EuroTimes Vol 25 Issue 4 April 2020

COVER STORY

PRACTICE MANAGEMENT

April 2020 | Vol 25 Issue 4

Adding

VALUE

to your

PRACTICE

CATARACT & REFRACTIVE | CORNEA | RETINA | GLAUCOMA PAEDIATRIC OPHTHALMOLOGY

38th Congress

Amsterdam 2020 3-7 October, RAI Amsterdam

Scientific Programme, Registration & Hotel Bookings

www.escrs.org

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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

COVER STORY

04 Establishing a practice

requires a ‘wow’ factor

CATARACT & REFRACTIVE 06 Dysphotopsias are a

significant source of patient dissatisfaction after cataract surgery

07 Intraoperative wavefront aberrometry helps improve outcomes

08 Calm but prompt action

can help reduce impact of surgical complications

09 A fully automated robotic cataract surgery platform tested in pig eyes

10 Ophthalmologists are one

of the more at-risk medical specialities for COVID-19

12 How to perform

cataract surgery in vitrectomised eyes

14 Conscious breathing can reset the mind when the unexpected happens

15 JCRS highlights

CORNEA 16 DMEK and DSAEK

continue to achieve broadly similar outcomes

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between February and December 2019 was 47,863

17 Different tools for

corneal measurements should not be used interchangeably

www.eurotimes.org

19 Femto laser may

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provide an alternative to cross-linking in early keratoconus

MEETING REPORT 20 All the highlights from

the 24th ESCRS Winter Meeting in Marrakech

RETINA 22 Eating a Mediterranean diet may be beneficial for those with age-related macular degeneration

24 No link between use of

systemic medications and AMD

25 Automated devices

may soon be used for intravitreal injections

26 Multimodal imaging

may shed light on AMD disease mechanisms

27 AI and big data hold

potential to assist with automated detection and identification of disease

GLAUCOMA 28 Automated

gonioscopy is a new technique for analysis of the iridocorneal angle

PAEDIATRIC OPHTHALMOLOGY 30 Paediatric surgery can be addressed with the right technology

31 New European trial is

investigating the effect of atropine in slowing myopia progression

32 Further studies needed

to address many unanswered questions in myopia prevention

REGULARS

35 Books 37 Travel 38 Random thoughts 39 Calendar

29 A smartphone slit

lamp system using AI can screen for angleclosure disease EUROTIMES | APRIL 2020

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EDITORIAL A WORD FROM PAUL ROSEN MD

GUEST EDITORIAL

Chasing perfection Perfection is not attainable, but if ophthalmologists chase perfection they can catch excellence

Paul Rosen

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Thomas Kohnen

Paul Rosen

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

EUROTIMES | APRIL 2020

I

am very pleased to be invited to write the editorial for this month’s EuroTimes.

Our Cover Story focuses on adding value to your practice, and explores how ophthalmologists can make the best use of their resources for the benefit of their patients.

This is a subject that we will discuss further at the ESCRS Practice Management and Development Workshops during the 38th Congress of the ESCRS in Amsterdam in October.

Everything we do has a cost and while it mustn’t be the prime determinant of how we deliver healthcare, it clearly has a major impact. Doctors generally don’t make natural business people but they need to know about the business of ophthalmology in its broadest sense and this applies to both the public and private systems.

The business of ophthalmology is not just about money, but includes all the components of running a small business including marketing, finance, human resources; however, it is ultimately about highly effective leadership. This is particularly important for ophthalmologists who decide to go into private practice and set up their own clinics. This involves I’ve seen a number careful and meticulous of projects that planning and working with and supporting their have failed because multidisciplinary team ophthalmologists It is important to manage try to do thousands the team’s expectations: there have been a number of cases. That isn’t of projects that have failed feasible because ophthalmologists are unrealistically ambitious. For example, if you’re building a clinic, you may have two or three consulting rooms, but the potential to expand to six; one operating theatre and the potential to expand to two or three.

The key is great customer service from the moment the patient makes contact with the clinic to the day they are discharged from your care.

I encourage ophthalmologists not only to read our cover story but also to attend the practice management sessions in Amsterdam.

As the great American football coach Vince Lombardi said: “Perfection is not attainable, but if we chase perfection, we can catch excellence.”

With that thought in mind, I look forward to seeing you in Amsterdam and urge you to take part in the ESCRS Practice Management and Development Programme.

Paul Rosen is the Chairman of the ESCRS Practice Management and Development Committee and a Consultant Ophthalmologist at Oxford Radcliffe Hospitals NHS Trust, UK

NUMBER 1!

80% of readers say it's an interesting read Reach

47,863

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* Average net circulation for the 10 issues circulated between 1 February 2019 to 31 December 2019. See www.abc.org.uk Results from the

EuroTimes Readership Study 2017

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COVER STORY: PRACTICE MANAGEMENT

Adding VALUE to your

PRACTICE Establishing a practice requires a ‘wow’ factor across the board. Aidan Hanratty reports

F

irst impressions last, as the saying goes. This counts as much for an ophthalmologist’s waiting room as anything else.

“There has to be a ‘wow’ factor when you enter the waiting room. Because at that moment, the patient already has an idea about the professionalism of the practice,” said Guy Sallet MD, FEBO, Medical Director, EUROTIMES | APRIL 2020

Eye Institute Aalst, Belgium, in an interview with EuroTimes.

When establishing his own practice, Dr Sallet visited other clinics to gain inspiration, both in terms of what to do and what not to do. A doctor may have all the right equipment but if the waiting room is small and cramped, that’s not going to encourage the patient. Instead, things like high-end furniture and open space are important to make the patient feel at ease.

The Wellington Eye Clinic in Dublin, Ireland, is a private practice that offers a range of vision-correcting procedures including laser vision correction, orthokeratology, refractive lens exchange as well as cataract removal, corneal crosslinking for keratoconus, dry eye and so on.

The clinic recently had a design overhaul, which involved removing a large, bespoke front desk that was bolted to the floor.

“You could have someone signing in,

COVER STORY: PRACTICE MANAGEMENT you could have someone checking out, you could have someone discussing a payment, all standing within earshot of one another,” said Arthur Cummings MD, Consultant Ophthalmologist and Medical Director of the Wellington Eye Clinic. “And the ladies sitting at the front desk were on a computer, busy on a phone call and trying to deal with the patients standing in front of them!”

While the new setup featured input by an architect, it was ultimately designed by the practice staff: “They’re the ones who use it every day, they’re the ones who see the way things work,” Dr Cummings added.

Reception staff now see one patient at a time, while calls and other administrative issues are directed away from the front desk.

Liz Brennan, Clinical Support/Research Manager at the Wellington Eye Clinic, advised anyone starting out to buy an “off the shelf” desk, rather than a bespoke desk to start out with, as this allows you to determine what will work best for you in the long term.

Similarly, Paul Rosen MD suggests starting small. “You need to have all the basics there, start off small, but with potential for expansion.”

Having seen clinics start and fail thinking that they’ll be tackling thousands of cases from the word go, he stresses the importance of more realistic expectations.

“If you’re building a clinic, you have two or three consulting rooms, but the potential to expand to six; one operating theatre, the potential to expand to two or three,” said Dr Rosen.

MULTI-FUNCTIONAL TEAM With a small team, it’s important to maximise the capability of staff. Dr Sallet has what he calls a “medium” group practice, where everyone is multi-functional.

“The optometrist can answer the phone, give consultation dates, give information about the operations, but is also aware about reimbursement policies,” he said.

This multi-functionality makes it easier when people are on annual leave or maternity leave, for example.

At the Wellington Eye Clinic, the approach is similarly multidisciplinary, with several ophthalmologists on hand as well as optometrists working full- and part-time. “So, if one of them had to leave, there’s always a depth of knowledge within that team,” said Lisa McLoughlin, Clinic Manager. “It’s never a case that only one person knows how to do one thing.”

You could have someone signing in, you could have someone checking out, you could have someone discussing a payment, all standing within earshot of one another Arthur Cummings MD That comes with limits, however.

Administration staff are clearly trained on when to answer questions and when to refer: “They would never give medical advice because they could be wrong. There might be some question that they’re not asking that could be very significant, and really to protect themselves, we just advise them not to answer any medical questions,” said Ms McLoughlin.

Patients expect results, and with elective procedures like laser surgery and premium IOL implantation the stakes are higher.

This is where the interests of business and medicine can collide. “Some people want a 100% guarantee. And we can’t give that,” said Ms McLoughlin.

“If there’s a patient who is frustrated because they’ve done two or three contact lens trials, but they didn’t really like any of them, it’s not meeting their expectations – the culture within the team is to say ‘This isn’t for you, I think the best thing for you to do is to not have surgery’,” added Ms Brennan.

When it comes to negative online reviews, Dr Sallet has designated staff who respond to unhappy patients. “We never go into discussion on social media. If there’s a problem, [we ask patients] please come into our practice and we can have a closer look at how to solve it,” he said.

An important thing to remember is never to argue with the patient, never tell them that you are right. “You just have to listen to their problem and say ‘well, I believe in your problems’. Maybe you don’t have the solution, but at least you have said you believe in it and if you have a solution try to present it. If you don’t have a solution you will do a very close followup so the patient feels regarded and cared for,” said Dr Sallet.

If anyone at the Wellington Clinic feels that a patient is having a rough time or feels they are being ignored or mistreated, they are at liberty to give them a voucher for a high-end

We never go into discussion on social media. If there’s a problem, [we ask patients] please come into our practice and we can have a closer look at how to solve it Guy Sallet MD, FEBO

department store on behalf of the clinic.

“You would imagine in a place where there’s a lot of things going on, it’s a very nice way to calm people down if they’re upset or waiting too long or something’s upsetting. ‘We really apologise, here’s a voucher, go spoil yourself’,” said Dr Cummings.

HIGHEST LEVEL OF MEDICINE A tough aspect of owning your own practice is knowing what machines to buy and when. There are key questions at stake, as Dr Sallet puts it: “What gain can we have with our practice? Will it help us in making better diagnosis? Will it help us in making better therapy modules? If it’s just an extra tool to show off to the patient it’s not of interest to us.” What’s important, he said, is to give the patient the highest level of medicine as possible.

Dr Cummings agrees. “We only ever buy equipment that we think is going to give us value. Not monetary value, but equipment that will help us make better decisions so that we avoid problems down the line.

Often, we’re quite early with acquiring technology and other times we sit back first and wait. Like the femtosecond laser for flaps, we only got involved after it had been released and proven in the market for a few years already, because we weren’t sure right at the start about its added value.”

“There could be a device that I think is really valuable,” he added, “but it takes twice as long to use and then it’s just not practical.”

“We try to look at it from the whole way through the patient journey,” added Ms Brennan. “Is it nice to use, do the patients like it, is the patient comfortable?” From the surgeon’s point of view, the quality of data and reports is also important, so all aspects of use are considered. And that works both ways.

All these issues and more will be discussed at the ESCRS Practice Management and Development Programme during the 38th Congress of the ESCRS in Amsterdam, the Netherlands Guy Sallet: dr.sallet@ooginstituut.be Arthur Cummings: abc@wellingtoneyeclinic.com Liz Brennan: elizabeth.brennan@ wellingtoneyeclinic.com Lisa McLoughlin: l.mcloughlin@wellingtoneyeclinic.com EUROTIMES | APRIL 2020

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CATARACT & REFRACTIVE

Disturbing optical

PHENOMENA Epidemiology, aetiology and intervention differ for positive and negative dysphotopsias. Cheryl Guttman Krader reports

D

ysphotopsias may be the most significant issue that negatively affects patient satisfaction after uncomplicated cataract surgery, said Nick Mamalis MD. Speaking at the 37th Congress of the ESCRS in Paris, France, Dr Mamalis discussed the epidemiology, aetiology and management of these unwanted optical phenomena.

Data on how many people experience dysphotopsias after cataract surgery varies, and most surgeons think that the incidence is low because patients may not spontaneously report the problem.

However, a study in which complaints were elicited showed that dysphotopsias affect up to 50% of patients early after surgery.

“Most of the time the symptoms go away or people get used to them, but dysphotopsias can persist and be a significant issue for some patients,” said Dr Mamalis, Professor of Ophthalmology, John A Moran Eye Center, Salt Lake City, UT, USA Dysphotopsias are broadly categorised as positive and negative. Between the two types, positive dysphotopsias are less common, but they are more visually disturbing than negative dysphotopsias and less likely to resolve spontaneously.

Positive dysphotopsias are perceived as bright forms in the visual field, including rings, arcs, halos or flashes of light.

“Imagine how disturbing it would be to your visual function if when driving at night, the light from an oncoming car’s headlight is directed right in the centre of your vision,” Dr Mamalis said.

The incidence of persistent positive dysphotopsias is reported to be as high

as 1.5%, and it varies depending on IOL material and optic design. Reports of the problem began to increase when hydrophobic acrylic IOLs were introduced, and it is also associated with a sharp edge optic design.

“Frosted or textured edges as well as bevelled designs have been implemented by manufacturers to decrease the intensity of stray light and the incidence of positive dysphotopsias, Dr Mamalis said.

He added: “Edge design may explain why silicone IOLs are rarely associated with positive dysphotopsias.”

In patients bothered by persistent positive dysphotopsias, IOL explantation and exchange using an implant made of a different material and especially with a round-edge optic can be effective for resolving the problem, Dr Mamalis said.

NEGATIVE DYSPHOTOPSIAS Negative dysphotopsias are seen as a dark crescent or shadow in the temporal visual field.

“Affected patients describe what they feel would be the sensation of horses wearing blinders on their eyes,” Dr Mamalis said.

According to the literature, more than 15% of patients report negative dysphotopsias on the day after cataract surgery, but within two months, the symptom resolves in the majority of patients. Negative dysphotopsias are a persistent problem after cataract surgery for between 0.2 and 2.4% of patients.

“Negative dysphotopsias do not necessarily go away, but rather there may be cerebral adaptation. However, because they often resolve, surgeons should not rush to intervene when patients complain about negative dysphotopsias early after surgery.”

Most of the time the symptoms go away or people get used to them, but dysphotopsias can persist and be a significant issue for some patients Nick Mamalis MD EUROTIMES | APRIL 2020

The aetiology of negative dysphotopsias is a subject for ongoing research. Findings from ray tracing analysis suggest the phenomenon may be related to the internal reflection of light around the peripheral edge of the IOL, leading to a dark, non-illuminated area in the peripheral nasal retina. “But it may not be that simple,” Dr Mamalis said.

