillary ring to allow the performance of the surgery as a routine procedure.

“This way you waste no vital energy and you remain calm and when the ring comes out, it is actually a beautiful operation. When you’re dealing with your patient who is not able to cooperate you want to do the same thing, which is to normalise the situation.”

COMMON NON-COOPERATIVE SCENARIOS

People with dementia are making up an increasing proportion of cataract lists, and many of these patients typically have communication difficulties and memory problems that can make it difficult for them to cooperate in a surgical setting. However, in patients where the condition is mild to moderate, sometimes all that is needed is reassurance and a good explanation of what’s happening before surgery. Sedation is rarely helpful in patients with dementia, and it usually makes dementia and compliance worse. General anaesthesia is sometimes necessary if the dementia is particularly severe.

Patients with severe hearing loss also have communication difficulties. Again, a good explanation of the surgery beforehand, together with sub-Tenon’s block, which provides ocular akinesia

as well as anaesthesia, can be very helpful.

Head-taping is a technique that is useful in limiting the mobility of the patient’s head and is especially helpful in those with difficulty communicating during surgery. It involves putting a band of tape across the patients’ forehead, giving the surgeon much more control, particularly when operating temporally when patients have a tendency to turn away when the surgeon’s hand is on the side of their head.

POSITIONING THE HEAD

However, some patients, particularly the older ones, will have difficulty in positioning so that their face is parallel to that of the floor of the theatre, as is ideal for cataract surgery. Sometimes, all that is needed is to make them more comfortable by placing a piece of foam beneath their neck. However, patients with heart failure, obstructive pulmonary disease or obesity need to have the weight taken away from their chest to allow for easy breathing. That can be achieved by having the patient sit up slightly with their neck hyper-extended.

Patients with kyphosis are often physically unable to extend their head on a plane with their body. In those cases, one option is to arrange the trolley so that the patient’s head is lying fairly flat on the bed, but the rest of their body is tilted upward, providing easy access to the surgeon from the side of the trolley.

Claustrophobia is a very common condition encountered in surgery. Although classically defined as an irrational fear of confined spaces, it is really much more complicated, involving the fear of losing control and not being able to leave a certain place. Cutting the drape or using a clear drape can be very useful, although sometimes sedation will be necessary, Dr Shalchi said.

He noted that anxiety during surgery is normal for most patients and very often hand-holding can be just as good as or better than oral or intravenous sedation. If the patient cannot or does not wish to hold hands, oral or intravenous sedation is very effective.

“In many cases it’s not just the medication you’re giving, it’s also the thought that they have been given something that makes them relax,” he added.

Zaid Shalchi: zshalchi@gmail.com

Understanding non-cooperative cataract patients’ difficulties is the key to a successful procedure. Roibeard Ó hÉineacháin reports

Expert opinions on complex cases

Plenty of questions for ESCRS opinion leaders at ‘Meet the Experts’ sessions. Priscilla Lynch reports

Should every toric patient be treated for dry eye even if it is not visible? Should NSAIDs be avoided after surgery in cases with dry eye? What is the best IOL power calculation formula is such situations?

These were among the many questions addressed during one of the 25th ESCRS Winter Meeting Virtual 2021 ‘Meet The Experts’ discussions, where key ESCRS opinion leaders tackled the latest issues in anterior segment surgery while audience members asked questions during 30-minute Zoom sessions.

During one of these very useful and practical sessions, on complicated cataract cases (glaucoma, extreme ametropias and dry eye) Professor Ewa Mrukwa-Kominek MD, Poland, outlined a number of such cases and discussed the best approaches while taking questions.

Discussing a complex case that involved dry eye disease and a shallow anterior chamber where it is more difficult to calculate the IOL power, her session co-host Guy Sallet MD, Belgium, said he always uses fluorescein staining for preoperative assessment.

“For every patient now, which I did not do always, when they come in for biometry, I have the topography and the calculation, and I always see every patient with fluorescein staining of the cornea. It is very simple, and this might show irregularities like the beginning of Bowman’s dystrophy, which otherwise with the slit lamp might be overlooked. I think this is quite helpful and very easy, he said.”

They both agreed that carefully managing patient expectations is also important in cases of cataract surgery with ocular surface disease, as the surgery will not cure that; just the cataracts.

During the session Dr Sallet went outlined an unusual case of his where there was a refractive surprise caused by dry eye disease in the patient.

It prompted some interesting questions and discussion, including whether patients with mild dry eye disease should be given lubricants before implanting a toric IOL.

Both Dr Sallet and Prof Mrukwa-Kominek agreed that dry eye should be treated before surgery. It is very important to moisten the anterior surface before calculating intraocular lenses, especially premium IOLs, as this will help to avoid unpleasant refractive surprises.

For moderate or severe dry eye, Prof Mrukwa-Kominek said she also uses cyclosporin and keeps the patient on it through the surgery period, which also addresses acute inflammation.

However, cyclosporin is not commercially available in all countries, including Belgium, noted Dr Sallet, who said he uses a low-dose steroid in these cases, although Prof Mrukwa-Kominek noted they can increase the symptoms of dry eye. Prof Mrukwa-Kominek also noted that dry eye symptoms can increase during post-cataract surgery prophylaxis, such as antibiotics and steroid treatment.

In relation to the use of NSAIDs in these patients postsurgery, Dr Sallet said he prescribes NSAIDs in every case, even dry eyes.

Ewa Mrukwa-Kominek: emrowka@poczta.onet.pl

Guy Sallet: dr.sallet@ooginstituut.be

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Getting our feet BACK ON DRY LAND

At the beginning of the COVID-19 pandemic my sixty-eight-year-old father was on a boat near a remote island in the Caribbean. As the virus spread across the globe, travel restrictions were rapidly implemented, preventing his journey home. As a result, he spent the next three and a half months alone at sea.

Many of us have felt a bit ‘lost-at-sea’ during the pandemic – isolated and unclear as to what the journey ahead might hold. Like many, my dad had to change the way he communicated with his loved ones, quickly developing new ‘tech’ skills to keep in contact with us. He got Facebook for the first time ever and joined organised Zooms with our family and friends. It was amazing to see his face on the screen so regularly despite physically being so far away.

User uptake of online communication platforms such as Zoom or Microsoft Teams have increased dramatically since the start of the pandemic. Restrictions have also forced health services to change how they deliver care in the short term through implementation or expansion of existing remote care or “telemedicine” in an attempt to minimise disruption. I helped conduct a study at Moorfields Eye Hospital on the use and acceptability of remote consultations in families with rare genetic eye diseases before and during the pandemic. Preferences for mode of contact changed during this period from telephone to video call, most likely due to increased familiarity with these platforms.

Telemedicine is not a new concept and is already used sporadically in ophthalmology, particularly in eye screening. However, it has the potential to address the biggest issues currently facing global eye health. The recently published Lancet Global health commission on Global Eye Health reports that developments in telemedicine and distance learning could potentially enable eye specialists to delivery high quality care that is more plentiful, equitable and cost-effective.

This applies both between and within high- and low-income settings. For example, cross-border initiatives such as Cybersight allow countries with a shortage of skilled eye specialists to communicate with specialists from other countries, share information and advice on cases.

A lack of human resources and geographic isolation are two major barriers to equitable eye care in low resource settings. Patients may have to travel long distances and incur enormous costs to access eyecare. Telemedicine helps eye health providers reach those most affected by poor vision and do more with less. For example, mobile phones are ubiquitous even in areas without access to basic eye care. Technologies such as PEEK (Portable Eye Examination Kit) have taken advantage of this in dozens of low- and middle-income settings to increase access to eye screening in schools. In Rwanda, telemedicine is already being used to improve access to diabetic screening, where it enables more screening with fewer personnel, delivers quicker results and creates integrated pathways for patients with diabetes.

In high resource settings, telemedicine also has the potential to increase access to eye care. Capacity building in health systems is required to meet the needs of an expanding and ageing population. Wider use of telemedicine could help improve access to visually impaired patients who may attend multiple appointments a year. Often, these patients find travelling more difficult. Telemedicine offers the possibility of carrying out more of these patients’ care in their own homes. In our UK study, half of families with rare genetic eye diseases reported that remote consultations increased their access to care.

However, telemedicine also has the potential to increase health inequities. Certain at-risk groups (e.g. older/ homeless people) have less access to the internet or internet-enabled devices. Health services need to be aware of this prior to implementation of telemedicine services and tailor remote contact to their local population needs by asking

service users about their access and preferred mode of contact. In our study, although families found remote contact acceptable (either by telephone or video), the majority preferred to be seen face-to face at some point during their care.

COVID-19 will change healthcare delivery and we have a say in how it will change. We have a great opportunity to make eye care more accessible and equitable at every population level. Pandemic restrictions have forced us to adapt temporarily but now we must look forward to making sustainable longterm change, ensuring that nobody is left behind. When my dad finally got his feet back on dry land, as an able-bodied man living in a high-income setting, he once again benefited from good access to healthcare. As we hopefully come to the end of this long and unpredictable voyage, we must move consciously into a new way of working with a global mindset to widen healthcare access and get all of our feet firmly back on dry land together.

Suzannah Bell is an ST1 ophthalmology registrar at Queen Alexandra Hospital, Portsmouth, UK

In her shortlisted essay for the John Henahan Prize 2021, Dr Suzannah Bell says COVID-19 will change healthcare delivery and ophthalmologists have a say in how it will change

Many of us have felt a bit ‘lost-at-sea’ during the pandemic – isolated and unclear as to what the journey ahead might hold

Keratoplasty in tenth decade

Good results can be achieved with corneal grafts in patients in their 90s.

Roibeard Ó hÉineacháin reports

Special considerations must be taken into account when performing keratoplasty procedures in very elderly patients, but in the great majority of cases there is good graft survival and good visual outcomes, according to a study presented by Harry Levine at the 25th ESCRS Winter Meeting.

