EuroTimes October 2024, Volume 29, Issue 8

ALSO IN THIS ISSUE

New Therapeutic Pathways in Keratoconus

Future combination treatments could improve outcomes and reduce risks.

Treating Adolescent Stargardt Disease Study suggests new drug may slow or prevent progression.

Fit for

Duty

Young ophthalmologists propose solutions for workplace stress.

Thinking of Selling Your Practice?

Planning an exit strategy is best begun early in a career.

By Hanita Lenses

THE FIRST AND ONLY IOL OF ITS KIND:

De veloped using a patented algorithm

Cr eated for maximum light utilization

Designed to redefine clarity and precision

Benefit from proven technology that minimizes disturbances while maximizing performance, ensuring unparalleled visual outcomes for every patient.

Available as:

• PRELOADED

• T ORIC

• 4 LOOP

• C LOOP

ESCRS

Leadership, Business & Innovation

ESCRS Practice Management Weekend

1–3 November

Zurich, Switzerland

Business and Practice Management Education Geared Specifically to ESCRS Members

Want a better handle on the financial operations of your department or clinical practice? Wondering how to evaluate AI tools and implement them into your daily work?

Join Hilary Hough, Vanessa Foser, and the ESCRS Leadership, Business & Innovation (LBI) team for a Practice Management Weekend Workshop in Zurich on 1–3 November!

Beginning with the November workshop, ESCRS will be partnering with the Trinity College (Dublin) Business School Executive Education programme. Trinity College offers one of the top-ranked MBA programmes in Europe and will be delivering business and practice management courses and workshops that are geared specifically for ESCRS members. In addition, it means Weekend Workshop attendees will earn continuing education credits for their participation.

Weekend Workshop Programme

Finance for Ophthalmologists

Led by Trinity Adjunct Professor Hilary Hough, this session is based on Trinity’s workshop on Finance for Healthcare Professionals. Prof Hough is a certified accountant and chartered director with a wide range of corporate finance, accounting, and general management experience. He lectures in the full-time and executive Trinity MBA courses and a range of other executive education programmes.

Gain an understanding of fundamental financial principles.

Develop the skills to analyse and interpret key financial statements, including balance sheets, income statements, and cash flow statements.

Learn to create, manage, and optimise budgets to ensure the efficient use of resources within your department/ clinical practice.

Apply financial knowledge to improve operational efficiency, streamline processes, and achieve better patient outcomes.

Engage in peer-to-peer learning to share insights, best practices, and innovative financial solutions.

What You Really Need to Know About AI Right Now

Join AI Business School Co-Founder/Chief Commercial Officer Vanessa Foser as she cuts through all the noise and hype about AI and focuses on what ophthalmologists need to know about using AI in clinical practice. Based in Zurich, the AI Business School supports organisations in their digital transformation. Ms Foser and her team are leaders in making workforces literate in (Generative) AI and its everyday use/application. In addition, members of the LBI Committee will share the AI tools they currently use in daily practice/daily life to improve efficiency and effectiveness.

Gain a better understanding of what exactly AI means.

Learn how to evaluate if an AI tool is valuable to incorporate into use.

Understand how to begin implementing AI into your clinical practice.

Attendance is limited to 25

Registration deadline is 25 October

Fit for Duty

Young ophthalmologists

Sheetal Brar MD and Sri Ganesh

Karen

Michael W Belin MD

Koji Kitazawa MD, PhD

Sadeer B Hannush MD

Lenses

Deborah S Jacobs MD

Cosimo Mazzotta MD, PhD, FWCRS

26 Anti-VEGF Proves

Effective Adjunct

Deniz Bagci MD

27 Cataract Surgery-Plus

Andrew Tatham MD, MBA, FEBO

28 CRISPR Vision

Mark Pennesi MD, PhD, FARVO

29 RP11 Treatment

Enters Human Trials

Fred K Chen MBBS (Hons), PhD (London), FRANZCO and Sri Mudumba PhD

30 Treating Adolescent Stargardt Disease

John R Grigg MBBS, MD, FRANZCO, FRACS

31 Cataract Surgery after Intravitreal Injection

Winnie Yu

32 Real-World Faricimab nAMD Outcomes

David Tabano PhD PAEDIATRIC OPHTHALMOLOGY

34 Bag-in-Lens for Ectopia Lentis Lyubomyr Lytvynchuk MD, PhD

Publisher

Filomena Ribeiro

Executive Editor

Stuart Hales

Editor-In-Chief

Sean Henahan

Senior Content Editor

Kelsey Ingram

Creative Director

Kelsy McCarthy

Graphic Designer

Jennifer Lacey

Lucy Matthews

Circulation Manager

Contributing Editors

Cheryl Guttman Krader

Howard Larkin

Dermot McGrath

Roibeárd O’hÉineacháin

Contributors

Laura Gaspari

Soosan Jacob

Timothy Norris

Colour and Print CitiPost

Advertising Sales

Roo Khan

MCI UK

Tel: +44 203 530 0100 | roo.khan@wearemci.com

EuroTimes® is registered with the European Union Intellectual Property Office and the US Patent and Trademark Office.

Published by the European Society of Cataract and Refractive Surgeons, Suite 7–9 The Hop Exchange, 24 Southwark Street, London, SE1 1TY, UK. No part of this publication may be reproduced without the permission of the executive 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

Essayists Stress the Importance of Beating Stress

Every year, the ESCRS sponsors the John Henahan Writing Prize for young ophthalmologists to address an important issue in the field. While there is only one winner, all the essays offer very useful insights into the upcoming generation of eye surgeons. This year, we struck a nerve, asking YOs to respond to the prompt, ‘Burnout is a chronic issue in ophthalmology, leading a growing number to abandon the field early in their careers. What should be done to reduce unnecessary stress in training and practice, allowing for a successful long-term career?’

We received 72 entrants—a record. The top three essays feature in this issue.

Burnout is generally defined as a triad of physical and/or emotional exhaustion, feelings of cynicism, and a low sense of accomplishment. The World Health Organization defines burnout as “chronic workplace stress that has not been successfully managed”, including exhaustion, job resentment, and reduced professional efficacy.

The toll of burnout includes emotional exhaustion, frustration, and lack of motivation for the profession. Inadequate coping abilities may result in emotional fatigue, diminished success, and dehumanisation of patients, culminating in a mechanical approach to procedures and interactions and ultimately leaving the profession.

Our contestants noted the already surprising rates of burnout among ophthalmologists are increasing, which they said applies to trainers and senior surgeons as well. They mentioned demographics of the ageing population increasing patient loads as an important factor. Many also cited a loss of support within the profession, eroded by changes in hospital management systems that value efficiency and paperwork above all else, ignoring the human cost. Notably, female ophthalmologists reported higher burnout rates, potentially influenced by gender-specific patient interactions.

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)

Proposed solutions included simple workplace changes, such as parking for staff, designated rest spaces, access to outdoor fresh air, and childcare facilities. Many called for more mentorship, not just with clinical skills but also lifestyle survival skills, time management, diversity, resilience, and autonomy.

Several essayists emphasised the individual’s role in preventing burnout beast through proper rest and nutrition, less doom scrolling, and making time for enjoyable activities.

Stress in the workplace is not a new issue. In an Eye Contact interview, Martin Severinsen spoke to Stig Severinsen and Stefan Palkovits about the ways ophthalmologists can deal with stress in the operating theatre and their day-to-day activities and how they can reduce anxiety in their patients. Scan the QR code to catch up on their discussion.

Sean Henahan Editor-in-Chief, EuroTimes

In Memoriam: Dermot McGrath 12 September 1967–24 June 2024

We are very sorry to report the unexpected passing of Dermot McGrath, a longtime contributor to EuroTimes Originally from Dublin, Dermot lived in Paris for more than 25 years. It was rare to encounter such great intellect paired with the easy-going charm and humour Dermot embodied. His contributions to EuroTimes were invaluable; we will profoundly feel his absence.

Marguerite McDonald (US)

Cyres Mehta (India)

Sorcha Ní Dhubhghaill (Ireland)

Rudy Nuijts (The Netherlands)

Filomena Ribeiro (Portugal)

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)

Thomas Kohnen Chief Medical Editor

José Güell Medical Editor

Paul Rosen Medical Editor

Call Open for Pioneer Research Award

The European Society of Cataract & Refractive Surgeons (ESCRS) is inviting ophthalmologists to submit applications for the Pioneer Research Award (PRA), which aims to support and encourage independent clinical research in the field of anterior segment surgery.

The competition is open to ophthalmologists and visual scientists up to the age of 45. Eligible participants must hold a full-time clinical or research position at a clinical or academic centre in the European region.

The purpose of the Pioneer Award is to:

• Support, encourage, and fund individuals interested in starting clinical research activities in the field of cataract and refractive surgery;

• Introduce and develop a body of clinical research work, addressing a challenging problem to devise a practical solution; and

• Facilitate and support an independent culture of study for the ultimate benefit of patients.

The Pioneer Award aims to fund various new initiatives, which may include:

• A novel research idea for the development of clinical trial studies;

• A non-interventional or observational study;

• A natural history/epidemiological study;

• A comprehensive series of retrospective case-control studies; and/or

• A patient or disease registry.

Successful applicants will receive up to €50,000 for a project with a project duration of no longer than two years.

How to Apply

Interested applicants are invited to submit their expressions of interest through the ESCRS PRA web page. An applicant to PRA requires clear reference to a current systematic review and meta-analysis, if available, published on the topic of which the applicant wishes to apply. The supervision of an established researcher is requested by ESCRS.

Deadline

Interested ophthalmologists have until 13:00 CET on 30 October 2024 to submit an application for the ESCRS Pioneer Research Award. Further details and the application form can be found on the ESCRS website. For additional information, please contact clinical.research@research.escrs.org

Education for All Is What Makes ESCRS Unique

BY LAURA GASPARI

In a field as rich in innovation as ophthalmology, it is crucial for physicians to pursue continuous learning to improve their skills. Scientific societies such as the ESCRS bear the responsibility of offering educational opportunities not just during meetings but throughout the year.

“People join ESCRS [not only] to go to the Congress and the Winter Meeting but also because they want to have some learning in between,” says Oliver Findl MD, chairperson of the Education Committee and immediate past president of ESCRS.

The Education Committee deals with a wide range of educational activities for the Society: organising skill labs and courses at the meetings, offering online opportunities, and providing ESCRS members with useful instruments and tools to refine their expertise. According to Dr Findl, these educational activities aim to address the needs of every ophthalmologist, from young trainees to high-level experts who want information on a special surgical technique or new products. For example, the new guidelines on cataract and refractive surgery—a project Rudy Nuijts started two years ago—aim to give ophthalmologists a useful and unique tool that will also influence national health policies.

Apart from coordinating and reviewing all courses and didactic programmes about cataract and refractive surgery and optics offered during the Annual Congress, the Education Committee is dedicated to e-learning platforms (like iLearn) and oversees the CME accreditation. Online education became crucial during the COVID pandemic and is still widely used by members. Dr Findl says the goal is to offer an educational platform that brings all learning resources together, from podcasts to videos to interactive courses to ESCRS On Demand, so members can easily access them from one place.

“I think we are going to have a system on the platform that can give you some suggestions according to your focus or the things you are aiming for,” he explained. “The idea is really to provide something members can do the entire year to keep themselves on top of things.”