Space between the iris and the IOL surface and the relationship between the anterior edge of the capsulotomy and the anterior IOL surface may be involved. IOL design and material may also be factors considering that negative dysphotopsias are seen more often in patients with an IOL featuring a square edge optic and with hydrophobic acrylic lenses, although they can occur with any IOL material.

Options for treating negative dysphotopsias include placing an IOL in the ciliary sulcus or implanting an addon IOL that will diffuse the light before it reaches the primary IOL. Reverse optic capture of the existing IOL with placement of the optic over the edges of the anterior capsule is also an alternative that targets the relationship of the capsular bag edge and IOL as the potential cause.

Laser anterior capsulotomy to increase the size of the anterior capsular opening has also been tried, and novel IOL designs have also been introduced. One, developed by Samuel Masket MD, features a groove on the anterior optic surface that allows a lip of the optic to override the anterior capsule. This approach is supported by evidence that the bag-inthe-lens IOL, which fixates the capsular bag behind the anterior lip of the optic, decreases the incidence of negative dysphotopsias.

Another recently proposed modification features an optic with a peripheral concave surface that would redirect light rays to illuminate the dark region of the nasal retina.

“Exchanging the IOL in-the-bag for one with a different material and round edge design is often not effective, providing further evidence that the factors causing negative dysphotopsias may not be simple as the lens material or optic design,” Dr Mamalis said.

Nick Mamalis: nick.mamalis@hsc.utah.edu

CATARACT & REFRACTIVE

Optimising outcomes in cataract surgery Studies highlight benefits of intraoperative wavefront aberrometry.

Cheryl Guttman Krader reports

I

Courtesy of Joaquim Neto Murta MD, PhD

ntraoperative wavefront aberrometry (ORA, Alcon) adds value to the use of modern preoperative IOL formulas for achieving better outcomes in refractive cataract surgery, said Joaquim Neto Murta MD, PhD. Speaking at the 37th Congress of the ESCRS in Paris, France, Dr Murta said he uses the technology in all patients when he is implanting a presbyopia-correcting or toric IOL. “Patients have high expectations for their visual outcome after refractive cataract surgery and expect to decrease their dependence on spectacles. Therefore, the importance of achieving emmetropia or the targeted postoperative refraction and correcting astigmatism is greater than ever.

Intraoperative wavefront aberrometry (IWA) increases refractive accuracy, improves patient outcomes and decreases the need for enhancements. I implant trifocal and toric IOLs in a high percentage of patients, and with the use of IWA in the last two years I have only done PRK in two of those cases,” said Dr Murta, Professor of Ophthalmology, University of Coimbra, Coimbra, Portugal.

The ORA system from Alcon

...the importance of achieving emmetropia or the targeted postoperative refraction and correcting astigmatism is greater than ever Joaquim Neto Murta MD, PhD

He added, “Using IWA gives me happier patients who help grow my premium practice.”

As evidence to support his comments, Dr Murta discussed two studies he conducted in which he analysed the impact of IWA on refractive outcomes. A nonrandomised, consecutive prospective study included 86 eyes of 86 patients undergoing uncomplicated cataract surgery with implantation of a trifocal or trifocal toric IOL. Biometry measurements were obtained with an optical biometer and IOL power decisions were made using IWA.

ACCURACY OF RESULTS Using measurements obtained two months after surgery, Dr Murta compared the accuracy of the achieved results with those predicted using three top formulas – Kane, Barrett Universal II, and Hill-RBF 2.0. The analyses showed no statistical difference between IWA and the formulas in analyses of mean arithmetic error and mean and median of the absolute prediction error.

For these endpoints, however, there were numerical differences favouring IWA, and the percentage of eyes ±0.25D of target and ±0.50D of target was highest using IWA. Another study focused on eyes undergoing toric IOL implantation and compared the prediction of residual astigmatism with its use versus the toric IOL calculator incorporating the Barrett algorithm with estimation of posterior corneal astigmatism.

The study included 50 eyes and found a mismatch in recommended power between IWA and the calculator in 52% of cases.

Using IWA in the latter subgroup increased the accuracy of residual astigmatism prediction, Dr Murta reported.

GETTING GOOD RESULTS Dr Murta offered several tips for obtaining reliable measurements with the intraoperative aberrometer. “Four simple characteristics are needed,” he said.

The eye should be widely open, and the tear film should be well hydrated and uniform, but not flooded. The eye should also be well pressurised and well aligned, and surgeons should check that the intraocular state of the eye is homogeneous, clear from debris or bubbles.

“Watch out for a dry cornea or pooling of moisture on the ocular surface. IOP should be set to 21mmHg, and if a toric IOL is being implanted, there should be no pressure on the limbus from the speculum,” Dr Murta advised.

Other benefits of using intraoperative aberrometry are that it provides outcome analysis and astigmatism management reports that allow surgeons to assess the consistency with which they hit the refractive target and the accuracy of their outcomes for astigmatism correction. In addition, the system is continuously optimised both globally and specifically to the surgeon.

“The personalisation is a very important feature,” said Dr Murta. “Each time a surgeon enters postoperative refractive outcomes, the global database will be reanalysed and updated, and the IOLs for which the surgeon has entered data will be personalised within the system.”

The manufacturer recommends that the postoperative results should be obtained at follow-up at least 10 days after surgery.

“In our centre, we use data from the twomonth postoperative visit,” Dr Murta said.

Joaquim Neto Murta: jmurta@netcabo.pt EUROTIMES | APRIL 2020

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CATARACT & REFRACTIVE

Learning from disaster Calm reflection when under stress can prevent a complication from becoming a plane crash. Roibeard Ó hÉineacháin reports

C

omplications such as capsulorhexis tears can be often be avoided by calm but prompt action when the surgery first begins to go awry, according to Brian Little DO, FRCS, FRCOphth, London, UK. “Despite the best training and quality of teaching available to us, all of us will have complications of one sort or another during our surgical careers. The underlying message that I want to get across is that the final outcome of any complication is determined not by the event itself but how you manage it. It is dealing with the unexpected, and it’s all about how you react when things go wrong,” Dr Little told the 37th Congress of the ESCRS in Paris, France.

He noted that even the most experienced surgeons can still come to grief if they are excessively stressed. But when decisions must be made under stressful conditions, it is not quick thinking but calm consideration of the situation that will win the day.

To illustrate how stress can affect decision-making, Dr Little described two famous incidents involving airplanes. In the first, which occurred in 1994, Lt Col Bud Holland, the most experienced test pilot in the US Air Force at the time, was doing a low-level practice flight in a B-52 bomber before his final retirement flight at an air show the following day. After completing the flyover he was approaching the tower and was told he had to alter his flight path to avoid flying over an ammunitions dump. His panicked response took the plane beyond its operational limits and it crashed killing all on board.

The second example was the famous “miracle on the Hudson” in 2009. After flying into a flock of geese three minutes into the flight and losing power in both engines at 3,000ft, pilot Captain Chesley Sullenberger still managed to land the plane safely in the middle of the Hudson river and all 155 passengers survived.

“Captain Sullenberger stayed calm under stress and assessed his situation, worked out his options and decided what he needed to do to land the aircraft, and three minutes later he did so and everyone survived. The difference between those two results is really your reaction to stress, Dr Little said.

CAPSULAR TEARS One dreaded complication in cataract surgery is capsular tears.

Dr Little presented a case of a capsular radial tear-out occurring during cataract surgery as an example of how not to react in such

circumstances. The case involved an eye with a deep chamber and a well-dilated pupil and a good red reflex. It was, overall, a fairly low-risk scenario and a very experienced surgeon was performing the procedure, Dr Little said.

However, as the surgeon was creating the capsulotomy, he failed to notice that the ophthalmic viscosurgical device (OVD) was leaking out of the incision, and the chamber started shallowing. He ended up going too far out with the initial capsular incision.

As the OVD continued to spill through the corneal incision, the capsulotomy began to spiral outward, Brian Little DO, FRCS, FRCOphth and just when might have retrieved it, the surgeon pulled it, ruining the capsulotomy. Had he refilled the chamber with OVD the radial tear would most likely not have happened, Dr Little said.

“This is what happens when you just rush things a bit and don’t react to what is actually going on, to the key indicators of what is actually going wrong. That is very much about losing your capacity to perceive clearly what is happening when there is adrenaline flowing and you are under stress,” he added.

Once the surgeon saw what had happened and was calmer and therefore more rational, he refilled the eye with OVD, made a second incision, unfolded the capsular flap to provide better linear access and pulled it backward and centrally and retrieved it internally. However, Dr Little pointed out that the complication would never have occurred had he remained calm and taken the appropriate action in the first place.

This is what happens when you just rush things a bit and don’t react to what is actually going on, to the key indicators of what is actually going wrong

Brian Little: eye.surgeon@me.com

INDIA VISIT OUR WEBSITE FOR INDIAN OPHTHALMOLOGISTS

EUROTIMES | APRIL 2020

www.eurotimesindia.org

CATARACT & REFRACTIVE

Robotic surgery getting closer Automated cataract surgery devices on the not-so-distant horizon.

Howard Larkin reports

A

fully automated robotic cataract surgery platform that extracts the nucleus and cortical materials has been successfully tested in pig eyes and could enter human trials in three-tofour years, Jean-Pierre Hubschman MD told a session of the American Academy of Ophthalmology Annual Meeting in San Francisco.

Known as IRISS, the automated cataract platform uses a complete preoperative OCT scan to construct a 3D model of the eye and plan surgery. Planning includes determining the precise trajectory of instrument tips to be used throughout the procedure, explained Dr Hubschman, of the University of California-Los Angeles, USA.

PRECISE GUIDANCE During surgery, real-time OCT data acquisition and processing provide precise guidance to the instrument inside the eye, allowing automated cleaning of the lens and cortical material located in capsular bag. A surgeon monitors the operation and can override the device if necessary, said Dr Hubschman, of the Stein Eye Institute and Director of the Advanced Robotic Eye Surgery Lab at UCLA. In a study involving fully automated surgery on 30 harvested pig eyes, all lens material was successfully removed from 25 eyes, with minute particles left behind or attached to the iris or capsule in five eyes, Dr Hubschman reported.

No posterior capsule ruptures occurred and completion time averaged less than five minutes.

Potential advantages of automated surgery include more complete nucleus and cortex removal and reduced risk of capsule rupture, Dr Hubschman said. This is done by providing better visualisation of the anatomical structures during the procedure, for example providing complete visualisation of the capsule periphery, which is normally hidden by the iris in manual surgery. He hopes to automate capsule polishing and IOL alignment soon.

“It takes the guesswork out of surgery,” he noted.

LIMITS HAND TREMOR Semi-automated systems envisioned for vitreoretinal surgery eliminate physiological tremor in surgeons’ hands and provides augmented visual and tactile feedback, enhancing precision and control, Dr Hubschman added.

These include a semi-automated robot-assisted retinal vein cannulation device that limits hand tremor and maintains a stable position with a surgeon operating the device, Dr Hubschman said.

A robotic device known as Preceyes for retinal membrane peeling and subretinal injections operated by a surgeon from a console also has been tested in humans.

Dr Hubschman and colleagues are developing the IRISS platform for fully automated cataract surgery and semiautomated retinal surgery, enhancing visualisation and increasing feedback. He expects a prototype ready for human trials around 2024.

2020 Applications are open for the Peter Barry Fellowship 2020. This Fellowship commemorates the immense contribution made by the late Peter Barry to ophthalmology and to the ESCRS. The Fellowship of €60,000 is to allow a trainee to work abroad at a centre of excellence for clinical experience or research in the field of cataract and refractive surgery, anywhere in the world, for 1 year.

Applicants must be a European trainee ophthalmologist, 40 years of age or under on the closing date for applications, and have been an ESCRS trainee member for 3 years by the time of starting the Fellowship.

The Fellowship will be awarded at the ESCRS Annual Congress in Amsterdam in October 2020, to start in 2021.

To apply, please submit the following: l l

l

l

A detailed up-to-date CV A letter of intent of 1-2 pages, outlining which centre you wish to attend and why A letter of recommendation from your current Head of Department A letter from your potential host institution, indicating that they will accept you if successful

Closing date for applications is 1 May 2020 Applications and queries should be sent to Danielle Maher at danielle.maher@escrs.org

Jean-Pierre Hubschman: hubschman@jsei.ucla.edu EUROTIMES | APRIL 2020

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CATARACT & REFRACTIVE

Coronavirus and ophthalmology What can ophthalmologists do to protect themselves, staff and patients from COVID-19? Priscilla Lynch reports

T

he emergence of the novel coronavirus SARS-CoV-2, and the resulting disease COVID-19, in December 2019 has created a major international public health challenge.

Having spread rapidly across parts of China initially, it has subsequently spread to multiple countries across the world, with the situation ever evolving.

While COVID-19 is not as deadly as other recent new coronaviruses such as SARS and MERS, with a fatality rate of about 3.4%*, it is far more infectious, notes Dr John Chang

MD, Consultant Ophthalmologist, Hong Kong Sanitorium and Hospital. Patients can be asymptomatic for days and perhaps weeks and be transmitting the virus to others during that period.

The majority of COVID-19 cases to date, around 80%, have been mild, with those most at risk of serious disease being the elderly or people with underlying health conditions, which is important to note, Dr Chang told EuroTimes.

However, a number of healthcare workers have also died from COVID-19, including the first doctor to raise the alarm about the novel coronavirus, Dr Li Wenliang, MD, a 33-year-old ophthalmologist working in

We’re still learning about this novel coronavirus and how transmissible it is; however, casual contact does not appear to constitute a significant risk Dr Cillian De Gascun MD EUROTIMES | APRIL 2020

Wuhan, China, Dr Chang acknowledged.

Ophthalmologists are one of the more at-risk medical specialities for this new pathogen due to the close physical contact nature of their work, he said. Anecdotal reports suggest COVID-19 can cause conjunctivitis and possibly be transmitted by aerosol contact with conjunctiva, but this remains to be confirmed.

