EuroTimes Nov 2019 | Vol 24 Issue 11 by EUROTIMES

SPECIAL FOCUS

PAEDIATRIC OPHTHALMOLOGY

November 2019 | Vol 24 Issue 11

CATARACT & REFRACTIVE | CORNEA RETINA | GLAUCOMA

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

Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS

CORNEA

PAEDIATRIC OPHTHALMOLOGY

18 Long-term medication

04 Everything you

20 Early treatment

need to know about dealing with younger patients

06 Corneal

transplantation in paediatric patients

08 The multifaceted nature of aniridia-associated keratopathy

10 Congenital aniridia and cataract

11 OCT can help

diagnose sickle cell retinopathy

CATARACT & REFRACTIVE 12 Vision at all distances possible with novel plate-haptic IOL

13 The pros and cons of

MSICS versus phaco

14 New femto approach for correcting refractive errors

15 JCRS highlights 17 All the news from the As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between February and December 2018 was 48,900

American Academy of Ophthalmology Annual Meeting

www.eurotimes.org

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can affect all layers of the cornea is paramount in keratoconus

22 Scoring system can

help reduce unnecessary cross-linking

RETINA 24 AI is already making

an impact in diabetic eye disease

25 Modern techniques are improving results in endophthalmitis

26 ‘Shoot first, ask

questions later’ in endophthalmitis

28 Mediterranean

diet proven to aid retinal health

REGULARS 32 Industry News 35 My Mentor 36 Random Thoughts 37 Travel 38 ESCRS Board Election 39 Calendar

29 Ophthalmologica highlights

GLAUCOMA 30 How useful is diagnosis before visual field defects occur?

31 OSD is a major problem in glaucoma care

Supplement November 2019

New Concept Monofocal IOL with Continuous Focus PP-XACT-EMEA-0012 – Date of Preparation: Oct 2019 Please read the xactTM Mono-EDoF™ Instructions for Use carefully before using the device Mono-EDoFTM Foldable Hydrophobic Acrylic Ultraviolet-Absorbing and Blue-Light Absorbing Posterior Chamber Intraocular Lens is indicated for visual correction of aphakia in adult patients in whom the cataractous lens has been removed by an extracapsular cataract extraction method. The lens is intended for placement in the capsular bag. For optimal performance of the Mono-EDoFTM it is suggested that this IOL is implanted in patients with preoperative corneal astigmatism of 1.0D and care should be excercised not to increase the postoperative astigmatism because of surgically induced astigamtisim.

Ocular Surface Disease Diagnosis & Management: Special Focus on the Lipid Layer

2018 Results

Included with this issue... Santen Supplement, Education Forum Supplement & Clinical Survey 2018 Results

EUROTIMES | NOVEMBER 2019

EDITORIAL A WORD FROM KEN K. NISCHAL MD

GUEST EDITORIAL

Inspiration and connection Melting pot brings direct and clear benefits to the children we treat

Ken K. Nischal

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan), John Chang (China), Béatrice Cochener-Lamard (France), Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India), Vikentia Katsanevaki (Greece), Daniel Kook (Germany), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland) Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands), Sathish Srinivasan (UK), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)

was delighted to be asked by EuroTimes to write this editorial at a time when paediatric and adult ophthalmology are increasingly working together to keep apace of the rapid developments in the field and the changing needs of patients. I was really pleased with the number of people, more than 150, who attended the recent paediatric subspecialty day during the 37th Congress of the ESCRS in Paris, France. What the day highlighted most was the fact that more and more people are turning their attention to detail, functional and structural changes in children. Part of that reason is that at the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) there is this interaction between those who do adult work and have some input in children, and those who deal with a lot of We are confident we paediatric problems but can break the 2,000 don’t have exposure to the adult world; that attendance barrier mix allows people to for a paediatric take away some of the ophthalmology and ideas they’ve seen in the adult world and apply strabismus conference them in children. this time, which has The 5th World never been done before Congress of Paediatric Ophthalmology and Strabismus (WCPOS V) will take in Amsterdam next October, along with the ESCRS, EURETINA and EuCornea Congresses, and again we will have these amazing joint symposia. In this melting pot there is a direct and clear benefit to the children we look after, which is really exciting. That is reflected in who we have chosen as our key speakers; for the Kanski Medal, which is given to someone who is not a paediatric ophthalmologist but whose work has influenced children, we’ve invited Marie-José Tassignon, Belgium, with her bag-in-the-lens approach and her work on the anterior vitreous space. We will have David Mackey of Australia for the keynote, who will speak about ocular genetics, and for the strabismus keynote lecture we will have Burton Kushner, USA – a very international line-up. We are confident we can break the 2,000 attendance barrier for a paediatric ophthalmology and strabismus conference this time, which has never been done before. We talk about connectivity in terms of cyberspace and the internet, but connectivity in a physical space between experts is just as important, as physical presence inspires people to do something new and something different for children. So do come join us next October!

Dr Ken K. Nischal is co-director of WSPOS EUROTIMES | NOVEMBER 2019

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

Keynotes Friday 2 October 2020 David Mackey

AUSTRALIA

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

Saturday 3 October 2020 Burton Kushner

USA

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

Sunday 4 October 2020 Marie-José Tassignon

BELGIUM

Kanski Medal Lecture A Thing of Beauty is a Joy Forever

Key Dates MONDAY 2 DECEMBER 2019

JANUARY 2020

Abstract Submission for Free Papers,Posters & Video Competition will open

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

FRIDAY 28 FEBRUARY 2020

FRIDAY 2 – SUNDAY 4 OCTOBER 2020

Abstract Submission closes for Free Papers, Posters & Video Competition

WCPOS V (5th World Congress of Paediatric Ophthalmology and Strabismus)

www.wspos.org

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Illustration by Claire Prouvost

Paediatric Cataract Surgery There are many factors to consider when dealing with younger patients. Soosan Jacob reports

ifficult patients, difficult eyes, difficult evaluationâ&#x20AC;Ś difficult decision-making, difficult follow-up and often difficult parents! With so much difficulty, why should we invest time and effort to know paediatric ophthalmology better and what should we know? I had discussed why, in a previous article (Paediatric Ophthalmology, EuroTimes, November 2017) and here will discuss briefly on some of what we need to know. Growth of the eye: Axial length of about 14.5-15.5mm and K value of about 52 dioptres at birth changes during three EUROTIMES | NOVEMBER 2019

growth phases: rapidly from birth to two years followed by two slow phases between two-to-five years and five-to-10 years. Hypermetropia at birth increases until about seven years, then slowly decreases till the eyes reach adult dimensions by about 16 years of age. Children with myopia before 10 years generally progress to more than -6D and should be referred to a paediatric ophthalmologist for possible treatment with low-dose atropine eyedrops. The importance of spending time outdoors and avoiding handheld digital devices should be stressed. Accurate refraction and amblyopia treatment is very important. Sometimes, decreased

vision may be untreatable and the ophthalmologist should guide parents about resources available for such patients. Examination of children: Techniques providing maximum information while minimising trauma to the child and frustration for the examiner are ideal. Sometimes, however, it may be necessary to use restraint for examination or to examine under anaesthesia. Visual acuity is assessed by Snellen chart in cooperative children or grossly with toys kept at different distances. For pre-verbal/ uncooperative children, pattern visually evoked potential, preferential looking test, fixation behaviour, Allen cards etc. help. A

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY lit-up small toy acts as an accommodative near target while simultaneously helping to assess corneal light reflex. In young infants, the red reflex (Brückner test) can help diagnose refractive errors, misaligned eyes, visually significant media opacities and even retinoblastoma. Glare testing assesses the real impact of minimal central opacities on vision. Parents/siblings should be evaluated if genetic abnormalities or conditions such as keratoconus are suspected. The paediatric eye is small, has low ocular rigidity and elastic structures. Surgery and postoperative management are both challenging and unpredictable. Cataract is the leading cause of treatable paediatric blindness. Early referral and if required, systemic/ genetic evaluation and Serum TORCH titres are performed. Timing of surgery and timing, material and power of IOL need to be decided. Vision is subcortically mediated for the first six weeks of life and there is some resistance to developing amblyopia within this age. Therefore, surgery for unilateral congenital cataracts by four-to-six weeks and bilateral congenital cataracts by sixto-eight weeks followed by refractive correction and occlusion therapy can avoid stimulus-deprivation amblyopia and result in good vision with fusion and stereopsis. The case for multifocals in paediatric eyes is weak, considering the expected refractive shift and possible deleterious effect of decreased contrast sensitivity, glare and haloes on the developing visual system. Corneal opacities should be evaluated carefully to assess the need for surgery. For eyes requiring corneal transplantation, close postoperative follow-up is a must. In very young children, difficult suture management, inability of children to express symptoms, secondary glaucoma and need for examination under anaesthesia can all lead to an increased risk of rejection and other complications, possibly more deleterious than the primary disease. Older and alert children who are cooperative for examination together

with aware and responsible parents can increase success rates of keratoplasty in children. Decisions should therefore be made judiciously and after a thorough examination and discussion with parents. Glaucomas, as in all age groups, have to be handled aggressively to prevent permanent irreversible visual loss. Brimonidine in children can cross bloodbrain-barrier and should ideally be avoided. Mitomycin-C is often required to deal with the aggressive scarring response seen commonly in children. Issues such as cataract, glaucoma, corneal pathology etc. may need to be tackled simultaneously or sequentially in anterior segment developmental anomalies, often requiring multiple complex surgeries. Premature babies must undergo screening for Retinopathy of Prematurity and be given laser/ anti-VEGF/ surgical treatment according to indication and should have continued monitoring. Retinal examinations and other evaluations of the pre- and post-geniculate system are indicated, especially in case of delayed visual maturation in children. Students complaining of headaches when studying should have a complete examination, including refraction and convergence assessment, both of which can be treated easily by spectacles and pencil push-up exercises respectively. The latter may also help keep certain exophorias under control. Nystagmus can be secondary to motor or sensory defects or neurological abnormality. History of inherited ocular/ systemic conditions in the family, maternal infections during pregnancy, difficult labour and prematurity should be taken. Treatment of cause as well as prism spectacles and surgery for nystagmus are possible. Oculoplastic conditions such as ptosis need surgery not only if the visual axis is occluded but also to improve confidence levels and the psychosocial development of the child. Nasolacrimal duct obstruction (NLDO) in infants presents with epiphora and/

or crusting. Infantile glaucoma is a differential for this and hints favouring it over NLDO include photophobia, enlarged cornea, Haab’s striae etc. Since 90% of congenital NLDO spontaneously resolves by nine-to-12 months of age, conservative management in the form of lacrimal massage and topical antibiotics when required is preferred. Probing may be done if not resolving beyond nine-to-12 months. Other situations that we may come across sometimes include congenital and acquired ocular infections, paediatric uveitis, ocular and orbital tumours, phacomatoses, various vitreoretinal, optic disc, and metabolic diseases etc. When required, these should be referred for treatment. The presence of dysmorphic features and systemic abnormalities should alert to need for systemic evaluation. Finally, the shaken baby syndrome secondary to physical abuse, generally by the caregiver, should be suspected by inconsistent or poor correlation of history with type/ degree of injury as well as by observing the family social interaction. Violent shaking causes unilateral/ bilateral retinal haemorrhages in 85% of cases. Vitreous haemorrhage, perimacular folds and retinoschisis may also be seen. Anterior segment and adnexa may be quiet but other prominent evidence such as subdural haematomas, subarachnoid haemorrhage, intracranial oedema, ischaemia, contusion and cerebral atrophy may be seen. Bruises, metaphyseal fractures, broken ribs etc. and signs of blunt trauma such as periorbital oedema, echhymoses, subconjunctival haemorrhage, hyphema, lens dislocation etc. may also be seen in child abuse. In many countries, child abuse is required by law to be reported to the appropriate governmental agencies. 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.

KEN K. NISCHAL ON PAEDIATRIC CATARACT SURGERY: Elasticity and healing of a child’s eye are completely different. If you also look at neuroplasticity, it completely changes the approach. Paediatric cataracts are visually significant either because they are total or because the location causes light diffraction. Dilating the pupil around a central cataract can buy time but can affect macular function. Therefore, a ≥3mm opacity in the central visual axis should be dealt with sooner rather than later. Surgery should, however, be safe. In infants, the risk of glaucoma is always present and studies show that operating after four weeks of age is better than operating before. Limbal or clear corneal incisions are preferred as scleral tunnels violate conjunctiva and affect success of any future filtration surgery. Under four years of age, posterior rhexis with anterior vitrectomy is important. I personally also do posterior capsulorhexis without anterior vitrectomy in children between four and 16 years of age, because doing YAG capsulotomy is never easy in children. I prefer the two-incision push-pull rhexis technique, described by me for both anterior and posterior capsules. Age of the child determines postoperative targeted refraction. In children below two years, rapid growth of the eye is expected. Below one year, an immediate postoperative +4D may result in -6D at two-to-three years age. So, under one year, I usually aim for +8D and at six months, for +10D. While that may appear problematic, remember that in the first 18 months of life, there is a 3.5mm growth of the eye, translating to approximately 10.5D shift, and this definitely needs to be taken into account. There is an argument to keep the child slightly myopic, but that is more relevant when the child is around three-to-six years of age. For children referred from other countries, a minimum six weeks’ follow-up allows a final refraction at four weeks, any complications to be dealt with and a proper surgical follow-up plan to be formulated with the local doctor.