Committee success stories

Dr Findl is especially proud of the IOL Calculator, an interactive resource designed by the Education Committee that allows an ophthalmologist to enter biometry data and get all the information needed for the seven major online formulas. The calculator has been a huge success, with more than 500 users every day. ESCRS launched a toric calculator in 2023, and a working group is currently designing a post-refractive surgery calculator.

“It is something really special, and it is much better than the older times when you had to go to each of the calculators on different websites and re-enter the data,” he observes. “Now you can compare them directly.”

Another Education Committee project that has registered a lot of success is the moving simulator. After surveying all European countries, ESCRS realised that not all provide access to a surgical simulator.

“ESCRS bought a simulator and made it travel all over Europe, especially in countries where there is none,” he

says. “Through a curriculum tailored by the ESCRS, people can use it for the first steps before starting surgery, and our sister national societies take care of the local logistics. We are receiving a lot of very positive feedback.”

Plans for the future

Wet labs, now called skill labs, could benefit from a renewal, and this is in the Education Committee’s plans for the future, Dr Findl says. With the use of artificial eyes for skill labs, it would be possible to improve the system of learning and training.

“We can record these labs and use the recordings to see what actually could be improved, the most common problems people have,” he says. “We could create a system where ophthalmologists can access these labs from elsewhere, needing just a small microscope and an artificial eye—not waiting for the Congress, where time is limited.”

The most important priority for the Education Committee, Dr Findl says, is to make the ESCRS one of the leading societies in the world for anterior segment surgery.

“The ESCRS is showing strong growth over the last 15–20 years, as demonstrated by the huge numbers attending the Congress,” he says. “This means the Society is an important point of contact for innovation and, most importantly, education.”

ESCRS ABROAD

Armenian Society Holds Conference, Encourages Member Exchange

The Armenian Society of Cataract and Refractive Surgeons (ArSCRS) has been active for two years. During this time, it has managed to earn a good reputation among Armenian ophthalmologists. There are almost 300 registered ophthalmologists in the country, and more than 190 of them are currently members of ArSCRS.

In 2023, our society held its official opening and first international conference, attended by 196 ophthalmologists. Both Armenian specialists and invited specialists from France, CIS countries, India, Italy, and Arab countries participated. Then-ESCRS President Oliver Findl welcomed ArSCRS as the 22nd national affiliated society of ESCRS, and Filomena Ribeiro and Rudy Nuijts presented online presentations. Conference participants received 6 CME theoretical credits.

This year the 2nd international ArSCRS congress was held. It was even larger, with 236 ophthalmologists participating and 16 theoretical credits awarded. The congress lasted two days and included sections on cataract, corneal and optometry, and vitreoretinal topics. We were delighted to welcome our international colleagues from various parts of the world. Additionally, we were honoured to have members of the ESCRS community, Marie-José Tassignon and Mark Wevill, accept our invitation and visit Armenia. The congress programme also included an interesting and informative historical and cultural tour for our guests.

ArSCRS considers the professional growth of our member doctors and the exchange of experiences among them as vital goals. For this purpose, our society took the initiative to launch the ‘Scientific and Practical Club of Ophthalmologists’ programme last year. This club is attended by Armenian ophthalmologists from both the capital city and the regions.

During the club meetings, the ophthalmologists listen to extensive and rich lectures prepared by the president of the society and the board member doctors. These lectures are dedicated to modern challenges and issues in ophthalmology

and their treatment. Following the lectures, discussions occur wherein practising doctors exchange their opinions and experiences. Each group has one day for practical training at the ‘SlavMed’ Eye Microsurgery Center.

After 5 club meetings, doctors earn 15 theoretical and 2 practical CME credits. So far, 10 such meetings have been held, in which 32 ophthalmologists have participated. Based on extremely positive feedback from the participants, ArSCRS intends to improve the club format by adding more practical activities.

Emphasising the safe medical practice of ophthalmologists and the safe medical care of patients in our country, ArSCRS actively performs awareness work in the field of medical practice insurance, leading to many ophthalmologists beginning to highlight its importance. ArSCRS is also actively involved in strengthening and creating new business connections with ophthalmological associations abroad to encourage the exchange of knowledge and experiences. Currently, we have close business relations with the French Society of Ophthalmology (SFO), the German Society of Ophthalmology (DOG), and the Leningrad Society of Doctor Ophthalmologists. We attend each other’s annual conferences, exchanging experience both in the professional field and in the field of improvement and development of the society.

Submitted

by

Satik Martirosyan Vice President and Executive Director, ArSCRS

Czech Society Hosts 21st Annual Congress Featuring Grant Competition

The 21st Annual Congress of the Czech Society of Refractive and Cataract Surgery (ČSRKCH) took place on the traditional third Friday and Saturday of May. Thanks to the active participation of many colleagues, we managed to put together a high-quality programme, which was reflected in the unprecedented number of attendees who filled the lecture hall from early morning until late afternoon.

This year’s congress set a record with more than 300 participants. We also saw significant interest from companies in the exhibition spaces, with numerous firms participating in the accompanying

exhibition alongside our main partners (Alcon, Bausch + Lomb, Johnson & Johnson, Medicontur, Videris, and Zeiss).

During the opening ceremony, the Professor Vanýsek Medal for outstanding contributions in cataract and refractive surgery was awarded to Associate Professor MUDr Jan Novák CSc, who became the ninth laureate of this prestigious award. For the first time, the ČSRKCH and ČLS JEP committees awarded honorary membership to our society, honouring four founders of our society: Professor P Kuchynka and emeritus chiefs Z Mazal, P Mašek, and M Janek.

As mentioned, the professional programme was very diverse and interesting. It is challenging to single out the best session, as each attendee likely found the most engaging part of the programme for them. The sessions “Videofestival,” “Duel,” and “Late Harvest” saw high attendance, and “News in Keratoconus Treatment” and “Combined Surgeries” were also highly rated. There were engaging discussions in both discussion blocks: “EDOF Lenses: Borderline Indications” and “Managing Patients Post-Refractive Surgery Approaching Presbyopic Age.”

A new feature was the Grant Competition, which featured four high-quality presentations by young colleagues under 35, who were subsequently awarded attractive financial prizes. The main prize was awarded to “Congenital Cataract with Persistent Fetal Vasculature and Plaque,” by authors from FN Motol, presented by Dr Zelenayová. The Audience Award was given to a well-produced and humorous entry, “IOL Explantation with Twist & Out Technique,” presented by Dr Pohanka from the Ophthalmology Department of the Regional Hospital in Zlín. We plan to continue this tradition, with the ČSRKCH committee announcing the next annual grant competition for 2024/25 with the same conditions and prizes.

According to preliminary plans, the 22nd Annual Congress of ČSRKCH is scheduled to take place 15–17 May, 2025.

Submitted by Andrea Janeková MD, FEBO Chief Physician of the Cataract and Refractive Surgery Centre

Deputy Head Physician Eye Centre, Prague

The best of

Barcelona

Memorable moments from the 2024 ESCRS Congress, capturing key connections and collaborations.

The Burnout Factory

BY IDOIA GOÑI GUARRO MD

Dear reader,

As we embark on this journey of introspection, I must forewarn you that this contemplation may claim a few precious minutes of your time. And if the notion of time’s passage already flutters in your mind, beckoning you to swiftly skip to what lies beyond these words, I must confess—you’ve unwittingly stepped foot into the realm of burnout.

Burn baby burn

It is true the inherent characteristics of work in the health field determine a context prone to instances of great stress given the nature of the activity and the frequent imbalance between external demands, self-demand, and often the resources available to efficiently comply with the objectives. The intensity and uncertainty of the events in the last three years determined in health professionals that coping with these situations in such a prolonged and continuous manner became in itself a burden, generating in some cases and increasing in many others symptoms of emotional exhaustion, frustration, and lack of motivation for the profession. Inadequate coping abilities may result in emotional fatigue, diminished success, and dehumanization of patients, culminating in a mechanical approach to procedures and interactions. These indicators collectively contribute to what is commonly recognized as ‘burnout syndrome,’ where individuals experience a sense of being overwhelmed and depleted by the demands of their work.

The ‘always on’ culture

In the realm of ophthalmology, burnout syndrome often flies under the radar, potentially due to misconceptions about the profession. Despite assumptions of high job satisfaction and low stress levels, ophthalmologists are just as susceptible to burnout as other medical professionals. Recognizing this disconnect between perception and reality is essential to address burnout within the field and support the well-being of current and future ophthalmologists.

A recent study by Jessica A Sedhom and Leonard K Seibold surveyed 592 ophthalmologists in the US, revealing a notable

37% showing symptoms of burnout syndrome. Distinctions among subspecialties showcased varying rates, ranging from 30.8% to 45.4%. Notably, female ophthalmologists reported higher burnout rates, potentially influenced by gender-specific patient interactions. Hospital-employed ophthalmologists also faced elevated burnout risks compared to their counterparts in private practice, prompting a call for healthcare institutions to address these contributing factors.

Additionally, other research has highlighted the significant impact of early career stages on burnout prevalence among ophthalmologists. Alarmingly high rates of emotional exhaustion and depersonalization among residents emphasizes the pressing need for intervention and support mechanisms at the onset of a practitioner’s career to combat burnout effectively.

It is known to everyone the usual shortage of time for consultations is compounded by the incessant flow of protocols, the increase in administrative tasks, social distancing, fear of contagion, error, and very importantly, the assiduous feeling of not practising the profession as desired and the lack of attention to other patients.

However, beyond what the statistics and studies reveal, it is important to consider that behind what these numbers represent there are real individuals with emotions, struggles, and vulnerabilities. This needs to serve as a reminder to truly appreciate the human element with its corresponding complex experiences.

The importance of self-reflection

Navigating burnout in the medical field requires a multifaceted strategy that addresses the well-being of healthcare providers on individual, collective, and institutional levels. By implementing early interventions and support systems, not only can we safeguard the mental health of professionals but also maintain the standards of patient care in the medical industry.

In the world of ophthalmology, where personal and professional spheres often overlap, finding a harmonious equilibrium is key. Mitigating stress through a blend of activities such as exercise, meditation, seeking counselling, socializing, indulging in hobbies, embracing spirituality,

ESCRS Patient Portal

and ensuring adequate rest can aid in maintaining a healthy work-life balance.

When considering upheavals within a practice, it’s vital to pace changes thoughtfully. Introducing too many modifications at once, even if beneficial, can overwhelm the system. For example, during a period of transition like relocating or expanding services, it may be prudent to hold off on additional transformations such as partnerships or new ventures to avoid unnecessary strain. Recognizing one’s tolerance for stress and upheaval is essential, as it differs from person to person. By proactively planning for changes and managing the overall flux in various facets of life, individuals can navigate challenges more effectively and safeguard their wellbeing in the long run.

Therefore, dear reader, it’s crucial to keep in mind that burnout can quietly encroach. Surrounding yourself with individuals capable of identifying stress indicators is a priceless asset. It’s not just about handling acute stress, but also about recognizing and managing longterm stress that can lead to burnout. Prioritize self-care and be proactive in seeking support when necessary. By doing so, you can effectively minimize avoidable stress during training and practice, setting the stage for a thriving and enduring career.

For citation notes, see page 40.

Dr Guarro came third in the 2024 John Henahan Writing Prize competition answering this prompt: ‘Burnout is a chronic issue in ophthalmology, leading a growing number to abandon the field early in their careers. What should be done to reduce unnecessary stress in training and practice, allowing for a successful long-term career?’.

Patients are understandably curious to learn as much as they can about their upcoming cataract or refractive surgery. ESCRS has developed a Patient Portal on its website to help inform patients about these surgeries.