While official advice and protocols vary from country to country, the World Health Organization (WHO) has recommended using protection for the mouth, nose and eyes when caring for patients potentially infected with COVID-19, and self-isolation for 14 days for anyone suspected of being in contact with an infected person.

The European Centre for Disease Prevention and Control (ECDC) has also issued guidance documents on infection control and personal protective equipment (PPE) needs in healthcare settings where patients suspected/confirmed of COVID19 infection are being treated, as well as regular updates on the spread of the disease (www.ecdc.eu).

CATARACT & REFRACTIVE In addition, emerging data on the disease and patient studies are being shared by the international medical community, with findings being published instantly online in journals such as The Lancet.

Speaking to EuroTimes, Dr Cillian De Gascun MD, Medical Virologist and head of Ireland’s COVID-19 Expert Advisory Group, said healthcare professionals need to ensure good infection prevention and control practices as standard, and take appropriate contact and droplet precautions, particularly for direct contact with potential COVID-19infected patients.

“We’re still learning about this novel coronavirus and how transmissible it is; however, casual contact does not appear to constitute a significant risk. It seems to be, from the cases described in the literature, that close unprotected contact is the main risk factor for acquisition. Droplet transmission results from coughing, sneezing and contamination of the surrounding environment, including door handles and surfaces etc. as opposed to widespread community transmission,” he said, adding that there is no evidence at this point that the virus is airborne.

“So what doctors and hospitals need to do, first of all, is try to prevent contamination of surfaces, and infection of individuals so that means protecting the mucus membranes and good hand hygiene.”

Standard infection protection measures “do work and are effective” on SARS-CoV-2, and there is no evidence it is particularly resistant to existing decontamination methods, Dr De Gascun stressed.

EYE PROTECTION “As so often is the case, ophthalmologists often lead the way and in the case of this coronavirus it is interesting that it was an ophthalmologist who picked up the disease well ahead of anyone else and

sadly contracted the condition from an asymptomatic patient and later died,” Dr Sheraz Daya FRCOphth, Medical Director, Centre for Sight clinics, UK, told EuroTimes.

“We as ophthalmologists are at considerably high risk, considering we are in close proximity to patients when examining them and transmission can be through mucous membranes, including the eyes,” he said.

“I have been trying to figure out how perhaps to adapt a slit lamp and install a large protective barrier between the oculars and the examination stage. The small barrier that exists on some slit lamps is woefully inadequate.”

Dr Daya’s practice has been monitoring the international situation closely and following UK Department of Health guidance; ascertaining if patients are at risk of being infected with COVID-19 before they are seen. In countries dealing with serious outbreaks, “it makes sense for all coming into close contact [with patients] to wear eye protection and consider wearing effective face masks”, Dr Daya said.

In the meantime, Dr Chang said ophthalmologists working in private practice must also prepare for the potential financial implications of COVID-19, as in Hong Kong, procedures in his private clinic reduced drastically over the quarantine period in the region.

...ophthalmologists are at considerably high risk, considering we are in close proximity to patients when examining them...

Dr Sheraz Daya FRCOphth

*Figures correct at time of printing The European Society of Cataract and Refractive Surgeons (ESCRS) is also carefully monitoring the situation through the WHO website, in relation to guidance regarding its upcoming educational meetings. See http://bit.ly/ET-coronavirus Dr Cillian De Gascun: nvrldirectorsoffice@ucd.ie Dr John Chang: John.SM.Chang@hksh.com Dr Sheraz Daya: admin@centreforsight.com

SOME PRACTICAL TIPS FOR THE OPHTHALMOLOGIST: The Goldman applanator (not only the tip but also the black housing) can touch the patient’s mask or mouth and transmit the virus to the examiner, so care should be taken to avoid not touching the applanator housing and sterilise it every time it is used.

A large A4-sized clear plastic sheet made for book binding covers can be purchased from any stationary store and a hole can be cut to fit between the ocular and slit lamp. One of our Hong Kong ophthalmology colleagues used his old MRI scan and mounted it on to his slit lamp!

Sophi Experience #sophifamily

«What really differentiates Sophi is the attention to detail which makes the surgery even more pleasant for the surgeon, the staff and above all the patient.»

Ches Heredia MD Philippines

www.sophi.info EUROTIMES | APRIL 2020

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CATARACT & REFRACTIVE

PHACOEMULSIFICATION in vitrectomised eyes Phaco in eyes following previous vitrectomy surgery can be complicated. Soosan Jacob MD reports

A

dvances in safety and efficacy have increased the number of vitrectomies being performed.

Consequently, associated complications have also increased, one being cataract formation.

With a wide range of incidence (1280%) reported, we are increasingly called upon to perform cataract surgery in vitrectomised eyes. However, these eyes can be challenging because of conjunctival scarring, low scleral rigidity, greater collapsibility, deeper anterior chamber (AC), lens-iris diaphragm retropulsion syndrome (LIDRS), increased mobility of posterior capsule secondary to lack of vitreous support, zonulopathy, fluid misdirection syndrome, poorly dilating pupils, lax and fragile capsular bag etc.

In addition, they may have complications – either iatrogenic or secondary to the retinal pathology – such as endothelial loss, lens touch with compromised posterior capsule, glaucoma, diabetic/other retinopathy, optic neuropathy, cystoid macular oedema, risk for retinal redetachment etc.

These cases need careful management.

Proper counselling, review of previous medical and surgical records as well as a comprehensive eye evaluation for emulsified oil droplets in AC, zonulopathy, pupillary dilatation, specular count, anterior/posterior capsular plaques or evidence of lens touch under coaxial illumination with dilated pupil, thorough retinal examination, assessment of visual potential etc. is advisable. A B-scan is done if the cataract is dense.

AC depth. Extensive posterior segment pathology can cause a poor red reflex.

In eyes with anterior capsular fibrotic plaques, rhexis can be initiated with 26-gauge needle and/or micro-scissors.

Extensive/ peripheral plaques can be cut through with micro-scissors or vitrector while small, central plaques can be included within the rhexis.

Hydrodissection should be done carefully as unidentified lens touch/ broken posterior capsule from previous intravitreal injection/vitrectomy can result in nucleus drop. Cataract developing soon after the primary procedure should make one suspect presence of such a break and in such cases hydrodissection should be avoided. These eyes have a higher risk for anterior and posterior capsular tears and zonular dehiscence.

Other problems that are encountered include equatorial and zonular stretch and LIDRS on instilling viscoelastic or initiating irrigation. Increased AC volume causes reverse pupillary block by causing 360-degree irido-capsular contact. Young age and high myopic eyes compound this effect. Sudden backward movement and deepening of the AC causes discomfort to the patient if surgery is under topical anaesthesia. An excessively deep AC necessitates holding instruments more vertically and increases the range of focus required.

Reverse pupillary block can be neutralised by lifting the iris edge off the anterior capsule and allowing fluid to equilibrate between anterior and posterior chambers, thus bringing the iris, zonules and lens back to a more normal position. This manoeuvre

generally brings the pupil back to its original size, though miosis may sometimes occur because of prostaglandin release. The reverse pupillary block repeats on initiating infusion each time and should be tackled in a similar manner. It can be prevented by placing a rod between iris and anterior capsule each time before initiating infusion. Despite breaking the reverse pupillary block, instruments may still need to be placed more vertical than usual, leading to greater difficulty in nucleus removal and cortex aspiration techniques.

Repeated shallowing of the AC can increase the risk of retinal re-detachment.

New phaco machines with active fluidics help. In addition, the AC should be filled by injecting viscoelastic with the left hand before withdrawing the phaco or I/A probe.

For soft nuclei, prolapse and supra-capsular phacoemulsification is easier than in-thebag nuclear disassembly.

However, nuclear sclerosis is usually dense and horizontal chopping may exert the least stress on the bag and zonules. A posterior capsular plaque may necessitate capsular polishing, plaque peeling, posterior capsulorhexis or a deferred YAG capsulotomy.

IOL implantation should be done after filling the bag well with viscoelastic to prevent haptic snag on a lax capsule.

Proper wound closure should be ascertained at the end of surgery and if required, suture should be applied.

POST-OP COMPLICATIONS These include wound leak, increased inflammation, cystoid macular oedema, pseudophakic retinal detachment, silicone

TECHNIQUE Though experienced surgeons can use topical and intracameral lidocaine, peribulbar block may be preferred as surgery is expected to be more difficult. Wellconstructed incisions are important to avoid fluid leakage and fluctuations of EUROTIMES | APRIL 2020

Increased AC volume causes reverse pupillary block by causing 360-degree irido-capsular contact. Young age and high myopic eyes compound this effect

CATARACT & REFRACTIVE oil migration to the AC, IOL calculation errors, late in-the-bag IOL subluxation etc. Postoperative retinal examination is important. Macular or other retinal pathology may limit postoperative visual acuity attained.

CHOICE OF IOL Silicone IOLs should be avoided in eyes that have undergone previous vitrectomy or that may require vitrectomy in the future as silicone oil may stick to its surface.

Both hydrophobic and hydrophilic IOLs are suitable, with hydrophilic being least prone to adhesion of silicone oil.

Hydrophobic IOLs are preferred with compromised corneal endothelium as hydrophilic IOLs can opacify secondary to air tamponade used in endothelial keratoplasty. PMMA IOLs are also acceptable.

Three-piece foldable IOLs are easily amenable to closed chamber translocation to glued IOL if progressive zonulopathy causes IOL subluxation/ dislocation.

In-the-bag single-piece acrylic IOLs may also be refixated using sutured segments or the sutureless glued capsular hook technique described by the author. Platehaptic IOLs should be avoided. Large optic IOLs that allow unhindered view of the retina is preferred. hacoemulsification may be planned together with silicone oil removal, often about six months after the vitrectomy.

Ultrasound biometry gives errors in axial length measurement and optical biometry should be done after selecting “silicone

Fig: Light refraction in a silicone oil-filled eye: A: In phakic and pseudophakic eyes, silicone oil forms a concave meniscus (green arc) with posterior lens/IOL surface, causing light rays to diverge from their normal path (dotted white line) to focus behind the retina (yellow); B: In aphakic eyes, silicone oil forms a convex meniscus (green arc), causing light rays to converge from their normal aphakic path (dotted orange line) to focus slightly earlier (yellow), though still behind the retina. In both scenarios in a normal dimensioned eye, a hyperopic refractive error is generally seen. Abbreviations: C- Cornea; I- Iris, L- Lens; Si- Silicone oil; R- Retina

oil” mode for IOL power calculation. If silicone oil is not removed, the shape of the posterior surface of the IOL is important as the meniscus formed by silicone oil can result in refractive surprises.

An IOL with plano posterior surface is preferable, but not easily available. With a biconvex IOL, silicone oil acts as a negative lens and alters IOL power by 3-to-5 dioptres. The hyperopic error gets corrected, however, once the silicone oil is removed.

Interim management is with glasses, contact lens or even a piggyback IOL. To conclude, though these cataracts are

more challenging, they can be handled.

Combined cataract with vitrectomy can be considered in the first stage itself, especially in patients with risk factors for developing cataract, such as older age, pre-existing nuclear sclerosis, diabetic retinopathy and if silicone oil or intraocular gas are being considered.

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

Grow Your Practice Through Innovation Win a €1,500 Bursary

ESCRS Practice Management and Development Innovation Award Submission Deadline Friday 24 July 2020

ESCRS

For further details email: innovation@escrs.org

Practice Management

& Development

EUROTIMES | APRIL 2020

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CATARACT & REFRACTIVE

Relaxing the surgeon Conscious breathing improves performance when under pressure.

Roibeard Ó hÉineacháin reports

W

hether free-diving in arctic waters without a wetsuit or dealing with an unexpected surgical complication, conscious breath control can prevent panic and help ensure a successful outcome, said Stig Severinsen MSc, PhD, at the 37th Congress of the ESCRS in Paris, France.

“Instead of saying ‘stop and think’ we should ‘say stop, breathe and think’,” said Dr Severinsen, who is the four-time world free-diving champion and holds several free-diving world records, his most recent being in Greenland where he swam 250 feet under the ice wearing only swimming trunks and goggles. He is also founder of the Breatheology institute and in his work life teaches conscious breathing to people in a broad range of professions.

He noted that like the sharpshooters from the Navy SEALs and the Danish Royal Air Force fighter pilots he works

with, surgeons are highly trained and RELAX ON DEMAND highly skilled professionals who have to One of the easiest and most useful conscious be very sharp and precise while under breathing techniques is called 1:2 breathing, extreme pressure. But the most important Dr Severinsen said. It involves four separate thing he teaches his students is how to phases starting with a long inhalation, relax through conscious breathing only through the nose, pausing for a techniques, he said. moment and then exhaling slowly He pointed out that people through the mouth in a manner breathe 40,000 times a day, akin to a sigh, then pausing again yet the importance of how and then repeating the exercise. we breathe is one of the most A variation of the technique overlooked aspects of dealing called “warrior breath” involves with stressful situations. also making a sound by directing That is because breathing is an air forcefully against the top of the unconscious, automatic exercise. Stig Severinsen throat while exhaling.

MSc, PhD Yet breathing is much easier to Stressful breathing, meanwhile, control than are our conscious thought has only two phases, in and out. In most processes, particularly when under cases, people breathe through the mouth, situations where one might panic. Under which increases the pressure on the chest and such circumstances, conscious breathing heart, raising the blood pressure and heart can reset the mind, allowing a more rate, amplifying the body’s stress response. measured and rational response to the However, conscious breathing can reverse difficulty at hand. that cascade, lowering blood pressure and

Instead of saying ‘stop and think’ we should ‘say stop, breathe and think’ Stig Severinsen MSc, PhD

CALL FOR ENTRIES

triggering the release of oxytocin, serotonin and dopamine. These changes allow the surgeon to regain control of the situation and take appropriate action, rather than responding on impulse, Dr Severinsen said. www.breatheology.com

JOHN HENAHAN

PRIZE 2020

Young ophthalmologists are invited to write an 800-word essay on

“Will Clinicians Be Replaced By A Robot To Perform Cataract Surgery?”