EUROTIMES | NOVEMBER 2019

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Paediatric

K E R ATO P L A S T Y Pearls and pitfalls of keratoplasty in children. Dermot McGrath reports

orneal transplantation in a paediatric patient population poses special challenges, but good results may still be obtained with careful case selection, rigorous surgery and meticulous postoperative care, according to Gerald W. Zaidman MD, FAAO, FACS. Speaking during a World Society of Paediatric Ophthalmology and Strabismus (WSPOS) symposium held during the European Society of Ophthalmology (SOE) meeting in Nice, France, Dr Zaidman said that paediatric corneal diseases remain a frequent cause of blindness in the developed and developing world, accounting for an estimated 10% of all cases of blindness in children. He noted that attempting keratoplasty in children is very different from adults and requires a fundamentally different approach. “The challenge is that we are dealing with severe ocular pathology in a technically difficult surgical situation with a small eye, an elastic sclera and very shallow anterior chamber, with anterior displacement of the iris and lens, a young patient who does not cooperate, who is hard to examine and who can reject their corneas literally overnight,” he said. The key first step is to accurately diagnose and manage a child with a cloudy cornea, said Dr Zaidman, who is Professor of Ophthalmology, New York Medical College, and Vice Chairman of Ophthalmology, Westchester Medical

Preoperative image of a paediatric patient undergoing corneal transplantation

Postoperative image of a the same patient

Preoperative image of a paediatric patient undergoing corneal transplantation

Postoperative image of a the same patient

Center, both in Valhalla, New York, USA. “There is every likelihood that you are going to have to perform an exam under anaesthesia (EUA) in a child under the age of three or four. You have to accurately

diagnose and manage all the problems and conditions that may be causing the clouded cornea. This means performing all the exams, monitoring the IOP, checking the corneal diameter and performing A/B ultrasound scans. I would also advise most importantly to use ultrasound biomicroscopy (UBM) because that will help you to visualise any anterior segment changes,” he said. The indications for paediatric keratoplasty are also markedly different than adult corneal transplant patients, the vast majority of whom have endothelial disease, keratoconus or failed grafts, said Dr Zaidman.

Courtesy of Gerald W. Zaidman MD, FAAO, FACS

The challenge is that we are dealing with severe ocular pathology in a technically difficult surgical situation with a small eye... Gerald W. Zaidman MD, FAAO, FACS EUROTIMES | NOVEMBER 2019

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

There is every likelihood that you are going to have to perform an exam under anaesthesia (EUA) in a child under the age of three or four Gerald W. Zaidman MD, FAAO, FACS

“I have performed over 400 transplants in children. Congenital diseases easily make up the vast bulk of the patients, primarily Peters’ anomaly, sclerocornea, endothelial dystrophy and congenital glaucoma. Trauma is the second single biggest indication and then in older children and adolescents we encounter keratoconus, herpes, corneal ulcers and rosacea,” he said. A key part of the preoperative assessment entails an assessment of the social situation of the child and ensuring that the parents and caregivers are fully aware of what treatment will entail. “They need to understand that this will be a marathon of eye drops, visits and examinations, many of them under general anaesthesia. We also need to realistically discuss success rates with them and explain that a clear cornea does not necessarily equate to good vision, and that treatment of amblyopia and glaucoma may severely impact on the outcomes,” he said. In newborn patients with congenital corneal disease, Dr Zaidman advised scheduling the first office visit prior to three weeks of age and then performing the first exam under anaesthesia at four-to-six weeks.

A 14-year-old patient who underwent corneal transplantation 13 years before

Surgery in the first eye is usually performed between eight-and-12 weeks of age and in the second eye from four-to-six weeks after the first surgery. For the surgery, Dr Zaidman said that all patients undergo general anaesthesia, with mannitol and hyperventilation to ensure a softer globe and optimal conditions for the keratoplasty. Donor tissue is used from donors aged four-to-19 years and the donor tissue is

oversized by 0.5mm. A scleral support ring is then put in place and the anterior chamber is entered carefully using plenty of viscoelastic before synechialysis is performed, said Dr Zaidman. Over the years, Dr Zaidman has developed what he calls the ‘sandwich technique’ in which the donor cornea is placed on to the host cornea and sutured into position into the recipient’s sclera. Once this has been done, the recipient’s cornea is then removed from under the donor cornea, avoiding vitreous and lens prolapse. Interrupted sutures then are used to adhere the graft in place, Dr Zaidman explained. “This technique works well and helps to minimise the extreme positive pressure typically encountered during paediatric surgery and to ensure a stable anterior chamber,” he said. In terms of postoperative care, the patient is examined two-to-three times weekly and eye exams under anaesthesia are performed frequently. Sutures are removed within one month for infants and three-to-four months for young children. Optical correction is advised as soon as possible after suture removal. Over the long term, topical steroids are tapered slowly over the course of one year and no vaccinations are administered for at least one year because of the risk of rejection. In terms of results, Dr Zaidman said that patients with Peters’ anomaly type I usually obtained the best visual outcomes, with more than 85% having clear grafts and 54% obtaining visual acuity of 20/100 or better after three years. Children with glaucoma generally had the worst prognosis, he added.

European Union Web-Based Registry The aim of the project is to build a common assessment methodology and establish an EU web-based registry and network for academics, health professionals and authorities to assess and verify the safety quality and efficacy of corneal transplantation.

ECCTR is co-funded by

Co-funded by the Health Programme of the European Union

www.ecctr.org EUROTIMES | NOVEMBER 2019

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Aniridia-associated keratopathy Research revealing genetic clues to aniridia-associated keratopathy. Roibeard Ó hÉineacháin reports

esearch is continuing to reveal the multifaceted nature of aniridia-associated keratopathy (AAK), said Associate Professor Neil Lagali PhD, Institution for Clinical and Experimental Medicine, Linköping University, Sweden, at a World Society of Paediatric Ophthalmology and Strabismus (WSPOS) session during the 37th Congress of the ESCRS in Paris, France. He noted that congenital aniridia is a rare but serious inherited eye disease requiring a lifetime of ophthalmic care, starting in infancy. The condition has a prevalence of one per 100,000 population. It is primarily caused by mutations in the PAX6 gene coding for the PAX6 protein. More than 400 such mutations in the PAX6 gene have thus far been identified. The defining characteristic of congenital aniridia is a partial or total iris hypoplasia. The phenotype also often involves aberrant development of the eye’s drainage channels, leading to glaucoma. Patients also tend to develop early cataract and most have nystagmus, as well as an underdeveloped fovea. In addition, congenital aniridia patients usually have limbal stem cell insufficiency, which, over time, leads to aniridia-associated keratopathy (AAK). Prof Lagali noted that although the pathobiology of AAK is not completely understood, it may result from a breakdown in the limbal stem cells leading to conjunctivalisation of the entire corneal surface. AAK is difficult to treat with keratoplasty, because of the associated high risk of graft rejection and inadequate wound closure. Keratoplasty in these patients also carries the risk of aniridia fibrosis syndrome, a condition that results in fibrotic structures developing in the anterior chamber. However, AAK is more than limbal stem cell deficiency, he noted. Other

Neil Lagali PhD speaking at a WSPOS session during the 37th Congress of the ESCRS in Paris, France

contributing factors include meibomian gland dysfunction and loss of meibomian gland cells, reduced tear production and increased tear film osmolarity. In addition, inflammatory mediators play a role. Prof Lagali reported a study in which he and his associates in Norway, led by Prof Tor Utheim, obtained tear samples of 35 persons with aniridia and 21 controls. The study showed up-regulation of six different immunomodulators, but also showed reduced levels of the IL-1βantagonist, IL1-RA. “Tear film activation of these immunomodulators could stimulate inflammatory cells to invade the cornea that can lead to rejection of any kind of implanted tissue,” Prof Lagali said. He added that genotype testing is critical for prognosis of AAK. In another recently

...Congenital aniridia is a rare but serious inherited eye disease requiring a lifetime of ophthalmic care... Neil Lagali PhD EUROTIMES | NOVEMBER 2019

published study, he and his colleagues in Germany, including Prof Barbara Käsmann-Kellner and Prof Berthold Seitz, found that around 70% of AAK cases have PTC/CTE mutations, which cause a progressive form of the disease, leading to eventual conjunctivalisation of the entire cornea. Some 10% have entire chromosomal deletions, which lead to an aggressive phenotype at a young age. On the other hand, around 10% of patients have PAX6 non-coding mutations, which result in a mild, non-progressive phenotype, as is similarly the case with the 10% having missense mutations. Moving forward, Prof Lagali noted that patient stratification by genotype is important not only for prognosis but for evaluating the effect of potential treatments for AAK in the future. Neil Lagali: neil.lagali@liu.se Acknowledgment: The work described here was in part supported by the European Union’s COST Program, under COST Action CA18116, ANIRIDIA-NET (www.aniridia-net.eu)

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SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Cataract surgery and aniridia Performing surgery in eyes with aniridia presents many challenges. Roibeard Ó hÉineacháin reports

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ood outcomes are difficult to achieve when performing cataract surgery in eyes with aniridia, Professor Paolo Nucci MD reminded attendees at a World Society of Paediatric Ophthalmology and Strabismus (WSPOS) session at the 37th Congress of the ESCRS in Paris. He noted that cataracts typically develop in aniridia patients at an age when the requirement for good vision is at its greatest, around the age people are learning to drive and going to university. At that age, the pressure to have good vision is at its greatest and patients and their parents put some pressure on their physicians for a surgical treatment that will ameliorate their condition. However, only a minority of cases will benefit from such procedures, said Prof Paolo Nucci MD Nucci, University Ophthalmology Clinic, of San Giuseppe Hospital, Milan, Italy.

UNBELIEVABLE (MIS)TREATMENTS “I have seen things you people would not believe. I have seen congenital aniridia patients treated with LASIK, I have seen patients implanted with lenses with no regard for the weakness of the zonules I have seen patients implanted with multifocal lenses, and I’ve seen patients treated with trabeculectomy and mitomycin-C with disastrous results.” he added. Prof Nucci stressed that both conventional ultrasound phacoemulsification and femtosecond laser-associated cataract surgery (FLACS) are highly problematic in aniridia patients due to corneal opacity and weak zonules. In addition, the irregularity of the cornea makes it difficult to achieve a perfect capsulorhexis with a femtosecond laser. However, using a femtosecond laser can help preserve limbal stem cells. He added that capsular tension rings are often not useful in eyes with aniridia because the zonular weakness in eyes with the condition extends the entire perimeter of the capsular bag. Multifocal IOLs are strongly contraindicated because of the possibility of decentration. In paediatric patients below the age of 12, the myopic shift should be taken into account.

IRIS PROSTHESES Prof Nucci noted that some have proposed the use of iris prostheses for congenital aniridia. However, there is as yet no published research showing any benefit of the devices in such patients. The prostheses require a large incision and their implantation is traumatic to the intraocular structures and also can also induce glaucoma. The use of the devices in congenital cases is market-driven rather than evidence based, he said. “The majority of studies proposing treatment for traumatic aniridia and only anecdotally with congenital aniridia. Every device we use means more complications, so keep in mind that less is sometimes more,” he concluded. Paolo Nucci: Paolo.nucci@unimi.it

EUROTIMES | NOVEMBER 2019

SPECIAL FOCUS: PAEDIATRIC OPHTHALMOLOGY

Detecting sickle cell retinopathy Study suggests role for OCT imaging as standard screening tool. Cheryl Guttman Krader reports

A bright vision on illumination

valuation of the macula with optical coherence tomography (OCT) should be performed as a routine screening test for retinopathy in paediatric patients with sickle cell disease, said Léopoldine Lequeux MD at the World Society of Paediatric Ophthalmology & Strabismus Subspecialty Day in Paris, France. Dr Lequeux’s recommendation was based on findings from a study in which 24 patients aged 6-to-15 years (mean 11 years) with sickle cell disease were evaluated for macular abnormalities using spectral domain (SD) OCT and OCT angiography, both with the Topcon Triton system. The OCT imaging revealed that atrophic maculopathy caused by ischaemic involvement was common in the examined paediatric population. Furthermore, there was a strong correlation between the presence of maculopathy and retinopathy – maculopathy was present in 93% of eyes with retinopathy and absent in 96% of eyes without retinopathy. “Screening for sickle cell retinopathy typically includes a fundus examination, supplemented by fluorescein angiography if necessary. We added examination of the macula with macular mapping using SD OCT and OCT angiography,” said Dr Lequeux, Centre Ophtalmologie Rive Gauche, Toulouse, France. “These findings suggest that macular OCT may be used instead of the more restrictive fundus examination as a screening test for sickle cell retinopathy.” Dr Lequeux noted that peripheral retinal ischaemia involvement of sickle cell disease and neovascular complications of sickle cell retinopathy are well known. Because ischaemic maculopathy has also been described, she and her colleagues were motivated to use OCT-based imaging to look for macular abnormalities and investigate their correspondence with peripheral retinal changes. Among the 24 patients in the study, eight (33%) had retinopathy. The retinopathy was early stage (stage I or II Goldberg classification) in all cases and more common among patients with the SC genotype of sickle cell disease (60%) than in those with the SS form (29%). Two patients had S-Beta thalassemia genotype sickle cell disease, of which neither had retinopathy. Macular abnormalities, mostly temporal retinal thinning, were identified with SD OCT in 33% of the 24 patients. The macular abnormalities did not translate to angiographic abnormalities, nor were they associated with any symptoms, said Dr Lequeux. OCT angiography identified macular ischaemia, showing deep capillary perfusion abnormalities in the same region as the macular atrophic changes found on SD OCT. Léopoldine Lequeux: drlequeux@gmail.com