“In our experience, corneal transplantation can be considered a safe and successful procedure in improving visual acuity for patients over 90 years of age with the proper preoperative screening. A multi-disciplinary approach involving ophthalmologists, anaesthesiologists and primary care providers is of key importance to achieve good outcomes in this challenging population,” said Levine an MD/MPH candidate at the Miller School of Medicine, University of Miami, Miami, Florida, US.

Levine, along with Guillermo Amescua MD, an associate professor of Clinical Ophthalmology and Medical Director of the Ocular Surface Program at the Bascom Palmer Eye Institute, Miami, FL, US, and their colleagues reviewed the charts of 58 eyes of 52 consecutive patients selected from a specimen database from the Florida Lions Eye Bank. All patients were at least 90 years old at the time of surgery, with a mean age of 93.2 years, and all had at least three months of follow-up, he noted.

The patients’ indications for surgery were pseudophakic bullous keratopathy in 29%, Fuchs’ endothelial dystrophy in 21%, perforated corneal ulcer in 19%, glaucomaassociated corneal decompensation in 27.6% and band keratopathy in 1.7%. Their ocular comorbidities included glaucoma in 62%, age-related macular degeneration in 24% and prior corneal transplant in 36%. Their systemic comorbidities were hypertension in 81%, hyperlipidaemia in 40.4% and arthritis in 61.5%.

The surgeries performed were penetrating keratoplasty (PKP) in 43%, Descemet’s stripping automated endothelial keratoplasty (DSAEK) in 48%, keratoprosthesis in 7% and a patch graft in 1.7%. Concomitant interventions were needed in 60% of cases. All cases were performed under monitored anaesthesia care with peribulbar block and sedation with midazolam and fentanyl or remifentanil.

Levine noted that patients’ mean best-corrected visual acuity (BCVA) improved by -0.3 LogMAR (p<0.01) at one postoperative month and by 0.4 LogMAR (p<0.01) at 12 postoperative months. There were no significant differences between the transplant types in terms of their achieved BCVAs.

Overall graft survival was 88% at 12 months and 66% at 24 months. Among eyes that underwent PKP, graft survival was 85% at 12 months and 47% at 24 months. Among DSAEKtreated eyes, graft survival was 94% throughout 48 months of follow-up. In the eyes receiving a keratoprosthesis, the implant remained intact throughout 48 months of follow-up.

Complications, apart from graft failure or rejection, included intraoperative choroidal haemorrhage in an eye undergoing PKP, pupillary block in a DSAEK-treated eye and retrolenticular membrane in an eye with keratoprosthesis. There were no major complications related to anaesthesia.

Harry Levine: h.levine1@med.miami.edu

Convenient Web-Based Registry

Cataract, Refractive and Patient Reported Outcomes in One Platform

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

Advancing biometry

Recent advances in anterior segment biometry devices in combination with the latest IOL formulas have greatly improved the accuracy of IOL power calculations for today’s patients, according to Jaime Aramberri MD.

“The latest generation of measuring devices have helped to improve accuracy in IOL calculations thanks to the ability to precisely measure both anterior and posterior corneal curvatures and take account of other relevant parameters that may affect the final outcome,” he said at the 25th ESCRS Winter Meeting.

Dr Aramberri noted that the development of high-quality swept-source OCT imaging has taken the accuracy and precision of modern biometry to new heights and made it easier to test eyes such as those with dense cataracts that were difficult to scan with traditional optical biometry devices.

Comparing the features of SS-OCT to optical biometers and Scheimpflug tomography devices, Dr Aramberri said that the difference is not flagrant when it comes to axial length measurements.

“Axial length measurements have been very accurate and precise since the first IOLMaster back in 1999. Many tests have been conducted showing excellent agreement and precision of most instruments with a high level of repeatability between devices,” he said.

The real advantage of being able to obtain a B-scan with SS-OCT, he explained, is the more precise measurement of anterior chamber depth (ACD) and lens thickness (LT) as the boundaries where the peaks are generated can be anatomically identified

“This all-surface detection makes it very useful in dense cataracts and abnormal eyes with modern power formulas for more accurate IOL position estimation. We can also clearly identify the pseudophakic boundaries with the B-scan in order to check and optimise the performance of the IOL predicting algorithm,” he said.

Another useful advantage of the B-scan’s cross-sectional image of the entire eye is the ability to check fixation in patients using the foveal pit scan, he added.

Calculating corneal power using only anterior surface measurements is a frequent source of error in IOL power calculations, said Dr Aramberri. Current biometric devices typically measure corneal power using a standardised keratometric index of refraction – usually 1.3375 – to convert the measured radius of the anterior corneal surface into keratometric dioptres.

This standard keratometric index of refraction assumes a constant ratio of anterior-to-posterior corneal curvature, which works well for normal eyes, but not with aberrated corneas or those treated with LASIK or other procedures that alter the anterior corneal curvature.

“To avoid this error in a particular eye, the total corneal power should be calculated from anterior and posterior measurements as well as corneal pachymetry,” he said.

A total corneal power parameter that can be input in regular formulas without IOL constant adjustment started years ago with the Equivalent K reading in Pentacam (Oculus), and later in Cassini (i-Optics). The new Total Keratometry (TK) value measured by the IOL Master 700 (Carl Zeiss Meditec) takes advantage of the high accuracy of SS-OCT in imaging the posterior cornea, pointed out Dr Aramberri.

Some recent studies indicate that higher prediction accuracy can be obtained using TK values along with some of the newly-

developed IOL calculation formulas. Fabian et al demonstrated that in comparison to conventional keratometry, a notable trend in lowering the absolute prediction errors was observed by applying TK input into the Haigis and the Barrett Universal II/Toric TK formulas in normal eyes (J Refract Surg. 2019;35(6):362‐368). For cases after laser refractive surgery, a study by Lawless et al showed that best results were obtained using TK together with Barrett True-K and Haigis formulas (Clin Exp Ophthalmol. 2020;10).

With a myriad of calculation formulas now available, Dr Aramberri said that studies have shown that more recent formulas such as Kane, Olsen and Barrett Universal II offer a greater degree of accuracy compared to older formulas such as Hoffer Q, Holladay 2 or SRK/T.

“There are a few reasons for this improvement. Firstly, the high quality of data in terms of measurements and refractions with optical biometry. Secondly, the improvement of IOL position estimation, and empirical fits to correct bias in extremes of ranges for axial length and keratometry. Finally, taking account of the role of the posterior cornea in the calculation has helped to improve our results,” he said.

Dr Aramberri stressed the importance, however, of intelligent use of the available formulas and methods.

“The key point is that the more regular the cornea is, the less it matters which regular formula we use, whereas thick lens models require adapted formulas and for extreme cases we need to use exact ray-tracing methods,” he said.

Jaime

Aramberri: jaimearamberri@telefonica.net

High-quality imaging has taken the accuracy and precision of modern biometry to new heights. Dermot McGrath reports

Very short AXL (14.57mm) and cataract with Anterion SS-OCT (Heidelberg)

Courtesy of Jaime Aramberri MD

Optimising outcomes for diabetic patients

Preoperative treatment of retinal pathology essential to good outcome of cataract surgery in diabetic patients. Roibeard O’hEineachain reports

In cataract patients with diabetic retinopathy, detailed informed consent and additional planning of the perioperative period can optimise surgical outcomes and help manage expectations, reports Catarina Pedrosa MD, Lisbon, Portugal.

“Cataract surgery may improve vision in patients with retinal diseases, but it is crucial to monitor and treat the underlying retinal pathology,” Dr Pedrosa told the 25th ESCRS Winter Meeting.

She noted that the presence of diabetic retinopathy can influence every aspect of cataract surgery, from the timing of surgery, to the surgical technique, the type of IOL used and the final outcome. She added that the prevalence of cataract among young diabetic patients is higher than that among others in their age-group. The cataracts occurring in eyes of diabetic patients usually involve cortical and posterior subcapsular opacities.

RETINAL DISEASE

Dr Pedrosa also pointed out that cataract surgery may exacerbate retinal disease in patients with diabetic retinopathy. In such eyes the procedure can break down the blood-retinal barrier and the bloodaqueous barrier enhancing intraocular inflammatory response. That, in turn, raises risk of retinopathy progression. Diabetic retinopathy also increases the risk of intra- and postoperative complications. Moreover, eyes of diabetic patients often have delayed wound healing and higher risk of developing epithelial defects or recurrent erosions due to the impairment of epithelial basement membranes and epithelial-stromal interactions. They are also more prone to dry eye because of diabetic neuropathy.

Small pupil is common in diabetic patients and frequently occurs in eyes that have undergone laser photocoagulation making cataract surgery technically challenging.

Alterations in pupillary function are mainly due to autonomic neuropathy, which mainly affects the sympathetic innervation of the iris dilator. Commonly used mydriatics and anticholinergic agents are less effective in eyes with the condition and the addition

of directly acting sympathomimetics may be required, Dr Pedrosa said. Although there is no direct evidence that diabetes influences the final outcome of biometry, there are special considerations regarding the eyes with diabetic macular oedema and those filled with silicone oil, Dr Pedrosa said. Axial length measurements in eyes with cystoid macular oedema (CME) obtained using applanation ultrasound differ significantly both statistically and clinically from those obtained with the IOLMaster. In addition to the indentation effect, the ultrasound devices measure the axial length from the corneal apex to the vitreoretinal interface, whereas the IOLMaster measures the axial length from the apex of the cornea to the retinal pigmented epithelium, being less affected by retinal thickening.