The Portal is split into two sections: Cataract and Refractive. Each section provides an easy-to-understand summary of the different types of conditions, including the benefits, risks, procedures, and aftercare of common conditions.

Each section is easily navigable, with clear diagrams and a glossary to convey all the information patients might need to help prepare for surgery or during aftercare.

Idoia Goñi Guarro MD is an ophthalmology resident at KBC Sestre Milosrdnice, Zagreb, Croatia.

Nurturing Resilience: Alleviating Burnout in Ophthalmology

BY BURAK MERGEN MD

“As the morning light fills the clinic, I’m met with a rush of patients awaiting care. Throughout the day, I juggle consultations, surgeries, and paperwork, each task demanding my full attention. The growing administrative load weighs heavily on me, leaving little room for breaks, and lunch becomes a distant luxury amidst the constant flow of patients.

In this whirlwind, a sense of disillusionment begins to creep in. While once finding immense satisfaction in restoring sight to patients, now fatigue looms large, overshadowing my efforts. Interactions feel routine, lacking the empathy and connection that once fuelled my passion for ophthalmology.

As the day progresses, I yearn for deeper connections, yet fleeting conversations offer little solace amidst the challenges of our profession. The camaraderie that once lifted our spirits has faded, replaced by a pervasive sense of isolation as we each navigate our own struggles.

By day’s end, exhaustion sets in, overshadowed by the looming threat of burnout. Despite my unwavering dedication to patient care, doubts linger, questioning whether there’s anything more I can give.” This sobering fictional reality underscores the urgent need to address burnout within ophthalmology.

In the realm of ophthalmology, where precision and empathy come together to safeguard one of humanity’s most treasured senses, burnout casts a pervasive shadow over the profession. With the escalating demands of training and practice, an increasing number of young ophthalmologists find themselves trapped in its grip, considering early departure from a field they once wholeheartedly embraced. Addressing this pervasive issue requires a multifaceted approach that integrates institutional support, self-care practices, and a cultural shift within the profession itself.

Erich Fromm’s profound insights into the essence of human existence offer guidance towards a more sustainable approach to ophthalmology.1 He posits true values stem not from material possessions but from intrinsic qualities that define our ‘being.’ This challenges the prevailing culture of materialism, urging us to redefine success and fulfilment in terms of inner richness rather than external acquisitions.

Critical to mitigating burnout is addressing systemic stressors entrenched within training and practice environments. Institutions must proactively implement measures to alleviate burdens placed upon trainees and practitioners. Overwork, administrative pressures, and lack of support contribute to the erosion of well-being among ophthalmologists, necessitating systemic reforms.

Prioritizing self-care practises is paramount to weathering the storms of burnout. Encouraging a healthy work-life balance through flexible scheduling and time management strategies allows individuals to recharge and reconnect with their passions beyond the operating theatre. Cultivating inner richness through mindfulness, meaningful relationships, and personal growth serves as a buffer against burnout’s insidious effects.

Crucially, effecting lasting change demands a cultural shift within the ophthalmic community. Destigmatizing vulnerability and fostering open dialogue regarding mental health are paramount. By embracing vulnerability as a strength, ophthalmologists can cultivate a culture of authenticity and mutual support, bolstering resilience against burnout’s tide.

Furthermore, recent studies have shed light on specific risk factors contributing to burnout among ophthalmologists. For instance, research by Chang (et al.) examined LGBTQ identity as a potential risk factor for burnout within an international

ophthalmologist cohort.2 Their findings revealed that LGBTQ ophthalmologists reported higher levels of personal and work-related burnout compared to their non-LGBTQ counterparts. Additionally, discrimination or harassment based on LGBTQ status in the workplace was identified as a contributing factor to increased burnout among this demographic.

Moreover, Sedhom (et al.) conducted a survey among ophthalmologists in the United States, uncovering significant associations between burnout and demographic factors such as gender, employment setting, and practice type. Specifically, female ophthalmologists exhibited nearly twice the odds of experiencing burnout compared to their male counterparts, while physicians employed in academic and hospital settings reported higher rates of burnout than those in large private groups.3 These studies underscore the importance of addressing diverse demographic factors and workplace dynamics in mitigating burnout among ophthalmologists.

Through collaborative implementation of the recommendations below, stakeholders in the ophthalmology community can create a supportive environment fostering resilience, preventing burnout, and enhancing well-being:

• Institutional Support: Implement policies promoting work-life balance, allocate resources to cope with stress, and offer tailored support programmes.

• Self-Care Practises: Prioritize physical, emotional, and mental well-being through regular exercise, healthy habits, and engaging activities outside work.

• Workload Restructuring: Assess workloads critically, identifying tasks incongruent with strengths or patient care contribution.

• Promotion of Autonomy: Empower ophthalmologists to make decisions aligned with values, fostering collaboration and professional growth.

• Peer Support and Mentorship: Establish networks enabling sharing experiences, seeking guidance, and fostering camaraderie among colleagues.

In conclusion, nurturing resilience and alleviating burnout in ophthalmology requires collective action from institutions, individuals, and the profession. By integrating Fromm’s insights and fostering a culture of openness and support, we can transcend burnout’s limitations, paving the way for a future defined by passion, purpose, and fulfilment.

For citation notes, see page 40.

Dr Mergen’s essay came second in the 2024 John Henahan Writing Prize competition answering this prompt: ‘Burnout is a chronic issue in ophthalmology, leading a growing number to abandon the field early in their careers. What should be done to reduce unnecessary stress in training and practice, allowing for a successful long-term career?’.

Burak Mergen MD, FEBO, FICO is a second year resident in Gengenbach, Germany. burakmergen@gmail.com

the state. Anticipate the future.

Regular Growth Control is essential for myopia management

See eye growth in detail and visualize the success of your treatment. myopia-master.com

OCULUS Myopia Master ®

Know Thy Enemy

BY HARRY ROSEN “

Know thy enemy,” said Sun Tzu, military strategist and philosopher. Trainees accept that burnout is an ugly, embedded part of modern training. Meanwhile, senior surgeons are often confused, even exasperated in trying to understand it. Most of us struggle to even define burnout. It is imperative we recognise and understand burnout, to make changes to prevent it.

Burnout is the damaging trajectory that occurs when exhausted, dissatisfied professionals in any field become sequentially disengaged, often to a point of no return. Figure 1 illustrates some of the key interactions between exhaustion, dissatisfaction, and disengagement and the multitude of factors that contribute.

The scale of the problem

Burnout is an acutely worsening problem. In the case of the UK, ophthalmology has the fastest growing rate of ‘high-risk’ burnout compared to any other specialty. 22% of ophthalmology trainees were at high risk of burnout in 2023, a 50% increase from 2022.1 Taken from the 2023 GMC survey of 70,000 responses, 93% of these stated they are likely to make a career change. Burnout and dissatisfaction were offered as the two main modifiable justifications for leaving.

Burnout is not a partisan nor polarising problem between trainees and experienced trainers. Rates of ‘high-risk’ burnout among senior trainers has also seen a significant rise over the last 3 years. Similar trends among ophthalmologists exist worldwide.2

Why are we burnt out and why now?

The rise in burnout is multifactorial. Figures 2 and 3 illustrate the recent rise in workload and dramatic drop in satisfaction among doctors in the UK. Among ophthalmologists alone, 53% of trainees say they work overtime daily or weekly (42% average among other specialties), 42% feel short of sleep at work, and 40% find the work emotionally exhausting.1

Patients are living longer, and resources available per patient are decreasing. Due to the geriatric, ‘high-flow’ nature of our patient footfall, ophthalmology is particularly sensitive to these demographic changes. Traditionally, this workload was offset by forgiving on-call and inpatient commitments. These silver linings are being overshadowed by increasing workload and a failing primary care sector.

As a competitive, vocational career, ophthalmologists have other unique challenges. Like myself, many trainees move hundreds of miles to take up training posts, leaving behind friends, families, and support networks.

What should be done?

We need specific, material, affordable changes we can implement locally. Each of the following changes could increase the retention of doctors. This would exponentially ease the burden of burnout, as quickly as the problem grows.

1. Mentoring

David Lockington recently wrote a powerful piece on burnout for The Ophthalmologist, hailing the protective benefits

of time management, diversity, resilience, and autonomy. Mentors such as these could guide trainees to develop these skills in both life and work. As he writes, Maslow’s hierarchy of needs states that ‘self-actualisation’ is the very peak of personal wellness. A trusted mentor is the best way to strive towards this, helping to set goals and guide trainees towards achieving them.

2. The team

One of the greatest recent losses among hospital workplaces is a sense of culture, camaraderie, and loyalty. Despite the noble intention of standardising patient care, medical practice has edged towards centralised, impersonal bureaucracy. Simple solutions could include regular social events, comprehensive inductions, longer (at least 12-month) rotational periods, and consistent theatre/clinic team members. These interventions not only improve patient care but also make work life enjoyable, efficient, and productive.

3. Prioritising teaching and learning

Curiosity and learning are often the first things we sacrifice in a busy operating list or clinic. These are the aspects that bring character and colour to the work we do. Likewise, the faster a trainee can practice independently, the lower the workload will be for the team. Maintaining a focus on continuous career learning both reinvigorates clinical practice and reduces our workload by developing competent trainees.

4. Resources

Any fresh-faced management consultant can tell you that appropriately resourced and happy staff will be more productive. Rest spaces (which aren’t used as backup filing storage), parking, coffee/food/drink access, access to outdoor space, appropriate changing facilities, childcare, flexible rota patterns, etc. are all low-cost interventions to protect staff well-being. Perhaps more importantly, they make staff feel valued by the organisation and motivated to do their best for patients.

Conclusion

There is no doubt that burnout is a growing and complex problem. Here, I have outlined the true nature of burnout, its root causes and some simple practical solutions to build resilient trainees for the future. As many have done already, all that remains is for leaders to take action.

For citation notes, see page 40.

Dr Rosen submitted the winning essay for the 2024 John Henahan Writing Prize competition answering this prompt: ‘Burnout is a chronic issue in ophthalmology, leading a growing number to abandon the field early in their careers. What should be done to reduce unnecessary stress in training and practice, allowing for a successful long-term career?’.

Harry Rosen is a Year 1 Specialty Trainee at Portsmouth Hospitals University NHS Trust in the UK. harrysrosen@gmail.com

Surgeons Split on Post-Surgery

Inflammation Control

Leading surgeons weigh whether or how to use a dropless regimen after cataract surgery.

CHERYL GUTTMAN KRADER REPORTS

There is no disputing relying on topical medications for controlling inflammation after cataract surgery has many drawbacks. However, opinions on using a dropless approach vary.

Ehud I Assia MD said a ‘less drops’ approach works better for him. Although he uses intracameral moxifloxacin for infection prophylaxis, Dr Assia prescribes a 1-month course of topical medications for infection control consisting of two medications, a steroid, and a nonsteroidal anti-inflammatory drug (NSAID), each given three times daily.

Providing the rationale for his approach, Dr Assia noted that unless formulated for sustained release, medications administered intracamerally provide only short-term efficacy. While the limited duration of coverage is adequate for preventing endophthalmitis, he said it is not sufficient to control inflammation.

Short-term efficacy, complication risk, and/or irreversibility decrease the acceptability of other injectable routes for delivering anti-inflammatory drugs—e.g., subconjunctival injection and approaches for posterior chamber placement. The intracanalicular dexamethasone insert offers reversibility, but available data show it is not more effective than topical steroids, Dr Assia said.

“The less drops regimen is effective, reversible, adjustable, and inexpensive,” he concluded.