Macular OCT may be used instead of the more restrictive fundus examination as a screening test for sickle cell retinopathy

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Léopoldine Lequeux MD EUROTIMES | NOVEMBER 2019

CATARACT & REFRACTIVE

Virtual Pinhole New acrylic single-focus biconvex lens for presbyopia. Roibeard Ó hÉineacháin reports

new plate-haptic intraocular lens based on a novel optical approach can provide vision at all distances without dysphotopsias, according to its inventor, J Stuart Cumming MD, Laguna Beach, California, USA. The lens, the SC11, from CORD LLC. (Cumming Ophthalmic Research & Development), is composed of a hydrophobic acrylic material and has a monofocal biconvex optic and opposing plate haptics, each with two paddle-like proximal extensions designed to partially surround the optic. The plate-haptic/paddle structures are semi-rigid longitudinally but flexible transversely, allowing the SC11 to be folded and implanted through a 2.5mm incision. “The IOL’s structure with a fixed length, longer than the bag diameter, is designed to consistently place the lens optic far back in the 5mm void left after removing the crystalline lens. This, in turn provides a narrow light cone to increase the depth of focus to provide a virtual pinhole effect,” Dr Cummings told EuroTimes in an interview. The new SC11 lens is modelled after CORD’s SC9 silicone lens, currently in a phase II trial by the US FDA, he added. In this exploratory trial, investigating both the lens and two insertion devices (Medicel, Switzerland) the method of implantation was finalised. Thirty-eight sequential patients underwent implantation of the lens by Juan Batlle MD, Centro de Microcirugia Ocular Y Laser, Dominican Republic. All patients with cataracts were included. Ten had a preoperative cylinder of 1.0 dioptre or more. Twenty-nine were included in the table. Nine were omitted, four with a BCDVA greater than 20/30, two with surgical complications, one with pre- and post-op cylinders of 2.0D, and two that were uncooperative. Two different A-constants were used, 119.0 and 120.0, to calculate the lens powers. Lenses were available in 1D steps. Surgery was performed under topical anaesthesia, with a clear corneal incision and phacoemulsification.

BROAD RANGE OF VISION Of 22 eyes with preoperative K readings of up to 1.08D, including 10 with postoperative refractive cylinders of 1D or more, 13/22 (59%) had uncorrected distance visions of 20/25 or better, and 18/22 (82%) 20/30 or better. In addition, uncorrected near visual acuity was 20/25 or better in 27%, 20/32 or better in 82% and 20/40 or better in 91%. It would be expected that with good uncorrected distance and near vision, the intermediate visions would be equivalent with a single focus optic. Unexplainably the recorded uncorrected intermediate visual acuity was 20/20 or better in 5%, 20/25 or better 18%, 20/32 or better in 55% and 20/40 or better in 27%. Furthermore, in 14 eyes, uncorrected distance, intermediate and near visual acuities after cycloplegia were as a good or better than they were before cycloplegia. Moreover, the amount of postoperative cylinder appeared to have no impact on uncorrected visual acuity with or without cycloplegia. The accommodative effect does not derive from a forward movement of the optic during contraction of the ciliary muscle, which was the proposed mechanism behind the Crystalens, which Dr Cumming developed in the 1990s. Instead the accommodative effect is a result of the greater distance between the posterior surface of the EUROTIMES | NOVEMBER 2019

Courtesy of J Stuart Cumming MD

The plate-haptic SC11 intraocular lens

cornea and the front surface of the IOL, which, in turn, results in a narrower cone of light leaving the consistently posterior located optic to reach the retina. This creates a virtual pinhole effect. “The pinhole effect is demonstrated by the similarity of the uncorrected visions with and without cycloplegia,” Dr Cumming said. He added that his own previous research has shown that the postoperative position of the optic on the anterior-posterior axis is much more consistent with plate-haptic IOLs than with loop-haptic IOLs. That is, the distance between the posterior surface of the cornea and the anterior surface of the optic can vary by as much as 3.15mm with loop-haptic IOLs, compared to a variation of only 1.45mm with the posteriorly locating plate-haptic lenses. Furthermore, because of their much more posterior position in the capsular bag tamponading the vitreous, plate-haptic IOLs appear to provide some protection against retinal detachment compared to loop-haptic IOLs, Dr Cumming said. In a study in which he and his associates compared outcomes in 1,750 eyes implanted with platehaptic lenses and 1,857 eyes with loop-haptic lenses. There were 16 retinal detachments, all in the loop-haptics group. “In loop-haptic IOLs the optic can be located in a forward position, increasing the post-operative volume of the vitreous cavity, allowing the solid vitreous more mobility to tug on the retina and cause a detachment,” he said. He added that although acrylic IOLs have historically been much more prone to dysphotopsias, no patients reported the phenomenon with the new presbyopic plate-haptic acrylic IOL. With regard to posterior capsule opacification (PCO), Dr Cumming noted that around 90% of eyes with the new lens require YAGlaser capsulotomy within one year. The opacification’s symptomatic manifestation generally occurs in the form of a reduction in near visual acuity. However, following YAG laser capsulotomies, patients generally recover their near visual acuity, and so far, there have been no cases of retinal detachment and only one case of cystoid macular oedema. During the study, he and his associates evaluated two Medicel inserter models designed to deliver the lens into the eye with the correct side up. An FDA study with the lens is due to begin soon. Stuart Cummings: jscumming@gmail.com

CATARACT & REFRACTIVE

MSICS and phaco Mastering both techniques has advantages in developed and developing areas. Howard Larkin reports

A phacolytic patient who is due to undergo MSICS

The patient has a hard nucleus

PHACO ADVANTAGES While MSICS requires no sutures and less follow-up than earlier manual procedures, phaco incisions are even smaller and recovery easier, Dr Vivekanadan said. Where MSICS generally is done under a sub-Tenon’s block often administered preoperatively by a resident or fellow, topical anaesthesia is sufficient for most phaco procedures. Patients are less likely to experience hyphema as well as conjunctival congestion and tenderness after surgery, and corneal complications may be reduced with phaco. Perhaps most significant, induced astigmatism is less with phaco, and a wider variety of foldable lenses are available than the PMMA lenses used in MSICS, leading to better uncorrected visual outcomes. These advantages make it easy to understand why wealthier patients prefer phaco – and why it’s desirable for surgeons in the developing world to master it. The revenue that paying patients bring in not only supports ophthalmologists and their training, in many cases, including Aravind, it subsidises procedures for those who cannot afford to pay anything. But why would surgeons in developed countries want to master MSICS? In two words, challenging cases. MSICS often is better suited for brunescent, glaucomatous and traumatic or subluxated cataracts, Dr Vivekanadan said. In addition, complications such as zonular dialysis or posterior capsule tears may require conversion to MSICS. Conversion may also be indicated if there is a risk of losing the nucleus into the vitreous or a risk of damaging endothelial cells from excess ultrasound, irrigation and anterior chamber manipulation. “Continuing phacoemulsification can lead to further complications.”

Courtesy of VR Vivekanadan MD

anual small-incision cataract surgery (MSICS) and phacoemulsification each offer advantages that make mastering both worthwhile regardless of practice location, VR Vivekanadan MD told the ASCRS ASOA 2019 Annual Meeting in San Diego, USA. For regions with great cataract need and few ophthalmologists to meet it, including India, much of Asia and most of Africa, productivity without sacrificing quality is paramount, said Dr Vivekanadan, of Aravind Eye Care Systems, Madurai, India. For these areas, MSICS offers distinct advantages. On the quality side, MSICS visual outcomes are excellent, with bestcorrected visual acuity similar to phaco across a range of cataract densities with similar complication rates – though phaco holds the edge in uncorrected VA due to less astigmatism, Dr Vivekanadan said. However, MSICS is significantly faster, less expensive and requires far less equipment and consumables. Several large studies have found MSICS procedures averaging about eight-to-nine minutes with many under six minutes, compared with 12-to-15 minutes for phaco, Dr Vivekanadan noted. “In a busy facility, a surgeon would be capable of handling higher volume with manual, sutureless, smallincision cataract surgery.” The surgical time also does not vary very much with the MSICS technique. For an experienced surgeon it takes more or less the same time for all types of cataracts, and can be much faster with harder cataracts because of minimal or absent cortical matter. MSICS is significantly less expensive as well. One study in India found the total allocated cost of MSICS averaged $15 per case, just over one-third the $42 for phaco. Factoring out fixed facility costs of $10 per case, phaco is more than six times more expensive. Costs are higher for phaco equipment as well as consumables, such as tubing and tips, and foldable lenses, putting it out of reach financially for many in developing countries, Vivekanadan pointed out.

The patient following the surgery

LEARNING MSICS AND PHACO Generally, MSICS has a shorter learning curve than phaco, though visual outcomes are more dependent on surgeons’ skills, so learning proper technique is essential, Dr Vivekanadan said. Steps to learn include constructing scleral tunnels to minimise astigmatism and ensure selfsealing, creating a larger capsulorhexis and complete hydrodissection and hydroexpression of the lens. Phaco requires learning phacodynamics, including application of power, vacuum and aspiration rate to maintain chamber stability. The learning curve is steeper, and risk of complications such as posterior capsule rupture is higher during training, Dr Vivekanadan noted. Overall, MSICS is faster, with correct vision similar to phaco, and safer for denser cataracts and complicated cases, while phaco is generally less painful and gives better uncorrected vision, Dr Vivekanadan said. Both have a place in the cataract surgeon’s armamentarium. VR Vivekanadan: vrvivek@aravind.org EUROTIMES | NOVEMBER 2019

CATARACT & REFRACTIVE

The next big thing in surgery? First-in-human study finds non-invasive refractive index femtosecond laser treatment safe. Howard Larkin reports

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fter a decade in development, a novel femtosecond laser for correcting refractive errors by altering the refractive index of lens materials has passed its first safety trial in humans, Scott MacRae MD told the innovators session at the ASCRS ASOA 2019 Annual Meeting in San Diego, USA. Using a Laser Induced Refractive Index Correction device (LIRIC, Clerio Vision), 27 monofocal pseudophakic patients received diffractive presbyopia corrections, creating a +2.5D add across a 3.0mm optical zone about 240 microns deep in the corneal stroma. All corneas were clear immediately after treatment and at one day, one week, one month and three months' follow up. No inflammation, light scatter, scarring or opacities were observed at any point. Mean corneal thickness change was -2.0±1.8%, and endothelial cell loss was negligible, establishing the safety of the LIRIC device in living humans, Dr MacRae reported. “LIRIC is a potentially safer, better way to refine the optics of the eye. It is a disruptive technology with the potential to revolutionise refractive surgery, cataract surgery and adjusting contact lenses,” said Dr MacRae, of the University of Rochester, New York, USA.

MULTIPLE APPLICATIONS Unlike femtosecond and excimer lasers that change refractions by cutting and ablating corneal tissue, LIRIC does so by changing the refractive index of corneal stroma. This creates diffractive Fresnel arrays that can correct sphere, cylinder and higher order aberrations, and add multifocality. Tests in animals and now humans show an increase in density and decrease in water in collagen treated by the laser, which is thought to change the refractive index, Dr MacRae said. LIRIC does minimal tissue damage, Dr MacRae added. Operating at a pulse energy of about 2.5 nanojoules, the LIRIC laser operates far below the 50-nanojoule threshold of tissue damage, and even farther below the 150-to-1,000 nanojoules of flap-cutting lasers. As a result, corneal cell death is far less than in femto-LASIK and no nerve fibers are cut. The epithelium remains intact, so no antibiotics are required. In addition to corneal tissue, LIRIC can change the refractive index of hydrogel and acrylic materials. This makes it possible to create multifocal contact lenses and increase the power of monofocal contacts without adding thickness, enabling customisation in refraction and size, and increasing oxygen permeability. LIRIC can also correct residual refractive error in implanted intraocular lenses, and add or subtract multifocality, Dr MacRae said. Preclinical tests show the optical quality of LIRIC corrections is very high, with negligible effect on visual acuity, contrast sensitivity, modulation transfer function or light scatter. Animal tests suggest corneal corrections are stable for at least two years. More clinical tests of the device are planned. Scott MacRae: scott_macrae@urmc.rochester.edu

EUROTIMES | NOVEMBER 2019

CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 45 ISSUE: 10 MONTH: OCTOBER 2019

BAG-IN-THE-LENS CALCULATION IN PAEDIATRIC PATIENTS Cataract surgery in paediatric patients presents many challenges, not least of which is calculating the correct IOL power for a growing eye. While the bag-in-the-lens (BIL) technique has been shown to significantly reduce postoperative PCO rates in these patients, little is known about predicting postoperative outcomes. A new consecutive case series study looked at the precision of BIL IOL power calculation in 87 eyes of 56 patients who were divided into four groups based on age. The researchers calculated IOL power using the SRK/T formula. The mean prediction error (PE) for the entire group was 1.79 dioptres. This ranged from 3.43D in the youngest patients (0-3 months) to 1.33 in the oldest patients (3-17 years). The PE after IOL implantation correlated inversely with age group and axial length, but not with corneal radii and corneal astigmatism. LM Lytvynchuk et al., JCRS, “Precision of bag-in-the-lens intraocular lens power calculation in different age groups of paediatric cataract patients: Report of the Giessen Pediatric Cataract Study Group”, Vol. 45, #10, 1372-79.