In eyes treated with silicone oil, the remnants of the vitreous base and the partial filling with silicone oil creates optical distortions that can make optical biometry findings inaccurate, with only a third of eyes within 1.0D of their refractive target postoperatively. Dr Pedrosa said that best practice is to perform biometry before injecting silicone oil. If that is not possible, measurement of the second eye or biometry after silicone oil removal are probably the best alternatives. She also recommended the use of convex-plano monofocal polymethyl methacrylate or foldable hydrophobic acrylic intraocular lenses (IOLs) with large optic diameter in these patients.

In general, when choosing an IOL for patients with macular lesions or who are at a high risk for progression, hydrophobic acrylic monofocal IOLs are the most appropriate, and multifocal lenses are best avoided, as are hydrophilic IOLs because they can be more prone to opacities, she added.

Phacoemulsification in vitrectomised eyes is surgically more challenging because of the relative ocular hypotony and the possible presence of anterior synechiae associated with small pupils, Dr Pedrosa said. Furthermore, in such

eyes the anterior chamber is deeper and fluctuating, the zonules are also weaker and the posterior capsule may be fibrotic or calcified because of surgical trauma.

She noted that the reduced vitreous pressure in vitrectomised eyes makes the capsulorhexis easier to perform and makes the running of the rhexis less likely to occur. Hydrodissection and hydrodelineation should be performed carefully and thoroughly. In eyes where the lens is adherent to the capsule, viscodissection may be necessary and, after irrigation aspiration, a cannula can be used to carefully release and aspirate the remaining cortical material, avoiding capsular rupture. Using low flow parameters will reduce the stress on the zonules by reducing the fluctuation of the anterior chamber. Complete aspiration of the cortical material will reduce the risk of postoperative inflammation.

MACULAR OEDEMA

Patients with diabetes are at higher risk of diabetic macular oedema (DME) and CME after cataract surgery, with an incidence of 4%. The risk rises with the staging of the ocular pathology and the systemic pathology and also the hardness of the cataract. The ESCRS PREMED study showed that subconjunctival triamcinolone acetonide (40mg) reduced the risk of postoperative CME in diabetics who underwent phacoemulsification, when applied additionally to the standard regimen of perioperative topical bromfenac and dexamethasone phosphate.

“Visual acuity improves after cataract surgery in patients with diabetic retinopathy regardless of the degree of disease, although eyes with the condition may take longer to heal and achieve a stable postoperative refraction. It is important to treat the disease preoperatively and to maintain vigilance in diabetic patients after cataract extraction with serial dilated funduscopic examinations, even when central macular oedema is not present immediately prior to cataract surgery. Eyes with prior DME treatment or non-central involved DME have a particularly high risk of developing central-involved ME after cataract surgery,” Dr Pedrosa added.

Catarina Pedrosa: pedrosa.catarina@gmail.com

The Law of Life

Change is the law of life, and those who look only to the past and present are certain to miss the future”

John F Kennedy

The COVID-19 pandemic has posed colossal challenges to the sustainable delivery of eye care. The ophthalmic consultation, traditionally requiring a face to face examination, poses particular risks to the physician and patient alike. As such, in March 2020, the Royal College of Ophthalmologists announced that all routine outpatient activity should be postponed, and over a three-month period at Moorfields alone, more than 100,000 outpatient appointments were cancelled.

INGENUITY

The resultant lockdown forced us to rapidly implement a number of off-theshelf solutions. My own eye casualty in Dublin was converted into an efficient tele-ophthalmology service. A telephone triage team was assembled with whom patients could discuss their complaints and e-mail a clinical photograph if appropriate. Many patients were managed simply with advice, a prescription and a follow-up call where necessary.

A drive-through glaucoma clinic was established in Dublin’s Citywest. This innovative model invited known glaucoma patients to have an IOP measured from the safety of their own car with an iCare device. Patients with concerning IOP’s were flagged and followed up physically in a glaucoma clinic. Those with reassuring measurements continued to be followed up through a tele-ophthalmology consult.Worldwide, and almost overnight, ophthalmology departments adopted tele-medicine and similar creative responses in an endeavour to continue the safe delivery of eye care.

EMBRACING TECHNOLOGY

We are at a unique advantage in ophthalmology as being the speciality that best marries medicine and modern technology. Countless applications exist that allow physicians to remotely test a multitude of ocular vital signs like visual acuity, colour vision, Amsler grid distortion and even visual fields. We are even close to an era where patients can capture their own fundus photographs with a commercially available iPhone attachment.

Going forward, validated versions of these applications could facilitate homemonitoring in a select patient population.

As an amateur photographer I am impressed also by the familiar names found in our photographic departments. Canon, Optos by Nikon, and Zeiss have revolutionised fundus photography and OCT respectively. Ours is a speciality where the diagnosis is often reached on history and observation alone, and these imaging systems allow us to appreciate much of the visual pathway at a resolution that matches that of the human eye.

The virtual clinic is one field that has arisen from this supposition. In this model, trained technicians measure visual acuity and IOP, and can perform fundus photography, OCT and visual field testing where indicated. The results can then be reviewed remotely by a specialist and decisions made on their care. A controversial opinion perhaps, but it might also be possible for the data to be analysed by artificial intelligence, removing entirely the need for physician input.

Stereo fundus photography has made virtual glaucoma clinics a reality, and OCT has paved the way for virtual medical retina clinics. I would argue that there are many other patient populations that could be followed similarly. I’m not advocating for our gradual obsolescence, but with 1,500 UK ophthalmologists managing 9 million outpatient appointments per year, we need to drastically re-imagine the way we “see” our patients. By pushing screening and monitoring away from the acute setting we can focus on treating patients who truly require our expertise.

THEATRE ACCESS

As well as restructuring our outpatient services there will clearly be a need to manage the backlog of patients awaiting cataract surgery. Ophthalmology after all, is the speciality with the highest number of patients waiting on an outpatient procedure.

Currently, many people with visually significant cataract are first diagnosed by their optometrist. Ideally, experienced optometrists working as part of an integrated cataract assessment pathway could refer suitable patients directly for surgery, avoiding unnecessary delays.

Many patients undergoing cataract surgery for the first time will also have a second cataract warranting removal soon after.

Consideration should be given to performing bilateral simultaneous cataract extraction in these individuals, a sentiment echoed by the Royal College of Ophthalmologists.

Postoperatively, patients who had uncomplicated surgery and have no ocular co-morbidities could be reviewed by their local optometrist or over the phone by a non-medical health care professional.

Don’t get me wrong, I look forward to the day when COVID is behind us. It has been an awful period both personally and professionally for many of us. I am excited, however, at the lessons to be learned from our response to the pandemic, and at how our long-term clinical practice will change. If we are to manage the ever-increasing demand on ophthalmic services then there needs to be an urgent re-evaluation of the old way of doing things. The COVID pandemic might just be the catalyst required to make such necessary changes.

Aaron Donnelly is a resident at Cork University Hospital and the South Infirmary Victoria University Hospital in Cork, Ireland

References on request

In his shortlisted essay for the John Henahan Prize 2021, Dr Aaron Donnelly says there needs to be an urgent re-evaluation of the old way of doing things

–

Consideration should be given to performing bilateral simultaneous cataract extraction in these individuals, a sentiment echoed by the Royal College of Ophthalmologists

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS

VOL: 47 ISSUE: 4 MONTH: APRIL 2021

IOL POWER CALCULATION POST-LASIK

Finding the best approach to power calculation in cataract patients who have previously undergone myopic LASIK or photorefractive keratectomy is a challenge. US researchers reviewed the charts of 101 eyes of consecutive patients undergoing cataract surgery. They found that even after normalisation of results, the use of total keratometry did not seem to materially improve IOL sphere power calculations in these eyes. Intraoperative aberrometry also did not appear to improve results. Rather, the review suggested that it might be best to use the Haigis-L or Barrett True-K formulas from the ASCRS website with AK values as the input. This would be expected to minimise (but not eliminate) the likelihood of refractive surprises, although it would not be an optimal strategy for reducing outliers. H Sandoval et al., “Cataract surgery after myopic laser in situ keratomileusis: objective analysis to determine best formula and keratometry to use”, Vol 47, Issue 4, 465-47.

SMILE AND BINOCULAR FUNCTION IN HIGH MYOPIA

The effect of small-incision lenticule extraction (SMILE®) for high myopia on patients’ binocular vision has been an open question. In a study of 138 eyes of 69 patients with high myopia, SMILE did not appear to alter binocular vision. Stereoacuity was assessed through two tests: the Randot Circles (Stereo Optical Company) and the (near) Frisby Stereotest (Clement Clarke). While mean spherical equivalent improved from a mean of -7.46 to -0.23 following surgery, stereoacuity did not change significantly. Binocular visual acuity, binocular contrast sensitivity and binocular summation were also unchanged. The researchers conclude that patients with high myopia that are undergoing SMILE can be informed that SMILE will not affect binocular function. A. Gyldenkerne et al., “Impact on binocular visual function of small-incision lenticule extraction for high myopia”, Vol 47, Issue 4, 430-438.

MUSIC HATH CHARMS TO SOOTHE THE CATARACT PATIENT

Recorded music could help first-time patients relax before, during and after phacoemulsification surgery, according to recent prospective, single-masked, randomised controlled trial. One hundred and sixty-five patients listened to music on an MP3 player pre- and perioperatively while an identical number had surgery without music. Only 4% of patients in the musical intervention group reported feeling anxious before surgery compared with 30% in the control group. The patients who were allowed to listen to music had significantly lower systolic and diastolic blood pressures in the postoperative period. This suggests that music can be an inexpensive and effective method to improve the patient experience of cataract surgery, the researchers report. SK

Muddana

et al., “Preoperative and perioperative music to reduce anxiety during first-time phacoemulsification cataract surgery in the high-volume setting: randomized controlled trial”, Vol 47, Issue 4, 471-475.

