Best of the Best in Amsterdam

Advances in cataract surgery, keratoconus treatment, and preoperative assessment for advanced IOLs highlighted at final session of ESCRS Congress. Roibeárd O’hÉineacháin reports from the 39th Congress of the ESCRS in Amsterdam

Presentations concerning advanced fluidics for phacoemulsification, customised corneal cross-linking (CXL), and innovations in preoperative assessment for patients considering multifocal and extended depth of focus (EDOF) intraocular lenses were among the “best of the best”, according to a panel of experts at the meeting’s final session.

Professor Oliver Findl MD, Austria, and Professor Boris Malyugin MD, Russia, were the session chairs. The panel included Professor Ehud Assia MD, Israel; Professor Sri Ganesh, India; Professor Thomas Kohnen MD, PhD, Germany; Professor Rudy Nuijts, the Netherlands; and Professor Filomena Ribeiro MD, Portugal.

ADVANCES IN FLUIDICS Starting with the notable videos, Prof Malyugin reviewed the 2021 Michael Blumenthal prize winner—Hisaharu Suzuki, Japan, for “Evolution of fluid system in cataract surgery”. The presentation described the use of a pressure sensor within a phaco handpiece with active pressurised fluidics to reduce the oscillations in anterior chamber depth (ACD) during phacoemulsification.

The video showed how, in a laboratory study using pigs’ eyes, the variation in the ACD was only 10% in eyes with the pressure sensor handpiece, 20% with a pressurised peristaltic pump and a conventional handpiece, 50% with a non-pressurised peristaltic pump and a conventional phaco handpiece, and 80% with a pressurised venturi pump and a conventional phaco handpiece.

Prof Nuijts noted better control of the pressure fluctuations with the active infusion and the pressure sensor could be particularly beneficial in glaucoma surgery. Prof Malyugin suggested it could also prevent anterior vitreous detachment by reducing the flow of aqueous through the zonule.

CATARACT SURGERY DURING THE PANDEMIC Another winning entry the panel highlighted was Lucio Buratto’s “Safety and prevention and protection in cataract surgery during the COVID-19 pandemic”, which took the first prize in the new “Pandemic” category. It outlined the many new safety measures adopted to prevent transmission of COVID-19 in the cataract clinic, such as daily PCR tests of surgeons and their staff and the use of masks by patients during surgery.

In his comments on the video, Prof Assia emphasised the most important precaution now is vaccination for the surgeon, staff, and patients. He added the danger of infection from aerosols during surgery may have been exaggerated in the early months of the pandemic. He pointed out that, as yet, there have been no reports of surgeons or their staff becoming infected with the COVID-19 virus from performing cataract surgery.

Prof Kohnen noted continuing with some of the precautions adopted for safety during the pandemic runs contrary to the current trend towards the reduced one-time use of plastics. On the other hand, he noted the attention which the pandemic has brought to potential infection in a clinical setting will be of benefit once the pandemic is over.

CUSTOMISED CXL Another video highlighted at the session was “Topography guided removal of the epithelium in keratoconus (TREK)” by Sneha Gupta, India. The presentation describes a technique of reshaping the keratoconic cornea by CXL. The video showed that when patients underwent CXL in this way, they had improvements in their visual acuity.

“I think this is great. We have to get to the point where we can improve vision, and we can only do this with a topography-guided procedure. Normally, when we do CXL now, we crosslink areas of the cornea where it is not actually necessary,” Prof Kohnen said.

Many presentations at the ESCRS Congress focused on the EDOF, mono-EDOF, and trifocal IOLs that have recently entered the market—particularly notable among these was the Binkhorst lecture delivered by Gerd Auffarth MD, PhD, Germany. In his lecture, titled “There is no free lunch”, he explained the greater depth of field a lens provides, the greater too will be the amount of dysphotopsia a patient will experience. Similarly, the greater the amount of chromatic aberration a lens has, the worse the polychromatic modulation transfer metrics. Conversely chromatic aberration correction reduces an IOL’s depth of focus.

The theme was expanded on further in the Main Symposium on Advanced IOLs. Joaquin Fernandez MD, PhD described several devices such as the SimVis and the VAO spatial light modulator that provide an estimation of a patient’s range of focus with a given IOL, based on preoperative simulations. In another presentation, Arthur Cummings MD, Ireland, described the use of Vivior monitor, a spectacle-mounted device that measures a prospective patient’s daily visual requirements, enabling choice of an IOL most suited to their needs.

Prof Assia noted multifocal IOLs and EDOF IOLs will always remain, and only a truly accommodating IOL will eliminate those that compromise presbyopia treatment. Prof Kohnen countered that the increased understanding of optics, as illustrated in Prof Auffarth’s lecture, will allow accommodating IOL optimisation once they become available.