PCO IN PAEDIATRIC CATARACT Posterior capsule opacification (PCO) is the most common complication of paediatric cataract surgery. Does the IOL type make a difference? A case series study compared outcomes in 103 eyes of 80 children who received either a hydrophilic IOL (Ocular ANU6 IOL) or a hydrophobic IOL (AcrySof SA60AT) and were followed for more than three years. When the posterior capsule was left intact, 39.3% of eyes in the hydrophilic group and 13.4% of eyes in the hydrophobic group developed PCO. When primary posterior capsulotomy and anterior vitrectomy were performed, 4.3% and 6.8%, respectively, developed PCO. Follow-up analysis showed a survival (i.e., no PCO formation at five-year follow-up) rate of 95.4% in the hydrophobic group and 88.8% in the hydrophilic group. P Sen et al., JCRS, “Posterior capsule opacification rate after phacoemulsification in pediatric cataract: Hydrophilic versus hydrophobic intraocular lenses”, Vol. 45, #10, 1380-85.

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

2018 OBSTBAUM AWARD BEST ORIGINAL ARTICLE

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

2018 ROSEN AWARD BEST TECHNICAL ARTICLE

Streamlined Method for Anchoring Cataract Surgery and Intraocular Lens Centration on the Patient’s Visual Axis Vance Thompson, MD

BLUE VERSUS VIOLET FILTER IOL COMPARISON

J Cataract Refract Surg 2018; 44:528-533

Violet light-filtering IOLs were developed to reduce exposure to the violet wavelength (400-to-440nm). Although these IOLs have been available for some time, clinical outcomes have not been reported. Japanese researchers conducted a prospective study of 55 patients with bilateral cataract who were randomly allocated to a blue lightfiltering IOL (AcrySof IQ SN60WF) in one eye and to a violet lightfiltering IOL (OptiBlue ZCB00V) in the fellow eye. Postoperative contrast sensitivity under photopic condition at one week and three months and contrast sensitivity under mesopic conditions at three months were significantly better with the violet light-filtering IOL than with the blue light-filtering IOL. S Nakano et al., JCRS, “Blue light–filtering and violet light–filtering hydrophobic acrylic foldable intraocular lenses: Intraindividual comparison”, Vol. 45, #10, 1393-97. JCRS is the official journal of ESCRS and ASCRS

EUROTIMES | NOVEMBER 2019

24th ESCRS Winter Meeting

M arrakech

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

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

Scientific Programme, Registration & Hotel Bookings

www.escrs.org

CATARACT & REFRACTIVE

Pictured at the ESCRS symposium at AAO 2019: (left to right) Oliver Findl, Rudy Nuijts, Béatrice Cochener-Lamard, Thomas Kohnen, Marcony R Santhiago, John Chang, George O Waring IV and Paolo Vinciguerra

AAO 2019 Refractive surgery outcomes, AMD and nutrition, robotics are all hot topics. Howard Larkin reports

rawing on primary research and extensive literature reviews, ESCRS officers presented longterm refractive surgery outcomes in a special symposium at the AAO 2019 Refractive Surgery Subspecialty Day in San Francisco, USA. While visual outcomes were generally good for PRK, LASIK and SMILE, Thomas Kohnen MD, PhD, FEBO, of Goethe University, Frankfurt, Germany, noted some issues. These include myopic regression with PRK and LASIK, with LASIK more stable after six years, and challenges predicting and preventing ectasia, and calculating IOL power for subsequent cataract surgery. Long-term uncorrected vision loss is also an issue with iris-supported and collamer phakic IOLs due to cataract formation and increased axial length, said Rudy MMA Nuijts MD, PhD, of

Maastricht University, the Netherlands. Endothelial cell loss runs two-to-three times physiological rates, and 10-year explant rates vary up to 12% for irisfixated and 18% for ICLs, suggesting patients should be counselled that pIOLs are a temporary solution. Toric IOL rotation mostly occurs in the first hours after surgery, though fibrosis may result in late rotation, said Oliver Findl MD, of Hanusch Hospital, Vienna, Austria. When implanting toric IOLs in younger patients, future axis shift should be compensated for. Multifocal IOLs are not advisable for patients at risk of central vision loss, said Béatrice Cochener-Lamard MD, PhD, of the University of Brest, France. Most complications occur in the short term with no reported explantation after 10 years, though 20-year outcomes are unknown, so care should be taken in implanting them in young patients.

Long-term uncorrected vision loss is also an issue with iris-supported and collamer phakic IOLs due to cataract formation and increased axial length Rudy MMA Nuijts MD, PhD

NUTRITION AND AMD Eating a Mediterranean diet, particularly a lot of fish, may be beneficial for those with early or even intermediate age-related macular degeneration, said Emily Y Chew MD, of the US National Eye Institute, Bethesda, Maryland, USA in the Jackson Memorial Lecture. In the general AMD population studied, a high fish diet reduced progression of AMD by 31%, while high adherence to a Mediterranean diet reduced progression to late AMD by 25-to-40%. “It’s never too late to start.”

ROBOTIC CATARACT SURGERY A fully automated robotic cataract surgery platform guided by intraoperative OCT that extracts the nucleus and cortical materials has been successfully tested in pig eyes and could enter human trials in three-to-four years, said Jean-Pierre Hubschman MD of the University of California — Los Angeles. Potential advantages include more-complete nucleus and cortex removal and reduced capsule rupture risk due to better visualisation and eliminating tremor in surgeons’ hands. Semi- and fully-automated devices for vitreoretinal surgery are also in the works. EUROTIMES | NOVEMBER 2019

CORNEA

Medications and the eye Ocular manifestations of systemic drugs highlighted. Dermot McGrath reports

orneal changes secondary to systemic medications may affect all layers of the cornea, so it is critical that patients receiving particular medications should be closely monitored to avoid long-term complications associated with ocular toxicity, according to Mohamed Elalfy MD, FRCopth. Speaking at the 10th EuCornea Congress, Dr Elalfy, Consultant Ophthalmic Surgeon at Queen Victoria Hospital, East Grinstead, UK, noted that systemic medications may reach the cornea via the tear film, aqueous humour and limbal vasculature and directly impact the homeostasis of the cornea. “Homeostasis maintains a healthy state of the cornea and ocular surface with constant adjustment of biochemical and physiological pathways. It allows the maintenance and regulation of the tissue stability needed to function properly,” he said. In dry eye disease (DED), for instance, the homeostasis of the tear film is disrupted leading to ocular surface inflammation and damage. Certain systemic drugs are known to potentially cause DED, said Dr Elalfy. “It is surprising to note that among the top 100 selling systemic drugs in the United States, 22 are known to cause dry eye. This is why a history of systemic medication is paramount

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Mohamed Elalfy MD, FRCopth, speaking at the 10th EuCornea Congress in Paris, France

in managing dry eye disease patients,” he said. An estimated 62% of dry eye cases in the elderly can be attributed to some systemic medications, including some nonsteroidal antiinflammatory drugs (NSAIDs), diuretics, vasodilators, analgesics/ antipyretics, antiulcer agents, sulfonylureas, cardiac glycosides, anxiolytics/benzodiazepines, anti-infectives, antidepressants/ antipsychotics, some hypotensive agents and antihistamines. Drug toxicity can also affect the delicate homeostasis of limbal stem cells, which are located in the basal epithelial layer of the corneal limbus, noted Dr Elalfy, potentially leading to limbal stem cell deficiency (LSCD). Ocular involvement is also common in patients with StevensJohnson Syndrome and Toxic Epidermal Necrolysis (TEN), said Dr Elalfy. “The most frequent single cause of TEN is drugs in between 80 and 95% of cases and nearly all of these patients will have ocular involvement. Furthermore, chronic ocular changes secondary to TEN develop in up to 29% of paediatric cases and 59% of adult survivors,” he said. A number of systemic drugs also induce corneal epithelium changes, characterised by deposits presenting as a punctate keratopathy, diffuse epithelial haze, vortex keratopathy or crystalline precipitates, said Dr Elalfy. “Corneal epithelial changes are often reversible on drug cessation with no or minimal long-term effect,” he said. Dr Elalfy added that patients on certain chemotherapeutic drugs should be closely monitored as these agents are known to have effects on the cornea. Mohamed Elalfy: info@eliteeyeclinic.co.uk

It is surprising to note that among the top 100 selling systemic drugs in the United States, 22 are known to cause dry eye Mohamed Elalfy MD, FRCopth

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CORNEA

Keratoconus options Early intervention urged in rethink of keratoconus treatment. Dermot McGrath reports

he management of keratoconus needs to shift from the current approach of late-stage intervention when disease has progressed significantly and keratoplasty is required to a more prophylactic form of early intervention to ensure that few, if any, patients ever actually require surgery, says Michael W. Belin MD, Professor of Ophthalmology & Vision Science at the University of Arizona, Tucson, Arizona, USA. “Few, if any, keratoconus patients should ever reach the stage where they require keratoplasty. If we look at penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) and intracorneal rings, they really all represent a management failure, not a success. The biggest limitation to date is a failure to diagnose at an earlier stage and prevent progression,” he told delegates attending the European Society of Ophthalmology (SOE) meeting in Nice, France. Looking at current therapeutic approaches to keratoconus, Dr Belin said that contact lenses are a double-edged sword. “Soft contact lenses are rarely effective, while PMMA and rigid gas permeable lenses greatly improve vision but can cause scarring and also mask disease progression. We see this too often. A patient is referred to an optometrist, they are fitted with rigid lenses, they see well, the disease progresses and by the time they get referred back to us for other treatment we are at the end stage disease,

Nevertheless, there is sufficient which requires DALK or PK,” he said. anecdotal data to recommend cessation Another option is the use of scleral of eye rubbing or modification of the lenses, which can treat advanced disease pressure point, said Dr Belin. not amenable to other lenses, said Dr “You often have to enlist the help of Belin. “They are very effective and can family members. We need to treat atopic treat a vast array of pathologic conditions disease and allergic disorders with topical on the cornea. The best known is the or systemic agents, and often we refer Boston scleral lens, but at the patients to an allergy specialist for moment only a limited number of desensitisation, which may be centres can fit the lenses. It can helpful,” he said. be challenging to fit and the In terms of cross-linking lenses are expensive,” he said. (CXL) intervention, Dr Belin The fundamental problem said it was high time for a with scleral lenses, however, rethink on the subject. is that fitting them means the “We don’t treat high blood disease has already progressed pressure after the patient’s first to the point of irreversible vision Michael W. Belin MD stroke, or diabetes only after an loss, said Dr Belin. episode of ketoacidosis or high “All patients requiring rigid cholesterol after the first myocardial lenses had early progressive disease at some infarction, so why do we wait to treat point so we failed to diagnose disease at an keratoconus only after the patient loses earlier stage. And the reason for that is that vision?” he asked. lens fitters tend to hold on to patients for In Dr Belin’s view the “holy grail” should too long for financial reasons. They are not be the earliest possible identification ophthalmologists or surgeons and they tend and treatment of progressive disease to refer patients way too late,” he said. with a high safety profile, with the Dr Belin said that it is important to try goal of preserving or preventing vision to prevent eye rubbing and to treat possible loss instead of limiting the damage after causes of it in keratoconus patients. the fact. “We don’t know at this stage if there “The concept of early intervention with is a direct cause and effect between eye CXL at a young age is not new. Back rubbing and keratoconus. Some have in 2009, the pioneers of CXL said that concluded that because atopic disease early treatment would be more efficacious and keratoconus appear coincidentally and limit some of the adverse effects,” he that there must be a cause and effect concluded. relationship. But that does not necessarily imply causation or an aetiology – they may Michael W. Belin: mwbelin@aol.com simply be linked,” he said.