What a difference a year makes

In his shortlisted essay for the John Henahan Prize 2021, Dr Stuart Guthrie says the changes that are lasting and beneficial in daily clinical practice will help to improve patient care, safety and ophthalmology training

Lifting the next set of case notes from an ever-expanding pile I look up at a sea of faces gazing at me in anticipation. A moment later I am responsible for a reverberation of disappointment as I call the “wrong” name. Sighs, groans and at times the occasional quietly muttered expletive lilt in the warm clammy afternoon air. Even the soothing tones of Marvin Gaye’s ‘Sexual healing’ from Smooth FM do little to abate the growing sense of frustration from the tightly packed ocularly challenged throng.

The lucky chosen one lifts themselves from their hard plastic chair slowly, joints stiffened and gluteus maximus numbed by hours of stasis. A quick rub of the knees and a shake of the legs and the assault course to my consultation room begins. Prams, hurried medical personnel and small sugar laden children attempt to scupper the poor chap’s attempt at his quest for a resolution in his ophthalmic complaint.

He makes it to my door physically unscathed but clearly in a degree of psychological distress. “Thank you so much for waiting today sir, it’s a been terribly busy clinic, please take a seat.” Comes my unconscious response for nearly every patient seen.

“What has brought you to the emergency clinic today Mr Anderson?”. The gentleman opens his mouth to begin when there is a knock at the door. A nurse pops her head in “Sorry to interrupt, I can’t cannulate the patient you requested an FFA on”. I attempt a reply but my mobile beginnings to loudly ring the classically awful Motorola ringtone. I nod apologetically to both nurse and patient.

“Hello, Dr Guthrie on call ophthalmology, how can I help?” another automated response comes.

“Afternoon, this is Dr Rashid, I’ve got a lady down in ED with fixed pupil, cloudy cornea and nausea and vomiting... think it may be angle closure. Would you be able to take a look?” Like watching the nucleus sink down through the posterior capsule into the ever welcoming vitreous, an impending sense

of doom enters my already fragile mind. “Yes, of course.” I say weakly.

I hang up and smile maintaining my professional façade. However, it is broken shortly when a most unwelcome guest makes his feelings known “grrrrrrrrrrr…. gggrrrrr”. Ah but of course, the familiar low growl of peristalsis attempting to evacuate an empty gastrointestinal tract. Thoughts of a missed lunch must be pushed to one side or alas, these patients, and I, will never leave this department.

......

“Stuart…..Stuart? wakey wakey!” I suddenly find myself in the same clinic, gazing absentmindedly out into the empty waiting area. “That’s your first patient in, Room 2. And put your mask over your nose you dafty.”

I turn back to my computer and finish replying to the email of a local optician who had sent in some photos for review of Mr. Anderson. Marginal keratitis I think. “Barn door” I mutter under my breath. I provide an appropriate management plan and click reply.

I rise, shake my stiff legs and enter my new automated routine. Wash hands, don gloves and apron, and take lens.

At that point, a text message alert pings from my phone requesting a video consultation from ED. Frustratingly, having just “donned”, I must, as they now say in common medical vernacular “doff”.

I accept the invitation and a familiar face now engulfs my display in crystal clear pixelated form.

“Dr Rashid! how can I help you today?”

“Good afternoon, I have a patient here with an abrasion, but the pupil looks a bit funny. He had a nasty fall yesterday.” Dr Rashid mounts the tablet on to the slit lamp adapter and focuses on the area of interest.

“I am afraid that’s a penetrating eye injury, Dr Rashid. The iris is peaking out of a small corneal wound”

I then immediately coordinate an appropriate management plan with ED and liaise with theatre staff and my seniors.

My concentration is temporarily broken by the TV blaring to the patient-

less waiting room. Statistics flash upon the screen dramatically. “Death count 25,345, Tested positive 50,678,” accompanied by aerial footage of mass graves outside New York. Sometimes I think I am in some awful dream. Not being able to see friends or family. Loved ones passing away with no one to comfort them. How life can seemingly change so quickly.

However, I take great hope in how we humans do what we have always done in response to crises. Adapt and become more creative, finding new solutions to new problems.

There is no doubt daily clinical practice has changed and will continue to change. But the changes that are lasting and beneficial will stay with us improving patient care, safety, and ophthalmology training for the future... and hopefully allow me to finally enjoy lunch.

Stuart Guthrie is an ST4 Ophthalmology specialist registrar at Queen Margaret Hospital, Dunfermline, Scotland

...I take great hope in how we humans do what we have always done in response to crises. Adapt and become more creative, finding new solutions to new problems

Endothelial keratoplasty

Good long- to medium-term graft survival and visual outcomes with DSEK and DMEK. Roibeard Ó hÉineacháin reports

Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK) appear to provide good visual acuity over the medium to long term, according to studies presented at the 25th ESCRS Winter Meeting.

In a single-centre retrospective consecutive series study, eyes undergoing DSEK had 10-year graft survival of 79%, said Lana Fu FRCOphth, King’s College Hospital NHS Foundation Trust, London, UK.

“DSEK remains a viable treatment option, especially in complex eyes with comorbidity,” Dr Fu added.

The study involved 356 eyes of 263 patients who underwent DSEK from January 2006 to January 2020 and had a median follow-up of 6.0 years (range: 0.5-14 years).The patients had a mean age of 72 years (range 35-95 years). The indications for surgery included Fuchs’ endothelial dystrophy (FED) in 59%, pseudophakic bullous keratopathy (PBK) in 25%, and previous graft failure in 5%.

Ten surgeons performed the procedures using a standardised protocol. In all eyes they prepared the donor buttons manually using the Melles technique. In the first year of the study they inserted the donor tissue with a forceps, but switched to using the Busin glide in 2007 and the Tan EndoGlide in 2010 .

Dr Fu noted that 189 (53%) eyes had low visual potential preoperatively due to ocular co-morbidities, glaucoma, age-related macular degeneration, optic neuropathy and retinal detachment surgery.

Cumulative graft survival of all eyes, including those with complex co-morbidities, was 85% at five years and 79% at 10 years, Dr Fu pointed out. Among eyes with glaucoma, the cumulative graft survival was 52% at five years and 35% at 10 years, among eyes with PBK it was 89% at five years and 62% at 10 years and among eyes with FED it was 97% at five years and 92% at 10 years.

The endothelial cell loss of all grafts was 46.5% at one year, 54.9% at three years, 59.21% at five years and 75.65% at 10 years. After exclusion of the failed grafts there was no statistically significant increase in central corneal thickness, she noted.

Complications included interface fluid, which occurred in 52 (14.6%) eyes, and re-bubbling was performed in 29 eyes (8.1%). There were also 70 (19.7%) rejection episodes, half of which occurred in eyes that had preoperative glaucoma. Graft failure occurred in 50 (14%) eyes, of which 27 underwent repeat transplants.

GOOD VISION MAINTAINED FOR FIVE YEARS AFTER DMEK

Another retrospective study, presented at the ESCRS meeting by Nikolaos Kappos MD, suggested that eyes undergoing DMEK maintain normal visual acuity levels for five postoperative years despite some loss of transparency.

The study involved 60 eyes of 51 patients who underwent DMEK at the Philipps University of Marburg, Germany. The patients had a mean age of 67 years and their indications were FED in 53 (88%) cases and BK in seven (12%) cases. None included in the analysis had undergone previous corneal surgery, complicated perioperative course, vision-limiting ocular comorbidity and/or incomplete follow-up data, said Dr Kappos, National and Kapodistrian University of Athens, Athens, Greece.

The primary outcome in the study was corneal densitometry, a measure of light scatter as determined with the Pentacam

HR (Oculus). Secondary outcomes were best corrected visual acuity, endothelial cell density measured with the Topcon SP2000P and central corneal thickness measured with the Pentacam HR.

“Light scattering constitutes a significant parameter in the evaluation of the corneal optical performance since back scatter interferes with its transparency. The rotating Scheimpflug camera in the clinical settings enables the objective quantification backscatter in greyscale units (GSU) in different layers and zones,” Dr Kappos said.

The study showed that mean corneal density decreased significantly in the central and paracentral zone for up to two years but increased slightly between the second and fifth year, although it remained significantly lower than the preoperative value (21 GSU vs 33 GSU, respectively).

In the mid-peripheral zone there was no change in corneal density postoperatively for up to two years, but there was a considerable increase between the second and fifth years, reaching levels higher than preoperative values.

Similarly, mean central corneal thickness decreased significantly from 686μm preoperatively to 527μm at three months but by two years had increased to 542μm and by five years had increased to 557μm. Mean endothelial cell density decreased by 60% from 2,500 cells/mm2 prior to implantation to 1,000 cells/mm2 at five years. Nonetheless, visual acuity improved from 0.3 (Snellen decimal) preoperatively to 0.8 (Snellen decimal) at six months and remained stable thereafter.

“Despite a slight corneal density increase at all layers of all corneal zones from the second to the fifth postoperative year, the excellent visual outcome was maintained throughout five years’ follow-up. Thus, DMEK seems to treat effectively corneal endothelial disease in the long term,” Dr Kappos concluded.

Lana Fu: LFu@Doctors.org.uk

Nikolaos Kappos: nickappos@gmail.com

DSEK remains a viable treatment option, especially in complex eyes with comorbidity

Lana Fu FRCOphth

Light scattering constitutes a significant parameter in the evaluation of the corneal optical performance since back scatter interferes with its transparency

Nikolaos Kappos MD

Limbal stem cell graft technique

Anew limbal stem cell transplant (LSCT) technique employing vacuum-dried amnion and fibrin glue to redirect conjunctival epithelium from encroaching on the cornea during re-epithelialisation appears to be a safe and effective technique for eyes with total limbal stem cell deficiency (LSCD), reported Darren Shu Jeng Ting MBChB FRCOphth at the 25th ESCRS Winter Meeting.