Support for subconjunctival steroids

Advocating for subconjunctival steroid injection, Neal H Shorstein MD reviewed findings from a recently published study reporting on the effectiveness of subconjunctival triamcinolone acetonide (TA) as a standalone treatment for preventing inflammation after cataract surgery.1 Dr Shorstein noted that in 2008, he and two colleagues at Kaiser Permanente Northern California began an injection-only protocol for their cataract surgery medication regimen using an intracameral antibiotic and subconjunctival TA.

84%

In one study, 84% of patients indicated a willingness to pay more for the dropless option.3,4

“We preferred the subconjunctival route versus a sub-Tenon’s injection for the steroid because using the subconjunctival approach, we could visualise the needle tip during delivery and the depot postoperatively, allowing us to avoid globe perforation and excise the depot postoperatively if necessary,” he said.

The steroid regimen was modified over time, transitioning from a 2 mg dose using TA 40 mg/mL to 4 mg using TA 10 mg/mL. Dr Shorstein explained the smaller dose of the higher concentration drug was associated with a significant IOP rise in a very small percentage of patients and was found to be less effective than topical prednisolone plus an NSAID. The higher dose using a lower concentration of TA was more effective and caused fewer IOP spikes.

The recent study included data from almost 70,000 eyes operated on between 2018 and 2021. They were assessed for development of macular oedema, rebound iritis, and glaucoma-related events occurring from 15 days to 1 year postoperatively. Eyes receiving subconjunctival TA were divided into subgroups by TA dose and concentration. Researchers used a multivariate analysis to compare the outcomes to a reference group receiving topical anti-inflammatory treatment.

Reviewing the results and weighing the benefits and risks, Dr Shorstein and colleagues concluded TA 4 mg (10 mg/mL) was the favoured regimen for preventing inflammation in routine cases. However, they suggested TA 4 mg (40 mg/mL) may be applicable for patients with pre-existing iritis because it further lowered the risks of macular oedema and iritis. However, close follow-up is important because TA 4 mg (40 mg/mL) was associated with higher odds of IOP elevation.

Also considering the risk for increased IOP, Dr Shorstein noted the need to exercise caution using subconjunctival TA in patients with an optic nerve at risk or elevated risk for a steroid response. With safety in mind, he also recommended using the studied product (Kenalog; because different triamcinolone products have different pharmacokinetics), monitoring IOP until the depot is no longer visible, and injecting the medication inferiorly versus superiorly.

Sustained release steroid

Seth M Pantanelli MD explained why he prefers the intracanalicular dexamethasone insert as his choice for a steroid after cataract surgery.

“The insert has been shown to be safe and effective for controlling pain and inflammation. Insertion is easy and fast—it can be done in less than 15 seconds, and patient perspectives about the insert are overwhelmingly positive,” Dr Pantanelli said.

“Although the insert adds cost for the medical system, the ambulatory surgery centre (ASC), surgeon, and patient, it can actually be cost-neutral or even revenue positive, depending on the comparator.”

Dr Pantanelli reviewed data from premarket approval studies demonstrating the intracanalicular insert was more effective than placebo for controlling inflammation and pain— but he also emphasised results from a retrospective chart review showing it was as effective as topical steroid drops, which is the more relevant comparator.2 Furthermore, results

Precizon.

from two studies in which patients underwent surgery with the insert in one eye and topical drops in the other showed the vast majority of participants (≥92%) preferred the insert. In one study, 84% of patients indicated a willingness to pay more for the dropless option.3,4

Regarding cost issues, Dr Pantanelli noted insert use might generate a per case profit of up to US$35 for the ASC or surgeon.

“We have to consider cost in this world of decreasing reimbursement, and we also have to consider cost to patients with topical drops,” he said.

Drs Assia, Shorstein, and Pantanelli spoke at ASCRS 2024 in Boston, US.

For citation notes, see page 40.

Ehud I Assia MD is Professor of Ophthalmology, Tel Aviv University, Tel Aviv, Israel. assia@eintal.com

Neal H Shorstein MD is an ophthalmologist, researcher, and associate chief of quality at Kaiser Permanente Medical Center in Walnut Creek, California, US. neal.shorstein@gmail.com

Seth M Pantanelli MD, MS is Professor of Ophthalmology, Penn State College of Medicine, Hershey, Pennsylvania, US. spantanelli@pennstatehealth.psu.edu

Meet the Precizon Family: best-in-class IOLs for any cataract challenge. Monofocal, enhanced intermediate vision and full range of vision lenses with patented CTF technology. Regular and Toric. With a natural fit and ingenious optics that deliver extraordinary results. For successful surgery and perfect natural vision.

ophtec.com/precizon-family

Precizon Family

Optimising Results of Toric IOL Surgery

Head-to-head study investigates outcomes achieved using two digital markerless systems for guiding intraoperative alignment.

CHERYL GUTTMAN KRADER REPORTS

Both a scleral image-guided limbal-based registration system (Callisto) and a femtosecond laser-enabled capsular marking system using iris registration (Intelliaxis) are safe and effective tools for assisting precise alignment of toric IOLs, a recent prospective randomised study concludes.

“We conducted this study after noticing the target meridian identified by the two systems sometimes differed when both were used in the same case,” said Sheetal Brar MD. “We believe ours is the first study to directly compare the accuracy and clinical outcomes achieved using these two approaches.”

There were no acquisition failures with either system nor were there any cases requiring repeat capture or postoperative repositioning of the toric IOL due to significant misalignment. However, analyses of data collected after one week and three months showed residual postoperative astigmatism was slightly but significantly higher when the limbal registration system guided alignment compared with the iris-based system.

“Our findings suggest the iris registration tool may have a potential advantage for more precise characterisation of the target meridian. As another advantage, it results in permanent capsular marks that facilitate postoperative determination of toric IOL position,” said Sri Ganesh MD.

“However, there are some practical advantages associated with the limbal registration system: it is a non-contact, less expensive approach that can be used independently of femtosecond laser-assisted cataract surgery. In addition, the limbal registration system can be used in small pupils and does not reduce the strength of the capsulorhexis, which is important in situations where capsular hooks are needed to stretch the capsule.”

Our findings suggest the iris registration tool may have a potential advantage for more precise characterisation of the target meridian.

The study enrolled eyes with regular corneal topography and astigmatism ranging from 0.75 D to 4.00 D. Sixty eyes were randomised 1:1 to have toric IOL alignment guided intraoperatively by the limbal registration system or the iris registration system.

The two groups were well matched preoperatively in their biometric characteristics. All eyes underwent femtosecond laser-assisted cataract surgery using the same laser (Lensar) performed by a single surgeon (Dr Ganesh) with implantation of a monofocal toric IOL under BSS. A plano target was used for all cases, and all IOL power calculations were done using the same formula (Barrett TK toric). Follow-up visits were conducted at one day, one week, and three months and included a check of toric IOL alignment using the tool found on a raytracing system (iTrace).

At postoperative day one and month three, mean cylinder was -0.07 D and -0.04 D, respectively, in the iris registration group and -0.20 D and -0.18 D, respectively, in the limbal registration group (P ≤0.05 for both comparisons). There was also a statistically significant difference favouring the iris registration group in the analysis of mean logMAR uncorrected distance visual acuity at both day one (0.03 vs 0.08) and month three (0.00 vs 0.08; P ≤0.04 for both comparisons). There were no statistically significant differences between groups in mean sphere, spherical equivalent, corrected distance visual acuity, or deviation from intended axis at either follow-up.

Dr Brar presented the study at ASCRS 2024 in Boston, US.

Sheetal Brar MD is a senior consultant in the Cataract and Refractive Department of the Brar Eye Hospital, Bathinda, Punjab, India. brar_sheetal@yahoo.co.in

Sri Ganesh MD is chairman and managing director at Nethradhama Superspecialty Eye Hospital, Bangalore, India. phacomaverick@gmail.com

Diverse Levels of Access to Cataract Surgery

Racial and ethnic disparities found in US study.

HOWARD LARKIN REPORTS

Cataract surgery rates in the United States are higher among patients aged 70–79 years, males, and those with Hispanic ethnicity and lower among non-Hispanic Black patients, according to a nationally representative cohort study. Self-employed, out-of-work, and retired patients are also more likely to receive cataract surgery than those working for wages.

The findings suggest persistent disparities in who receives cataract surgery in the US, especially regarding race and ethnicity, and indicate a need for interventions to address health disparities and promote equal access to cataract surgery, said Ms Karen Fernandez.

Diverse cohort

One challenge with examining healthcare access disparities is ethnic and racial minorities are often underrepresented in academic studies, Fernandez noted. The patients and data for this study were drawn from the ‘All of Us’ research programme run by the US National Institutes of Health. The programme tracks medical information for a large and diverse national cohort, of whom nearly half are racial and ethnic minorities. Information collected includes self-reported health surveys, electronic health records, and some genomic data.

The current study examined factors associated with undergoing cataract surgery in more than 37,000 patients in the ‘All of Us’ cohort diagnosed with at least one cataract, of whom about 20% received at least one cataract surgery. Factors examined included age, race, and sex at birth, as well as social factors, including employment, education, income, and relationship status. The study also looked at cataract surgery rates for the entire cohort of more than 400,000 patients.

Significant disparities seen

The study found an overall rate of cataract surgery among patients with cataract diagnoses of 30.6 per 1,000 person-years of follow-up, Fernandez reported. The rate was higher for persons aged 70–79 at 58.5, Hispanics at 39.0, and males at 31.8. Amongst all race and ethnicity categories, non-Hispanic Black patients had the lowest rate at 24.4. The cataract surgery rate for the entire patient cohort, including those without cataract diagnoses, was 6.5.

In a multivariable Cox model, compared with rates for non-Hispanic White cataract patients, Hispanic cataract patients had an increased hazard of undergoing cataract surgery with a ratio of 1.31, and non-Hispanic Black patients had a lower hazard ratio of 0.88. Females had a decreased hazard ratio (0.94) compared with males. Male patients were also

found to have more rapid progression to cataract surgery, and non-Hispanic Black patients a slower progression. Hispanics had shorter times to cataract surgery than other groups.

Compared with patients employed for wages, self-employed cataract patients had a higher hazard of cataract surgery at a ratio of 1.13, as did out-of-work patients at 1.12 and retired patients at 1.24. No significant differences were observed in cataract surgery rates by education, income, insurance, or relationship status, Fernandez reported.

“Overall, we saw a significant association among cataract surgery rates by sex at birth, age, and race and ethnicity,” Fernandez said. Time from diagnosis to cataract surgery was also significantly associated with all these factors. Though the researchers did not investigate reasons for these disparities, she added they hypothesised local barriers to access, transportation issues, and language, trust, and miscommunication issues may help explain the differences.

Ms Fernandez reported at ARVO 2024 in Seattle, US.

Karen Fernandez is a second-year medical student at Stanford University School of Medicine, Stanford, California, US. karenf6@stanford.edu

Removing Epi Removal Problems

Full steam ahead for epithelium-on phase 3 study.

Enrolment is currently at an advanced stage in the United States for phase 3 trials of a novel minimally invasive epithelium-on cross-linking treatment for corneal ectasia, according to Michael Belin MD.

Speaking at EuCornea 2024, Dr Belin said that recruitment is proceeding at a faster rate than initially anticipated, with 357 patients of a total 800 already enrolled following successful phase 2 trials of EpiSmart™ (Epion Therapeutics). That study resulted in mean improvements in corrected distance visual acuity, uncorrected visual acuity, and Kmax at both 6 and 12 months and an excellent safety and efficacy profile.