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

EUROTIMES | NOVEMBER 2019

11th EuCornea Congress

AMSTERDAM 2 â&#x20AC;&#x201C; 3 October 2020 RAI Amsterdam, The Netherlands

www.eucornea.org

CORNEA

DUCK score CXL patient selection enhanced by using routinely obtained additional data. Roibeard Ó hÉineacháin reports

new keratoconus progression scoring system called the Dutch Crosslinking for Keratoconus (DUCK) score may identify those who do not require corneal cross-linking (CXL) treatment more accurately than conventional scoring based on maximum change in keratometry alone, according to a study carried out at two centres in the Netherlands. The DUCK score is based on five routinely assessed clinical variables. The prospective cohort study, published in JAMA Ophthalmology (Wisse et al, doi:10.1001/ jamaophthalmol.2019.0415), showed that adhering to the new scoring system rather than maximum keratometry, was associated with a 23% reduction in the overall rate of CXL treatment, without increasing the risk of disease progression. “A proper selection of CXL candidates reduces unnecessary burden and risks to the patient. I think this is the most important message, since the procedure is inevitably painful and carries around a 1-to-5% risk of secondary infection. CXL can also bring about unwanted changes in manifest refraction that can profoundly affect uncorrected visual

acuity. That is especially relevant for mild cases of progressive keratoconus who are not dependent on visual aids,” Robert P. L. Wisse MD, PhD, University Medical Centre Utrecht, Utrecht, the Netherlands, lead author of the study, told EuroTimes in an interview. He added that research he and his associates conducted in 2015 showed that the mean total costs for one eye treated with CXL were €1,754.06 or $1,929.47.

vs 72% men) and maximum keratometry (53.5D vs 52.7D). Dr Wisse and his associates compared the DUCK scores to the conventional criterion of a 1.0D increase in maximum keratometry occurring within the previous 12 months. They found that if the decision to treat had been based on increase in maximum keratometry, 180 eyes (36%) would undergo CXL. That compared to only 138 eyes (27%) when using the DUCK scoring system.

UNNECESSARY TREATMENTS REDUCED

DUCK SCORE REQUIRES ONLY ROUTINE EXAMINATION

The study involved a total of 504 eyes of 388 patients referred for keratoconus between January 1, 2012, and June 30, 2014, to two academic treatment centres The patients included a longitudinal discovery cohort of patients referred to the University Medical Center Utrecht, and a validation cohort referred to the Maastricht University Medical Center. All eyes had data available on disease progression at 12 and 24 months of followup. Analysis began in March 2017. Baseline patient characteristics of the discovery cohort and the validation cohort were comparable in terms of mean age (26.8 years vs 26.3 years), sex (65%

The DUCK score is based on routinely assessed clinical parameters; namely, age, visual acuity, refraction error, keratometry and subjective patient experience. Each criterion is scored from 0 to 2 points. An overall score of 5 or more is an indication for CXL. “I think the beauty of the DUCK score is in the fact that it is device independent, and as such accessible to many eye care practitioners. New tech is often expensive, and only available for specialised centres,” Dr Wisse said. Dr Wisse and his associates considered changes to uncorrected distance visual acuity (UDVA) the most sensitive

Courtesy of Robert P.L. Wisse MD, PhD

EUROTIMES | NOVEMBER 2019

CORNEA

A proper selection of CXL candidates reduces unnecessary burden and risks to the patient Robert P. L. Wisse MD, PhD

parameter for visual function, since unreported adjustments to spectacle or contact lens prescriptions will not affect the measurements. In the DUCK scoring system, a loss of less than one line of UDVA counted as zero points, a change of one or two lines counts as one point and a change of two lines counts as two points. Age was an important parameter, since younger patients tend to have more progressive disease and conversely there tends to be less progression in older patients. Age younger than 18 years counts as two points, 18-to-35 years 1 point and older than 35 years counts for 0 points. Regarding maximum keratometry, a

change of less than 1.0D counts as zero points in the DUCK scoring system, a change of 1-to-2D counts as one point and a change of more than 2.0D counts as two points. The same changes in spherical equivalent are accorded the same score as with changes in keratometry. Visual quality is based on the patient’s subjective assessment of their visual experience. No impact on daily life counts as zero points, mild impact counts as 1 point and severe impact counts as 2 points.

SOME FALSE NEGATIVES Dr Wisse noted that in 95 eyes, keratoconus progressed despite fitting neither the maximum keratometry criterion nor the DUCK score for CXL treatment. The addition of other risk factors may yield fewer false negatives, he said. For example, research is yielding insights into the way that inflammatory activation affects the ocular surface, opening a promising new diagnostic avenue. A structural assessment of ocular inflammation, enriched with biomarkers, should make the identification of suitable patients even better. He noted that Rohit Shetty and his associates have showed that proper control of extraocular inflammation can reduce keratoconus progression. In the current study, the researchers assumed

inflammation is controlled, in accordance with the Dutch centres’ clinical protocol. “Corneal thickness is another factor that might be considered; from a biological standpoint, the tissue thinning is the archetypal result of keratoconus. However, it has no direct effect on visual acuity and its measurement is devicedependent. Moreover, corneal thickness can vary, based on prior contact lens use, for instance. Maybe a future validation stud y can answer this question,” Dr Wisse added. Robert P. L. Wisse: R.P.L.Wisse@umcutrecht.nl

I think the beauty of the DUCK score is in the fact that it is device independent, and as such accessible to many eye care practitioners Robert P. L. Wisse MD, PhD

EU-CC-NP-0014

EUROTIMES | NOVEMBER 2019

RETINA

Artificial intelligence and retinal disease AI is helping to level playing field in DR management. Dermot McGrath reports

rtificial intelligence (AI) is already making a direct impact in the screening and management of diabetic eye disease in the face of a growing epidemic of diabetes worldwide, Ursula SchmidtErfurth MD, PhD, said at the 19th EURETINA Congress in Paris. “AI-based image analysis offers a rapid, cost-effective, precise and reliable screening and monitoring of diabetic retinopathy (DR) and diabetic macular oedema (DME). This technology is not here to replace doctors but to assist them in managing their diabetic patients more efficiently,” she said. Prof Schmidt-Erfurth told delegates that machine learning and AI applications will become increasingly important in tackling the impending global epidemic of diabetes-related ocular disease. “Diabetes mellitus affects 420 million people who will eventually develop diabetic retinopathy, which includes over 20 million people with macular disease. On the other hand, there are only 210,000 retinologists working in the world to try to keep this under control. This clear disproportion highlights the need for AI support to manage such a widespread disease,” she said. The first USA Food and Drug Administration (FDA) clearance for an autonomous AI-diagnostic system (IDx-DR) to automatically detect more than mild DR in previously undiagnosed adults with diabetes was granted in 2018, explained Prof Schmidt-Erfurth. “This is a screening device and not a monitoring device. It does not replace eye doctors but it brings the right patients to the eye doctors at the right time. The FDA decision was based on proof of principle studies, which showed that AI is as accurate or better than the human eye in the analysis of digital fundus images,” she said. The AI system also integrates quality assessment of the underlying image acquisition, which is critical in providing a clear diagnostic conclusion and a clinically plausible diagnostic decision, noted Prof Schmidt-Erfurth. Approval of the IDx-DR system followed a study in 900 diabetic patients at 10 primary care centres in the United States, with the algorithm trained to detect more than mild DR and/or DME versus mild or no DR. “It is not about detecting a single aneurysm at 280 degrees – this device is made to recognise clinically relevant disease,” said Prof Schmidt-Erfurth. The reference standard was provided by a certified expert reading centre, which was offered four ultra-wide-field stereo images for determination of ETDRS scores and also optical coherence tomography (OCT) for DME diagnosis by three independent readers. “This was unfair competition because the human experts were much better equipped. Despite this, the AI system provided a EUROTIMES | NOVEMBER 2019

Ursula Schmidt-Erfurth MD, PhD, at the 19th EURETINA Congress in Paris, France

sensitivity of 87% and a specificity of 91%, outperforming the superiority endpoints set by the FDA,” she said. The initial trial results were subsequently confirmed by a global peer-reviewed validation, which led to an expanded use of AI for diabetic screening in multiple countries in Europe. AI also has rich potential in the monitoring of DME, which is particularly useful given that most patients who attend clinics are already at an advanced stage of disease and often present with visual loss due to macular oedema, noted Prof Schmidt-Erfurth. Histology studies have shown that intraretinal fluid typically presents in a cystoid formation, which intensively damages neurosensory structures. “The more cysts, the greater the vision loss, and the bigger the cysts the more irreversible the vision loss,” she said. Non-invasive high-resolution OCT imaging not only visualises intraretinal and subretinal fluid but also offers precise measurement of fluid volumes that can then be analysed using a machine-learning algorithm. “In diabetic microvascular disease, there are a lot of cystic changes in the retina, which clinicians are unable to count and monitor. However, this kind of information is needed if we want to precisely follow and judge disease progression or a good therapeutic response,” she said. Some recent studies have shown that intraretinal cystoid fluid (IRC) in the central fovea is what matters most for vision, said Prof Schmidt-Erfurth. “Our studies showed that during the follow-up it is persistent IRC at weeks 12 and 24 that matter for predicting visual outcome and to determine whether a treatment is successful or not,” she said.

RETINA

Endophthalmitis rates increasing Modern vitrectomy techniques improving results in acute endophthalmitis. Dermot McGrath reports

Courtesy of Andrew Chang MD, PhD, FRANZCO

odern microincisional identified 53 patients with postvitrectomy surgery is IVI endophthalmitis and 48 with effective in improving post-cataract surgery infections. vision in patients “In this cohort the post-IVI presenting with acute infections had poorer visual endophthalmitis, Andrew Chang MD, outcomes, with increased numbers PhD, FRANZCO, told delegates of streptococcus infections and attending the 19th EURETINA an increased likelihood of Congress in Paris. a final visual acuity less “Advances in vitrectomy than counting fingers. technology and In eyes that did instrumentation allows the have streptococcus option of earlier vitrectomy as the causative compared to traditional organism, there was a guidelines based on the decreased likelihood of Endophthalmitis Vitrectomy improving vision and a 17 times Study (EVS),” he said. greater chance of evisceration or Andrew Chang Progress in surgical technology MD, PhD, FRANZCO enucleation,” he said. allied to the changes in patient In another more recent study presentation, with significantly more at the Sydney Eye Hospital of 248 postoperative infections related to patients from 2012 to 2017, Dr Chang intravitreal injections (IVI), means that and co-workers observed a changing a review of the EVS guidelines is perhaps spectrum of endophthalmitis. overdue, said Dr Chang. “Among the changing patterns we “Much of what we do in terms of observed was an increase in post-IVI decision-making stems from the 1995 endophthalmitis (57%). Staphylococcus EVS study, but much have progressed epidermis was still the most common since then. We now have more modern organism, although, surprisingly, there vitrectomy technology, newer antibiotics was less streptococcus in post-IVI cases, and we are dealing with a different possibly related to greater use of masks patient group with more post-IVI and reduced talking when administering endophthalmitis. In the real world, there intravitreal injections. There were no is a trend towards earlier vitrectomy differences in outcomes between postfor debridement of bacteria, toxins and cataract and post-IVI endophthalmitis in inflammatory debris, better diffusion of this cohort,” he said. antibiotics and potentially a more rapid Vitrectomy was performed in 135 cases visual recovery,” he said. out of 248, said Dr Chang. “Those patients Infective endophthalmitis remains a were more likely to have presenting vision feared and devastating complication of of light perception or worse, positive intraocular surgery including cataract culture and streptococcus as the organism surgery and, increasingly, postresponsible. The prognosis was also poor intravitreal injections, said Dr Chang. The if streptococcus was found to be the five cardinal clinical signs of infection to responsible organism,” he added. watch for are pain, redness, swelling, To try to determine predictive factors discharge and loss of function. for better visual outcomes in early He noted that there has been an vitrectomy in acute endophthalmitis, exponential rise in the number of another retrospective study at the intravitreal injections (IVI) and the risk Sydney Eye Hospital was carried out of endophthalmitis in recent years. that included 64 consecutive patients An initial study of 101 patients with treated between 2009 and 2013. All acute endophthalmitis carried out at received vitrectomy within 72 hours of Sydney Eye Hospital from 2007-2010 presentation with acute endophthalmitis

Severe endophthalmitis

from a range of inciting procedures. All patients were treated immediately on presentation with a 23-gauge vitreous tap and injection of vancomycin and ceftazidime. The next step was the vitrectomy, which was performed within 72 hours of presentation. The mean time of onset from the inciting procedure was 5.7 days and the mean time between tap and inject to vitrectomy was 0.8 days, noted Dr Chang. The inciting procedures were phacoemulsification in 53%, IVI in 36% and trabeculectomy in 3%. Responsible organisms were staphylococcus epidermis in 43% and streptococcus in 33%. Vision improved from a mean of 3.1 logMAR (hand motion) baseline to 1.02 logMAR at one year. Vision improved in 89% of patients, and 42% had a final vision better than logMAR 0.477. Patients with post-cataract surgery endophthalmitis had better visual outcomes than post-IVI. Those that were culture negative also did better than those that were culture positive. Complications included intraoperative retinal detachment in six eyes, postoperative retinal detachment in four eyes, epiretinal membrane in six eyes and hypotony in one eye. Two of the 64 eyes were eviscerated. Andrew Chang: achang@sydneyretina.com.au EUROTIMES | NOVEMBER 2019