The prize is a travel bursary worth €1,000 to attend the 38th Congress of the ESCRS in Amsterdam,The Netherlands

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

EUROTIMES | APRIL 2020

CATARACT & REFRACTIVE

THOMAS KOHNEN European Editor of JCRS

JCRS HIGHLIGHTS VOL: 46 ISSUE: 2 MONTH: FEBRUARY 2020

EDOF EVOLUTION Several extended depth-of-focus (EDOF) IOLs are being developed to bridge the current clinical shortcomings between monofocal and multifocal IOLs. The primary objectives are to provide improved visual acuity at intermediate distances with fewer or less severe visual disturbances and better contrast sensitivity. A review article describes the four main types of EDOF IOL and provides information on the clinical experiences with the technology. The four EDOF technologies now in the clinic include: small-aperture design IOLs; bioanalogic IOLs; diffractive optics; and non-diffractive optical manipulations. The article notes that in general EDOF IOLs provide good-to-excellent visual acuity at distance, improved intermediate visual acuity compared with monofocal IOLs and functional near visual acuity. T Kohnen et al., Extended depth-of-focus technology in intraocular lenses, Volume 46, #2, pp 298-304

ˆ ˆ

JCRS is the official journal of ESCRS and ASCRS

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An analysis from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) suggests good news and bad news on the issue of dropped nucleus. The analysis of 1,715,348 cases revealed a rate of dropped nucleus of 0.071%.

White cataract, previous vitrectomy, poor preoperative visual acuity, small pupil, pseudoexfoliation, diabetic retinopathy and male sex were significantly related to dropped nucleus. The bad news – eyes with the complication of a dropped nucleus also had a poorer visual and refractive outcome compared with eyes with existing risk factors but no such complication. The good news – the overall rate of dropped nucleus showed a significant trend of decreasing occurrence over time. M LundstrĂśm et al., “Risk factors for dropped nucleus in cataract surgery as reflected by the European Registry of Quality Outcomes for Cataract and Refractive Surgeryâ€?, Volume 46, #2, pp 287-292.

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The healthcare sector is one of the largest contributors to greenhouse gas emissions. And with cataract surgery accounting for a large percentage of surgeries performed worldwide, efforts are under way to reduce its associated waste. Malaysian researchers conducted a prospective study of waste associated with 203 phacoemulsification cataract procedures. The total waste produced was 167.965 kg, of which 56.6% was clinical waste, 37.6% was general waste and 5.8% was sharps. A little over half of the general waste was recyclable. Trainees produced significantly more waste than experienced surgeons. The researchers suggest that increasing the efficiency of resource use and extending the useful life of products would help reduce waste production, while immediate sequential bilateral cataract surgery could improve efficiency. HG Khor et al., “Waste production from phacoemulsification surgery�, Volume 46, #2, pp 215-221.

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’ ˆ “ ”•–”— ˜™˜™ EUROTIMES | APRIL 2020

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CORNEA

DMEK vs DSAEK studies continue Trial finds DMEK and UT-DSAEK achieve broadly similar visual outcomes. Dermot McGrath reports

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

Join

the ECCTR Registry

Track

your Surgical Results

www.ecctr.org ECCTR is a project funded by the ESCRS with initial support from the EU

D

escemet Membrane Endothelial Keratoplasty (DMEK) and ultrathin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) achieved broadly similar visual outcomes but with a higher complication rate for DMEK, according to the results of a multi-centre randomised controlled trial presented at the 10th EuCornea congress.

“We found no significant difference in mean postoperative visual acuity one year after surgery, although a higher proportion of DMEK patients attained better visual acuity. The endothelial cell loss was comparable after both techniques, stabilising after three months. However, there were more complications following DMEK in terms of re-bubbling and re-grafts,” said Mor Dickman MD, PhD, University Eye Clinic, Maastricht University Medical Center, Netherlands, who presented the study outcomes.

Dr Dickman noted that DMEK procedures have been steadily increasing in recent years in both the US and Europe. Data from the Eye Bank Association of America showed that there was a slight decrease in DSAEK numbers in each of the past three years, whereas DMEK increased 64% in 2015 and 37.6% in 2016.

“All the data shows that DMEK procedures are increasing while DSAEK remains more or less the same, so this means we are operating more, and that the threshold to operate has decreased,” he said.

REPORTED ADVANTAGES Carried out at six clinics in the Netherlands, the prospective randomised study compared best-corrected visual acuity, endothelial cell density and complications after DMEK and UT-DSAEK in 54 eyes of 54 patients with Fuchs’ endothelial corneal dystrophy (FECD).

“We really wanted to assess the reported advantages of DMEK versus those of UT-DSAEK. DMEK is widely considered to offer better visual recovery, less graft rejections, potentially shorter surgery time and a neutral refractive procedure. The perceived advantages of UT-DSAEK, at least when one has good experience with the technique, are less graft detachments and less graft failures, a short learning curve, and it works well in complex eyes,” he said.

The study included patients with FECD, 21 years or older who had already undergone cataract surgery. Only one eye was treated in the study and all grafts were pre-cut and prestripped from the same eye bank. Preoperative visual acuity, age and donor endothelial cell density were closely matched for both treatment arms.

There was no statistically significant difference in mean postoperative visual acuity between DMEK and UT-DSAEK after 12 months follow-up. However, a higher proportion of DMEK patients attained better visual acuity outcomes, said Dr Dickman.

Patients treated with DMEK also experienced faster recovery of contrast sensitivity and straylight symptoms, while there was no statistical difference in total corneal aberrations or visionrelated quality of life outcomes. The results of a cost-effectiveness analysis comparing both techniques are expected next year.

Mor Dickman: mor.dickman@mumc.nl

EUROTIMES | APRIL 2020

CORNEA

Corneal measurements Total corneal measurements with swept-source OCT and Scheimpflug camera repeatable but not interchangeable. Roibeard Ó hÉineacháin reports

T

he total corneal refractive power (TCRP) measurements of the Pentacam Scheimpflug camera and the total corneal power measurements (TK) of the IOLMaster (ZEISS) swept-source ocular coherence tomographer (OCT) both have high repeatability but cannot be used interchangeably, reports Mehdi Shajari MD, Ludwig Maximilians University Hospital, Munich, Germany.

Dr Shajari noted that, like the Scheimpflug imaging, the recently introduced optical biometer, the IOLMaster 700, can measure the total corneal power. He and his associates conducted a study to evaluate the repeatability and validity of TK compared to TCRP measurements of the Pentacam.

During the 37th Congress of the ESCRS in Paris, France, he described a prospective randomised controlled trial that measured 94 eyes of 94 patients three times with the IOLMaster 700 sweptsource optical biometer, and three times with the Pentacam (Oculus) Mehdi Shajari MD Scheimpflug camera.

Repeatability of both instruments was high although meridians show great variability, suggesting numerous measurements must be made

The investigators took the measurements in a random order.

None of the patients had irregular corneas, previous corneal surgery or dry eyes. Also excluded were eyes with corneal astigmatism above 3.0D. They then compared TK values obtained with the IOLMaster 700 to standard K obtained with the same device, and to SimK, total corneal refractive power and the true net power (TNP) values obtained with the Scheimpflug device. They analysed repeatability by calculating the within-subject standard deviations and analysed the validity of the optical biometer measurements by Bland Altman Analysis, Dr Shajari explained.

They found that repeatability was 0.4 for TK, 0.42 for standard K, 0.45 for TCRP, 0.43 for TNP and 0.56 for SimK. Bland-Altman analysis revealed no significant difference between standard K and TK (p=0.193), with a mean difference of -0.047D and coefficient of repeatability of 0.326. However, they found a significant difference when comparing TK to TCRP with a mean difference of 0.018D and coefficient of repeatability of 0.612 (p=0.001).

Moreover, they found a difference greater than 0.5D between the TK and TCRP astigmatism values in 11 cases. The closest correspondence between the two devices regarding the astigmatism values was between the mean astigmatism vectors of TK and TNP (0.01 @ 3 degrees).

“Repeatability of both instruments was high although meridians show great variability, suggesting numerous measurements must be made. In addition, total corneal refractive power measurements between the recently introduced TK and TCRP cannot be used interchangeably. It is always best to stick to one device,” Dr Shajari concluded.

Mehdi Shajari: mshajari@med.lmu.de

Convenient

Web-Based Registry

Cataract, Refractive and Patient Reported Outcomes in One Platform

Join

the EUREQUO Platform

Track

your Surgical Results

www.eurequo.org

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

EUREQUO is free of charge for all ESCRS members

EUROTIMES | APRIL 2020

17

11th EuCornea Congress

AMSTERDAM 2 – 3 October 2020 RAI Amsterdam, The Netherlands

Hotel Bookings Open www.eucornea.org

CORNEA

Laser technique for keratoconus Femtolaser circular keratotomy shows promise for early-stage keratoconus.

Dermot McGrath reports

F

emtosecond-laser induced circular keratotomy (FSCKT) seems to be safe and effective in halting the progression of early-stage keratoconus and may provide a viable alternative to corneal collagen cross-linking (CXL) in patients contraindicated for that procedure, according to a study presented at the 37th Congress of the ESCRS in Paris.

“Our three-year results indicate that FSCKT is effective in stopping the progression of keratoconus of stage I and II in nine of 10 eyes. The mean visual acuity, corneal thickness and keratometric values all remained stable over the follow-up period,” said Detlev Breyer MD, owner and leading anterior segment surgeon, Breyer-KaymakKlabe Augenchirurgie, Düsseldorf, Germany.

Dr Breyer’s retrospective study included 10 eyes treated with FSCKT, 114 eyes with CXL and 85 eyes with iontophoresis-assisted corneal crosslinking (ICXL). The analysis of results included follow-up of up to five years for FSCKT and CXL and one year for ICXL. The surgical technique for FSCKT is essentially a refinement of circular keratotomy, with the penetrating dissection made with a proprietary femtosecond laser (Femto LDV Z6, Ziemer) instead of a trephine knife.

“The idea is to use the laser to create an intrastromal cut but without perforating either Bowman’s layer or Descemet’s membrane in order to create a circular scar that stabilises the corneal surface. The desired effect is an intrastromal scar, which acts like a stabilising ring. The advantages of this approach are that it is sutureless and faster than manual keratotomy, with minimal risk of infection and greater comfort for the patient,” he said.

Detlev Breyer MD

The study also sought to assess the outcomes of iontophoresis-assisted corneal cross-linking, an epithelium-on approach that increases the absorption of riboflavin into the corneal stroma with a non-invasive delivery system via a small electric current.

“The main advantage of this approach is that the epithelium remains intact, the patients don’t experience pain and there is no risk of infection. So, if it would work it would be a clear improvement on conventional CXL,” said Dr Breyer.

In terms of results, one eye initially treated with FSCKT displayed progressing keratoconus and was retreated with CXL. In the CXL-group, the outcomes remained stable or improved, whereas the

Our three-year results indicate that FSCKT is effective in stopping the progression of keratoconus of stage I and II in nine of 10 eyes Detlev Breyer MD

The main advantage of this approach is that the epithelium remains intact, the patients don’t experience pain and there is no risk of infection Detlev Breyer MD first results for ICXL turned out to be less effective at halting the progression.

“Therefore, we regard it as a proper alternative to CXL only for early stages of keratoconus. For FSCKT the results are promising but we need outcomes in more eyes with a longer follow-up to determine the safety and efficacy of the procedure and the longevity of keratoconus stabilisation,” he concluded.

Detlev Breyer: d.breyer@augenchirurgie.clinic EUROTIMES | APRIL 2020

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MEETING REPORT

24 th ESCRS Winter Meeting

M arrakech Building a bridge History was made in Marrakech, Morocco as the ESCRS convened its Winter Meeting outside of Europe for the first time

T

he 24th ESCRS Winter Meeting attracted more than 1,970 delegates from 78 different countries, including more than 700 delegates from the host country Morocco.

“We are delighted to be holding our Meeting on the African continent for the first time and to be joined by our colleagues from SAMIR, the Moroccan Society of Implant & Refractive Surgery,” said Professor Rudy MMA Nuijts, President, ESCRS. “Our past President Professor Béatrice Cochener-Lamard is to be congratulated for taking this initiative to be the bridge between European and African ophthalmology,” said Prof Nuijts.

“SAMIR and the Pan Arab Refractive Council have made a significant contribution to the scientific programme and I would like to thank all involved for their time and support. I would also like to thank the SAMIR President, Dr Abdelfettah Benkirane, and Professor Mouhcine El Bakkali for their continuous efforts and valued support,” he said.

The scientific programme was very well attended with highlights including Cornea Day, organised in conjunction with EuCornea, the Young Ophthalmologists Programme and didactic courses in Cornea, Basic Optics, Cataract and Refractive Surgery and the ESONT Didactic EUROTIMES | APRIL 2020

SAMIR President Abdelfettah Benkirane, ESCRS past President Béatrice Cochener-Lamard, ESCRS President Rudy MMA Nuijts, and SAMIR past President Dr Mouhcine El Bakkali at the 24th ESCRS Winter Meeting in Marrakech, Morocco

Day, organised by the European Society of Ophthalmic Nurses and Technicians.

Other highlights included four Main Symposia, a range of Surgical Skills Training Courses, Instructional Courses, Free Paper and Moderated Poster Sessions, and a Near Live Surgery Session organised by SAMIR, and Symposia organised by SAMIR and the Pan Arab Refractive Council.

POSTER PRIZES A prize of €1,000 was awarded for the Meeting’s best Cataract and Refractive Poster presentations.

The prize in the Refractive category went to Emilio Torres-Netto, Switzerland, for his poster ‘Stromal bed smoothness after excimer laser surface ablation as a key element for the expression of inflammatory genes’.

The prize in the Cataract category went to Chaimae Khodriss, Morocco, for her poster ‘When we forget the

essentials: About an unexpected corneal complication of cataract surgery’.

CASE PRESENTATIONS The best cases in each of the four sections of the ESCRS/EuCornea Cornea Day were awarded with a certificate for their winning case presentations.These were Mounia Ait Al Jazzar, Myrsini Petrelli, Prateek Agarwal and Nienke Visser.

“With so much on offer, it would have been impossible to attend every session.

However, if you log on to the Education Portal on the ESCRS website, you can access the sessions and didactic courses on ESCRS On Demand and ESCRS iLearn, as well as discover a wide range of video content and other materials.

“I hope you found the Meeting beneficial and rewarding, and I look forward to seeing you in Amsterdam at the 38th Congress of the ESCRS in October,” said Prof Nuijts.