“This limbal stem cell transplantation technique serves as an effective ocular surface reconstruction technique in managing total LSCD and improving vision, said Dr Ting, who is currently a Medical Research Council / Fight for Sight Fellow at the Queen’s Medical Centre, Nottingham, UK.

The retrospective, interventional case series study included 10 eyes of 10 patients with a mean age of 46.2 years who were diagnosed with total LSCD. Causes of LSCD were chemical eye injury (30%), congenital aniridia-related keratopathy (30%), ocular surface malignancy (20%), Steven-Johnson syndrome (10%), and contact lens overuse (10%). All procedures were performed by Prof Harminder S Dua.

All eyes underwent a modified form of the amnion-assisted conjunctival epithelial redirection (ACER) procedure, a technique first described by Prof Dua at Queen’s Medical Centre, Nottingham, UK, in 2017 as a means of preventing re-conjunctivalisation of the cornea after LSCT.

After mean follow-up duration of 21.4 months, 60% of eyes had a complete corneal epithelialisation without conjunctivalisation and 20% had a complete epithelialisation but with partial conjunctivalisation sparing the visual axis. The remaining 20% were treatment failures, defined as conjunctivalisation not sparing the visual axis.

The mean time to complete corneal re-epithelialisation was 1.14 months. Corrected distance visual acuity improved in 70% of eyes. Corrected distance visual acuity improved from 1.53 logMAR to 0.23 logMAR (p=0.004). The success rate was significantly higher among the 50% of patients receiving autologous grafts compared to those receiving allogeneic grafts (p=0.048).

The original ACER technique involves removing fibrovascular pannus from the diseased cornea then performing a 360-degree peritomy and suturing the graft tissue in place at 12 and six o’clock. Then a small amniotic membrane is placed on the cornea and a large amniotic membrane is draped over the cornea and sutured into place with the peripheral conjunctiva. The new version of the technique involves using vacuum-dried amnion (Omnigen), instead of cryopreserved amnion, and fibrin glue instead of sutures, Dr Ting explained. The fibrin glue acts as a physical barrier for conjunctival cells and when they start to grow after dissolution of the fibrin, they are re-directed on to the amnion graft preventing admixture with limbal-explant derived cells. The amnion sheet was removed at two-to-four weeks postoperatively.

“Vacuum-dried amnion has the advantages of being used off-the-shelf and of having higher transparency, allowing a better visualisation of the corneal healing postoperatively. The use of fibrin glue, instead of sutures, helps shorten intraoperative time and obviates suture related complications and the need for suture removal postoperatively,” he added.

Darren Ting: ting.darren@gmail.com

New transplant approach may reduce risk of conjunctivalisation. Roibeard Ó hÉineacháin reports

What is dry eye disease?

Research bringing greater clarity to dry eye disease definition and classification. Roibeard O’hEineachain reports

The definition of dry eye disease (DED) continues to evolve as research reveals new aspects of its aetiology and pathophysiology, said Prof Jose M Benitez-del-Castillo MD PhD, at the 25th ESCRS Winter Meeting.

The Tear Film and Ocular Surface Society’s report from the 2007 international dry eye workshop (DEWS) defined DED as “a multifactorial disease that results in symptoms of discomfort visual disturbance and tear film instability with potential damage to the ocular surface accompanied by increased osmolarity of the tear film and inflammation of the ocular surface” said Prof Benitez-del-Castillo, Universidad Complutense de Madrid, Spain.

He pointed out that DED had previously been considered a disorder of the tear film, but this definition defines it as a disease of the ocular surface. He added that the inclusion of visual disturbance is also very important because a bare unmoistened corneal epithelium has a very rough and optically imperfect surface, as can be seen with scanning electron microscopy.

The newer DEWS II revised definition of 2017, defines DED as “a multifactorial disease of the ocular surface characterised by the loss of homeostasis of the tear film accompanied by ocular symptoms in which tear film instability, hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play aetiological roles”.

Prof Benitez-del-Castillo noted that this definition lacks a key element in that it does not include visual symptoms. On the other hand, the emphasis on tear film homeostasis and the aetiological implication of neurosensory abnormalities bring the definition more closely into line with clinical experience and the current scientific understanding of the condition.

HOMEOSTASIS BREAKDOWN

He noted that ED results from a breakdown in the homeostasis that maintains the ocular surface as a functional unit. In eyes with dry eye disease there is an impaired sensory input, the lachrymal glands become populated with inflammatory cells and cytokines and there is ocular surface damage. That in turn leads to more tear film instability and more hyperosmolarity.

Neurosensory abnormalities are related to inflammation and confocal microscopy photographs of the ocular surface show

that in the normal eye the nerve density is high with very few antigen-presenting cells, whereas in the dry eye it is the reverse, with low nerve density and a high number of Langerhans cells, he said.

DIAGNOSIS & CLASSIFICATION

When diagnosing DED, patients’ responses to answers to the DEQ-5 or OSDI questionnaire will provide a good overview of their symptoms, he noted. In addition, one should look for at least one of three signs namely, non-invasive tear break-up time or fluorescein break uptime, Osmolarity higher 308mOsm/L or interocular difference of more than 8 Osm/L and ocular surface staining.

Patients presenting with dry eye can be symptomatic or asymptomatic, Prof Benitez-del-Castillo said. However, there is not always a correlation between symptoms and signs. For example, a patient may have many signs of the condition but few of the symptoms, as might be the case in an eye with neurotrophic keratopathy. Conversely, a patient can have many symptoms but few signs, as may occur among patients with neuropathic pain, a complication of dry eye disease.

Once a patient has a diagnosis DED it is necessary to differentiate between evaporative and aqueous deficient dry eye, examining the eye though the slit-lamp and looking for signs of meibomian gland dysfunction and assessing the tear volume with a tear meniscus height. However, he noted that the limit between the two DED categories is very complex and unclear and around a third of patients have a mix of signs and symptoms of both DED types.

He added that wettability of the ocular surface is an important factor in tear film stability, so much so that poor wettability DED, a result of mucin deficiency, might be considered a third DED category alongside aqueous deficient and evaporative dry eye. The different types of DED can be distinguished by their characteristic tear break-up patterns.

MGD IN THE 21ST CENTURY

Prof Benitez-del-Castillo noted that meibomian gland dysfunction is a chronic diffuse abnormality of the meibomian glands characterised by terminal duct obstruction and changes in the quantity and quality of meibum secreted. This may result in the alteration of the tear film and clinically apparent inflammation and ocular surface disease.

The initiating factors of MGD can include poor blinking habits and infections. He noted that long hours before a computer screen not only reduces the frequency of blinking, but also causes people to blink in an abnormal, partial way, resulting in reduced meibum secretion. He added that the COVID-19 pandemic has not only led to people having increased screen time, but the wearing of masks may also be contributing to an increased incidence of MGD-related infectious dry eye, in addition to increased rates of other MGD-related conditions such as chalazion and hordeolum. He noted that masks tend to direct exhaled air across the ocular surface, both drying the eye and exposing it to a multitude of bacteria.

Jose M Benitez-del-Castillo: benitezcastillo@gmail.com

Courtesy of Prof Jose M Benitez-del-Castillo MD PhD

Dry eye and cataract

Treating dry eye disease before cataract surgery and minimising trauma to the ocular surface will optimise outcomes. Roibeard Ó hÉineacháin reports

Optimal dry eye management in cataract surgery candidates requires a well thought out strategy to treat the dry eye and protect the ocular surface from the potentially damaging effects of the cataract procedure, emphasises Prof Marc Labetoulle MD, Paris-Saclay University, Paris, France.

“To optimise outcomes in dry eye disease patients the first step is to make the correct diagnosis and adopt a surgical strategy prior to surgery followed by the use of optimised techniques during surgery and careful follow-up after surgery,” Prof Labetoulle told the 25th ESCRS Winter Meeting.

He noted that dry eye disease has been greatly underdiagnosed for many years in cataract surgery candidates. Research suggests that around half cataract surgery patients have clinically definitive meibomian gland dysfunction and 56% have meibomian gland atrophy. In addition, around 22% have a prior diagnosis of DED, and 60-to-70% of patients report ocular dryness.

The DED that occurs after cataract surgery is also often underdiagnosed. The procedure itself increases the frequency of DED. Some studies suggest dry eye occurs in around 10% of patients following uneventful cataract surgery, with increased staining in around 60%, and smaller increases in symptoms and Schirmer scores.

Prof Labetoulle noted that he and his associates have developed a testing strategy for dry eye, which their research shows can reduce the time required to diagnose or rule out DED to one minute in 95% of patients with no history of dry eye. The testing duration is five minutes in only 4%, and only 1% require a testing period longer than five minutes.

One important point is that the lachrymal hyperosmolarity characteristic of DED causes greater variability in biometric examinations. The significant variations in mean keratotomy and corneal astigmatism measurements can make the IOL calculation inaccurate, he said.

TREATMENT LADDER

Regarding treatment strategies, Prof Labetoulle recommended that cataract surgery candidates with mild DED should continue with the same treatment for their condition as before. However, if they were not receiving dry eye treatment they should be prescribed one.

In patients with moderate DED, the treatment should be increased and followed to monitor improvements in their eyes’ condition. In addition, their surgery should be delayed one-to-two months with a last check before surgery. In eyes with severe DED, the treatment should be increased and surgery should be delayed by four-to-six months, again with a last check before surgery.

The DEWS II report suggests that treatment of mild dry eye should involve patient education and environmental and dietary modifications. In addition, drugs that reduce tear secretion should be withdrawn and patients should instead receive artificial eye drops, and adopt some eyelid hygiene practices, Prof Labetoulle said.