RETINA

Shoot first, ask questions later Earlier injection recommended in suspected bacterial endophthalmitis. Dermot McGrath reports

rompt intervention using intravitreal antibiotics is essential in cases of suspected bacterial endophthalmitis after cataract surgery, emphasised Prof Jan van Meurs at the 19th EURETINA Congress in Paris. “The evidence suggests that we really need to act quickly as soon as the patient presents with suspected endophthalmitis. It is a case of ‘shoot first and ask questions later’, as the data shows there is a good outcome for most patients even with antibiotic injections only. For those patients who did badly with little or no light perception or evisceration, the key factor appears to be the type of bacteria involved and the fact that they probably received antibiotic treatment too late for it to be effective,” he said. Prof van Meurs, Rotterdam Eye Hospital, the Netherlands, added that intravitreal dexamethasone, either with or without preservatives, should no longer be used. “A study carried out by our research team recently showed that dexamethasone as an adjuvant to intravitreal antibiotics does not improve visual acuity in patients treated for suspected bacterial endophthalmitis after cataract surgery,” he said. Dr van Meurs’ double-blind, prospective, multi-centre, randomised, placebocontrolled trial included 167 patients over a 10-year period, 81 of whom were treated with dexamethasone and 86 with placebo. The final best-corrected visual acuity (BCVA) did not differ between the dexamethasone and the placebo group, nor did the number of patients with final vision of no light perception. “The good news was that after one year 70% of patients could see better than 20/40 and more than 80% could see better than 20/200, which are very good figures. Interestingly, the major prognosticator for bad outcome was the bacterial culture result. When we look at eyes that were eviscerated or did badly in terms of light perception, most of them were Gramnegatives or the more severe type of Grampositive bacteria,” he said. Prof van Meurs said that a recent study EUROTIMES | NOVEMBER 2019

Jan Van Meurs speaking at the 19th EURETINA Congress in Paris, France

with a similar design by Nijmegen et al of 126 patients also confirmed the efficacy of antibiotic injections only and the fact that the virulence of the bacteria was the key prognostic factor for a poor outcome. For the more severe endophthalmitis cases, the timing of the injections may be the key factor, he said. “This is borne out by a study by Michelle Cellegan et al in 2011 on the efficacy of vitrectomy in improving the outcome of severe endophthalmitis. The major finding was that vitrectomy and antibiotics were useful but that the intervention had to bew quick – any later than four hours after infection rendered both of the treatments ineffective. From a purely practical viewpoint it is much easier to be quick with antibiotics than with a vitrectomy,” he said. More detailed study of the eyes that performed poorly in Prof van Meurs’ own study also showed that all of the bacteria identified were sensitive to antibiotic treatment but it had simply been administered too late. “The key point is that the eyes that were eviscerated or had little light perception

were already lost on presentation in our current way of dealing with them. The choice of antibiotics is not the issue as even these bacteria were sensitive to these drugs, so the only answer is to move the treatment forward,” he said. Moving to earlier intervention has yielded dividends in the field of neurology, so perhaps ophthalmology could follow its example, suggested Prof van Meurs. “It was shown in a large series of patients with meningitis in Sweden that those who received faster intervention died less frequently and had less morbidity. So, we would propose a strategy to give injections earlier than we currently do, setting up a system with direct intravitreal antibiotics either at the A&E at the hospital, or more optimally by the referring ophthalmologist the moment that endophthalmitis is suspected. They could then send the patient in for biopsy and with improved PCR techniques we can confirm the diagnosis without relying on live organisms,” he concluded. Jan van Meurs: J.vanMeurs@oogziekenhuis.nl

Euretina Congress Amsterdam

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EURETINA AMSTERDAM

RETINA

Euretina

Winter Meeting

Vilnius 20–21 March | Lithuania Abstract Submission now open Submission Deadline: 6 December 2019

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Nutrition and retina health Mediterranean diet on the menu for healthy retinas. Leigh Spielberg MD reports

here is now plenty of evidence to confirm that a healthy diet plays a significant role in retinal health, according to Cécile Delcourt PhD, Director of Research at the Bordeaux Population Health Research Centre in France. Dr Delcourt presented an overview of the research to date regarding the nutritional threats and benefits for the retina at the 19th Annual EURETINA Congress in Paris. The most highly studied nutrients are antioxidants (vitamin E, vitamin C and zinc), the macular pigments lutein and zeaxanthin and omega-3 fatty acids. “Although most of the research has involved specific nutrients involved in retinal health, I find that concentrating on dietary profiles, rather than individual nutrients, is more effective and interesting,” said Dr Delcourt. This is because of the probable synergistic effect of the different nutritional components in an entire diet, rather than selected supplementation of micronutrients. Dr Delcourt cited the Mediterranean diet, which is associated with longevity and lowered risk of cardiovascular disease and cognitive decline. “The Mediterranean diet is rich in the micronutrients and essential fatty acids, such as omega-3, that have been shown to be beneficial to retinal health,” she said. High plasma levels of omega-3 are associated with a 40% lower risk for advanced AMD. The micronutrients include vitamins, carotenoids and polyphenols, she noted. Post-hoc analysis of the Age-related Eye Disease Study (AREDS) showed that the risk of progression to advanced AMD was reduced by 26% in those who were highly adherent to the Mediterranean diet, and that this Cécile Delcourt PhD effect was stronger in individuals who had a high genetic risk of developing advanced AMD. An even stronger effect (41%) was demonstrated by the EyeRisk project, based on the Rotterdam Study and the Alienor Study. “The Mediterranean diet is based on a rich culinary tradition that is varied, colourful and tasty,” she said. “It is not a restrictive diet that is focused on counting calories, but rather can be adhered to for a long period of time.” Adherence to these diets is measured via questionnaires. However, these are long and tedious to complete and are a subjective assessment, which makes them susceptible to reporting bias. But there are newer, more accurate tests to determine plasma levels of certain nutrients, called nutritional biomarkers, which are quick, objective and precise. “Measuring nutritional biomarkers could both help identify individuals with nutritional deficiencies and could help monitor nutritional interventions,” concluded Dr Delcourt.

The Mediterranean diet is rich in the micronutrients and essential fatty acids, such as omega-3

Cécile Delcourt: cecile.delcourt@u-bordeaux.fr EUROTIMES | NOVEMBER 2019

RETINA

SEBASTIAN WOLF Editor of Ophthalmologica

OPHTHALMOLOGICA VOL: 242 ISSUE: 4

AFLIBERCEPT EFFECTIVE IN RETINAL ANGIOMATOUS PROLIFERATION In eyes with retinal angiomatous proliferation (RAP), an aggressive subtype of neovascular age-related macular degeneration (nAMD), aflibercept produces outcomes comparable to those reported in eyes with type 1 and type 2 nAMD in the pivotal VIEW Study. The patients in the 96-week trial followed the same treatment protocol as in the VIEW study. Of 46 patients who completed the study, 13 (28%) patients had gained 15 or more letters and had a mean reduction in central macular thickness (CMT) of 162μm (p=<0.0001). Furthermore, univariate analysis showed no significant difference between any of the visual and anatomical outcome measures and number of injections required in this study and those of the pivotal VIEW study. AC Browning et al, “Intravitreal Aflibercept for Retinal Angiomatous Proliferation: Results of a Prospective Case Series at 96 Weeks”, Ophthalmologica 2019, Volume 242, Issue 4.

LONGER EYES LESS RESPONSIVE TO RE-VITRECTOMY WITH APC Patients with persistent full-thickness idiopathic macular holes respond less well to re-vitrectomy with autologous platelet concentrate (APC) if they have long eyes or a long interval between the initial and second surgery, according to the findings of a retrospective study. In 103 eyes with persistent MHs after vitrectomy, re-vitrectomy with APC and endotamponade resulted in a macular hole closure rate of 60.2%. There was negative correlation between the closure and axial length, time between first and second surgery, and there was a positive correlation between the closure rate and the experience of the surgeon (p<0.05). V Degenhardt et al, “Prognostic Factors in Patients with Persistent Full-Thickness Idiopathic Macular Holes Treated with Re-Vitrectomy with Autologous Platelet Concentrate”, Ophthalmologica 2019, Volume 242, Issue 4.

FREE FLAP GRAFTING CLOSES MACULAR HOLES IN COMPLICATED RETINAL DETACHMENT CASES Perfluorocarbon-assisted neurosensory retinal free flap transplantation may be a good option in closing macular holes in eyes with concomitant macular hole and complicated retinal detachment, a retrospective study suggests. It involved consecutive case series of seven patients with concomitant macular hole and complicated retinal detachment with proliferative vitreoretinopathy. All eyes underwent free neurosensory retinal flap transplantation into the macular hole, and subretinal fluid drainage through iatrogenic retinectomy/retinotomy followed by air-fluid exchange with gas or silicone oil tamponade. In all eyes the retina was successfully reattached and the macular hole was closed. S Chen et al, “Perfluorocarbon Liquid-Assisted Neurosensory Retinal Free Flap for Complicated Macular Hole Coexisting with Retinal Detachment”, Ophthalmologica 2019, Volume 242, Issue 4.

CALL FOR ENTRIES

JOHN HENAHAN

PRIZE 2020

Young ophthalmologists are invited to write a 900-word essay on “Will Clinicians Be Replaced By A Robot To Perform Cataract Surgery?” The prize is a travel bursary worth €1,000 to attend the 38th Congress of the ESCRS in Amsterdam,The Netherlands

CLOSING DATE FRIDAY 29 MAY 2020 Entries to be sent to:

henprize@eurotimes.org

For further information visit: www.escrs.org.

Ophthalmologica is the peer-reviewed journal of EURETINA

EUROTIMES | NOVEMBER 2019

GLAUCOMA

OCT and glaucoma Debate highlights pros and cons of glaucoma diagnosis before visual field defects occur. Dermot McGrath reports

18 months and 24 months in 516 newly he development and ongoing printouts, which intuitively leads and diagnosed POAG patients randomised to improvement of imaging guides us towards pathology. However, latanoprost or placebo eye drops. The test technologies such as optical they do raise the red flag a bit too often clustering enabled the researchers to detect coherence tomography and mislead many clinicians to make a statistically significant differences in visual (OCT) will play an increasing false positive diagnosis of glaucoma,” he fields between treated and untreated role in the diagnosis, management and said. One recent retrospective analysis patients after an observation detection of progression in primary of more than 2,300 OCT scans revealed period of 12 months. open-angle glaucoma (POAG) artefacts in 46% of cases, he said. While this approach of before visual field defects have There are also question marks over the clustering visual field tests occurred, according to Ingrida reliability of detecting progression in OCT. using a linear regression Januleviciene MD, PhD, “We are used to working with visual model to identify speaking at the European fields and the normal databases K rapid progressors Society of Ophthalmology are age adjusted. However, is very interesting (SOE) meeting in Nice, France. no OCT has age-correction and promising, “We are not questioning the for progression analysis in importance of visual field data but Ingrida Januleviciene further validation is the commercial models MD, PhD needed before it can rather the management of glaucoma currently available, so we be recommended in before visual field defects become are not taking into account routine clinical practice, said apparent. The pure statistical output may the normal thinning of the Dr Januleviciene. miss clinically important defects,” said Dr retinal layers due to ageing, “It holds promise but we need Januleviciene, Professor of Ophthalmology which might raise the red flag Gauti Johannesson MD more than necessary,” he said. to bear in mind that simulations at the Eye Clinic of the Lithuanian University are all based on the assumption of Health Sciences, Kaunas, Lithuania. Another issue is that POAG that visual field loss will occur linearly over Visual field testing is far from a perfect is often a mild disease in many patients, time, an assumption for which there is diagnostic tool, noted Dr Januleviciene. said Dr Jóhannesson. really not good evidence,” she said. The commonly used standard automated “We know this from many randomised The current role of imaging in the perimetry (SAP) 24-2 test pattern is disliked controlled trials with an untreated versus diagnosis of glaucoma is unclear but of great by patients, is prone to a high variability of treated arm. More than 65% of the untreated clinical importance, said Dr Januleviciene. mean deviation and does not detect early normal tension glaucoma eyes in the “Using spectral domain OCT is not a glaucomatous damage in most cases, she said. Collaborative Normal Tension Glaucoma sufficient stand-alone test for the detection The utility of visual field testing in Study Group study did not progress during of glaucoma or for triage use in primary care, newly diagnosed glaucoma patients is also a five-year follow up,” he said. but it has value in conjunction with clinical questionable, pointed out Dr Januleviciene. Early detection may in turn lead to examination and perimetry,” she said. “Performing a single visual field test overtreatment with eyedrops containing Using OCT for evaluation of glaucomatous per year is a common practice in newly preservatives that are damaging to the ocular damage can help in early diagnosis by diagnosed glaucoma patients. However, surface and that may jeopardise the success detecting progressive retinal nerve fibre this approach is insufficient and probably of future filtration surgery, he added. layer (RNFL) thinning and can serve as an as bad as not doing it at all,” she said. However, perhaps the most compelling essential component in guiding management In the United Kingdom glaucoma argument against diagnosing PPG is the decisions, evaluating treatment efficacy and treatment study (UKGTS), impact it has on the patient’s quality of life providing prognostic information about repeated visual field tests were (QoL), said Dr Jóhannesson. patients with increased risk for developing included at baseline and after “I think in many cases we forget the person functional impairment, she concluded. surrounding the eye. While advanced disease Presenting the case against diagnosing undoubtedly impacts on QoL, a literature pre-perimetric glaucoma (PPG), Gauti review by Quaranta et al. found that falsely Jóhannesson MD, Associate Professor diagnosing patients as having glaucoma can at the Department of Clinical Sciences, significantly impact their QoL and wellOphthalmology, Umeå University, Sweden, being. In another study, 34% of patients said that PPG is not even mentioned in the reported at least a moderate amount of fear European Glaucoma Society guidelines. of blindness after glaucoma diagnosis, which “This poses a problem for obtaining dropped to 11% at five years. This indicates a diagnosis. In the section on OCT and that a lot of the fear sits in the diagnosis and imaging the guidelines state that ‘no imaging not in the actual visual disability caused by device provides a clinical diagnosis’,” he said. the visual field defects,” he concluded. Another problem is the high frequency of false positives and artefacts in OCT images. Ingrida Janulevičienė: “We all have these fantastic high-tech Ingrida.Januleviciene@lsmuni.lt gadgets in our clinics with bright red Gauti Jóhannesson: Ingrida Januleviciene MD, PhD gauti.johannesson@umu.se ©

las

berg Sjö

We are not questioning the importance of visual field data but rather the management of glaucoma before visual field defects become apparent

EUROTIMES | NOVEMBER 2019

GLAUCOMA

OSD and glaucoma Ocular surface disease can degrade treatment outcomes. Howard Larkin reports

reventing optic nerve degeneration by controlling intraocular pressure (IOP) is the top priority in glaucoma treatment. As a result, some ophthalmologists – and even patients – view topical drug side-effects such as red eyes, irritation and burning as tolerable and not worth treating, according to Christophe Baudouin, MD, PhD, FARVO. However, over the multiple decades glaucoma must be treated, ocular surface disease (OSD) can significantly degrade outcomes, Dr Baudouin said. Beyond reducing medication compliance, OSD reduces the IOP-lowering effect of topical drugs, and increases failure rates of subsequent glaucoma surgery. “OSD is not a minor side-effect, it is a major problem for glaucoma care that should be recognised and treated,” said Dr Baudouin, who is Professor and Chair, Quinze-Vingts National Eye Hospital, and Vision Institute, Paris, France.