MEETING REPORT

EUROTIMES | APRIL 2020

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RETINA

AMD and diet Eating fish and a Mediterranean diet may slow progression.

Howard Larkin reports

E

ating a Mediterranean diet, particularly a lot of fish, may be beneficial for those with early or even intermediate age-related macular degeneration (AMD), said Emily Y Chew MD in her Jackson Memorial Lecture at AAO 2019 in San Francisco, USA. Research shows that a diet high in fish can reduce the chances of developing late AMD by 65% for patients who also have protective genes, Dr Chew said. In the general AMD population, a high fish diet reduced progression of intermediate AMD, with bilateral large drusen, to geographic atrophy by 31%. High adherence to a Mediterranean diet reduced progression from intermediate to late AMD, with geographic atrophy or neovascularisation, by 25-to-40%.

A Mediterranean diet was defined as one high in fruits, vegetables, nuts and legumes, moderate in fish, white meat and whole grains, moderate-to-low in alcohol and low in red meat and refined sugar, with a high ratio of mono-unsaturated to saturated fat intake. As well as reducing progression from intermediate to late AMD, it also reduced progression from the small drusen of early AMD to large drusen of intermediate disease. “It’s never too late to start,” she said.

GENES AND AMD RISK The findings Dr Chew presented are based on data from 7,765 patients without baseline late AMD from the landmark Age-Related Eye Diseases (AREDS) and AREDS2 studies, supplemented by diet surveys, and analysis of patient records, retinal images and genetic tests of patients followed for 10 years each.

A study team including researchers from the University of Pittsburgh, the US National Eye Institute, the Oregon Health and Science University and the University of Michigan combined these data with findings from previous large-scale studies of the genetics of AMD to assess the effects of genetics on AMD progression, and to develop and test prediction models that include genetic data as well as other AMD risk factors, Dr Chew said.

The AREDS/AREDS2 analysis confirmed earlier findings that the gene for complement factor H (CFH) on chromosome 1 was associated with greatly increased risk of drusen formation, while ARMS2 on chromosome 10 is associated with haemorrhage and poor visual acuity (Ophthalmology 2018;125(4):559-568).

An earlier study by the AMD Gene Consortium found these two genes accounted for 60% of hereditary AMD risk, and these were included with another 50 previously identified AMD genetic risk markers in a genetic risk score tool (Nat Genet 2016;48:134143). The AREDS/AREDS2 analysis identified additional AMD genetic risk alleles, Dr Chew said.

These analyses are important for research and understanding the pathways of AMD progression, Dr Chew said. But are they clinically useful? To find out, the group tested several AMD progression prediction models with and without a genetic risk score. Other factors in the models were baseline age, education, smoking status and baseline AMD severity scores in both the study and fellow eyes.

The most powerful predictors turned out to be baseline severity scores for both the study and fellow eyes, with genetic risk scores only minimally improving performance when added to such a model. (Genetics 2017;206:119-133) The results “point to the importance of an eye exam”, Dr Chew said.

No interaction was observed between genetic factors and a Mediterranean diet for AMD progression, Dr Chew said. However, for patients with a protective gene for CFH, consumption of fish was EUROTIMES | APRIL 2020

Emily Chew MD receives the Jackson Memorial Lecture Award from Richard K Parrish II MD

strongly associated with reduced AMD progression risk. Even low fish intake reduced risk of progression from intermediate AMD to geographic atrophy by 50%, while high fish intake reduced it 65%.

While these findings are important for research, Dr Chew sees little clinical use for genetic testing for AMD. Commercial gene testing services offer AMD gene evaluations, but no prospective data support testing for predicting progression or response to therapies, or for dietary recommendations. For these reasons the AAO does not recommend genetic testing for AMD, she said.

AI AND AMD The Simplified Severity Scale developed through AREDS classifies the severity and risk of progression to late AMD on a person level based on the presence of large drusen, pigmentary changes and neovascularisation or geographic atrophy in fundus images of both eyes. However, it requires expert analysis by retinal specialists.

To broaden access to AMD screening, NEI researchers harnessed AI to automate analysis, Dr Chew said. Based on a training set of more than 58,000 AREDS images, the DeepSeeNet project developed deep learning neural networks to assess each of the three image subgroups; drusen, pigmentary changes and late AMD. In a test of 900 images, DeepSeeNet was more accurate in detecting drusen and pigmentary changes and only slightly less accurate in detecting late AMD than an AREDS retinal specialist panel assessing the same images, Dr Chew said. (Ophthalmology 2019;126:565-575) She believes DeepSeeNet’s accuracy in detecting late AMD will improve with more training images and is likely to surpass human readers. Dr Chew does not see deep learning systems replacing ophthalmologists, but they may soon improve diagnosis and clinical management.

“We highlight the potential for this system in enhancing decision-making in AMD,” she concluded.

Emily Chew: echew@nei.nih.gov

th

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RETINA

Is AMD linked to medication risk?

No demonstrable risk found in common medications.

Leigh Spielberg MD reports

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here is no strong evidence for an association between the use of systemic medications and the occurrence of age-related macular degeneration (AMD), Vincent Daien MD, PhD, told delegates at the 19th EURETINA Congress in Paris, France, during a session on the epidemiology of retinal disease.

Many studies have been performed on both the potential risks of medications as well as their protective effects regarding AMD. Dr Daien presented his own research at the conference.

One large study pooled data from the Beaver Dam Eye Study (n=3,012), the Rotterdam Eye Study (n=3,434) and the Blue Mountains Eye Study (n=2,203). Despite the vast number of patients analysed in this meta-analysis, the study showed no strong associations between medications and early AMD, said Dr Daien, Chief of Ophthalmology, Montpellier University Hospital, France.

Investigations have found no increased risk associated with the use of aspirin, L-thyroxine or beta-blockers, all of which were suspected to possibly increase the relative risk.

Nor have there been protective effects identified in medications such as statins and anti-inflammatory treatments.

“Regarding statins, the evidence was insufficient to come to a reliable conclusion,” said Dr Daien.

The anti-inflammatory effect of NSAIDs on AMD has also been investigated.

“Although basic research that identified the role of inflammation in the early pathogenesis of AMD had led us to assume that that NSAID use might lower the risk of neovascular AMD, this does not seem to be the case,” said Dr Daien.

He continued: “Although anticholinergic use has been associated with cognitive disorders, and cognitive disorders Vincent Daien MD, PhD are associated with AMD, there is no apparent link between anticholinergic drug use and AMD.” It must be remembered that these studies are difficult to design and carry out. There are many confounding factors, including differentiating between the effect of a medication and the effect of the systemic disease, which might in itself be associated with AMD or its progression, he explained.

For example, if there were an association discovered between beta-blocker use and AMD, might this not potentially be caused by the underlying arterial hypertension, rather than the beta-blocker? The same thing could be said for the inflammatory disease for which NSAIDs are used, or the hyperthyroidism for which L-thyroxine is prescribed.

In conclusion, there is not much concern regarding systemic medication intake, and so patients need not worry that the medications that they have been prescribed by other physicians might adversely affect their retinal health.

Regarding statins, the evidence was insufficient to come to a reliable conclusion

Vincent Daien: v-daien@chu-montpellier.fr EUROTIMES | APRIL 2020

RETINA

25

Robotic surgery Robotic tools and systems hold promise for targeted drug delivery within the eye. Dermot McGrath reports The first approved robotic device on the market, the Preceyes Surgical System, has been successfully deployed to perform epiretinal peeling on human patients. Earlier this year the device received CE mark approval to assist surgeons during vitreoretinal surgical tasks under local or general anaesthesia.

Another company, Ophthorobotics AG, has been focusing its attention on intravitreal injections, developing a fully automated system for safe and highly precise injections into the eye, noted Mr Charreyon.

A magnetically-steered microcannula for performing subretinal injections The technology utilises specific sensors to identify and track patients’ eyes, performs automatic “This is interesting in ophthalmology intravitreal injections, and features a sterile because it allows us to build tools that laminar airflow for reduced risk of infection. are much smaller and more flexible than Patients can be prepared by the nursing staff, conventional rigid tools for increased and the injections are remotely controlled safety,” he said. and monitored by the treating physician Possible applications for the catheter from another examination room or office, include subretinal delivery of drugs, allowing for a larger patient throughput. gene therapies, or stem cells for retinal “The demand for intravitreal injections regeneration, autonomous navigation of a has increased over the past 10 years due to laser tool for treating diabetic retinopathy the availability of new drugs, but also an (DR) or safer epiretinal membrane peeling. ageing population. This type of system will “For drug delivery, this tool would allow potentially increase throughput for clinics the surgeon to precisely navigate to a while increasing the comfort of the patients desired location, hold the device in place, and decreasing the cost of care,” he said. monitor it with OCT and then create this Another new technology being developed subretinal bleb into which therapies are at ETH Zurich is the magnetic steerable injected,” he said. catheter, which could have some exciting For DR treatments, the catheter could be applications in ophthalmology, said Mr connected to a laser and steered to multiple Charreyon. Unlike a conventional catheter, points on the retina to perform a type of which is steered manually, the magnetic targeted photocoagulation treatment. version is operated from a computer via Another more futuristic application of an external magnetic field. This enables the the technology is the deployment of ocular front part of the catheter to be bent in any microrobots – tiny, untethered devices direction with the highest level of precision. that can be controlled inside the eye using magnetic forces.

“This could be used for many applications, including loading drugs, by steering it to a desired location and performing slow release of the drugs before it is retrieved from the eye,” he said.

Courtesy of Samuel Charreyon MSc

A

lthough eye surgery is currently lagging behind other fields of medicine in the use of robotic technology, the indications are that automated devices may soon be deployed for a range of applications such as intravitreal injections, epiretinal peeling or targeted drug delivery inside the eye, Samuel Charreyon MSc told delegates attending a symposium of artificial intelligence at the 37th Congress of the ESCRS in Paris, France.

“We have seen two decades of research in robots for eye surgery but there is only one robot that has so far been approved for commercial use and it still needs to prove that it is useful enough to be adopted for standard use in ophthalmology. So, while there is clearly some way to go in eye surgery robotics in general, we are now seeing some interesting technological solutions emerging from the lab that may have a role to play in the ophthalmic field in the near future,” he said.

There is a clear case to be made in terms of robotic surgery filling an unmet need in ophthalmology, particularly given the miniscule scale of the tissue structures encountered, said Mr Charreyon, a researcher at the Multi-Scale Robotics Lab at the ETH Zurich University in Switzerland.

“Eye surgery requires phenomenal dexterity where we are talking about precision needs that are measured in microns. Hand tremor is a real concern for the precision and accuracy of tissue manipulation. Robotics can offer increased dexterity and stability, and possibly also some sensing and feedback to be given to the surgeon,” he said.

He explained that robotic systems for surgery fall into two broad categories in terms of control paradigms: co-manipulation and tele-manipulation. The former approach is where the surgeon physically manipulates the robot, while in the latter scenario the surgeon is completely decoupled from the robot and interacts with it through a console or joystick.

Eye surgery requires phenomenal dexterity where we are talking about precision needs that are measured in microns Samuel Charreyon MSc

Samuel Charreyon: samuelch@ethz.ch EUROTIMES | APRIL 2020

26

RETINA

Multimodal imaging Histology and multimodal imaging combination valuable in macular pathology.

Dermot McGrath reports

W

hen combined with histology, multimodal imaging has the potential to shed light on previously unelucidated or poorly understood anatomical features and disease mechanisms in agerelated macular degeneration, according to Rosa Dolz-Marco MD, PhD, FEBO. “We are fortunate in that we now have a lot of imaging modalities with which to analyse our patients in detail. We can learn a lot from these images, but even more so when we can correlate them with histology to help us explain things we do not understand with imaging alone. The two approaches complement each other and help to fill in the information that we are lacking,” she told delegates attending the Young Ophthalmologists Programme at the 19th EURETINA Congress in Paris.

Dr Dolz-Marco, Oftalvist Clinic, Valencia, Spain, highlighted a number of areas in which histology combined with multimodal imaging has helped to answer some important questions concerning AMD and disease progression as part of a research project conducted by Dr Christine A. Curcio in the University of Alabama, and Dr K Bailey Freund at Vitreous Retina Macula Consultants of New York.

In macular atrophy, she noted that conventional thinking has been that choroidal hyper-transmission on OCT scans always correlated with the area of retinal pigment epithelium (RPE) atrophy.

“OCT certainly provides us with valuable 3D information and enables us to detect early changes or signs of neovascularisation.

In histology, however, the RPE does not always end in a clearly defined border, but the external limiting membrane (ELM) ends in a curved line that delimits the area of photoreceptor atrophy,” she said.

This curve or descent of the ELM, corresponding to the histologic border of photoreceptor atrophy, may serve as a useful marker of photoreceptor atrophy, she said.

“To determine ELM descent on OCT we need high-quality scans because they will not be visible on low-quality images,” she said.

In further studies, Dr Dolz-Marco and her co-workers were able to identify clear steps in outer retinal tubulation (ORT) formation by tracking the ELM descent and classifying its shape (flat, curved, reflected and scrolled) at the border of outer retinal and RPE atrophy.

“This helped us to understand progressive steps in the development of ORT and to hypothesise that scrolling EUROTIMES | APRIL 2020

Rosa Dolz-Marco MD, PhD, FEBO

ORT is usually a point of no return in order to develop advanced neurodegeneration of the macula with involvement of Muller cells. This kind of marker could be useful going forward in clinical trials in patients with macular atrophy,” she said.

Histology matched with OCT B-scans also proved valuable in revealing tissue features in geographic atrophy in an 86-year-old female patient, said Dr Dolz-Marco.

“The questions we wanted to answer in terms of the OCT scans related to the hyperreflective plaques over Bruch’s membrane, the presence of hyporeflective drusen and the hyporeflective wedgeshape,” she said.

The researchers concluded that the hyporeflective wedge shape corresponded to a reorganisation of Henle's fibre layer (HFL) and the outer nuclear layer (ONL), while the hyperreflective plaques located above Bruch’s membrane corresponded to cholesterol crystals. Finally, the hyporeflective drusen corresponded to multilobular

We are fortunate in that we now have a lot of imaging modalities with which to analyse our patients in detail Rosa Dolz-Marco MD, PhD, FEBO

calcific nodules, signifying the end stage of soft drusen and a marker for progression to geographic atrophy, she said.