If the eye is unresponsive to these treatments or the DED is of a more moderate character, anti-inflammatory therapies should be introduced, including Omega 3 supplements and macrolides if needed to restore function to the meibomian gland. If the condition is very severe and insufficiently responsive to other measures, immunomodulators may be considered, along with more complex approaches such as autologous serum.

He noted that although immunomodulators like cyclosporine and lifitegrast are best reserved for the more extreme DED cases, numerous studies have demonstrated their efficacy in dry eye treatment. Tacrolimus has been approved as a treatment for severe allergies and there is some research suggesting it also may have promise as a treatment for dry eye.

DROPPING THE DROPS

Prof Labetoulle noted that much of the disturbance that cataract surgery inflicts on the ocular surface can be avoided in the weeks preoperatively by reducing the number of eyedrops patients receive

and avoiding eye drops that contain benzalkonium chloride as well as antibiotic eyedrops, which provide no prophylaxis against endophthalmitis.

The use of Mydrane® (Théa) by intracameral injection can obviate the need for local anaesthetic drops or mydriatic drops during surgery. In addition, research shows that, compared to conventional eye drops, Mydrane induces less toxicity on the ocular surface and causes less epithelial alteration, allowing a faster recovery of the integrity of the ocular surface. As a result, patients have less frequent and milder eye symptoms.

Other measures that can be taken to avoid inducing or aggravating dry eye during cataract surgery include avoiding the use of aspirating speculums, limiting the light exposure during surgery, and limiting the thermal energy delivered by the phacoemulsification device. Regular wetting of the cornea and using the remaining hyaluronate on the cornea at the end of the surgery are also useful techniques.

Inflammation can influence postoperative results of cataract surgery and there is now research suggesting that postoperative administration of topical cyclosporine reduces symptoms and objective measures of dry eye following phacoemulsification. The research also suggests that even in cataract patients with no DED preoperatively, topical cyclosporine can improve postoperative corneal sensation and contrast discrimination.

“Ocular surface disease, most frequently dry eye disease, must be diagnosed and treated before the patient undergoes cataract surgery. There are multiple treatment options and ladder scale of therapy is available that can be adopted before during and after surgery,” Prof Labetoulle concluded.

Marc Labetoulle: marc.labetoulle@aphp.fr

To optimise outcomes in dry eye disease patients the first step is to make the correct diagnosis and adopt a surgical strategy prior to surgery followed by the use of optimised techniques during surgery...

Prof Marc Labetoulle MD

Alzheimer’s disease diagnosis

Retinal pathology targeted as accessible indicator of disease in the brain. Cheryl Guttman Krader reports

The identification of ocular biomarkers of Alzheimer’s disease (AD) pathology in the retina has been an area of active research for more than 10 years as investigators aim to develop non-invasive techniques for diagnosis, monitoring disease progression and evaluating responses to therapeutic interventions.

To date there have been promising advances. However, there is much work yet to be done before any finding related to the eye becomes accepted as a biomarker for AD, said Maya Koronyo-Hamaoui PhD.

Dr Koronyo-Hamaoui is Associate Professor of Neurosurgery and Biomedical Sciences at Cedars-Sinai Medical Centre, Los Angeles, CA, USA. A decade ago, she, Yosef Koronyo and colleagues showed for the first time that amyloid-β protein (Aβ) plaques, which represent the neuropathological hallmarks of AD, were present in the retina of post-mortem eyes of patients with AD.

Dr Koronyo-Hamaoui told EuroTimes that while there has been much progress in the development of structural, functional, and molecular imaging technologies for identifying AD-related pathology in the brain, the molecular tools are more suitable for research purposes and are still limited for wide-scale deployment in the clinical setting.

“Current brain imaging technologies used for AD diagnosis, including positron emission tomography among others, are expensive, not widely available, have limited resolution or specificity, and some are invasive, requiring the use of unsafe radioisotopes,” she said.

Interest in studying the retina lies in the fact that this neural tissue is an extension of the brain that shares many structural, functional, and biochemical characteristics, and it is the only central nervous system structure that is not shielded by bone. Therefore, it is accessible to live imaging with non-invasive techniques, she explained.

FOCUSING ON THE EYE

Investigators searching for ocular biomarkers of AD have followed a number of different paths. Their studies include characterisation of functional consequences, including changes in contrast sensitivity, colour perception, pupillary responses, saccadic eye movements and circadian rhythms, which are modulated by photosensitive retinal ganglion cells. In addition, researchers have looked for signs of structural changes in the retina using OCT, changes in vascular structure and blood flow using OCT angiography, and evidence of inflammation.

However, Dr Koronyo-Hamaoui believes that identification of Aβ plaques in the retina may be the most appropriate target. She explained: “AD is associated with neurodegeneration, inflammation and vascular pathology. Those changes in the brain lead to cognitive impairment and in the eye they have functional implications as well. However, neurodegeneration, inflammation and vascular changes in the retina can occur with ageing and

with other CNS, vascular diseases, or purely ocular diseases.”

“Aβ deposition along with pTau protein pathology are recognised as very early biomarkers of AD and thought to induce and amplify the development of the inflammation and vascular changes that result in the synaptic and neuronal losses, which ultimately manifest as clinically evident dementia. While a person with Aβ plaques in the brain will not necessarily develop AD, nor is it known for certain that Aβ deposition is the earliest sign of AD and the driving factor for other AD pathology, Aβ plaques are specific to AD and necessary for AD diagnosis.”

DOCUMENTING RETINAL Aβ DEPOSITION

Evidence supporting a focus on retinal Aβ comes from studies of paired brain and retina post-mortem tissue from patients with neuropathologically-confirmed AD that showed a strong correlation between the two sites in the severity of the Aβ burden and in other AD-related pathology, including presence of pTau, neurodegenerative changes and atrophy.

Non-invasive in vivo retinal amyloid imaging became possible when the Cedars-Sinai group developed technology that was subsequently developed for commercial use by several manufacturers. The approach involves oral administration of curcumin, a safe and natural fluorochrome that binds specifically to amyloid, and its detection with laser ophthalmoscopy.

More recently, researchers at the University of Minnesota, Minneapolis, USA, developed a hyperspectral imaging technique as another non-invasive approach for detecting retinal Aβ. Based on the principle that Aβ has a wavelength-dependent effect on light scatter, it measures a retinal reflectance spectrum without the need for an exogenously administered label.

Using their system in clinical studies, Dr Koronyo-Hamaoui and colleagues showed the retinal Aβ burden in patients with AD was higher than in cognitively normal controls. In another study, they showed that it correlated with hippocampal volume in patients with mild cognitive impairment. Forthcoming publications from the Cedars-Sinai group are reporting that retinal Aβ burden predicts a certain AD-related memory domain loss, Dr Koronyo-Hamaoui said.

The imaging technique has also been used in animal models and pilot clinical trials that documented reduction in retinal Aβ plaques in response to immunomodulation therapy. It is now being used in larger scale studies to assess outcomes of investigational interventions for AD.

“It can take up to 20 years before AD-related pathology in the brain progresses to a state where clinical symptoms appear. Early intervention during the preclinical stage will be key for limiting the devastating consequences of AD. Finding non-invasive tools that will provide early AD diagnosis and allow repeated monitoring to evaluate therapeutic response is critical for identifying effective treatments,” Dr Koronyo-Hamaoui added.

Maya Koronyo-Hamaoui: Maya.Koronyo@cshs.org

A library of symposia, interviews, video discussions, supplements, articles and presentations

Spotlight on:

 Toric IOLs and Presbyopia

 Glaucoma

 Ocular Surface Disease

 Corneal Therapeutics

 Refractive IOL Patient Journey

 Phaco Fundamentals

forum.escrs.org

Paediatric Cataract Surgery Registry

EuReCCa aims to capture practice trends for paediatric cataract surgery across Europe.

Cheryl Guttman Krader reports

Members of the steering group of the European Registry of Childhood Cataract (EuReCCa) are getting ready to launch the project, which aims to improve surgical outcomes in infants and children with cataract.

“EuReCCa is designed to capture reallife practice for paediatric cataract surgery across Europe. Ultimately, we expect its findings will improve quality of life for children with cataract and their parents,” said Marie-José Tassignon MD, PhD.

“We are now finalising our review of the data collection forms and expect that the registry will be accessible to ESCRS members as a sub-registry of the EUREQUO platform in April or May of 2021,” she told EuroTimes.

Dr Tassignon, Emeritus Professor and Head, Department of Ophthalmology, University Hospital, Antwerp, Belgium, is serving as co-coordinator of the EuReCCa steering group with G Darius Hildebrand MD, President, European Paediatric Ophthalmological Society and Head, Paediatric Ophthalmology and

Strabismus, Oxford University Hospitals, Oxford, UK. Mats Lundström MD, PhD, Karlskrona, Sweden, is the group’s director on behalf of EUREQUO.

The registry will collect systematic prospective data on visual outcome, refractive outcome, and complications. In the future, a form will be added to gather patient-reported outcomes.

RESEARCH AIMS

The specific research aims of EuReCCa are to characterise visual outcomes and identify associated predictive factors; improve understanding of emmetropisation in children with unilateral and bilateral cataract; establish recommendations for the optimal timing of surgery in children; define an updated childhood cataract grading system; and answer the question of whether IOL implantation is safe at any age and if aphakia is still an option in the current era.

The data collected in EuReCCa will be analysed to identify risk factors for main surgical and postoperative complications

and reasons for reoperations. By comparing outcomes associated with different approaches, EuReCCa will help to define standard surgical procedures.

“Our hope is that using the collective data, we will be able to build the first multivariate risk model for paediatric cataract surgery that can be used to inform parents about surgical outcomes and guide ophthalmologists in their surgical planning,” Dr Tassignon said.