DETECTING AND REDUCING OSD About 20% of patients have dry eye signs and symptoms before topical glaucoma treatment begins. Preservatives in glaucoma eyedrops, notably benzalkonium chloride (BAK), can cause inflammation, and the risk increases with the number of preserved drops a patient takes. In addition, about 20% of patients have interactions with active medication compounds. In one survey Dr Baudouin conducted, 40% of 300 general glaucoma patients said they had changed or stopped a topical medication due to OSD signs or symptoms. “It’s not 3 or 4%, it’s 40%. That’s huge.” Dr Baudouin recommended checking for OSD in glaucoma patients who complain of foreign body sensations, burning, dry eye or irritation; display signs such as conjunctival redness or tearing; or who regularly use artificial tears – and it doesn’t take long. “One drop of fluorescein, and in 30 seconds you get a lot of information on surface disease.” Where surface damage is not severe, OSD often can be managed without referral to a corneal specialist, Dr Baudouin said. In patients taking multiple glaucoma drops, reducing the number often helps, and treating OSD can reduce the number of glaucoma drops needed (Dubrulle P et al. J Glaucoma. 2018 Dec;27(12):1105-1111). “Try to identify if there was a drug added that caused the problem and try removing it first,” he advised. Using combined drugs when available, switching from a more reactive compound to a less reactive alternate in the same category and using unpreserved drugs when possible also help. Combining strategies may be particularly powerful. One recent study found that moving from a bimatoprosttimolol combination, whether preserved or unpreserved, to an unpreserved tafluprost-timolol combination, significantly reduced OSD signs and symptoms (Bourne R et al. BMJOpen 2018; 9(4)). Procedures such as trabeculoplasty also can reduce the need for topical drugs, and choosing a surgical option earlier, especially with the new range of MIGS, can be more effective in the long-term, Dr Baudouin said.

Keep learning. Stay relevant.

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Christophe Baudouin: cbaudouin@quinze-vingts.fr EUROTIMES | NOVEMBER 2019

INDUSTRY NEWS

Avedro’s Boost Epi-On CXL technology

INDUSTRY

NEWS

New cross-linking technology

Avedro showcased early data on its novel Boost Epi-On cross-linking (CXL) technology for the treatment of keratoconus during an educational session at the 37th Congress of the ESCRS in Paris, France. Presentations highlighted the positive early clinical experiences of several clinicians from different countries who have evaluated Boost Epi-On CXL, a non-invasive corneal CXL procedure that does not require removal of the epithelium. The latest-generation technology addresses the limitations of prior epi-on procedures through the addition of supplemental oxygen. This drives oxygen diffusion across the epithelium to enhance CXL, better stabilising and strengthening the cornea and ultimately halting or slowing keratoconus progression, an educational session heard. The procedure is thus easier, with less postoperative ocular discomfort and a faster recovery time. It is also safer, with less risk of complications, and preserves corneal thickness as well as improving visual acuity, speakers said. Speaking to EuroTimes, Avedro CEO Reza Zadno PhD noted that keratoconus is a disease that particularly impacts young people, “and treating and halting its progression leads to a major quality of life improvement for these patients”. He added that keratoconus patients are a very large market from a business point of view, with an estimated 600,000 people affected in the US alone, and a non-invasive procedure is a very attractive option for both patients and doctors. https://avedro.com/

TRIFOCAL TORIC FULLY PRELOADED IOL LENS Rayner launched its RayOne Trifocal Toric fully preloaded IOL at the 37th ESCRS Congress in Paris, France. “At Rayner, we only focus on visual outcomes and aim to offer the best. Our trifocal technology has become the lens of choice for many surgeons thanks to its low light loss and reduced dysphotopsia. The missing piece of the jigsaw has been to have the same tried and tested technology for astigmatic patients,” said Tim Clover, Rayner CEO. Mr Allon Barsam, Medical Director and Founder of Ophthalmic Consultants of London (UK) implanted the world’s first RayOne Trifocal Toric on 15 July 2019. “It is great to be the first centre in the

EUROTIMES | NOVEMBER 2019

world to implant Rayner’s latest high technology offering,” he said. “Ethical innovation requires a careful balance ensuring patients have access to the latest and also safest technology once thorough R&D has been completed. A multi-centre pilot study across Japan, Germany and the UK reported high patient satisfaction, spectacle independence at all distances and high cylinder reduction after the first week. The uncorrected distance visual acuity was reported as 0.00 ± 0.09, intermediate at -0.03 ± 0.05 and near at 0.05 ± 0.05. All surgeons involved in the study reported a high level of product satisfaction, said Rayner. https://rayner.com/

CLINICAL STUDY SERVICES Medeuronet, a medical device consulting firm focused on European market entry, has acquired the clinical study business assets from IROC Science in a private transaction. IROC Science (Zug, Switzerland) will continue to operate, focusing on developing ophthalmology products, collaborating with medeuronet until companies are ready to go to market. “After collaborating on ophthalmology projects over the past five years, this acquisition of IROC Science’s clinical business makes sense given medeuronet’s growing focus on clinical study services in ophthalmology,” said Kristine Morrill, medeuronet co-founder and lead on clinical studies and medical communications services. Prof Dr Michael Mrochen, founder and CEO of IROC Science said: “We are looking forward to working together to transition our clients over to the medeuronet team given its strong ability to successfully design, set-up and manage clinical studies in ophthalmology ranging from first-in-human to post-market clinical follow-up studies.” With the implementation of the new Medical Device Regulation (MDR) in just under a year, medeuronet is increasingly focused on assisting its clients in anticipating the new clinical data requirements that will be necessary to obtain and maintain CE marking. “There continues to be a great deal of misinformation and uncertainty about the new clinical requirements under MDR” said Ms Morrill. “We are helping our clients chart a practical path through this uncertainty, without significant increases in expenses. We remain positive about the benefits of European market entry and commercialisation and firmly believe that a ‘Europe first’ approach is the right one,” she said. https://www.medeuronet.com/

INDUSTRY NEWS

NEW OFFICE OPENS IN CHINA EyeKor, Inc., an imaging and data management company for the ophthalmic pharmaceutical clinical trial and ocular preclinical laboratory industries, has announced that it is opening a new office in China to enhance its capability to provide local support for clinical trial sponsors and sites in China and the APAC region. “Over the past few years, EyeKor has actively collaborated with partners in China, building successful relationships with sponsors, hospitals, academia, reading centres and trial sites. With this new office, EyeKor aims to build upon these partnerships as an imaging contract research organisation (CRO), providing focused support for ophthalmic clinical trials and vision science endeavours in China and the APAC region,” said an EyeKor spokesperson. “EyeKor is proud to contribute to this momentous trend in China’s drug development paradigms. Establishing a team of imaging trial professionals who are well versed on international regulatory standards, EyeKor is positioned to assist sponsors in China in developing new and urgently needed therapies, particularly for patients suffering from ophthalmic diseases that currently lack approved effective treatments,” said the spokesperson. EyeKor is dedicated to delivering excellence in data management and analysis services for clinical and preclinical studies and strives to provide added value to clinical trial projects through superior quality, services and deep scientific expertise. EXCELSIORTM is a unique data/imaging management platform offering from EyeKor and is an FDA 510(k)-cleared Class II medical device and compliant with HIPAA, 21 CFR Part 11 and other regulatory requirements. https://www.eyekor.com/

The ZEISS SL 800 slit lamp

State-of-the-art optics

Ergonomic controls for all slit-lamp functions, including magnification, light filters and a stop brake for movement, are all within easy reach of one hand – meaning you’ll never have to put down your lens or let go of the joystick during patient exams. Carl Zeiss Meditech’s new SL 800 features state-of-the-art optics using apochromatic ZEISS lenses with anti-reflex coating, providing true-to-life colour and high-contrast images. An integrated LED light source accompanied by a halogen filter provide the advantages of both illumination characteristics. Continuous magnification steps of 6x, 10x, 16x, 25x and 40x show more-detailed structures for enhanced insights. Modular options include the ZEISS SL Imaging Solution, enabling convenient capturing of high-quality images and videos for documentation, patient consultation or presentation. The Fundus VarioView enables increased binocular field of view while examining the posterior segment. For measuring intraocular pressure, the AT 030 applanation tonometer can be easily integrated. The ZEISS SL 800 is a high-end device designed to deliver maximum efficiency and image quality that help ophthalmic surgeons meet growing demand. And the device integrates with seamlessly with other data and image sources through the ZEISS Integrated Data Platform, further enhancing overall practice efficiency. https://www.zeiss.com/

INNOVATION COMES IN MANY FORMS, HELPING PATIENTS TO SEE BETTER, CONNECT BETTER AND LIVE BETTER Johnson & Johnson Vision announced a series of new products and innovations at the 2019 American Academy of Ophthalmology (AAO) Annual Meeting in San Francisco, CA, USA. The company announced the US Food & Drug Administration (FDA) approval of the iDESIGN Refractive Studio Wavefront-guided PRK indication and the availability of TECNIS Simplicity Delivery System. “Innovation comes in many forms – ranging from products and treatment techniques, to innovations that make practice management easier so that ophthalmologists can focus on the work that matters most – helping patients see better, connect better, live better,” said Tom Frinzi, Worldwide President, Surgical, Johnson & Johnson Vision. “At AAO, we announced our new IOL insertion system TECNIS Simplicity, adding a PRK indication to our

industry-leading iDESIGN Refractive Studio, and introducing CHiME Manage, a new innovation in inventory management.” TECNIS Simplicity Delivery System, now FDA-approved, is a new preloaded, disposable IOL delivery system that is designed to prevent loading errors, simplify lens delivery and protect against contamination to help elevate the standard of care for patients when paired with a TECNIS 1-piece IOL. The FDA has approved the use of Wavefront-Guided PRK for the iDESIGN Refractive Studio, expanding options for surgeons across LASIK, PRK and monovision procedures. New clinical data presented at AAO raises the bar for the industry in visual acuity outcomes and patient satisfaction for the WFG-PRK procedure. The new software will be commercially available in the first quarter of 2020.

Johnson & Johnson Vision has also announced CHiME, a new programme committed to allowing ophthalmologic practices the freedom to focus on patient care. Building on the unveiling of Customer Connect, a breakthrough e-commerce system launched earlier this year, Johnson & Johnson Vision is introducing CHiME Manage – an all-inclusive smart inventory management system that will automate the inventory process for its products, while also providing safeguards in patient care. CHiME Manage will help practices plan and optimise inventory utilisation, streamline ordering, provide valuable insight with actionable reporting, reduce human picking errors and assist in expiration management. The cabinet will be piloted in several practices across the US this autumn. https://www.jjvision.com/

EUROTIMES | NOVEMBER 2019

J IN US

IN BOSTON, MA Come to the 2020 ASCRS Annual Meeting, the preeminent anterior segment surgical meeting,

May 15-19, 2020!

Visit Annualmeeting.ascrs.org, the new ASCRS Annual Meeting registration portal, to register today!