Although not directly correlated with histology, multimodal imaging has also led to important new findings such as the choroidal caverns first described by Giuseppe Querques, said Dr Dolz-Marco.

Found relatively infrequently in eyes with geographic atrophy, the caverns appear as gaping angular hyporeflective cavities in areas devoid of choroidal vessels, often with punctate/linear hyperreflectivities internally.

“The choroidal caverns are nonreflective spherical structures within the choroid with a posterior tail of hypertransmission with no evidence of flow signal on OCT-A and they match the lipid globules described by Friedman, which are extracellular, extravascular lipid in normal and AMD eyes, and are primarily choroidal but also located within neovascular membranes and sclera,” she said.

Histology allied to multimodal imaging also proved valuable in the case of an 84-year-old man with exudative aneurysmal type 1 (AT1) neovascularisation and haemorrhage secondary to age-related macular degeneration (AMD).

“We were able to show that in aneurysmal type 1 neovascularisation, the neovascularisation was located in the sub RPE-basal lamina space and has a choroidal origin,” she concluded.

Rosa Dolz-Marco: rosadolzmarco@gmail.com

RETINA

AI and AMD AI’s ‘huge potential’ in AMD screening and management.

Dermot McGrath reports

A

rtificial intelligence (AI) and big data analysis hold enormous potential to improve screening and monitoring of age-related macular degeneration (AMD) and to assist with automated detection and identification of the disease, according to Anat Loewenstein MD. “Artificial intelligence can also help to reduce the burden of repeated visits to the clinic and provide predictability for various treatment options,” she told delegates attending the 37th Congress of the ESCRS in Paris, France.

Dr Loewenstein, Director of the Department of Ophthalmology at the Tel Aviv Medical Center, Tel Aviv, Israel, noted that the development of AI technology in the field of ophthalmology has been particularly swift and successful compared to other domains of medicine.

“Similar to radiology, ophthalmology is largely based on the visual identification of images, which lends itself well to machine learning solutions. In retinal disease, AMD and diabetic retinopathy (DR) are common diseases with elaborate imaging that allows for large training datasets to be applied,” she said.

There is an urgent need to leverage technology to help with the growing incidence of AMD worldwide, said Dr Loewenstein, noting that the introduction of anti-VEGF agents in the mid2000s radically transformed the management of neovascular AMD and greatly reduced the incidence of severe vision loss associated with the disease, she said.

With spectral domain optical coherence tomography (SD-OCT) widely available and representing the current gold standard in diagnostic imaging in the management of the most common macular diseases, the key problem for clinicians lies in processing and interpreting increasing volumes of data on a daily basis, said Dr Loewenstein.

This is where AI and machine learning applications can make a discernible difference in screening images for the development of choroidal neovascularisation and to help relieve the burden from monitoring and treatment, she said.

The potential applications of AI in AMD can be broadly divided into three categories, said Dr Loewenstein: automated classification, automated segmentation and disease prediction.

In terms of classification and screening, she cited the work of Ting et al., who used almost 500,000 images from different screening initiatives to develop and evaluate a deep learning system for detection of glaucoma, AMD and DR with a specificity of over 90% for glaucoma and DR and almost 89% for AMD. Another successful example is the DeepMind AI system, which can recommend the correct referral decision – urgent, semi-urgent, routine referral or observation only – for a wide range of retinal pathologies, said Dr Loewenstein.

“Crucially, the system did not miss a single urgent case for referral in the cases of 1,000 patients, which really underscores the positive effect and potential Anat Loewenstein MD

Similar to radiology, ophthalmology is largely based on the visual identification of images

Anat Loewenstein MD

for AI in screening and classification of disease,” she said.

Automated segmentation has also been successfully validated as a means to detect intraretinal fluid, subretinal fluid, drusen, blood vessels and geographic atrophy in a number of recent trials, said Dr Loewenstein.

“The performance of recent automated segmentations is comparable to that of experienced human graders,” she said.

An algorithm, Notal OCT Analyser (NOA), developed by Notal Vision with the support of Dr Loewenstein’s team in Israel, has also demonstrated its efficacy at identifying, ranking, mapping and quantifying lesion activity in the retina, she said.

Notal Vision is developing a portable OCT device designed for technician-free operation by AMD patients at home.

After scanning their eyes with the device, the images are automatically uploaded to a secure server to be analysed by the NOA algorithm. If retinal fluid is detected, a report is generated

by NOA and conveyed to the treating physician, helping to reduce the time from fluid onset to the next treatment. In December 2018, the device was granted breakthrough status by the FDA, and clinical studies are ongoing, including in Dr Loewenstein’s centre.

Dr Loewenstein said that such a home-based OCT device also holds rich promise in optimising emerging treatment modalities for sustained-delivery devices and long-acting formulations such as brolucizumab, faricimab, abicipar and conbercept currently undergoing phase II and phase III trials.

“With up to three months between treatments it is vital to ensure that the drug is working and treatment intervals are personalised to each patients response,” she said.

Anat Loewenstein: anatl@tlvmc.gov.il EUROTIMES | APRIL 2020

27

GLAUCOMA

Improving

GONIOSCOPY Automated imaging device opens the door to new understanding.

Cheryl Guttman Krader reports

A

utomated gonioscopy is a useful new imaging technique for topographic analysis of the iridocorneal angle, according to Professor Jean-Paul Renard MD. Speaking at the ESCRS/EGS Glaucoma Day meeting, Prof Renard described the technology, its operation and limitations.

He also provided numerous examples demonstrating its value for patient care, research, training and medicolegal documentation.

“By providing rapid visual access to the angle, automated gonioscopy allows more frequent examination of this essential zone in clinical practice. This device gives precise topographic localisation of any abnormalities and facilitates follow-up of the angle in glaucoma and all angular illnesses,” said Prof Renard, Ophthalmological Center Breteuil, and Hôpital Cochin Paris Descartes University, Paris, France.

The technology is based on the concept of an electronic image acquisition system adapted for an acquisition over 360°. It incorporates a Goldmann goniolens with 16 mirror-coated facetted lenses to observe the various sites of the angle.

The tip of the device comes in indirect contact with the ocular surface through a 1.5mm thick disk of ophthalmic gel on the surface of the prism. The examination is completed in approximately one minute.

Seventeen images are acquired from each facet of the prism on a focal length

Courtesy of Jean-Paul Renard MD

28

Angle closure glaucoma (left) and circular stitching of the iridocorneal angle, as seen using 360-degree gonioscopy

of 5mm. A rotary function scans all facets of the mirrors in order to acquire optimal images of each portion at various focal planes. The instrument’s software creates assembled images of the best focused images, providing both linear and circular 360° representation of the angle. The device also features data storage.

Prof Renard presented high-resolution images from examinations showing that automated gonioscopy allows analysis of the anatomical landmarks of the angle, the degree of angle opening, the iris root insertion level, the iris periphery and the amount of pigmentation. Additional examples included images from eyes with polycystic ciliary body disease, synechiae, traumatic glaucoma, ciliary body tumour or that had undergone various types of glaucoma filtration surgery and MIGS.

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Prof Renard concluded by noting the device has limitations, which include a necessary learning curve and an inability to be used for dynamic examination to distinguish anterior synechiae from iridotrabecular apposition, but he reiterated its advantages, especially for the follow-up of the angle in glaucoma and exciting potential.

“We know that more precise and detailed analysis of the angle with the possibility of magnification offer the exciting possibility to study the relationships between angle closure and IOP and of the IOP curve and angle closure. More precise analysis of the new angular surgeries, and of the angular surgicals devices, also allows better understanding of its results and adverse events.”

Jean-Paul Renard: pr_renard@yahoo.fr

Türkiye

GLAUCOMA

Smartphone AI prediction tool Portable slit lamp uses AI to detect angle-closure in primary care setting.

Roibeard Ó hÉineacháin reports

A

novel portable smartphone slit-lamp prototype system employing artificial intelligence (AI) is showing promise as a low-cost screening tool for angle-closure disease and could be suitable for use in the primary care setting, said David Chen FRCOphth, Department of Ophthalmology, National University Hospital, Singapore.

“The portable smartphone slit lamp prototype provides strong positive correlation with selected anterior chamber measurements taken with anterior segment OCT,” Dr Chen told the 37th Congress of the ESCRS in Paris, France.

The new device called the Mobile Imaging Device for Anterior Segment (MIDAS) imaging consists of a portable slit-lamp prototype that can be attached to most of the major brands of smartphones. It is designed to assess anterior chamber depth of phakic patients with an undilated pupil. The system uses artificial intelligence to show correlations between the anterior chamber parameters predicted by MIDAS and measurements made with anterior segment optical coherence tomography (AS-OCT).

In a prospective, single-centre imagevalidation study, Dr Chen and associates performed sequential image capture using two devices, the MIDAS with Samsung Galaxy S7 smartphone and the Tomey SS-1000 CASIA (AS-OCT) device. They scanned 49 eyes of 49 patients, three of whom had clinically detectable angle-closure disease.

David Chen FRCOphth The patients were older than 60 with no history of laser or intraocular surgery.

The study showed that the three angle-closure eyes in the study had significantly different anterior chamber parameters than the remaining 46 without angle closure. The mean temporal angle opening distance (AOD-500) was 91.5µm in narrow angle eyes, compared to 286.0µm in normal eyes (p<0.01). The mean central anterior chamber depth (ACD) was 1746µm in narrow angle eyes, compared to 2694µm in normal eyes (p<0.01).

All three angle-closure eyes were successfully predicted by MIDAS. There was also a strong correlation between the ACD predicted by MIDAS and those measured by the CASIA AS-OCT. A Bland-Altman plot showed more than 50% of predicted ACDs were within 20µm (1%) of measured ACDs and more than 95% of predicted ACDs were within 200µm (10%) of measured ACDs. “In this proof of concept study, this is the first AI developed on a portable slit lamp device that successfully predicted central anterior chamber depth measurements of asymptomatic patients. Recruitment for more patients and data points is under way,” he concluded.

The portable smartphone slit lamp prototype provides strong positive correlation with selected anterior chamber measurements

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David Chen: dzychen18@gmail.com EUROTIMES | APRIL 2020

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30

PAEDIATRIC OPHTHALMOLOGY

New tools for surgery ‘Groovy gadgets’ can simplify complex cases and improve outcomes.

Howard Larkin reports

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aediatric cataract surgery presents special challenges that can be addressed with the right technology, Ken K Nischal MD, FAAP, FRCOphth, told the AAO 2019 Paediatric Ophthalmology Subspecialty Day in San Francisco, USA. Posterior capsule opacification after cataract surgery is a particular risk in children because their lens epithelial cells proliferate much more aggressively than in adults. The bag-inlens (BIL) intraocular lens designed by Marie-José Tassignon MD, PhD, effectively prevents this problem, said Dr Nischal, who is chief of paediatric ophthalmology at the University of Pittsburgh Medical Center, Children’s Hospital, Pittsburgh, USA. Available for about 15 years, the BIL features a groove around the lens periphery into which the edges of openings in both the anterior and posterior capsule are inserted.

“What this does is it sequesters the lens epithelial cells and you really get no visual axis opacification at all,” said Dr Nischal.

He cited studies by Prof Tassignon and colleagues showing that BILs implanted in children under the age of six have remained completely clear for up to seven years’ followup and counting. (Tassignon MJ et al. Acad Geneeskd Belg 2005;67(4):277-88. Tassignon MJ et al. J Cataract Refract Surg

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2007;33(4): p. 611-7. Tassignon MJ et al. J Cataract Refract Surg 2011;37(12):2120-9.)

While the BIL is not difficult to implant, there is a learning curve, Dr Nischal noted. It requires precisely sized and positioned capsulotomies, both anteriorly and posteriorly.

Foldable rings that Dr Tassignon developed to guide the anterior capsulotomy work well in children even though their capsules are more flexible, and the anterior opening serves as a template for the posterior, Dr Nischal said.

Snapping the capsule edges into the lens groove, which has short oval haptics protruding from the posterior and anterior surfaces at right angles to facilitate capture, requires practice, but can be done quickly with experience, he said.

PRECISION PULSE CAPSULOTOMY Due to the greater elasticity and tear resistance of the capsule, capsulotomy can be more challenging in paediatric patients than in adults. A precision pulse capsulotomy (PPC) device (Zepto, Mynosys, Fremont, California, USA) may help, Dr Nischal said.

The PPC device consists of a small foldable suction cup with a nitinol loop that is opened inside the anterior chamber and attached to the anterior capsule with the loop held against the capsule. Electronic pulses through the nitinol loop cut a precise round opening, though the opening may stretch slightly in young eyes.

Dr Nischal cited a paper finding successful use of PPC capsulotomies in 21 paediatric patients with margins overlapping the optic edges in 19 eyes, even though the opening was slightly larger than expected. (Chougule P et al. BMJ Open Ophthalmol 2018;4(1)).

“This technology may become useful if we can make it a little bit smaller for children, but it is available,” Dr Nischal said.

INTRAOPERATIVE OCT Intraoperative OCT is useful in paediatric cases for visualising common cataract complications such as posterior ruptures, fibrosis and intumescent cataracts in real time. This allows surgeons to see precisely where they need to cut to separate entangled tissues and avoid complications, Dr Nischal said.

For example, in cases of posterior rupture, OCT displayed alongside the direct image in the microscope viewfinder allows direct visualisation of vitreous. Dr Nischal said that contrary to adult cataracts, in paediatric patients he commonly removes the soft lens peripheral tissue first, leaving the nucleus in place.

This simplifies management of any rupture behind the nucleus, allowing it to be controlled with viscoelastic tamponade, and conversion of the tear into a posterior capsulotomy before anterior vitrectomy. No air or staining are required.

Live OCT is particularly useful in traumatic cases because it allows precise identification of lens matter and vitreous, Dr Nischal said. OCT helps locate lakes of fluid in intumescent cataracts, which then can be opened in a controlled manner by applying aspiration directly as they are lanced, preventing large tears.

“They’re not just toys for boys or pearls for girls. Groovy gadgets can be used to improve outcomes,” Dr Nischal said.