“Through the reports generated by EuReCCa, participating centres and individual surgeons will also be able to compare their outcomes to the entire registry.”

Some future improvements in the user-friendliness of the EuReCCa platform would be making it compatible with the participant’s electronic medical record, allowing Digital Imaging and Communication in Medicine (DICOM)compatible uploading of surgical videos to improve cataract classification.

EuReCCa is financially supported by the ESCRS. If any doctor wishes to register their interest they can visit registries.escrs.org.

Stepping on the same banana peel

Things it would have been useful to know before the pandemic.

EuroTimes Executive Editor Colin Kerr reports

American musician Father John Misty talks about a post-apocalyptic world in his song ‘Things It Would Have Been Useful To Know Before The Revolution’. The song reflects on a post-apocalyptic world after a seismic event.

To promote the song, Misty and his record label Sub-Pop produced a striking animated video portraying a lone survivor trying to come to terms with her ‘New Normal’. The song, combined with the video, is a humorous yet striking statement about what may lie ahead when society breaks down.

In an interview, Misty explained that the song looks at “human beings stepping on the same banana peels over and over again”.

Which is why we need to talk about COVID-19. In the past 12 months EuroTimes has talked to ophthalmologists from all over the world about their COVID-19 experience.

Our community of medical writers has also given us their first-hand experience of life as doctors on the pandemic frontline. Here is one reflection that we did not publish: “The situation is changing so fast. Three of my department are already covid +ve. The stress is immense.”

HOPELESS, HELPLESS

The words “hopeless”, “helpless”, and “burnout” were repeated frequently in our reports. Many doctors were angry with the inadequacy of health systems around the world and the failure to control the spread of the virus.

One thing that struck me while editing our COVID-19 features was that the majority of ophthalmologists who were asked to perform COVID-19 functions were young ophthalmologists.

Many of them have young families

which would have added to the pressures they were under every day.

Dr Clare Quigley, in an article entitled Lockdown Limbo, articulated her fear of contacting the virus: “I am careful at work, but I know that I am the most likely to get exposed, and go on to bring COVID home, and from there spread it on to my brother’s family and their two children,” she said.

Thankfully front-line workers like Dr Quigley are now less likely to contract the virus thanks to the increasing availability of COVID-19 vaccines.

They can also start to look forward to returning to their old routine, but lessons have been learned that will have a major impact on the future practice of medicine and ophthalmology.

And to return to Father John Misty, let’s try to stop stepping on the same banana skin over and over again.

Igniting wood

The mind is not a vessel that needs filling, but wood that needs igniting.” — Plutarch Achieving professional and academic success requires many ingredients – hard work, focus, domain knowledge, skills, empathy, nurturing and supportive environments at work and home and, most importantly, good fortune to have the right mentor.

Mentors play a key role – they lift you up, give vision and direction, support you when you are disheartened and may carry you if you feel you cannot go on. I feel blessed to always have had good mentors.

Dr. S Viswanathan, along with many other wonderful teachers, encouraged me and taught me the science of Medicine and of Ophthalmology.

However, it is a whole new world when you start practice and from the early stages, I had the good fortune to be associated with a wonderful husband-and-wife duo, a celebrity Ophthalmology couple – Dr Athiya and Dr Amar Agarwal.

When I joined Dr Agarwal’s Eye Hospital, I was inspired by these two strong personalities who were not afraid to do things differently, never said no to a challenge and who were insanely hardworking! I saw them not afraid of swimming against the tide or of pushing boundaries.

With innovations such as no-anaesthesia cataract surgery,

phakonit, aberropia and glued IOL – Dr Amar made me understand the need to look beyond textbooks and to constantly think of how to improve further on existing solutions. With her passion, dedication and her love and concern, Dr Athiya made me feel at home and wanting to work equally hard.

As mentors, they constantly encouraged me, never held me back and taught me to live the principles of learn, unlearn and relearn. They also taught me to look beyond silos which has enabled me to be able to contribute in my own small ways back to Ophthalmology.

Making me attend conferences, learn from other leaders, interact with greats and push my bar by cheering me on with my first international publications, paper and video film presentations, surgeries, surgical teaching, innovations and to this day for my successes, be it from the many awards to being selected to the Top-100 Power Women Ophthalmologists, they have been my family at work.

As Steven Spielberg put it: “The delicate balance of mentoring someone is not creating them in your own image, but giving them the opportunity to create themselves” –and for this I will always be thankful to them.

The delicate balance of mentoring someone is not creating them in your own image, but giving them the opportunity to create themselves, says Soosan Jacob, MS, FRCS, DNB

Dr Soosan Jacob (centre) with her mentors Dr Athiya (left) and Dr Amar Agarwal

Early summer

Haircuts at home, empty classrooms and warm beaches.

YouTube is useful. When I open the site these days, the top suggested videos are from the cataract coach, Uday Devgan. Browsing his channel, there are lots of interesting clips, where he gives feedback to surgeons in training and beyond. Devgan analyses different techniques for operating technically challenging cases, including posterior polar, and white pressurised cataracts. With a pleasant speaking voice, he is easy to listen to, and gives an honest appraisal, but in a generous manner. He extracts learning points from each case.

After Devgan’s channel, there are a variety of videos on the homepage, generated by my searches of late. Surgical knot tying. Walking tours of cities that are under consideration for fellowship; it seems likely now that I will need to decide where to go without physically visiting, given the COVID situation. Music videos, especially from the Red Hot Chili Peppers. Most recently, how to cut your hair.

Even if the procedure were to go completely pear-shaped, I reasoned, I could hide it. In work, I could wear a theatre cap all day, along with scrubs. This would be unusual, as most of the time in clinic people wear ordinary clothes, not scrubs. Scrubs are worn when working in theatre. But I could get away with it, I imagined. People – patients and colleagues – would assume that I was in scrubs as I might be just coming back from, or about to go to, the operating theatres. And a theatre cap goes along with scrubs, naturally, so my hair could be tucked up into it, out of sight.

Outside work, I could get in the habit of wearing a hat. That way, only my family at home would need to see my new hair. I told myself this, before taking up a scissors in front of the mirror in the kitchen. This was months after I had last had a haircut, with the hairdressers still shut, and no indicative date for re-opening.

It is odd how normal this new way of life has become. No restaurants, no theatres, no pubs, no parties. The last time we went to the cinema was in December 2019, to Knives Out (it was fantastic). The last foreign holiday we took was to Galicia, Spain, in August 2019 (highly recommended). These days, weekends involve a stroll around the neighbourhood, taking in the local parks and playgrounds, with a takeaway flat white as a treat.

Considering the few exams I have coming up, it may be a good idea not to have too many distractions. Settling down to reading and MCQs is that bit easier when the alternative activities are not too enticing. Alongside studying, as I imagine must be the case elsewhere, we are strongly encouraged to do research and audit. Narrowing my focus down to get a manuscript polished and ready to go is that much more doable in lockdown. And of course, we need to take part in departmental teaching.

At the last teaching session it was my turn to present – I spoke about topics in cornea, my current rotation – and I found myself alone in an empty clinic room, talking to other ophthalmologists in training via Zoom on my laptop, about keratitis and techniques for sampling or gluing corneas. Presenting in that way, I alternate between self-consciousness, listening to the sound of my own voice, and unease about whether attendees can hear me and see the slides. Mostly, I miss the chat, before and after, often over a coffee.

When COVID case numbers had fallen enough for the government to allow us to move outside a five-kilometre radius of home, it took a few days for the idea of this new freedom to properly sink in. There was a sense like we were being let out of an institution, when the radius of potential free movement opened up. It happens that there are a few keen sea swimmers in the Eye and Ear, and when it looked like the weather would be good, we took advantage of that first weekend of travel-within-county to make for the sea.

That Saturday, summer had arrived early. Perfectly blue sky, with bare wisps of fluffy clouds. The sea at Killiney beach was bitterly cold, but the sun and the sand were warm. Sitting eating sandwiches and watching the sea glitter, was a good dose of normality.

So, in the end, I went for it. There was a YouTube video, ‘Bob haircut! DIY’, that looked suitably quick and straightforward. I enlisted my husband to tidy up the back, which he agreed to do, only after I had promised not to give out if I did not like it. It turned out that I did not have to be so tactful as Uday Devgan with my feedback, as my husband did a pretty good job.

Even if the procedure were to go completely pear-shaped, I reasoned, I could hide it.

I could wear a theatre cap all day, along with scrubs

Clare Quigley is a specialist registrar in the Royal Victoria Eye and Ear Hospital, Dublin, Ireland

Clare Quigley MRCSI (Ophth), FRCOphth, reports

Illustration by Eoin Coveney

100% SOLAR POWER

Johnson & Johnson Vision has announced that its ACUVUE global headquarters in Jacksonville, USA, will run on 100% solar power after agreeing a deal with JEA of Northwest Florida. The deal, which goes into effect in 2022, will help Johnson & Johnson Vision meet its renewable electricity target and means that all ACUVUE brand contact lenses will be made using 100% renewable electricity, said a Johnson & Johnson spokesperson.

INDUSTRY NEWS

Next generation surgical platform

Oertli have launched the new OS 4, which the company say is the next generation of their OS 4 surgical platform for retinal, glaucoma and cataract surgery.

“The highlights of the next OS 4 generation undoubtedly include the two Power LED light sources with 45% more power and extended control range for even more application possibilities, as well as the high-resolution contrast viewing by means of the Power LED Plus,” said a company spokeswoman.

