Newsmaker Interview

ESCRS

NEWSMAKER

INTERVIEW

EuroTimes Editor-in-Chief Sean Henahan talks to ESCRS President Oliver Findl about the many challenges facing ophthalmology during a time of multiple world crises.

ET: What a time to become president! As if the COVID pandemic wasn’t enough, you have war to your east in Ukraine, and the planet faces a major challenge in the form of climate change. Let’s start with Ukraine. What is the ESCRS response to the current crisis?

OF: This took us all by surprise. Two or three days after the invasion, we rolled up our sleeves and asked how we could help. We were in continuous contact with our Ukrainian colleagues as we were to hold an ESCRS symposium in Kyiv at the beginning of March. It became clear we should do something as quickly as possible. We reached out to our industry contacts, and they responded quickly. Then the question became logistics, how to get medical supplies into the country.

Our managing director Tom Ogilvie-Graham has some experience in that field. He visited Poland and Lviv and helped set up two warehouses where we keep aid supplies. We also have some contacts with United Nations for transport. Our Ukrainian colleagues have a good network and can anticipate where the supplies will be needed most. This should be well underway by the time this [magazine] goes to print.

In the first days, our colleagues were obviously worried about their families, and there were major efforts to get as many women and children out of there as possible. We got messages and photos from them in bunkers during shelling. The men are staying to help patients. It is difficult for us to understand what is happening. I believe some are filling in as combat surgeons.

ET: What sort of supplies is the ESCRS providing?

OF: Basic supplies such as suture materials, viscoelastics, and instruments needed for ocular trauma surgery. One company donated a small phaco/anterior vitrectomy machine which had been used by military personnel. One company is donating surgical loupes, which can be used if a microscope isn’t available.

We are trying to organise—together with EURETINA and the European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS)—a network of doctors in Europe and North America to provide 24-hour second opinions and consulting. The goal is to help surgeons in Ukraine who may not be trauma surgeons or vitreoretinal surgeons. This will be done via mobile phone.

ET: Millions of refugees have arrived in Western Europe. How are ophthalmology departments accommodating colleagues and patients?

OF: I received emails from some female Ukrainian ophthalmologists who were able to flee and are now here with their children— even in Vienna. I have met two who arrived in the last weeks. I’m discussing with our hospital management ways to integrate them into our hospital. There are issues with red tape, licensing, language barrier, etc. For starters, we might use them as translators when we are seeing Ukrainian patients, of which there are quite a few in our area. They may have eye problems of all sorts that need to be addressed. Eventually, the doctors may be able to help their fellow Ukrainians directly.

Throughout the EU, the refugees are automatically socially insured. If refugees have been treated before in Ukraine, for example, with intravitreal injections for AMD, that should get continued without a pause. That is something we learned with COVID—intervene quickly to maintain care. So, from that perspective, we may be a little better off than we might have been before the pandemic.

ET: What about our Russian colleagues?

OF: This is a very difficult question for all sides. My belief is that we are all medical doctors, and the highest of our priorities is to take care of our patients. I believe our Russian colleagues feel the same way. That is why we have become doctors. I have been in touch with Russian colleagues. It is very difficult for them: they are locked into their country now and not able to speak freely.

ET: How are things looking for the annual ESCRS Congress in Milan?

OF: We were sad we could not have our winter meeting in Vilamoura in person in February, but that would have been too risky. It looks like COVID is easing up in Europe now. Currently,

we are very confident Milan will take place in person. We have set up a very full programme. For those who cannot attend because they are too far away or their regulations make it difficult, there will also be a hybrid component.

We have substantially revamped the Congress. We realised that, especially for junior doctors, there has been a two-year gap in training. We will have significantly more wet labs and basic courses than we did in Paris, our last full-scale meeting. Amsterdam was a successful hybrid meeting. Milan will be hybrid, but we are really emphasising the face-to-face side.

Of course, there will be a lot of sessions on cataract and refractive surgery. But we will also have a cornea and glaucoma day on Friday and a combined symposium with our paediatric colleagues from WSPOS.

The general programme offers a lot to young ophthalmologists. I’m hoping this will be very valuable for young doctors whose training was interrupted. In addition to a YO day and YO symposium, there will be a track with courses and wet labs tailored to their needs. As in the years before, after the President’s dinner on Saturday, the young ophthalmologists are invited to join us in the disco and have a party.

We’re also organising a new element called iNovation. It takes place Friday, before the ESCRS meeting. It is a meeting of industry partners, key opinion leaders, and start-up companies looking at trends and challenges of ophthalmology. I’m looking forward to it—it will be pretty exciting.