Ken Nischal: kkn@btinternet.com

PAEDIATRIC OPHTHALMOLOGY

Myopia:

A GLOBAL PROBLEM European trials follow on from Singapore efforts in attempts to prioritise myopia control. Roibeard Ó hÉineacháin reports

A

new trial investigating the effect of atropine in slowing progression of myopia in children is now under way in Ireland, reports Professor James Loughman, Professor of Optometry and Visual Science and Head of the Centre for Eye Research, Technical University, Dublin Ireland.

“The prevalence of myopia is escalating at an alarming rate, not only in Asia, but across the globe.

“Myopia control is now an urgent public health priority given the risk of potentially blinding ocular pathology associated with myopia including cataract, glaucoma, retinal detachment and myopic maculopathy,” said Prof Loughman at Retina 19, a meeting held in Dublin by Fighting Blindness, a patient-led charity that is also sponsoring the trial.

Called the Myopia Outcome Study of Atropine in Children (MOSAIC), the randomised controlled doublemasked trial has a recruitment target of 250 children aged 6-to-16 years with progressive myopia. In the initial phase of the trial, half of the patients will receive a daily preservative-free single-unit dose of atropine eye drops at a concentration of 0.01% for two years and the control group will receive a placebo.

In the following 12 months, the placebo group will cross over into active treatment and higher 0.02% doses may be considered for non-responders, said Prof Loughman, who is lead investigator of the trial along with Prof Ian Flitcroft, Temple Street Children’s University Hospital, Dublin, Ireland.

The trial is based on the findings of the Atropine in the Treatment of Myopia (ATOM) 1 and ATOM 2 trials conducted in Singapore. The ATOM 1 trial involved

400 children aged 6-to-12 years of age.

The study showed that atropine eye drops applied daily in one eye over a period of 24 months reduced the progression of myopia by 77% compared with the untreated eye (1.2D vs 0.28D).

The ATOM 2 study demonstrated that there was no significant difference in efficacy between atropine at concentrations of 0.5%, 0.1% or 0.01%, and that, even at a concentration as low as 0.01% atropine reduced progression by 59%.

The possibility of using a reduced concentration reduces many of the unwanted side-effects of atropine, such as inability to read and increased light sensitivity requiring the use photochromic sunglasses. Although not generally available, the MOSAIC researchers have acquired the full supply of unpreserved atropine 0.01% and placebo eye drops to complete the trial.

Prof Loughman noted that an important difference between the ATOM studies and the MOSAIC trial is that the current trial will involve European patients. Atropine has an affinity for melanin and the Irish patients will likely include many patients with lightercoloured irises than the Singaporean patients of the ATOM studies. Moreover, it is the first European trial to use the lowdose 0.01% atropine eye drops.

Already the global prevalence of myopia is three times higher than that of obesity, he noted. Currently, there are around 2.5 billion people with myopia worldwide and if the current trend continues, by 2050 the condition will affect five billion people, more than half the world’s population at that point. In addition, the degree of myopia in Asian populations has increased, raising the risk of sight-threatening consequences such as cataract, glaucoma and retinal detachment.

He added that compared to non-myopes, eyes with only -1.0D to -3.0D of myopia have over a two-fold higher lifetime risk of glaucoma, cataract and myopic maculopathy and a three-fold higher risk of retinal detachment. In fact, the ocular risks associated with low myopia are greater than the risk of hypertension and smoking for cardiovascular events like heart attacks and stroke. Moreover, the risks increase with the degree of myopia, and in particular the relative risk for myopic maculopathy, an untreatable condition, is 127-fold higher in eyes with over -7.0D of myopia compared to non-myopes.

“The burden of blindness from myopic maculopathy will increase significantly without efforts to reduce the development of myopia and also improve the management of myopic maculopathy,” Prof Loughman said.

GLOBAL PREVALENCE

There are several measures that can be taken to prevent or delay the progression of myopia. They include identifying those at risk for the condition, for example those children with a strong family history, poor lifestyle habits or who are less hyperopic than normal for their age. Providing parents with suitable advice, such as encouraging their children to engage in more outdoor activities, is also important.

“If we delay myopia onset, later onset coupled with a slower progression rate will lead to a lower final refractive degree of myopia, a better quality of life and a decreased risk of complications and blindness,” Prof Loughman added.

Prof Loughman noted that the prevalence of myopia has been increasing around the world in recent decades.

That is particularly true in some parts of Asia, where myopia now affects up to 96% of teenagers and young adults. That compares to prevalences of 10-to-20% 60-to-80 years ago.

The prevalence of myopia is escalating at an alarming rate, not only in Asia, but across the globe Prof James Loughman

PREVENTING PROGRESSION

James Loughman: james.loughman@tudublin.ie EUROTIMES | APRIL 2020

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PAEDIATRIC OPHTHALMOLOGY

Myopia prevention Low-dose atropine appears safe and effective in preventing myopia progression, but many unanswered questions remain. Dermot McGrath reports

U

sing a low-dose formulation of atropine appears to be safe and effective in slowing the progression of myopia in children, although further studies are needed to address many of the unanswered questions relating to its use in myopia prevention and progression, according to Andrzej Grzybowski MD, PhD. “Low-dose atropine seems to offer an appropriate risk-benefit ratio with no clinically significant visual side-effects balanced against a reasonable and clinically significant 50% reduction in myopia progression,” he told delegates attending the 19th EURETINA Congress in Paris.

Dr Grzybowski, Professor of Ophthalmology at University of Warmia and Mazury, Olsztyn, Poland and the Head of the Institute for Research in Ophthalmology, Poznan, Poland noted that data attesting to the clinical efficacy of atropine has been accumulating in the scientific literature in recent years.

The reason why we care so much about the increase in myopia prevalence worldwide is high myopia, which accompanies the general trend in myopia, and highly myopic eyes develop many pathological outcomes, which make high myopia a major cause of uncorrectable visual impairment. Pathological outcomes include retinal detachments, myopic macular degeneration, staphyloma and myopic retinoschisis, which are currently difficult and costly to treat. The development of these pathological outcomes is not prevented by correction of the highly myopic refractive errors, and is higher in with higher myopic errors.

A meta-analysis by Huang et al in 2016 that compared the efficacy of 16 interventions for myopia control in children concluded that the most effective treatments were atropine and pirenzepine, with orthokeratology and peripheral defocus modifying contact lenses shown to have moderate effect on progression.

Furthermore, the side-effects associated with the use of high-dose atropine in early studies seem to have been greatly reduced with the use of lower concentrations of 0.01% and 0.05%, said Dr Grzybowski.

The Low-Concentration Atropine for Myopia Progression (LAMP) study compared atropine in concentrations of 0.05%, 0.025% and 0.01% and found that all were well tolerated without an adverse effect on vision-related quality of life. However, 0.05% atropine was most effective in controlling spherical equivalent progression and axial length elongation up to one year, he said.

Over the two-year period, the mean SE progression was 0.55±0.86D, 0.85±0.73D, and 1.12±0.85D in the Andrzej Grzybowski MD, PhD 0.05%, 0.025%, and 0.01% atropine groups, respectively (p=0.015, p<0.001 and p=0.02, respectively, for pairwise comparisons), with mean AL changes over two years of 0.39±0.35mm, 0.50±0.33mm and 0.59±0.38mm (p= 0.04, p<0.001 and p=0.10, respectively). Compared with the first year, the secondyear efficacy of 0.05% and 0.025% atropine remained similar

Low-dose atropine seems to offer an appropriate risk-benefit ratio with no clinically significant visual side-effects

EUROTIMES | APRIL 2020

Andrzej Grzybowski MD, PhD

(p>0.1), but improved mildly in the 0.01% atropine group (p=0.04).

For the phase 1 placebo group, the myopia progression was reduced significantly after switching to 0.05% atropine (SE change, 0.18D in second year vs. 0.82D in first year [p<0.001]; AL elongated 0.15mm in second year vs. 0.43mm in first year [p<0.001]). Accommodation loss and change in pupil size in all concentrations remained similar to the first-year results and were well tolerated. Visual acuity and vision-related quality of life remained unaffected.

Over two years, the efficacy of 0.05% atropine observed was double that observed with 0.01% atropine, and it remained the optimal concentration among the studied atropine concentrations in slowing myopia progression.

There are still many unresolved questions related to the use of atropine in myopia prevention, said Dr Grzybowski.

“We need to know if there is potentially a role for high-dose atropine in cases of rapid progressors? We also do not know the additive effect of combining atropine with other emerging myopia therapies such as peripheral defocus contact lenses or spectacles, and environmental interventions with increased outdoor time which we know is important in helping to prevent myopia in children,” he said.

In addition, clinical treatment algorithms are not yet established in terms of which children would most benefit from treatment in terms of age, level of myopia, rate of progression and family risk factors, he said.

“We also need more data on when atropine should be started and stopped, and for how long it should it be used. All of these questions need to be addressed in future studies,” he added.

A number of randomised controlled trials that are currently being conducted in Europe for low dose atropine should help in this regard, said Dr Grzybowski. He said that a European Network for Myopia Control, made up of experts from different European countries, has recently been established to foster research in the field, and interested parties could contact him for further information.

Andrzej Grzybowski: ae.grzybowski@gmail.com

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

Registration & Abstract Submission Open

Membership to WSPOS is available for FREE online

www.wspos.org

ASCRS is your trusted source for innovative education, philanthropy and advocacy â&#x20AC;&#x201C; for every stage of your career.

Join today: ASCRS.org

BOOK REVIEWS

PUBLICATION VIDEO ATLAS OF ANTERIOR SEGMENT REPAIR AND RECONSTRUCTION

LEIGH SPIELBERG MD Books Editor

BOOK

Reviews PUBLICATION MULTIFOCAL INTRAOCULAR LENSES EDITORS JORGE L. ALIÓ AND JOSEPH PIKKEL PUBLISHED BY SPRINGER

A comprehensive review of multifocal treatment

Multifocal intraocular lenses are all the rage. Patients have become accustomed to the possibility of spectacle independence and increasingly request this option. However, successful implantation of multifocal lenses is more than simply a surgical procedure.

There are dozens of different lenses and just as many types of patients, and matching the correct IOL with the correct patient is a skill unto itself.

This is where Multifocal Intraocular Lenses: The Art and the Practice, Second Edition (Springer) comes in. Edited by Jorge L. Alió and Joseph Pikkel, this 380-page text is a comprehensive overview of all aspects of multifocal treatment, from the preoperative assessment to suggested solutions for the unhappy patient.

The text starts with a short introduction on what multifocal lenses can offer in the current era. What follows is an in-depth coverage of everything that requires consideration before implantation of a multifocal lens.

Chapter 3 reviews the basic principles, Chapter 4 the preoperative considerations and Chapter 5 covers the neuroadaptation required for a patient both to get used to and enjoy their newly recovered multifocality. “Implanting a multifocal intraocular lens is, in a way, a ‘disturbance’ that makes it more difficult for the brain to create a well-detailed image.” Because the neuroplasticity required for neuroadaptation decays with age, “patient selection is absolutely a key factor in gaining a satisfactory outcome. Ignoring neuroadaptation may result in prolonged patient complaints.”

Particularly interesting was the chapter entitled “Considerations in Special Cases”. These include children, patients with glaucoma, maculopathy, amblyopia and dry eye. Patients who have undergone corneal refractive surgery are also considered.

Of course, surgery isn’t surgery without complications, and these are covered in Chapter 8, which is followed by a chapter on post-implantation residual refractive error and another one on “Solutions for the Unhappy Patient”. This might be the most useful chapter.

The second half of the book is devoted to information on each of the available lens types, including EDOF and accommodative IOLs. Intended for ophthalmologists who currently implant multifocal IOLs or plan to do so in the future.

USEFUL TIPS FOR VR SURGEONS IN TRAINING

PUBLICATION THE POCKET GUIDE TO VITREORETINAL SURGERY EDITORS JASON N. CROSSON PUBLISHED BY SLACK

The Pocket Guide to Vitreoretinal Surgery (Slack), edited by Jason N. Crosson, is a quick-read manual on retinal surgery that introduces the reader to the basic concepts of VR surgery.

Starting with “Setting Up for Vitrectomy: How to Get Started”, the book then progresses from basic vitrectomy techniques to approaches to retinal detachments, peeling and other day-today surgical procedures.

At 155 small pages, it is indeed a guide rather than a textbook.

As an early-career vitreoretinal surgeon myself, I picked up some useful tips that I plan to incorporate into my surgical practice.

This |book EUROTIMES MONTHseems YEAR most appropriate for ophthalmology residents who are preparing for their vitreoretinal surgery rotation or deciding whether VR surgery is for them, as well as for starting VR fellows.

EDITORS AMAR AGARWAL & PRIYA NARANG PUBLISHED BY THIEME

STEP-BY-STEP GUIDE FOR ADVANCED SURGEONS The Video Atlas of Anterior Segment Repair and Reconstruction: Managing Challenges in Cornea, Glaucoma and Lens Surgery (Thieme),

by Amar Agarwal and Priya Narang, stands out primarily for its detailed videos and photography of each intraoperative step required to perform complex procedures like DSAEK, keratoprosthesis implantation, pupilloplasty and intrascleral fixation of intraocular lenses.

Composed of five sections (reconstructing the cornea, iris, aqueous drainage, lens and ‘miscellaneous’), the book serves primarily as a textual explanation of what can be seen in the nearly 40 videos.

The procedures described are for the advanced surgeon with extensive experience in anterior segment surgery.

As such, the book is intended for those surgeons who are looking to move to the next level or simply refine their technique.

PUBLICATION OPHTHALMIC PLASTIC SURGERY OF THE UPPER FACE EDITORS MICHAEL A. BURNSTINE, STEVEN C. DRESNER, DAVID B. SAMIMI & HELEN A. MERRITT PUBLISHED BY THIEME

COMPLETE GUIDE TO FACIAL IMPROVEMENT Ophthalmic Plastic Surgery of the Upper Face: Eyelid Ptosis, Dermatochalasis and Eyebrow Ptosis (Thieme) was written by a team of four physicians from the University of Southern California and Eyesthetica in Los Angeles. Drs Burnstine, Dresner, Samimi and Merritt collaborated to produce this 250page work, which organises the approach to the patient with these disorders.