“The integrated endo laser no longer requires manual operation thanks to the fully automated laser user protection filter,” according to Oertli. “The multifunctional pedal offers over 100 setting options and thus the preferred control for every surgeon. The phaco test is performed in record time and massively speeds up a user-friendly preparation for surgery. In general, the new OS 4 ensures speed in the operating theatre – without compromising comfort or safety.” www.oertli-instruments.com

GROWTH MILESTONES

LENSAR achieved significant growth milestones during 2020, including an increase in global market share from 13 to 16%, a 10% increase in customer installed base and a 15% increase in procedure volume in their two largest markets, according to the company. “We maintained our leading laser system utilisation position with an average of 430 procedures performed per laser vs. 232 with competitive systems. These successes are a testament to our dedication to bringing ophthalmic surgeons the most advanced and beneficial laser system available today,” said Nick Curtis, Chief Executive Officer of LENSAR. “I am also pleased to report that we remain on track to file the 510K application in the first quarter of 2022 and launch ALLY later that year,” said Mr Curtis. www.lensar.com

NIDEK will mark its 50th anniversary on 8 August, 2021 with a new logo, the first time that the company has renewed its logo since its establishment. While the new logo continues to use the image of an eye, the company says that the elegant lines shaped like an “N” express the growth of the company.

NIDEK President and CEO Mr Motoki Ozawa, said: “Since our foundation in 1971, we have been operating globally in three fields, ophthalmology and optometry, lens edging and coating based on our three pillars: bringing invisible to visible, visible to recognition and our desire to enhance the eye with our products. The growth curve in our logo represents the prosperity of both our customers and NIDEK,” said Mr Ozawa. https://www.nidek-intl.com/50th

As part of the new ACUVUE® sustainability resources, the brand is also encouraging contact lens wearers not to flush their lenses down the toilet or sink to prevent them finding their way into streams, rivers and oceans.

www.acuvue.com/sustainability

MEDICAL AFFAIRS APPOINTMENT

Santen EMEA has announced the appointment of Dr Ioana Grobeiu as Vice President, Medical Affairs. With over 20 years of experience in pharmaceuticals, Ioana will lead the medical affairs strategy and report to Luis Iglesias, President and Head of Santen EMEA, said the company.

“We are delighted to welcome Dr Grobeiu as our new Vice President of Medical Affairs EMEA. Ioana’s breadth and depth of experience will be invaluable as we continue to collaborate with the ophthalmology community to protect the precious sense of sight,” said Mr Iglesias. www.santen.com

US HEADQUARTERS

The ZEISS Innovation Center in Northern California is the new US headquarters for Carl Zeiss Meditec, Inc. The company say that this longterm commitment to the US market is crucial and strongly supports exciting new innovations developed in close collaboration with partners from industry, research, and local communities to benefit customers.

“The new Center serves as a global beacon for high technology and digital innovation, and it’s through this and ZEISS’ global market presence that we continue our commitment to the development of advanced technologies, creating the clinical solutions and milestones,” said a company spokesperson. www.zeiss.com

The new OS 4 from Oertli

Making the most while you can

After more than a year without travel, Aidan Hanratty looks forward to the possibility of revisiting Amsterdam

In my younger days, I visited Amsterdam for a music conference-slash-festival called Amsterdam Dance Event. Almost a week in length, it features industry panels, talks and product demonstrations during the day, with extensively packed club shows at night. The top DJs and producers in the world of house and techno and other forms of electronic music descend upon the city for that week in October, providing clubbers of every taste with a range of potential nights out.

This October, the city will play host to the 39th Congress of the ESCRS, a thoroughly different kind of conference. Industry and practitioners abound, once more, but instead of the electronics of music it’s the electronics behind ophthalmology that will be on display, as well as the cutting edge of science in one of the fastest-moving areas of medicine.

Due to the COVID-19 pandemic, the 38th Congress of the ESCRS was a virtual affair. That means we are all even more anxious for a face-to-face meeting, as well as being able to enjoy the sights, sounds and tastes of a city away from home.

Amsterdam has so much to offer visitors, it’s difficult to know where to begin.

From the Dutch masters on show at the Rijksmuseum to modern and contemporary art at the Stedelijk Museum, there’s a world of art to be seen.

The Tropenmuseum houses a range of exhibitions, most notably Afterlives of Slavery, in which visitors are confronted with the legacies of slavery that still shape Dutch society in the here and now. Reallife artefacts and first-hand accounts lend weight to the exhibition, personalising the experience and forcing visitors to put enslaved people centre stage. https://www. tropenmuseum.nl/

The Foam museum celebrates its 20th anniversary this year, having opened in December 2001. The photography museum celebrates the work of established artists as well as calling for new blood with its annual Foam Talent Call. https://www.foam.org/

The KattenKabinet is, as the name suggests, a museum dedicated to cats, including works by Pablo Picasso,

Rembrandt, Henri de Toulouse-Lautrec and more, and as well as featuring cats on the walls, real-live cats are known to roam the building. https://www.kattenkabinet.nl/

A’DAM Toren is a multi-purpose building that houses hotels, office spaces, a “forbidden garden” and restaurants. There’s also a viewing platform offering a 360-degree panorama of the city, as well as a daring “sensational swing” that suspends viewers back and forth 100 meters above the ground. https://adamtoren.nl/

Readers of this publication may be familiar with the letters FEBO as meaning Fellow of the European Board of Ophthalmology. In Amsterdam, these letters mean something different. Named after Ferdinand Bolstraat, the site of the company’s original home, FEBO is an automat restaurant, with a counter for fries and a wall of vending machines serving potato croquettes, mince hot dog, hamburgers and similar hot food.

One thing Amsterdam natives love is mayonnaise. Buy a portion of the fries mentioned above, served in a paper sleeve, and you’ll be offered a healthy dollop of the condiment, with no regard for its calorific content.

After a meal one can enjoy a stroopwafel or two. These were born in the city of Gouda, and while the yellow cheese that takes its name from its birthplace may be more famous, these delectable waffles fused with

caramel are nonetheless worth a bite, best enjoyed after sitting on top of a cup of tea or coffee, allowing the caramel to soften and melt.

There’s also the Heineken Experience, a tour of the brewery that’s been providing the world with the famous lager for more than 150 years. A combination ticket allows you to step straight from the brewery on to a barge that will give you a tour of the city’s canals.

https://www.heinekenexperience.com/en/

If eating and drinking aren’t on your menu, it’s worth renting a bike. With more than 500km of bike lanes, it’s one of the most bike-friendly cities in the world, second only to Copenhagen (a city that took its inspiration from its Dutch counterpart for its canalways, but that’s another story). If you’re walking, however, make sure you don’t step on to the cycle lane – you will be heckled.

For a variety of reasons, many of the sites I visited before will be gone by the time I see Amsterdam again. The large nightclub Trouw closed in 2015, for example, and the building now houses a co-working space. Some venues have closed due to bankruptcy, others have shut their doors temporarily during the pandemic.

Walking past these same spots, changed utterly, will nonetheless bring special moments to mind. All those moments will be lost in time, like tears in rain. So let’s make the most of them while we can.

Amsterdam is one of the most bike-friendly cities in the world

Due to the COVID-19 virus, a number of meetings have been cancelled or rescheduled. The information in this calendar is correct at the time of going to print; please check the meeting website or email the conference organisers to confirm all meeting dates.

↙ LAST CALL

JUNE 2021

EPOS 2021 Virtual Conference

Virtual Meeting

18 –19 June

https://epos2021.dk/

JULY

AECOS 2021 Summer Symposium

15 – 18 July

Deer Valley, UT, USA

https://aecosurgery.org/ 2021-summer-symposium/

2021 ASCRS Annual Meeting

23 – 27 July

Las Vegas, NV, USA

https://annualmeeting.ascrs.org/

33rd APACRS–SNEC 30th Anniversary Joint Meeting

Virtual Meeting

30 – 31 July

http://apacrs-snec2021.org/

AUGUST

Virtual Congress on Global Controversies in Ophthalmology: Global (COPHy GLOBAL)

Virtual Meeting

20 – 21 August

https://cophy-global.comtecmed.com/

SEPTEMBER

NEW

12th EuCornea Congress

Virtual Meeting

25 September

https://www.eucornea.org/

The AECOS 2021 Summer Symposium will take place in Utah, USA

SEPTEMBER

EURETINA 2021 Virtual Virtual Meeting

9 – 12 September

https://www.euretina.org/

OCTOBER

39th Congress of the ESCRS

8 – 11 October

Amsterdam, The Netherlands

https://www.escrs.org/

NOVEMBER

NEW

SFO Autumn

E-Congress

Virtual Meeting

6 November

https://www.sfo.asso.fr/

AAO 2021: Re/Create

12 – 15 November

New Orleans, LA, USA

https://www.aao.org/ annual-meeting

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

 EyeJC (ESCRS Journal Club)

 ESCRS CONNECT Academy Webinar with HSIOIRS

 Eye Contact Interviews

 Video of the Month

 Video Journal of Cataract, Refractive & Glaucoma Surgery

 Young Ophthalmologists Videos: “My Early Surgeries” player.escrs.org

AAO 2021: Re/Create will take place in New Orleans, LA, USA

The 39th Congress of ESCRS will take place in Amsterdam, The Netherlands

SmartSight: level up your vision.

Thoroughly minimally invasive.

SCHWIND SmartSight®

• Safety through intelligent eye tracking

• Cyclotorsion compensation for effective treatment

• Improved eye comfort through curved patient interface geometry

• Tissue-saving through optimised lenticular geometry

• High flexibility through compact design

SCHWIND SmartSight ® is an up-to-date minimally invasive femtosecond laser procedure without a flap. The advancement of lenticule extraction features intelligent eye tracking with pupil recognition and cyclotorsion compensation. This enables very easy and precise centring. The curved patient interface reduces pressure on the eye during positioning, for more patient comfort. The compact design and user-friendly operation provide high flexibility and allow an efficient corneal surgery workflow.