ET: The world is also facing an existential threat in the form of climate change. How is the ESCRS responding?

OF: Even in the midst of COVID and the Ukraine war, we need to address the sustainability issue. Four percent of the world’s total trash is medical waste. And of that, cataract surgery is a key contributing factor. We will be meeting with ASCRS and APACRS to find ways to reduce waste and reduce our carbon footprint in the operating theatre.

This will be a theme at the conference. At the opening ceremony, we’re going to have a young ophthalmologist from the Netherlands who is very involved in sustainability describing the problems and possible solutions we could implement.

Conferences have a major carbon footprint. My aim is to make our meetings carbon neutral at the latest by next year. We are heading that way in Milan. We are working with a company that focuses on sustainability and congresses. They are helping us understand what we are doing and how we can reduce our carbon footprint. Delegates registering for the meeting will have the option of paying a fee to offset the effect of flying to the meeting; I very much hope that all will participate. I started offsetting all my flights last year.

We will be using more recyclables and placing an emphasis on sustainable food options. My ideal would be for people to take a step towards less red meat, maybe refrain from eating meat altogether during the four days of the meeting.

“Even in the midst of COVID and the Ukraine war, we need to address the sustainability issue. Four percent of the world’s total trash is medical waste. And of that, cataract surgery is a key contributing factor.”

Retinal Considerations for Cataract Surgery

Don’t lose sight of retinal disease when visualising outcomes. By Dr Soosan Jacob MS, FRCS, DNB

Far from the realms of the cataract surgeon but still crucial to planning and outcomes, appropriate knowledge about retinal diseases is important when contemplating cataract surgery. The goal is to provide a good visual outcome without exacerbating underlying retinal disease or creating any new problems with the retina.

Should cataract surgery be performed in patients with agerelated macular degeneration? As with so much in this field, patient selection is key. The just-published Age-Related Eye Disease Study (AREDS) report #27 concluded patients with AMD benefitted from cataract surgery, with an average gain in visual acuity (VA) persisting for at least 18 months. Eyes with milder AMD or increased severity of lens opacity gained more lines of VA than eyes with advanced AMD or mild lens opacity.

That study also reported similar visual outcomes among advanced AMD sub-types (geographic atrophy/choroidal neovascularization, CNV). There were reports of significant improvement in quality of life after cataract surgery for moderate cataracts with mild-moderate AMD. Patients with geographic atrophy/CNV or mild cataracts with any grade of AMD, on the other hand, did not benefit greatly in vision or QOL.

Reports on the effect of cataract surgery on AMD progression vary, with some reporting an association with early AMD, late AMD, and even both, but not proving causation. However, AREDS2 report #27 clearly states cataract surgery did not increase risk of developing advanced AMD in participants with up to 10 years of follow-up.

DIABETIC RETINOPATHY Diabetic patients tend to develop cataracts earlier and need good glycaemic and blood pressure control before surgery. The compromised blood-aqueous barrier increases postoperative inflammation. Capsular opacification and contraction are common and compromise retinal monitoring and treatment. Cataract surgery in these patients benefits from the creation of a larger rhexis, complete cortical clean-up, aggressive control of postoperative inflammation, and early retinal therapy soon after cataract surgery. Using larger optic IOLs is also recommended.

Decreased lens volume after cataract surgery causes a forward shift of vitreous and release of angiogenic factors and cytokines. The literature reports increased rates of new onset retinopathy and worsening of diabetic macular oedema and existing retinopathy after cataract surgery. The rate of progression can reportedly double in the first postoperative year. The risk is higher with extracapsular cataract surgery and in patients with combined diabetic retinopathy and hypertensive retinopathy.

The ESCRS Prevention of Macular Edema after Cataract Surgery study (PREMED 2) concluded diabetic patients who received a postoperative subconjunctival injection with triamcinolone acetonide had a lower macular thickness and macular volume at 6 and 12 weeks postoperatively than patients who did not. Intravitreal bevacizumab had no significant effect.

RETINAL VEIN OCCLUSION A significant improvement in postoperative vision has been found following cataract surgery in patients with retinal vein occlusion (RVO). However, these patients have an increased risk of cystoid macular oedema (CME), even with uncomplicated cataract surgery. Perioperative topical NSAIDs and corticosteroids are beneficial.

“The literature reports increased rates of new onset retinopathy and worsening of diabetic macular oedema and existing retinopathy after cataract surgery.”

Preoperative evaluation and adjunctive therapy such as preoperative laser, intravitreal anti-VEGF, or steroids may be indicated in patients with exudative AMD, diabetic retinopathy, and RVO. Intravitreal anti-VEGF treatment may also be used perioperatively. Rapid regression of new vessels in PDR can cause tractional retinal detachment, so exercise caution in this situation.