Starting with classification and aesthetic anatomy of the upper face, each procedure is then described, providing a step-by-step guide to procedures such as internal eyebrow lift, open coronal pretrichial browlift surgery and the Fasanella-Servat procedure.

This text is intended for current and future oculoplastic, plastic and aesthetic surgeons who are looking to offer their patients the whole spectrum of possibilities for upper facial aesthetic improvement.

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

EUROTIMES | APRIL 2020

35

SYMP SIA

HIGHLIGHTS

AT THE ANNUAL MEETING

WHAT TO EXPECT IN BOSTON Research shows that symposia topics are the primary influence when anterior segment surgeons are deciding whether to attend the ASCRS Annual Meeting.

SYM101 Intravitreal Injection Essentials for the Anterior Segment Surgeon SYM102 Management of Vitreoretinal Complications of Anterior Segment Surgery SYM103 Challenging Cases in Cataract Surgery Video Symposium SYM104 Complications by Proxy SYM105 Getting You Better IOL Refractive Outcomes— Hearing from Us and You SYM106 The Cuts are Coming.... The Cuts are Coming....

INNOVATE! SYM107 Glaucoma Essentials SYM108 Management of Complicated Cases in Cataract and Refractive Surgery (Presented in Spanish) SYM201 Surgical Essentials: Getting You out of Trouble in Cataract Surgery SYM202 Cornea Essentials SYM203 Debates and Controversies for the Young Ophthalmologist: How Will You Shape Your Practice?

SYM204 Inside the Circus, featuring Mark McKinnon SYM205 How to Hit a Home Run in Refractive Cataract Surgery SYM206 Boston MIGS Party: Gettin’ MIGS’y with It SYM207 You’re Great in the Aqueous Humor, but How Good Is Your Sense of Humor?

SYM208 Controversies in Anterior Segment Surgery SYM209 Challenges and Controversies in the Management of Anterior Segment Diseases SYM210 The Winning Pitch Challenge (non-CME session) SYM301 Keratoconus Essentials SYM302 Cataract Surgery Essentials: Surviving and Thriving in the Clinic and Operating Room SYM303 Advanced Cataract Surgery: Achieving 20/Happy in 2020 SYM304 Drop Free Cataract Surgery: Regulatory Landscape and FDA Perspective SYM305 The 2020 ASCRS Cataract Surgery Olympics SYM401 X-Rounds: Refractive Cataract Surgery to the Max

Need more convincing? Come see Coach Mike Krzyzewski, “Coach K,” the winningest coach in college basketball history, attend the bestowment of the inaugural ASCRS Educator Award, listen to Scott Gottlieb, MD, Former Commissioner of the U.S. Food and Drug Administration, and experience the first ASCRS Cataract Day and many more exciting events.

REGISTER TODAY!

annualmeeting.ascrs.org

EXPLORING AMSTERDAM

The Moco Museum in Amsterdam

AMSTERDAM

3

TO TRY ...

GET LOST DOWN THE MEANDERING NARROW STREETS OR QUICKLY SEE THE SIGHTS Of all Europe’s capital cities, Amsterdam is arguably one of the easiest and most rewarding to explore on foot. Getting lost in the meandering narrow streets, wandering down the canals, letting your imagination be your guide is a great pleasure – providing you have the time. If, on the other hand, it’s a challenge to fit leisure time into your schedule, consider making the most of a free morning or afternoon by organising a private tour. You will go at your own pace and see only what’s important to you. Your guide could introduce you to the famous Red Light District, picturesque Jordaan and charming Begijnhof but could also suggest any number of lesser known alternatives based on your personal interests. A bespoke private walking tour of three hours costs in the region of €250. Details at http://bit.ly/ET-ams-walking-tour

ON YOUR BIKE FOR A TOUR AS EASY OR AS CHALLENGING AS YOU LIKE If you want to ‘feel like a local’ there’s no quicker or better way than to hop on a bike. And if you want to cover maximum territory in minimum time a bike scores there, too. No wonder bike tours are one of the most popular tourist activities in Amsterdam. If there’s anything better than a bike tour, it’s a private bike tour.

If you want to bike flat out with few stops, it’s up to you. If you feel that a cup of coffee and a piece of apple cake make the wheels turn more smoothly, that’s your call as well. Locals, one of my favourite tour companies, offers a private guided bike tour that takes about three hours and costs €101. Meet the guides available for your dates and book. http://bit.ly/ET-ams-bikes

SIT BACK AND ENJOY YOUR OWN PRIVATE TRIP DOWN THE CANALS Water, water everywhere… and canal cruises everywhere, too. But why not sit back in your own boat while your skipper navigates through the canals and under the bridges, telling you the local history (or keeping silent if you prefer)? Zavi is a comfortable saloon boat that is heated, with an open or closed roof. It has an onboard toilet and can carry you – or up to 12 guests – on every water in and around Amsterdam. There’s a wine bar on board or BYOB (corkage fee applies) The cost is €200 for the first hour and €150 per hour thereafter. Book at https://www.vaartuig.amsterdam

‘Subversive Art’ on display Modern and contemporary arts find a congenial new home on Museumplein. Maryalicia Post reports A three-minute walk from the Rembrandts and Vermeers in the Rijksmuseum, a one-minute stroll from the Van Gogh Museum, a new exhibition space presents the work of Banksy, Dali, Warhol and their contemporaries. Described as a ‘boutique museum’, Moco (Modern and Contemporary Art Museum) was set up by a local couple, Lionel and Kim Logchies, proprietors of a popular gallery in Amsterdam’s Art Quarter.

The works of art on show have been borrowed by the Logchies from an international network of art collectors in order to “offer visitors an unparalleled collection of subversive art in which irony and humour are used to reflect on modern society”. The museum’s permanent exhibition, ‘Moco Masters’, celebrates a variety of artists with ‘Rock Star’ status such as Andy Warhol, Jean-Michel Basquiat, Jeff Koons, Damien Hirst and Keith Haring, but when I visited, it was a temporary exhibition of Banksy’s work that was drawing the crowds.

Moco is installed in the Villa Alsberg on Museumplein. A private home until 1939, it was designed in 1904 by Eduard Cuyper, the nephew of the architect of the nearby Rijksmuseum and of the Amsterdam Central Station. Reconfigured as a museum in 2016, the exhibition spaces are on several floors. (Not wheelchair accessible).

In addition, there are art installations in the Moco Gardens.

The museum’s popularity is a force to be reckoned with; buy tickets online and visit early or late in the day to avoid the crush. www.mocomuseum.com. If you haven’t bought a ticket online, note that the entrance fee at the door is by credit card only. The museum is open daily from 9.00 and closes at

19.00, except on Friday and Saturday when it is open until 20.00.

A museum no photography buff should miss is FOAM, which tops the ‘Expert Photography’ list of the world’s best photography museums. Installed in a beautiful old canal-side house in Amsterdam’s City Centre, it’s a stylish space with exhibits on several levels, a cafe and a book and print shop where prices range from €6.50 for an enamel food pin to €1,000 or more for a print. Free one-hour guided tours in English Thursday evening 19.30.

Website at www.foam.org.

A 10-minute walk along the Keizersgracht Canal brings you to Huis Marseille, Amsterdam’s first photography museum, founded in 1999. Two adjacent canal houses were joined to provide 14 exhibition spaces; the houses themselves are exquisite examples of 17th-Century Amsterdam architecture. There’s a charming garden that can be visited and a photo book shop (but no coffee shop). Closed Mondays.

Website: https://huismarseille.nl/en/ Admission to all museums mentioned (except Moco) is free with I amsterdam City Card A MOCO patron looks at the work of French artist JR

EUROTIMES | APRIL 2020

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RANDOM THOUGHTS

Taking the wait out of

WAITING ROOM Some tips to make the patient experience easier.

Maryalicia Post reports

M

ost of us have a complicated relationship with time.

We willingly spend it, save it, kill it, but nobody likes wasting it. And waiting for an appointment often feels like time wasted.

In a perfect world, every ophthalmologist patient would arrive on time, be seen within 10 minutes and leave the clinic with thoroughly positive feelings about the experience. That’s certainly a goal worth striving for and there are lots of online suggestions to help you achieve it.

But a late patient, an emergency, a complication can block the best-laid patient flow. What then?

If a wait is unavoidable, the best plan B is to make the delay seem shorter than it is.

The waiting room facilities are key. I know because the waiting room of a practitioner I visit occasionally is a textbook case of what can be wrong.

EUROTIMES | APRIL 2020

A gruff ‘take a seat’ floats up from behind the bunker that is the receptionist’s station when a new patient arrives. Behind this bunker, which takes up most of the available floor space, the receptionist is cut off from the patients, lifting her head only occasionally to call out a name. Metal chairs are strung out along the wall where patients perch like birds on a wire. There’s nothing to look at on the walls bar flu vaccine posters.

Magazines are stacked high, some so old you can still join the debate on whether Prince William will ever marry Kate Middleton. A TV plays forlornly and unwatched.

What I’d like would be good Wi-Fi so I could work on my phone or iPad while I wait. I’d appreciate comfortable chairs, grouped informally. Some green plants would make the room seem warmer, along with an interesting painting or wall decoration. A few attractive ‘coffee table’

books would be diverting. There would not be a TV, though low background music would work. Crucially, the receptionist would know my name, let me know if the wait was going to take longer than 10 minutes and apologise sincerely if the wait, however unavoidably, goes into overtime.

I’m certainly not alone. There are some excellent observations on the waiting experience in the literature.

A simple formula for improvement of the waiting room is covered in this article (http://bit.ly/ET-waitingroom) – which has checked just about everything on my wish list and a few things more. It works off the premise that the place where the patient experience begins should be considered the ‘reception area’ not the ‘waiting room’.

When the mindset shifts from the practitioner’s viewpoint of ‘waiting’ to the patient-oriented concept of ‘reception’, the way forward seems a bit clearer.

CALENDAR

↙

LAST CALL

APRIL 2020

Delhi Ophthalmological Society 71st Annual Conference 2020 (DOS 2020)

Brazilian Retina and Vitreous Society 45th Meeting 2020 (BRAVS 2020) 22 – 25 April São Paulo, Brazil http://retina2020.com.br/

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

MAY ARVO 2020

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

SFO 2020 Congress

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

↙

3 – 5 April New Delhi, India http://dosonline.org/confrences/ annual-conference

The European Paediatric Ophthalmological Society 2020 (EPOS 2020) will take place in Copenhagen, Denmark

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

18th SOI International Congress

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

European Paediatric Ophthalmological Society 2020 (EPOS 2020) 28 – 30 May Copenhagen, Denmark https://epos2020.dk/

EyeAdvance 2020

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

MAY 14th EGS Congress

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

JUNE Nordic Congress of Ophthalmology 2020 (NOK 2020) & 21st Retina International World Congress 2020 4 – 6 June Reykjavík, Iceland https://www.nok2020.com/

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

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

The 20th EVRS Meeting 2020 will take place in Stockholm, Sweden

EUROTIMES | APRIL 2020

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40

CALENDAR

JULY

XXI International Congress of the Brazilian Society of Ophthalmology

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

33rd Asia-Pacific Association Of Cataract & Refractive Surgeon Annual Meeting 2020 (APACRS 2020) 9 – 11 July Suntec City, Singapore https://apacrs-snec2020.org/

American-European Congress of Ophthalmic Surgery Summer Symposium 2020 (AECOS 2020) 9 – 12 July Utah, USA https://aecosurgery.org/ 2020-summer-symposium/

NEW DATE 6th San Raffaele OCT Forum 2020 17 – 18 July Milan, Italy https://www.octforum2020.eu/

ASRS 2020

24 – 28 July Seattle, USA www.asrs.org

AUGUST NEW DATE 34th Asia Pacific Academy of Opthamology Congress 2020 (APAO 2020) 5 – 9 August Xiamen, China http://2020.apaophth.org/

NEW 5th Asia Pacific Glaucoma Congress 2020 (APGC 2020)

The Ophthalmic Anesthesia Society 34th Annual Scientific Meeting 2020 (OAS 2020) will take place in Chicago, USA

SEPTEMBER 50th Cambridge Ophthalmological Symposium 2020 (COS 2020) 2 – 4 September Cambridge, UK https://www.cambridgesymposium.org/

NEW 32nd Meeting of the Club Jules Gonin 2020

2 – 5 September Dubrovnik , Croatia https://www.clubjulesgonin.com/member/ index.asp

5th International Glaucoma Symposium

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

SEPTEMBER

Ophthalmic Anesthesia Society 34th Annual Scientific Meeting 2020 (OAS 2020)

11 – 13 September Chicago, USA https://eyeanesthesia.org/page-1271154

NEW 49th European Contact Lens and Ocular Surface Congress (ECLSO) 18 – 19 September Paris, France https://www.eclso.eu/

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

38th Congress of the ESCRS 3 – 7 October Amsterdam, The Netherlands www.escrs.org

OCTOBER

NOVEMBER

20th Euretina Congress

AAO Annual Meeting 2020

11th EuCornea Congress

100th SOI National Congress

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

14 – 16 August Kuala Lumpur, Malaysia https://apgc2020.org/

OCTOBER

WCPOS V 5th World Congress of Paediatric Ophthalmology and Strabismus

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

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

CO NE NT W EN T A library of symposia, interviews, video discussions, supplements, articles and presentations Spotlight on: l Toric IOLs and Presbyopia l Glaucoma l Ocular Surface Disease l Corneal Therapeutics

Visit forum.escrs.org for details EUROTIMES | APRIL 2020

ESCRS

Membership

FREE 5 year member ship for train ees

• Reduced Registration Fees for ESCRS Congresses • Subscription to Journal of Cataract & Refractive Surgery • Access to ESCRS Grants, Bursaries and Research Awards

Access to: • ESCRS iLearn

Online CME accredited interactive courses

• ESCRS On Demand

Online library of presentations from ESCRS Congresses

• EUREQUO

European Registry of Quality Outcomes for Cataract and Refractive Surgery

• ECCTR

European Cornea and Cell Transplantation Registry

Join today. www.escrs.org

YOUR NAVIGATING PARTNER IN CATARACT AND CORNEA

Take control of your future.

Belong to something powerful. Join us.

Visit www.escrs.org for information about membership &Thebenefi ts FEMTO LDV Z8 and the GALILEI are CE marked and FDA cleared. For some countries, www.ziemergroup.com

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