“The goal with this treatment is to eventually offer a cost-effective procedure that is both physician and patient friendly, enhance the risk-benefit ratio, and [provide] the ability to treat on initial diagnosis of keratoconus,” he said. “The goal in medicine should really be to prevent sequela of disease and not wait until there is a visual performance deficit before we intervene.”

Being able to offer a safe and effective cross-linking treatment without the need for epithelial removal would bring several clear advantages, Dr Belin said.

“Epithelial removal has multiple complications that we all are aware of. By contrast, EpiSmart is a true epithelium-on treatment, and there’s no need for supplemental oxygen,” he said. “We don’t use oxygen goggles, and we do not use any type of epithelial loosening agent or preservatives to loosen the epithelium.”

EpiSmart provides full thickness limbus-to-limbus riboflavin

The goal in medicine should really be to prevent sequela of disease and not wait until there is a visual performance deficit before we intervene.

stromal saturation, and Dr Belin noted the US FDA deemed its safety profile similar to a prescription dry eye medication.

“Because of this and the excellent safety profile, we actually do bilateral simultaneous treatments if both eyes qualify,” he said.

The treatment uses a proprietary concentrated riboflavin formulation, Ribostat, that contains sodium iodide as its key active ingredient to enhance epithelial penetration and stabilise stromal riboflavin.

“We are not waiting for progressive disease to treat both eyes simultaneously,” he said. “If both eyes qualify, it’s a oneto-one active sham. We do allow rescue treatment if there is a significant decrease in vision in the sham-treated eye or tomographic progression, and all sham-treated eyes will be offered active treatment at the end of the 12-month follow-up.”

The EpiSmart procedure uses a specially designed sponge to remove the mucin layer, followed by a 30-minute application of Ribostat via a loading sponge to maintain drug concentration during stromal loading.

“It’s a full thickness limbus-to-limbus stromal saturation. To date, not a single patient has required supplemental riboflavin application,” Dr Belin said. The final part of the procedure uses a pulsing UVA exposure for 20 minutes.

The procedure is very similar to standard cross-linking, with the key difference being that EpiSmart is designed for use much earlier in the disease process.

“We are treating fairly early subclinical disease (up to advanced disease), and if we compare this again to currently available epithelium-off treatment in the United States— which is really designed for moderate to late disease—we are going after a much wider spectrum of disease,” he concluded.

Dr Belin presented at EuCornea 2024 in Paris.

Michael W Belin MD is Professor of Ophthalmology at the University of Arizona, US, and Chief Medical Officer of Epion Therapeutics, Burlington, Massachusetts, US. mwbelin@eyes.arizona.edu

New Therapeutic Pathways in Keratoconus

Future combination treatments could improve outcomes and reduce risks.

Ongoing research and technological advances in biomarking and genetic therapies are paving the way for innovative treatments that could transform keratoconus in the near future, according to Koji Kitazawa MD, PhD.

“Significant challenges remain, but we are making steady progress. Biomarkers play a pivotal role in the diagnosis, monitoring, and potential treatment of keratoconus— while gene therapy holds promise as a potential cure for keratoconus by addressing the genetic causes of the disease,” Dr Kitazawa said.

Dr Kitazawa defined biomarkers as measurable indicators of a biological condition or state.

“In the context of disease, they can be substances or processes indicating the presence, stage, or progression of a disease,” he explained. “Biomarkers can identify keratoconus early, even before significant symptoms appear. They can help with monitoring disease progression and the effectiveness of the treatment. Biomarkers also allow for a more personalised medical approach, leading to better clinical outcomes and reduced side effects.”

These biomarkers can be broken down into three broad subcategories: structural, proteomic, and genetic.

“Structural biomarkers identify changes detected through imaging techniques such as corneal topography or tomography that show characteristic thinning or bulging of the cornea,” he said. “Proteomic biomarkers show protein expression levels that differ between healthy and keratoconus-affected corneas, and genetic biomarkers show variations or mutations in specific genes associated with keratoconus.”

To highlight the potential utility of structural biomarkers in keratoconus, Dr Kitazawa and team evaluated the diagnostic performance of the different indices obtained between normal eyes and keratoconic eyes using anterior segment optical coherence tomography.

“Our findings revealed the anterior surface and posterior surface ratio was smaller in forme fruste keratoconus and keratoconic eyes, suggesting—theoretically—that the posterior surface area became enlarged compared to the anterior surface at the initial stage of the disease,” he said.

Proteomic biomarkers can be obtained using tear film analysis, which is minimally invasive and allows clinicians to monitor upregulation or downregulation of particular proteins for possible disease progression.

However, it is in the domain of genetic biomarkers that research progress has perhaps been the most striking in recent years, said Dr Kitazawa.

“Some reports have identified multiple loci associated with central corneal thickness and keratoconus in European and Asian populations,” he said. “Identification of these gene mutations brings into focus the potential for gene therapy for keratoconus for diagnosis and progression and paving the way to eventual gene therapy, whether in the form of gene editing, gene replacement, or gene silencing techniques.”

Multiple challenges remain in the optimal delivery method and safety of any potential gene therapy treatment, but Dr Kitazawa believes there are good grounds for optimism with each research breakthrough.

“In an ideal future scenario, the patient would go to the hospital for genetic analysis and biomarkers, and then we would integrate gene therapy with biomarker-guided therapies. We also envisage combination therapies incorporating gene therapy with other treatments such as corneal cross-linking or biomarker-guided therapies for a comprehensive approach,” he observed. “The ideal goal would be to offer more personalised medicine tailoring gene therapy to individual genetic profiles, enhancing efficiency and reducing risks.”

Dr Kitazawa presented at EuCornea 2024 in Paris.

Koji Kitazawa MD, PhD is Assistant Professor at Kyoto Prefectural University of Medicine, Kyoto, Japan. kkitazaw@koto.kpu-m.ac.jp

Surgery for Anterior Corneal Disease

Achieving vision improvement and minimising morbidity by tailoring the procedure to the pathology location.

CHERYL GUTTMAN KRADER REPORTS

When surgery is indicated for visual rehabilitation of an eye with corneal disease not affecting the endothelium and Descemet’s membrane, think about an anterior procedure instead of penetrating keratoplasty, advises Sadeer B Hannush MD.

“There is no reason to do a full-thickness graft in this situation,” Dr Hannush said. “Even a partial thickness graft may not be necessary.”

The choice of surgical intervention is guided by whether the pathology lies anterior or posterior to Bowman’s layer (BL) and, if posterior to BL, how deep. If there is only visually significant basement membrane disease, superficial keratectomy—which only removes the epithelium and basement membrane—is an effective and simple but underused procedure, according to Dr Hannush.

“Lamellar keratectomy for basement membrane disease results in rapid and significant visual improvement,” he said. “Frequently, patients see clearly before they leave the office.”

Anterior lamellar keratectomy, which removes the anterior stroma, can be done instead of a graft procedure in cases where the corneal pathology is posterior to BL but within the anterior 200 microns of the stroma. It may be performed by freehand dissection, phototherapeutic keratectomy with an excimer laser, or microkeratome- or femtosecond laser-assisted keratectomy. After the tissue is removed, mitomycin-C is applied, followed by copious irrigation.

“Visual improvement also occurs fairly rapidly after these procedures,” Dr Hannush said. “It is not necessary to remove every opacity for the patient to achieve significant improvement in vision.”

Deep anterior lamellar keratoplasty (DALK) is indicated for treating eyes with corneal ectasia that have failed rigid gas permeable or scleral contact lenses or for those with stromal dystrophies or stromal scars from previous infection or non-penetrating trauma. The dissection in the host cornea removes most or all the corneal stroma down to either the pre-Descemet’s layer (PDL), also known as Dua’s layer (DL), or to Descemet’s membrane (DM) itself. After initial debulking of the host stroma, further dissection may be accomplished manually or by the Big Bubble (BB) technique, viscodissection, or femtosecond laser-assisted air dissection.

Dr Hannush noted when performing the BB technique, surgeons should be aware the desired type 1 BB occurs 90% of the time, forms centrally first, and extends to the periphery with significant emphysema (whitening) of the cornea. Here, the air bubble forms between the posterior stroma and PDL. In about 10% of air injections, a type 2 BB develops, with the

bubble forming in the periphery and extending centrally with minimal whitening of the cornea. The bubble forms between the PDL and DM. It is important to recognise the type 2 BB scenario because it presents a fragile situation associated with an increased risk of DM rupture.

“Whereas the PDL has a bursting pressure of about 500–700 mmHg, DM bursts quickly at a pressure of about 30 mmHg.

“Some surgeons might decide not to proceed with removing the posterior stroma if a type 2 BB occurs, but it is not necessary to abort the DALK procedure in this situation,” Dr Hannush said. “The surgeon may either remove the posterior stroma carefully, paying attention not to come in contact with DM (this may be facilitated by softening the eye by removing some aqueous through a paracentesis). Alternatively, the surgeon may continue with layer-by-layer manual dissection, leaving a thin layer of posterior stroma.”

Dr Hannush spoke at 2024 ASCRS Cornea Day in Boston, US.

Sadeer B Hannush MD is an Attending Surgeon at Wills Eye Hospital and Professor of Ophthalmology, Thomas Jefferson University, Philadelphia, US. sbhannush@gmail.com

Slide 1: DALK air injection.

Slide 2: Debulking the cornea during DALK.

Consider Scleral Lenses for Keratoconus

Aiming to increase acceptance by overcoming misconceptions.

CHERYL GUTTMAN KRADER REPORTS

There has been much misinformation about scleral lens use and the outcomes of keratoplasty for patients with keratoconus. When considering the facts, however, the bottom line on the role of these options is no patient should undergo keratoplasty for keratoconus without first trialling a scleral lens, said Deborah S Jacobs MD.

“While surgery for keratoconus is thought to be generally successful, the unfortunate truth is that it typically results in low patient satisfaction,” Dr Jacobs said. “Furthermore, we have learned outcomes are better with scleral lenses than after keratoplasty, even in stage IV keratoconus.”

Other obstacles to more widespread scleral lens use were early limited accessibility and the idea that fitting was too labour intensive. However, after industry saw scleral lenses as an area for market growth, the technology became widely available, and fitting guides and clinical education opportunities are addressing fitting concerns, Dr Jacobs said.

While surgery for keratoconus is thought to be generally successful, the unfortunate truth is that it typically results in low patient satisfaction.

Various misconceptions about what patients can be considered viable candidates for scleral lenses also served as barriers, as some clinicians thought keratometry >65 to 70 D or axial scar were reasons for exclusion. The realities, however, are that no cornea is too steep for a scleral lens because the lens vaults over the cornea, and an axial scar is not an absolute indication of keratoplasty.

“Vision in a rigid lens should be assessed before deciding on surgery for patients with an axial scar because irregularity that would be corrected by a scleral lens may be the reason for vision loss rather than opacity from the scar,” she said. “Furthermore, remember that putting a patient in a more

KERATOCONUS NORMAL

KERATOCONUS

physiologic lens can lead to resolution of a scar by allowing the surface to heal and remodel.”

Additional clinical pearls

Dr Jacobs noted no brand of scleral lens is superior, as it is the person fitting that matters, not the piece of plastic.

“There are also no data yet to show advantages of newer lenses reflecting innovations in manufacturing (e.g., moulding) or design (e.g., profilometry-based fits).”

When there is a problem with fit or tolerance, Dr Jacobs advised, “go larger and go looser.