MY MENTOR

The personalised approach An effortless educator inspired Luke Sansom MD

uring one of my first rotations I was timetabled simplest, like it was the most complex and challenging that to attend a weekly corneal clinic with Mr James you have ever faced. A statement from a man so clearly Ball (Corneal and Refractive Surgeon, obsessed with not just wanting to do the right thing, but St James’ University Hospital, Leeds, determined to execute that plan to the absolute best of UK). As I waited, slightly nervously, his abilities. in his clinic room on my first day I was met by a It is these lessons, the ones that cannot be learnt by warm handshake and a welcoming smile. I was reading a textbook or attending a lecture, that have invited to take a seat and we talked. stuck with me until this day. It is likely that Mr Ball Seemingly unfazed by the increasingly busy waiting may well have never known that I considered him my room Mr Ball asked me about my life, my career and mentor should I not have written this article, which in my aspirations. Here was someone who really cared, many ways makes the impact he has had all the more not necessarily so much about whether I could list every impressive. His ability to seemingly effortlessly educate, James Ball corneal dystrophy or the disadvantages of LASEK, but guide and inspire showed true mentorship indeed and for about what made me tick. Someone who clearly appreciated that I am truly grateful. that the more he understood about an individual resident, the Dr Sansom is a Specialty Trainee at the York Teaching better he could enhance their experience, identify and work on Hospital NHS Foundation Trust, Yorkshire, UK their deficiencies and ultimately develop a more rounded, selfreflective and happy surgeon. Each week Mr Ball would arrive from his busy morning theatre to a frequently overbooked clinic and a scrum of residents and fellows looking for advice. Rather than showing displeasure or frustration he would launch into his work with the vitality and vigour of a Lieutenant Colonel rallying his troops into battle and tackling each problem with a reassuring calmness, utter clarity and unwavering charm. He had an uncanny ability to remember not just his patients but details about their lives and families too. He invariably found ways to relate to each patient, be that joking about homework with teenagers to regaling a retired hairdresser with entertaining stories of his own mother’s life in the same profession. This personalised approach to each patient which allowed him to build rapport and develop trust was akin to finding a unique key to a locked door and opening it. Here was someone who seemingly could nearly always find l Eye Contact Interviews that key. A metaphorical locksmith. Over time you could see within my fellow residents some of the l Video of the Month mannerisms and techniques that they, like me, had observed, adopted l Video Journal of Cataract and rehearsed. Clearly, I wasn’t the & Refractive Surgery only one who was l Technologies from the Experts impressed. It is often when l Online Museum I feel particularly tired, rushed or frustrated that I recall the best piece of advice that Mr Ball gave me. To treat every task and operation, even seemingly the

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

A statement from a man so clearly obsessed with not just wanting to do the right thing, but determined to execute that plan to the absolute best of his abilities

player.escrs.org

EUROTIMES | NOVEMBER 2019

RANDOM THOUGHTS

David Spalton delivering the HSIOIRS Kelman Lecture in Athens, Greece

Innovation today Truly original changes need a particular kind of environment. Aidan Hanratty reports

oes regulation result in decreased levels of innovation? Looking at the history of ophthalmology, one has to wonder if the advances made by the greats such as Harold Ridley and Charles Kelman would have been possible if the arms of medical ethics and safety were as prevalent as they are today. “Things were different in those days,” said Prof David Spalton in a EuroTimes Eye Contact interview with Paul Rosen MD following his HSIOIRS Kelman Lecture, which he delivered at the 23rd Winter

Automation, robotic surgery is coming in, and we’re going to see that taking an increasing role Prof David Spalton EUROTIMES | NOVEMBER 2019

Meeting of the ESCRS in Athens, Greece. “These days, with ethics and regulation – I think there’s always room for someone with a brilliant new idea to do things differently, but I don’t think anyone could do it in the same way that they did, which was really without any ethics, consent or that sort of thing.“It’s a good thing now, things are better regulated and that must be in the patient’s interest.” Harold Ridley, who first saw the possibilities of intraocular lenses and indeed brought them to reality, performed his first operations in secret, such a revolutionary procedure it was at the time. It’s important to remember that while the reward was truly great, for many millions of patients, there was also substantial risk in his novel idea. “Had Harold Ridley’s first operation gone wrong, we might not be here,” said Prof Spalton. Indeed, the materials used to sterilise early PMMA lenses leached into the eye, causing anterior uveitis, to give just one example of something that could ideally be prevented by regulation. “Times were different back then – surgeons had an idea and they could try it out and experiment,” adds Prof Spalton. Charles Kelman, a showman by nature as well as being a pioneering ophthalmologist,

took the opposite approach, going on television talk shows to expound about the possibilities of his approach, which he famously arrived at after many failed attempts over a course of nearly three years searching for a method of cataract removal that would require no hospitalisation. It almost goes without saying that phacoemulsification is now the norm, and advances like femtosecond laser-assisted surgery have been shown only to be as good as phaco. It’s unclear what the next major change in ophthalmology will be, but artificial intelligence is sure to play a part, Prof Spalton believes. “Automation, robotic surgery is coming in, and we’re going to see that taking an increasing role.” He also suggests that eye trackers could be combined with femto lasers for lens removal. Maybe not just yet, but the rate of progress to date has been such that nothing can be ruled out. Whether such things will be helpful in creating a truly accommodative lens, the next hurdle for ophthalmology according to Prof Spalton, remains to be seen. The only change we can be certain of, is change.

EXPLORING MARRAKECH

Caption The High Atlas Mountain

MARRAKECH

TO KNOW ...

KEEP YOUR WITS ABOUT YOU AND KEEP SOME 50S TO HAND Don’t look lost in Marrakech, even if you are. An open map or a puzzled air and you will immediately be offered ‘help’ to find your way. There will be no hint that you are expected to pay for this service, but money will be demanded at the end – and loudly. If you really need help, accept it but prepare for a scene if you don’t hand over about 50 Dirham as a ‘thank you’. Don’t be surprised if a monkey handler or snake charmer in Jemaa el-Fnaa settles his animal on your shoulders so you can take a picture. But settle a price (and there will be a price) before you do. As for the free cup of tea the rug seller offers as you browse his wares, this will cost you about 50 Dirham if you plan to walk away without a purchase.

NO DRINKING IN PUBLIC, AND ALWAYS WASH YOUR HANDS BEFORE YOU EAT Alcohol is served in hotels and restaurants in Marrakech, but drinking an alcoholic beverage in public is against the law. Obviously, that would mean in a park or public garden; it also means not on a balcony facing the street. Many roads serve alcohol in their private courtyards, as do European style restaurants and hotels. Bars, restaurants and riads usually have smoking and non-smoking areas but if in doubt, look around and see what others are doing. If you’re offered food from a communal tagine, the host will give you a bowl in which to wash your hands first. Just hold your hands over it and he will pour water on them. When shaking hands, eating, offering and receiving – use your right hand.

KNOW THE RULES OF THE GAME WHEN IT COMES TO GETTING A TAXI Taxis in Marrakech come in two sizes. petite and grands. The petite takes three customers, the grand up to six. Be sure to ask for the meter (the compteur) to be turned on in a petite taxi. Do not believe it is broken! For a grand taxi, speak first to the ‘Mul-taxi’ or the man in charge of all the grands taxis in the area. Ask him to set a price for your destination and the number of passengers. Carry some small bills and change or you may have to accept less than the change due you. At the airport, both petite and grands taxis operate. Check in advance with your hotel for the fare to expect. Or better yet, if your hotel offers a pick-up service, take it.

Spring in bloom A visit to the Ourika Valley awaits delegates to the 24th ESCRS Winter Meeting. Maryalicia Post reports The glittering mountain peak beckoning from Marrakech is called Jebel Toubkal. It’s the highest point in the western High Atlas mountain, part of the range that includes the steep Ourika Valley, home of romantic-looking kasbah and pink Berber villages. Good news for delegates to the 24th ESCRS Winter Meeting: the area is at its best between February and March when the cherry and almond trees are in bloom. A marked contrast to crowded Marrakech, the area, only 60km from the city, is a deservedly popular day trip both with tourists and with local families, who tend to come on weekends. If you pencil it in for ‘time off’ on your agenda, be sure to invest in a private tour. Either ask your concierge for recommendations or browse the tours offered by Morocco Insight Tours https://www.moroccoinsighttours. com, the private guided day tours from Getyourguide.co.uk or the dependable offerings at www.toursbylocals.com. What makes a private tour the best option? Because only activities you choose will feature on the excursion. And doublecheck with the booking agent that the ‘private’ tour is indeed for you or your party only. There can be surprising latitude in the definition of ‘private’. Above all, do not sign up for a tour offered to you in the market, on the street or by a taxi driver. If you do, you’ll find yourself being taken to meet the driver’s first cousin and made to visit his shop. It’s a mistake I made and found myself more or less stranded in the taxi driver’s cousin’s pharmacy while the driver and his relation caught up on old times. Among the sights in the Ourika Valley, are seven spectacularly beautiful waterfalls. Though many tourists settle for a view only

of the most accessible one, it is possible to proceed to the more remote and less visited of them if you have the stamina and the footwear. Tea with a Berber family is also a possibility, as is a visit to an oil-producing factory. If you have never experienced the peculiar sensation of a camel ride, why not now? Other attractions include potteries, watermills, a salt mine and quarries. What to wear? Sport shoes or trainers with a good grip are advisable as some of the walk will be on rubble. Though you can wear shorts and a tee shirt, women especially will feel more comfortable walking through the little mountain villages with their legs and shoulders covered. A sun hat and really good sunglasses make viewing easier at this altitude. Bring along a few layers of clothing and a light jacket; the weather can change suddenly in the mountains.

Caption

A table with a view

EUROTIMES | NOVEMBER 2019

ESCRS NEWS

ESCRS Board Election 2019 An election for five positions on the Board took place earlier this year and 17 full members of the ESCRS were nominated. The following candidates were successful in being elected and their term of office will begin in January 2020. Jorge Aliรณ, Spain Jorge Aliรณ MD, PhD, FEBO, is Professor and Chairman of Ophthalmology, University Miguel Hernandez, Alicante, founder of Vissum Corporation, Spain, and the Jorge Aliรณ Foundation for the Prevention of Blindness. He is a high-volume surgeon in cataract, cornea and refractive surgery with over 50,000 surgeries performed.

Bruce Allan, UK Bruce Allan has been on the staff at Moorfields Eye Hospital in London, UK, since 1998, chair of the UK Refractive Surgery Standards Working Group since 2015 and an EuCornea Board member since 2017. He has lectured and published widely.

Vikentia Katsanevaki, Greece Vikentia Katsanevaki, MD, PhD, of the Orasis Eye Center, Athens, Greece, has been active within the ESCRS for the past 15 years. She has been, and continues to be, a member of the Programme Committee, Poster sub-group, faculty of the refractive surgery didactic course, invited lecturer and faculty of various instructional courses and senior instructor of refractive wetlabs. She has been an elected member of the ESCRS Board since 2015.

Nic Reus, The Netherlands Nic Reus, Amphia Hospital, Berda, the Netherlands, is a member of the ESCRS Programme Committee and a member of the Poster sub-group. Since 2011, he has been a senior course and wetlab instructor and on the faculty of the Young Ophthalmologists Programme at ESCRS meetings. He also acts as liaison between the ESCRS and the European Society of Ophthalmic Nurses and Technicians (ESONT). He has been a board member of the Netherlands Intraocular Implant Club (NIOIC) since 2009.

Filomena Ribeiro, Portugal Filomena Ribeiro, Hospital da Luz, Lisbon, Portugal, has been an ESCRS Co-Opted Board Member and a member of the Programme and Young Ophthalmologists Committees. She is the head of the Hospital da Luz Ophthalmology Department, Professor of Ophthalmology and Biomedical Engineering at the University of Lisbon, and on the Board of the Portuguese College of Ophthalmology.

EUROTIMES | NOVEMBER 2019

CALENDAR

The 10th EURETINA Winter Meeting will take place in Vilnius, Lithuania

↙

LAST CALL

NOVEMBER 2019

33rd European Ophthalmology Congress

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

DECEMBER

MARCH

World Eye and Vision Congress

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

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

2020 FEBRUARY All India Ophthalmology Conference 2020 13–16 February Gurugram, India https://aios.org/aioc2020.php

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

24th ESCRS Winter Meeting Marrakech 21–23 February Marrakech, Morocco www.escrs.org

MARCH Frankfurt Retina Meeting 2020

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

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

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

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

MAY SFO 2020 Congress

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

World Cornea Congress VIII 13–15 May Boston, USA www.corneasociety.org

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

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

EUROTIMES | NOVEMBER 2019

CALENDAR

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

EyeAdvance 2020

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

14th EGS Congress

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

JUNE 20th EVRS Meeting 2020

The XXI International Congress of the Brazilian Society of Ophthalmology will take place in Rio de Janeiro, Brazil

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

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

OCTOBER WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

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

JULY

OCTOBER

XXI International Congress of the Brazilian Society of Ophthalmology

20th Euretina Congress

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

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

11th EuCornea Congress

ASRS 2020

23–28 July Seattle, USA www.asrs.org

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

↙

SEPTEMBER 5th International Glaucoma Symposium

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

38th Congress of the ESCRS

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

NOVEMBER AAO Annual Meeting 2020

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

NOVEMBER

100th SOI National Congress

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

NE W CONTE N A library of symposia, interviews, video discussions, supplements, articles and presentations Spotlight on: l

Toric IOLs and Presbyopia

Glaucoma

Ocular Surface Disease

Corneal Thereapeutics

Visit forum.escrs.org for details EUROTIMES | NOVEMBER 2019

Take control of your future.

Visit www.escrs.org

for membership information

Belong to something powerful. Join us.

38th Congress of the ESCRS

Amsterdam

2020 3-7 October RAI Amsterdam