EPIRETINAL MEMBRANE (ERM) AND VITREOMACULAR TRACTION Studies have shown roughly 7–8% risk of CME after cataract surgery in eyes with epiretinal membrane (ERM). Vitreous liquefaction and forward movement of the vitreous are known to increase the risk of CME. Epiretinal membranes are more common in diabetics, and these further increase the risk of CME. In addition, the ERM may progress more quickly after cataract surgery necessitating surgery. The decision to combine phacoemulsification with ERM peeling depends on the visual significance of the ERM. Amsler grid distortion and disruption of the outer retinal anatomy on OCT are indications for combined surgery.

RETINAL TEARS AND RETINAL DEGENERATIONS Cataract surgery may cause retinal detachment (RD) in the presence of high-risk retinal lesions. Such lesions should therefore be treated prior to surgery. Explain symptoms of retinal detachment and advise the patient to report symptoms immediately.

Pre-existing floaters may become more noticeable after cataract surgery and vitreous liquefaction may induce new floaters. In this case, employ phacovitrectomy or cataract surgery followed by vitrectomy. RETINAL COMPLICATIONS OF CATARACT SURGERY Cataract surgery can also induce retinal complications. These range from globe perforation during the peri-ocular block to posterior capsular rent (PCR) with ensuing vitreous loss, nucleus or IOL drop, and/or retained lens fragments. Several factors may increase the risk for CME, vitreous base traction, retinal tears (including giant tears), and retinal detachment. These include chamber fluctuations, PCR or other complications, postoperative inflammation, complex or comorbid eyes, and certain inappropriate surgical manoeuvres. Pseudophakic rhegmatogenous retinal detachment occurs in about 1% of cases, with 50% occurring within the first year of surgery.

Prophylactic topical steroids and NSAIDs are of use in patients at risk for CME. Treatment is also with topical NSAIDs and steroids. For resistant CME, try intravitreal and peri-ocular steroids. Try anti-VEGFs for non-responsive persistent CME. Consider YAG laser vitreolysis, surgical release of vitreous adhesions, and iris capture in select situations.

Hypotony and retinal or uveal damage can cause vitreous haemorrhage. Suprachoroidal haemorrhage and endophthalmitis are two sight-threatening complications that can cause irreversible vision loss.

Various retina procedures can induce cataracts. This will be discussed in a future article.

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.

Which IOL for Patients with Retina Disease?

Monofocal IOLs are preferred in patients with macular pathology or progressive retinal disease as decreased contrast sensitivity and altered macular function degrade multifocal IOL outcomes. Monofocals are also preferred in patients who may need future surgeries or low vision aids who are best served by a simple optical system within the eye.

Toric IOLs do not degrade contrast sensitivity and may be used in this patient group. However, corneal astigmatism induction from possible future surgeries—e.g., telescopic IOLs—may complicate astigmatism management later.

Complete spectacle freedom is not always possible. Set realistic expectations regarding limited visual outcomes and counsel regarding the natural history of the disease.

Silicone IOLs should be avoided in eyes with previous vitrectomy or may require future vitrectomy, as silicone oil sticks to its surface. Additionally, tiny fluid droplets may coat the exposed posterior surface of silicone IOLs during fluid-air exchange, impairing the surgeon’s view. Hydrophobic and hydrophilic IOLs are suitable, with hydrophilic lenses being least prone to oil adhesion. Hydrophobic IOLs are preferred if the corneal endothelium is compromised, as hydrophilic lenses may opacify following 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 IOL may also be refixated using sutured segments or sutureless glued capsular hook technique described by the author. Plate haptic IOLs should be avoided. Large optic IOLs allowing an unhindered view of retina are preferred. Even in high myopes with zero power, IOL implantation is preferred to create a barrier between the anterior and posterior segments as well as provide an ultraviolet barrier.

The role of blue light-blocking IOLs in AMD in decreasing oxidative stress from shorter wavelength high energy blue light is controversial. Recent studies show no advantages in decreasing AMD risk or progression while taking away blue light necessary for optimal mental and physical health as well as scotopic and mesopic vision.

Special IOLs such as the implantable miniature telescope, mirror telescopic IOL, IOL-VIP System, EyeMax Mono, and Scharioth macula lens (SML) have brought new hope to patients with AMD and other macular disorders.

Samsara Vision’s new generation SING Implantable Miniature Telescope lens received a CE mark for the European Union in 2020.

The Medicontur SML is an intraocular sulcus lens that has a bifocal design with a central optical zone of 1.5mm in diameter.