“Smaller scleral lenses are easier to fit and more comfortable, but they develop suction, and we all know that suction sucks. In my experience, lenses with a diameter <18 mm are rarely satisfactory long term,” she said.

Dr Jacobs also recommended using a mast cell stabilizer (cromolyn 4% or lodoxamide 0.1%) for managing patients who develop follicles at the limbus and/or corneal infiltrates with scleral lens wear.

“Presence of follicles or infiltrates is not a reason to take patients out of a scleral lens. I think these individuals do better when kept in their lens,” she said. “While tapering a soft steroid can be helpful, it has risks in the setting of lens wear. Twice daily treatment with a mast cell stabilizer can be continued safely long term, however.”

Dr Jacobs spoke at 2024 ASCRS Cornea Day in Boston, US.

Deborah S Jacobs MD is Associate Professor of Ophthalmology, Harvard Medical School, Boston, US. deborah.jacobs@meei.harvard.edu

Limits and Complications of Cross-linking

Attention to the ocular surface key to reducing problems.

Although no treatment is perfect, corneal cross-linking (CXL) has effected a veritable paradigm shift in keratoconus management and treatment over the past 15 years, according to Cosimo Mazzotta MD, PhD.

Speaking at the 2024 EuCornea Congress in Paris, Professor Mazzotta said that while his presentation was geared towards discussing the limitations and complications of CXL, it was important to put these downsides into context.

“The encouraging message is that epithelium-off cross-linking is safe and effective in stabilizing keratoconus progression,” he said. “Today, we have a technique with a high safety profile, and a recent study has shown a dramatic reduction in corneal transplants for keratoconus after the extensive application of cross-linking.”

The long-term data also confirms this positive viewpoint, demonstrating the CXL procedure is effective in treating keratoconic eyes in the progressive stage of the disease and achieving long-term stabilization up to 15 years after treatment without the occurrence of serious complications and side effects, he added.1

Prof Mazzotta explained the scientific literature reported retreatment rates between 8% and 14% up to 15 years after treatment.

The key message is ocular surface inflammation is [just as] important for complications as predisposing factors.

And while cross-linking is a repeatable procedure if keratoconus continues to progress, there are serious complications to bear in mind, such as burns, serious infections, and corneal ulcers—which in some scenarios may ultimately result in transplantation.

Geographic, ethnic, and environmental conditions typically influence the rate, type, and severity of complications, Prof Mazzotta noted.

“Our complications in Europe are different from those in India, Africa, and the Middle East because we have different keratoconus stages at presentation, different sunlight overexposure, different hygienic conditions and environments that influence the rate, type, and severity of complications and the compliance of patients to medications and controls,” he said.

Treating thin corneas with keratoconus is no longer an issue thanks to a novel pachymetry-based nomogram (M nomogram), which uses an accelerated pulsed light protocol based on baseline minimum corneal thickness.2

Complications of epithelium-off CXL include infectious keratitis, non-infectious keratitis, haze, stromal melting, epithelial healing defects, dry eye, reduced uncorrected and corrected distance visual acuity, and failures and retreatments.

There are, however, some predisposing factors for CXL complications, Prof Mazzotta said. “The key message is ocular surface inflammation is [just as] important for complications as predisposing factors. Blepharitis, meibomian gland dysfunction, and dry eye para-inflammation are really predisposing factors that must be cared for and addressed before CXL treatment.”

He also urged clinicians to care for the ocular surface in terms of contact lens bandage, hygiene, environment, and compliance.

“We should try to avoid treatment errors in terms of proper patient selection, consistency in surgical techniques, and choosing the right CXL protocol,” he added.

Complications can typically be divided into temporary issues that last anywhere from 3 to 12 months and more persistent complications longer than 12 months.

“We may have corneal oedema; haze or scarring; melting or perforation; infectious keratitis; bacterial, viral, fungal or wound-related complications; or inflammatory conditions, and everything is influenced by genetic, geographical, and environmental factors and ocular surface inflammation,” he said.

Post CXL endothelial burn hot spot after stromal expansion with hypotonic riboflavin solution in a thin cornea. Hypotonic solutions are not recommended.

Severe haze after epi-off CXL with extreme thinning and flattening-inducing hyperopic shift.

The future perspective is for more epithelium-on treatments. Epi-on high fluence protocols with pulsed light (with or without oxygen) and new generation chemically enhanced or boosted riboflavin solutions offer promising results for early progressive keratoconus, avoiding complications.

Prof Mazzotta observed the choice of CXL protocol must be individualized based on patient age, baseline pachymetry, risk factors for progression, comorbidities, and patient compliance.

The ocular surface must also be borne in mind. “This is my key message today: The inflammatory diseases of the ocular surface—such as blepharitis, dry eye-related para-inflammation, and vernal and allergic forms—must be recognized and treated before any CXL treatment. We must prepare the surface and the cornea to receive the cross-linking just to prevent complications. Epi-on is the way out,” he concluded.

Prof Mazzotta presented at EuCornea 2024 in Paris.

For citation notes, see page 40.

Cosimo Mazzotta MD, PhD, FWCRS is Head of the Siena Crosslinking Center, Siena, Italy; Anterior Segment Surgeon, Departmental Ophthalmology Unit of the Alta Val d’Elsa Hospital, Campostaggia, Siena, Italy; Professor of Corneal Pathology, Postgraduate Ophthalmology Specialty School at the University of Siena, Italy; and International Keratoconus Society (IKS) co-founder. cgmazzotta@libero.it

iLEARN

ESCRS iLearn is an online learning platform, free for ESCRS members.

Visit elearning.escrs.org to access over 30 hours of interactive, assessed, and accredited e-learning content, including surgical videos, diagrams, animations, quizzes, and forums.

Anti-VEGF Proves Effective Adjunct

Subconjunctival bevacizumab shown to reduce inflammation and improve the ocular surface.

Subconjunctival injection of bevacizumab can reduce corneal neovascularisation and conjunctival inflammation and support stable ocular surface restoration in patients with limbal stem cell deficiency (LSCD), a new study indicates.

“Subconjunctival injection of bevacizumab has long been known to be effective in regressing corneal neovascularisation (CoNV),” Deniz Bagci MD said. “This application—when performed at the right time—can serve as a vector to ensure the main treatment achieves better clinical results in the long term, especially in cases of neovascularisation, which affects the failure of treatments in LSCD.”

She noted there are potentially multiple causes of corneal neovascularisation, including infection, inflammation, loss of limbal barrier, hypoxia, trauma, and neoplasia. The typical treatment approach is either medical—steroids, NSAIDs, cyclosporin, VEGF inhibitors, MMP inhibitors, aganirsen (GS101)—or interventional in the form of argon laser, photodynamic therapy, and diathermy.

Dr Bagci’s study aimed to evaluate the safety and effectiveness of subconjunctival bevacizumab in treating CoNV in patients with LSCD managed with various treatment approaches, including cultivated limbal stem cell transplantation. The retrospective study was carried out at Ege University Department of Ophthalmology in Izmir, Turkey, between 2023 and 2024, evaluating the medical records of 17 eyes of 14 patients. Accompanying CoNV was scored clinically, she said.

The mean age of the patients with LSCD was 42 years, and the causative agent for LSCD was detectable in 15 eyes: chemical injury in 10 eyes, ocular rosacea in 2 eyes, vernal conjunctivitis in 2 eyes, and lichen planus in 1 eye. Treatment options included surgical cultivated limbal stem cell transplantation (LSCT) in five patients, conventional LSCT in six patients, and medical treatment in 3 eyes.

Results deemed the CoNV completely regressed in 1 eye, partially regressed in 14 eyes, and unchanged in 2 eyes. The average corneal neovascularisation scores were 13.82 before injection and 8.17 after injection.

These outcomes were largely in line with previous results in the scientific literature, Dr Bagci said.

“A meta-analysis of seven clinical trials of subconjunctival bevacizumab showed a pooled reduction of 32% in the neovascular area. Although intrastromal bevacizumab has been found to be more effective, there is a risk of Descemet’s membrane perforation and detachment,” she said. “In studies, topical bevacizumab has been found to be less effective than subconjunctival administration and may cause corneal epitheliopathy and epithelial defects. Bevacizumab is used more frequently in the treatment of CoNV than other traditional anti-VEGF agents because it is cost-effective, has strong therapeutic efficacy, and is widely available.”

Summing up, Dr Bagci said after LSCT, a minimum of six months is required for the transplanted cells to settle in and function properly.

“Within six months, bevacizumab therapy has been found effective in suppressing inflammation and preventing the increase of neovascularisation prompted by the unrepaired corneal injury. In cultivated LSCT, it takes one year for the surface to stabilise,” she concluded. “During this year-long process, bevacizumab therapy has been observed to effectively control neovascularisation and related inflammation to maximise the success of the treatment.”

Dr Bagci presented at 2024 EuCornea in Paris.

Deniz Bagci MD is an ophthalmologist at Ege University, Department of Ophthalmology, Izmir, Turkey. denizbagci@gmail.com

Cataract Surgery-Plus

New bleb-forming surgeries are best left to glaucoma specialists.

ROIBEÁRD O’HÉINEACHÁIN REPORTS

With the rise of minimally invasive glaucoma surgery (MIGS)—typically combined with cataract surgery—cataract surgeons have increasingly taken on the role of glaucoma surgeons. The ability of cataract surgeons to offer ‘cataract surgery-plus’ procedures increases access to MIGS and provides an opportunity for optimising glaucoma control at the time of cataract surgery for a larger number of patients. However, there are challenges regarding surgical technique and postoperative management, cautions Professor Andrew Tatham MD.

“We already have two tiers of glaucoma surgeon: the cataract surgeon-plus and the fellowship-trained glaucoma surgeon. There are some challenges and opportunities with that, particularly regarding patient and device selection,” he said.

Prof Tatham noted the European Glaucoma Society’s (EGS) Guide on Surgical Innovation distinguishes between the ab interno MIGS procedures—such as the iStent, Hydrus, OMNI, and iTrack—and the novel subconjunctival bleb-forming surgeries, such as the Xen Gel stent and the Preserflo Microshunt, sometimes referred to as minimally invasive bleb-forming surgeries (MIBS). The guide emphasises that bleb-forming devices or procedures should be used by surgeons with experience in traditional filtering surgery and wound-healing modulation and management, including the administration of intra- and postoperative antimetabolites.

“Procedures that create a bleb are our most powerful IOP-lowering option, but with the power comes an element of risk,” he said. “It makes sense that bleb-forming procedures should be performed by glaucoma specialists with experience in bleb management and dealing with bleb-related complications.”

He noted data from US Medicare registries shows a decline in the number of trabeculectomies performed over the past decade and a large increase in the number of MIGS procedures. The data also shows that while glaucoma specialists performed 80% of trabeculectomies, non-glaucoma specialists performed up to 75% of MIGS procedures.

The prevalence of both glaucoma and cataract has increased in recent years. In Europe, 3% of 40- to 80-year-olds have glaucoma; England alone had about 608,000 publicly funded cataract surgeries performed in 2022, around 6% of which involved patients with glaucoma and around 0.2% involved patients with previous trabeculectomies. The UK has 2,800 ophthalmologists for a population of 65 million. About 20% of the UK’s consultant ophthalmologists self-identify as glaucoma specialists, whereas around 57% are cataract surgeons.

