Experts discuss the best

Exciting potential

Panel of international experts discusses best videos from the 38th Congress of the ESCRS. Dermot McGrath reports

An overview of the exciting potential of hydrogen to revolutionise treatment of a range of ocular diseases, tips for small pupil management and a new artificial implant for corneal transplantation were among some of the topics discussed in an ESCRS online review session of the best videos from the 38th Congress of the ESCRS.

Co-chaired by Oliver Findl MD and Boris Malyugin MD, the session brought together a panel of international experts – Bruce Allan MD from the United Kingdom, Guy Kleinmann MD from Israel and Gabor Scharioth MD, PhD, from Germany.

The session commenced with a video from Hisaharu Suzuki MD of Japan entitled “Hydrogen will change the world of ophthalmology” which was awarded the best overall video award at the 38th Congress. Dr Suzuki highlighted hydrogen’s ability to selectively scavenge free radicals – and in particular cytotoxic hydroxyl – and thereby potentially improve outcomes in the treatment of retinal ischaemia as well as in cataract surgery. The video outlined the beneficial effect of using hydrogen in an irrigation solution in protecting the corneal endothelium in phacoemulsification in a randomised clinical trial in 32 patients.

In the panel discussion, Dr Kleinmann said that the research was very interesting and that anything that could help to have better and safer surgery represented a welcome development. However, he said that it was not clear how hydrogen-infused BSS would be commercially produced for surgical use. He also stressed the importance of ensuring that the action of hydrogen to scavenge free radicals did not lessen the efficacy of the phaco tip during surgery.

Dr Malyugin added that free radicals are just one of many factors, including mechanical and chemical trauma, affecting intraocular structures during phaco. He also questioned how the hydrogen solution would perform alongside the use of dispersive OVDs that protectively coat the corneal endothelium. Dr Scharioth suggested that hydrogen might also have potential applications in posterior segment surgery in helping to control inflammatory response and combating cystoid macular oedema.

The next video, by Milan Izák MD, PhD, from Slovakia, featured lessons learned from the cataract surgery of a 66-yearold patient who had undergone radial keratotomy (RK) 30 years previously. Both eyes had extensive corneal scarring and the endothelial cell density was particularly low in the left eye. Dr Izák’s take-home message He also stressed was to go through the scleral tunnel in order to perform cataract the importance of ensuring that the surgery as safely and gently as possible and action of hydrogen to avoid touching the RK scars to promote swifter healing. to scavenge free radicals did not Dr Malyugin said that while the video lessen the efficacy was strong on some of the phaco tip technical aspects of the surgery, it did not during surgery really address one of Guy Kleinmann MD the key challenges of such cases, namely the issue of IOL power calculation. Dr Allan said that he typically used the Haigis-L formula but that it is never easy to ensure accurate postoperative refraction for such complex eyes. Dr Kleinmann said it was very important to remain patient after the surgery as he had often witnessed significant improvement of the postoperative refraction over time in such post-RK eyes.

Small pupil cataract surgery was the topic of the subsequent video ...the surgical by Jiří Cendelín MD of the Czech Republic. community is Dr Cendelín weighed currently divided the pros and cons of various iris hooks and into two parts – the pupil expanders and the multiple options now first one is using available to surgeons iris hooks, the to provide capsular support during small second one, pupilpupil cataract surgery. Dr Scharioth said that he rarely uses any expansion rings for small pupil mechanical device for pupil expansion. “For cataract surgery the past 10 or 15 years Boris Malyugin MD I have usually been able to manage small pupils with cohesive viscoelastic devices such as Healon 5 or DisCoVisc and it works well in my hands,” he said. Dr Allan remarked, meanwhile, that iris hooks are the modality of choice at Moorfields Eye Hospital. Dr Malyugin added that the surgical community is currently divided into two more or less equal parts – the first one is using iris hooks, the second one, pupil-expansion rings for small pupil cataract surgery. However, there is a growing body of evidences that pupil-expansion rings are more friendly to the iris tissue, require less operative time and decreases the chance of atonic, fixed pupils postoperatively.

The next video up for discussion was Jung Yeol Choi MD from South Korea, which looked at the effect on corneal endothelial cell loss during phacoemulsification using novel thermosensitive hydrogels (Poloxamer) versus sodium hyaluronate. Dr Scharioth remarked that while the research was very interesting he felt that endothelial cell loss was not as critical an issue as in times past thanks to advances in phacoemulsification and fluidics technology. He also wondered how IOLs would potentially react to these new hydrogel materials and said that there were a few unresolved issues which merited further investigation in the future.

The final video of the session featured research at CSI Heidelberg from Gerd Auffarth MD and colleagues who have been looking into the possibility of performing Descemet’s Membrane Endothelial Keratoplasy (DMEK) using an artificial implant instead of human tissue.

“The proof of concept presented in the video is certainly exciting,” said Dr Allan. “Anything that can help us to deal with the problem of the shortage of expensive donor tissue may have a massive impact. If this continues to perform well in future trials it could be a complete game-changer,” he added.