“In many healthcare settings, the lack of glaucoma specialists creates a lack of capacity, and that can cause harm. Appointments can be delayed and rescheduled, and in the UK, glaucoma is the most frequent cause of vision loss due to

capacity constraints,” Prof Tatham said. “It is important we better risk stratify patients and ensure those at high risk are seen in a timely manner by appropriate specialists. Lower risk patients with mild to moderate disease, who may not be seen by a glaucoma specialist, are the most likely to benefit from early intervention with cataract surgery-plus procedures.”

He noted the MIGS procedures have a short learning curve and require a similar set of skills to cataract surgery—except for gonioscopy, which is under-practised. A key step to successful MIGS surgery is ensuring good angle visualisation. It is also important to be aware of the risk of over-diagnosis and over-treatment—for example, due to overreliance on OCT normative databases for diagnosis, particularly in myopic patients where false positives are frequent. Cataract surgeons performing MIGS should also know when referral to a glaucoma specialist for a bleb-forming procedure may be more appropriate than a canal-based MIGS procedure, such as rapidly progressing patients.

Prof Tatham presented his paper at the 2024 European Glaucoma Society Congress in Dublin, Ireland.

Andrew Tatham MD, MBA, FEBO is based at the Princess Alexandra Eye Pavilion, Edinburgh, UK. He is the NHS Scotland Research National Lead for Ophthalmology and is Visiting Professor at the University of Lausanne, Switzerland. andrew.tatham@nhs.scot

CRISPR Vision

Gene editing technique produces functional improvements in patients with CEP290-related retinal dystrophy.

ROIBEÁRD O’HÉINEACHÁIN REPORTS

Anew gene therapy using CRISPR-Cas9 technology produced significant visual acuity improvements among patients with a common variant of Leber’s congenital amaurosis in the BRILLIANCE phase 1–2, openlabel, single-ascending-dose study.

“I think this is just the very beginning of using CRISPR technology for a whole variety of inherited retinal degenerations,” said the study’s principal investigator, Professor Mark Pennesi MD, PhD. “And this is really a new era where this technology is going to be adapted for many other patients.”

The study involved 14 patients with CEP290-related retinal dystrophy, which accounts for 15–20% of cases of Leber’s congenital amaurosis. All underwent a single intraretinal injection of the EDITAS AAV vector, which carries EDIT-101, a gene-editing complex of clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) to edit a pathogenic variant CEP290 gene.

The first patients were 2 adults with severe vision loss who received a low dose of the virus, followed by 5 adult patients with varying degrees of visual loss who received a medium

dose, 2 adults who received a high dose, and 2 paediatric patients who received a medium dose of the virus.

At a follow-up of six months to two years, full-field stimulus threshold testing showed a significant improvement in six patients. In addition, four of the patients had a statistically significant improvement of three or more lines of visual acuity, and some had a dramatic 1.0 logMAR improvement.

“That’s almost 10 lines on the eye chart, so that’s going from hand motion to almost being able to see the big E, which is quite phenomenal,” Prof Pennesi added.

Moreover, 4 out of 14 patients had a significant improvement in their score on the Ora-Visual Navigation Challenge mobility test, increasing by three levels of difficulty. In addition, 6 patients had a significant improvement in their quality-of-life scores on the National Eye Institute Visual Function Questionnaire or the Children’s Visual Function Questionnaire. Overall, 11 out of 14 patients had higher scores in at least one metric of improvement, and 6 of 14 patients had higher scores in two or more metrics of improvement.

Adverse events included inflammation, which was treatable, and retinal deposits, possibly due to inflammation. The deposits did not appear to affect vision and resolved over time or with steroid treatment.

Prof Pennesi noted that CEP290-associated inherited retinal degeneration causes severe early-onset vision loss due to pathogenic variants in the CEP290 gene, whose protein is crucial for photoreceptor function. A characteristic of the disease is the abundant presence of structurally normal photoreceptors in the eyes of patients with little or no vision.

The size of the CEP290 gene makes it difficult to treat with conventional gene therapy. The EDIT-101 CRISPR-Cas9 complex was designed to edit one of the more common pathogenic variants of the CEP290 gene. The mutation, present in a non-coding portion of the gene, prevents the correct protein production.

“We did see functional improvement in these patients, and this does give us proof of concept that gene editing can work in vivo,” Prof Pennesi added.

Prof Pennesi presented his paper at the Retina International Congress 2024 in Dublin. Details of the study were published in the May 26, 2024, issue of the New England Journal of Medicine.1

For citation notes, see page 41.

Mark Pennesi MD, PhD, FARVO is director of the Ophthalmic Genetics Retina Foundation, Dallas, Texas, US, and professor of ophthalmology and professor of molecular and medical genetics, Casey Eye Institute, Oregon Health and Science University, Portland, US. pennesi@retinafoundation.org

RP11 Treatment Enters Human Trials

Safety and promising efficacy seen in phase 1 study.

HOWARD LARKIN REPORTS

Preliminary results of a first-in-human study suggest a treatment for retinitis pigmentosa type 11 (RP11) may be safe. Results in one study subject are promising for efficacy as well, reported Fred K Chen PhD.

Affecting about 3% of all RP patients, there currently are no approved treatments for RP11. An autosomal dominant condition, RP11 is caused by a mutation in one of the pair of pre-mRNA processing factor 31 genes (PRPF31). The PRPF31 protein is a splicing factor present in tissues throughout the body but only appears to affect the retina when its supply is impaired by this mutation. Affected patients experience progressive retinal dystrophy, leading to vision loss and, eventually, blindness.

Variable effect

However, not all patients with the mutation are equally affected, Dr Chen noted. There is no correlation between the genotype and early or late onset of retinal dystrophy—or the speed of progression. What is known is the expression of PRPF31 varies from patient to patient, and those with higher levels are more likely to remain asymptomatic. The mechanisms controlling this variance are not known.

VP-001 (PYC Therapeutics), the potential treatment developed by Dr Chen and colleagues, has been shown in a patient-derived cellular model to increase PRPF31 indirectly. It uses RNA to bypass a gene expressing another pre-mRNA factor, CNOT3, which downregulates the expression of PRPF31. Reducing CNOT3 increases PRPF31 production from the unmutated gene, which could slow or stop RP11 progression. A small molecule injected intravitreally, VP-001 uses a proprietary cell-penetrating peptide to help the drug enter target cells more efficiently, increasing the effect at lower doses than unassisted RNA treatment.

Ascending doses

Dr Chen reported preliminary results of an open-label single ascending dose study in which three cohorts of three patients received retinal injections of 3 μg, 10 μg, or 30 μg of VP-001. No serious treatment-related adverse events were observed in any of the three cohorts, though one case of inflammation did occur. For one patient in the highest dose cohort, about 10% of retinal loci examined on microperimetry showed increased retinal sensitivity of 7 dB after eight weeks. Scotomatous points decreased in the treated eye and increased in the untreated eye—encouraging signs of an efficacy signal, Dr Chen said.

Since Dr Chen’s report, PYC has amended the clinical protocol and administered another dose (75 μg) in three patients. In this cohort, no treatment-related adverse or serious adverse

events were observed. Additionally, PYC started another dose-ascending trial in July 2024 in six patients receiving 30 μg or 75 μg of VP-001 in three doses repeated at eight-week intervals, said Sri Mudumba PhD, the firm’s chief research and development officer. Investigators hope to see a repeat of the efficacy signal in patients injected with the higher doses earlier in the disease. Upon completion of the repeat dosing trial, he added PYC plans to initiate additional trials globally in 2025.

Dr Chen presented at ARVO 2024 in Seattle, US.

Fred K Chen MBBS (Hons), PhD (London), FRANZCO is an ophthalmologist, associate professor, and research scientist at the Lions Eye Institute, Royal Perth Hospital, and Perth Children’s Hospital in Perth, Australia. He heads the Lions Eye Institute’s Ocular Tissue Engineering Laboratory and is acting head of the Centre for Ophthalmology and Visual Science at the University of Western Australia in Perth. fred.chen@uwa.edu.au; fred.chen@lei.org.au

Sri Mudumba PhD is chief research and development officer at PYC Therapeutics, Nedlands, Australia. sri.mudumba@pyctx.com

Treating Adolescent Stargardt Disease

Study suggests drug may slow or prevent progression.

HOWARD LARKIN REPORTS

In a 24-month Phase 2 clinical trial, an oral drug that reduces retinol delivery to the eye—which in excess can contribute to retinal cell death—slowed progression of atrophic retinal lesions and loss of vision in patients with Stargardt disease type 1 (STGD1), according to John Grigg MD.

The drug (Tinlarebant, Belite Bio) works by blocking retinol-binding protein 4 (RBP4). This protein transports retinol from the liver to the retina, where it supports rapid visual adaptation and cycling. In Stargardt disease, toxic retinoid waste products accumulate in retinal and retinal pigment epithelium cells due to various mutations in the ABCA4 gene, which eventually leads to retinal cell death. In theory, modulating retinol uptake by blocking RBP4 should help prevent the accumulation of toxic retinoids, preserving cell function, Professor Grigg said.

Promising results

The study largely confirms this hypothesis. It included 13 adolescent subjects ranging from 12 to 18 years old with clinically and genetically confirmed Stargardt disease type 1, showing only questionably decreased autofluorescence (QDAF) retinal lesions at baseline, indicating some retinal damage. Each received 5 mg of Tinlarebant daily for 24 months. They experienced 80 to 90% reductions of RBP4 levels in the eye, which is reversible when the drug is withdrawn.

More importantly, in 7 patients who developed lesions with definitely decreased autofluorescence (DDAF), which indicates retinal atrophy, the lesions grew at only half the rate of matched historical controls over 24 months. No DDAF lesions developed in the other 5 patients over the 24 months,

suggesting the treatment was successful. In addition, no DDAF lesions grew into the macula after 16 months, reducing central vision loss.

Consistent with these anatomical findings, best-corrected visual acuity remained stable over 24 months, showing a mean loss of 5 letters. Six patients who had experienced a loss of 10 letters per year before the trial had a mean loss of 1.9 letters per year during the study period.

Safety was also demonstrated. A total of 38 drug-related adverse events were reported, all of which were mild. These included chromatopsia in 10 patients and delayed dark adaptation in 9 patients. Prof Grigg said these side effects were anticipated, given the drug’s mechanism of action.

He added the findings are promising for further development of Tinlarebant. The drug is currently being evaluated in adolescent Stargardt disease in a Phase 3 study, with interim data expected in late 2024, and as an ongoing Phase 1b and Phase 2/3 trial. It is also in evaluation for treating geographic atrophy in a Phase 3 study for age-related macular degeneration, which has a similar pathophysiology.

“Tinlarebant may not only prevent healthy retinal cells from [toxic retinoid] damage, but also potentially even halt disease progression,” he said.

Prof Grigg presented at ARVO 2024 in Seattle, US.

John R Grigg MBBS, MD, FRANZCO, FRACS is professor and head of specialty clinical ophthalmology and eye health at the University of Sydney Save Sight Institute, Sydney, Australia. john.grigg@sydney.edu.au

Cataract Surgery after Intravitreal Injection

Study finds risk of vitreous haemorrhage, retinal detachment, and glaucoma surgery increases.

Patients who received bilateral intravitreal injections (IVI) before cataract surgery had about twice to triple the risk of several post-surgery complications. Non-clearing vitreous haemorrhage, retinal detachments, retinal tears, anterior vitrectomy, and glaucoma surgery were all significantly increased in IVI-exposed patients, according to a population-based cohort study conducted in Canada.

A previous study found increased risk of retained lens fragments and endophthalmitis for IVI patients after cataract surgery. It did not, however, find any increase in new primary open-angle glaucoma diagnoses, noted researcher and medical student Winnie Yu. A more comprehensive study would further articulate cataract surgery risks for IVI patients.

Billing codes

Based on an analysis of diagnostic and procedural codes for patients enrolled in the Ontario Health Insurance Plan, the study identified medical records of more than 170,000 patients aged 20 years or older who were diagnosed with retinal disease and had cataract surgery from 2009 to 2018. Of these, almost 6,000 had bilateral IVI treatments before cataract surgery. Patients who had received unilateral IVI treatments were excluded. Complications after surgery were tracked using the same database, and adjusted hazard ratios (aHR) were calculated using multivariable Cox proportional hazards models.

Compared with non-IVI patients, those who received bilateral IVI before cataract surgery had an aHR of 3.04 for developing non-clearing vitreous haemorrhage, which was the most common post-surgical complication. The study also found aHRs of 2.57 for retinal detachment, 2.66 for retinal tears within three months after surgery, and 3.36 for glaucoma surgery within two years after surgery—all statistically significant findings at p<0.0001. Increased risk of anterior vitrectomy was also noted. Risk differences for retained lens fragments, corneal transplant, and intraocular lens (IOL) repositioning were not significant. No risk difference was observed for IOL exchange.

Potential causes

Though the study did not examine specific causes for complications, Yu suggested the increase in glaucoma surgery rates may be related to increased intraocular pressure from repeated IVI treatments, while the need for anterior vitrectomy could indicate a higher rate of posterior capsule rupture, possibly due to damage to the capsule from IVI treatments. Vitreous haemorrhage could be due to cataract surgery upregulating angiogenic factors such as VEGF. Limitations in the database made it difficult to determine granular information—such as precisely

when anterior vitrectomies were performed and the specific IVI injections patients received, she added.

“Cataract surgery patients with retinal disease who previously received IVI had a greater risk of post-surgical complications,” Yu concluded. These findings should be considered in preoperative counselling of cataract patients as well as surgical planning.

Winnie Yu presented at ARVO 2024 in Seattle, US.

Winnie Yu is a researcher and medical student at the University of Toronto, Canada. wy.yu@mail.utoronto.ca

HOWARD LARKIN REPORTS

Real-World Faricimab nAMD Outcomes

First-year results promising for efficacy and extending treatment intervals.

HOWARD

PLARKIN REPORTS

atients with neovascular age-related macular degeneration (nAMD) treated with faricimab on average saw visual acuity improve or stabilise, and retina central subfield thickness (CST) decrease during their first year of treatment, a large retrospective study indicates. Many also were able to extend the interval between faricimab injections while apparently maintaining disease control.

Faricimab is the first bispecific monoclonal antibody for treating nAMD and diabetic macular oedema. In addition to targeting vascular endothelial growth factor (VEGF), it blocks angiopoietin-2, stabilising blood vessels and reducing leakage and inflammation, which theoretically could increase faricimab’s efficacy compared with anti-VEGF-only alternatives. It is also designed to reduce the risk of systemic exposure and inflammation.

Large cohort

A real-world retrospective study reported by David Tabano MD examined electronic medical records of more than 19,000 eyes of nearly 16,000 nAMD patients treated with faricimab injections for at least 12 months. It included nearly 15,000 patients previously treated for nAMD with other anti-VEGF agents and about 1,100 who were treatment naïve. The records

were drawn from the American Academy of Ophthalmology’s Intelligent Research in Sight (IRIS) registry, which includes data on more than 75 million unique ophthalmic patients seen by 16,000 clinicians across the US.

All patients had at least 12 months of medical record data prior to receiving faricimab, including at least two measurements of visual acuity and two CST measurements for a CST subgroup. About 42% of treatment-naïve eyes and 52% of previously treated eyes had best documented visual acuity (BDVA) of 20/40 or better at the time of first treatment with faricimab. Previously treated eyes received about seven injections at about 45-day intervals in the 12 months prior to switching to faricimab. Two-thirds of eyes previously used aflibercept.

Positive outcomes

Overall, the study found that mean BDVA improved slightly for treatment-naïve patients, rising an average of nearly 3 letters after five faricimab injections; while previously treated patients were stable, losing 0.3 lines after five treatments. These findings are consistent with other studies that have seen an improvement in visual acuity early in treatment, followed by preservation later in treatment, Dr Tabano said.

Eyes With Disease Control (CST ≤ 280 µm) Increased to ~60% After 2 Faricimab Injections in Patients with nAMD

Similarly, CST improved more in treatment-naïve eyes, steadily declining from a mean 311.0 μ at treatment outset to 262.1 μ after four injections. By comparison, previously treated eyes declined from a mean CST of 295.3 μ to 272.6 μ after four treatments, which was in addition to any reduction they had seen on the previous treatment, Dr Tabano pointed out. Nearly two-thirds of treatment-naïve eyes and more than one-third of previously treated eyes saw CST reduced by 10% or more following faricimab initiation.

Furthermore, the percentage of eyes not controlled dropped for both groups after faricimab was initiated, from 46% to 17% after four injections in treatment-naïve eyes and 38% to 29% in previously treated eyes.

Fewer injections were needed to control nAMD after the first 6 months of treatment with faricimab, falling from a mean of 4.0 to 2.4 in the second 6 months for treatment-naïve eyes, and from 4.3 to 3.2 in previously treated eyes. In particular, treatment-naïve eyes saw comparable injection frequency in 12 months to the Tenaya and Lucerne phase III clinical trials for faricimab. This suggests physicians may be comfortable extending treatment intervals based on early anatomical response, although Dr Tabano said this is not certain because the rationale for extending is not included in the electronic records.

The results suggest real-world effectiveness and durability of faricimab treatment, which could effectively increase system capacity to treat nAMD, Dr Tabano concluded.

Dr Tabano presented at ARVO 2024 in Seattle, US.

David Tabano PhD is principal health economist at Genentech, South San Francisco, US. tabano.david@gene.com

Bag-in-Lens for Ectopia Lentis

Vitrectomy-sparing technique yields good results at one year.

HOWARD LARKIN REPORTS

Children with ectopia lentis treated with an adapted Tassignon bag-in-lens technique had good refractive results and no lens decentration one year after surgery in a study conducted by Lyubomyr Lytvynchuk MD, PhD.

The procedure typically requires no vitrectomy and preserves ocular anatomy, Dr Lytvynchuk said. It provides an alternative to watching and waiting for lens subluxation to advance—which risks uncorrectable refractive error and amblyopia—or treating advanced cases with lens and capsular bag extraction and aphakic contact lenses or spectacles. Generally, he added, iris-fixated or intraocular lenses (IOLs) sutured to the sclera are unsuitable for children.

Multiple implants

The procedure involves bag-in-lens IOL implantation supported by a capsule tension ring. The lens is fixated by fitting the edges of both posterior and anterior capsulorhexes into a groove around the lens edge—helping prevent posterior

capsule opacification since there is no posterior capsule behind the lens, though lens opacities develop in about 5% of cases, Dr Lytvynchuk noted.

Since patients with ectopia lentis lack zonular support for the capsule, two bean-shaped ring segment implants anchor the lens implant. The exterior convex side of each ring is placed in the sulcus, and the interior concave side is placed in the lens groove, holding the lens in place. The lens is then centred in the eye using a 6-0 polypropylene loop around its groove, fixated to the sclera with a flange similar to the Canabrava technique. Dr Marie-José Tassignon developed the procedure—having also invented the bag-in-lens IOL and the bean-shaped ring segments in collaboration with Dr Luc Van Os and Dr Darius Hildebrand.1

Favourable outcomes

Dr Lytvynchuk reported on a consecutive series of paediatric cases, including 11 eyes of 7 patients aged 2–16 years diagnosed

Figure 1. Surgical steps of adapted bag-in-the-lens implantation technique in children with congenital ectopia lentis: A) implantation of the bag-in-the-lens IOL; B) implantation of the bean-shaped ring segment implants; C) implantation of a 6-0 polypropylene loop around the lens groove; D) adjustment of the IOL position with flanging of the 6-0 polypropylene loop. Courtesy of Dr Lytvynchuk, Justus Liebig University, UKGM, Giessen, Germany.

with ectopia lentis. Molecular genetics helped diagnose Marfan syndrome in 5 patients. In all cases, lenses were severely subluxated upward with preserved but stretched ciliary zonules. Preoperative refraction revealed high astigmatism in all eyes, with a risk of amblyopia.

In our clinic, this is standard procedure for treating paediatric cataract starting from age 6 or 8 weeks.

Surgery was successful in all patients without severe adverse events. In 3 eyes of 2 patients, anterior vitrectomies were performed to remove vitreous strands in the anterior chamber seen before surgery. Optimal centration of the bag-in-lens was achieved in all cases.

Postoperative refraction was considerably improved for both visual acuity and astigmatism in all patients. A minimal displacement of the polypropylene loop was observed without decentration of the lens in one case. In about 50 cases performed at 4 centres, approximately 10% of patients developed anterior uveitis, which was successfully treated with steroids, Dr Lytvynchuk said.

“This is quite a complex surgery,” Dr Lytvynchuk noted. However, it is minimally invasive, and the learning curve is not steep for surgeons experienced with bag-in-lens IOL implantation for cataract treatment.

“In our clinic, this is standard procedure for treating paediatric cataract starting from age 6 or 8 weeks.”

Further studies are needed to prove the efficacy of this technique in a larger patient cohort, he concluded.

Dr Lytvynchuk spoke at ARVO 2024 in Seattle, US.

For citation notes, see page 41.

Lyubomyr Lytvynchuk MD, PhD is acting director at the Justus-Liebig-University, Department of Ophthalmology, University Hospital Giessen, Germany. Lyubomyr.Lytvynchuk@augen.med.uni-giessen.de

Figure 2. Anterior eye segment photo before (A) and the first day after the surgery (B). Courtesy of Dr Lytvynchuk, Justus Liebig University, UKGM, Giessen, Germany.

THINKING OF SELLING YOUR PRACTICE?

Planning an exit strategy is best begun early in your career.

ROIBEÁRD O’HÉINEACHÁIN REPORTS

The unrelenting progress of years eventually brings all practising surgeons to a day when they must consider transitioning to a new phase of life, less active in the surgical sphere. The various exit strategies to consider were the topic of a webinar held by the Leadership, Business, and Innovation (LBI) committee of the ESCRS. LBI chairperson Paul Rosen led the discussion with participants Arthur Cummings MD, Milind Pande, and Omid Kermani MD.

Negotiating a sale

Dr Kermani noted that when he began his refractive and cataract surgery practice in 1993, laser refractive surgery was in its infancy. As an early adopter, his primary strategy was to offer his patients the latest and best procedures in refractive and cataract surgery and thus lead his practice to success.

His primary focus was to make his clinic a successful venture, and he had the foresight to see the importance of branding his clinic in a way to pass it on as a going concern. By 2010, the comprehensive practice was performing around more than 10,000 procedures per year. When he reached the age of 55, he realised he would have to consider an exit strategy. Possibilities included passing it on to one of his sons, but as they had taken different professions, the other option was to sell it.

He noted, however, that selling his practice was not easy, and the first attempt failed. The initial offer from potential investors he and his partner received was tempting but was connected to numerous side deals and restrictions. After some sleepless nights, he eventually decided not to go through with the deal, leaving the potential investors disappointed and angry.

“They give you the feeling that you owe them because of the time they had spent in their due diligence, but I told my partner since we are still relatively young and let’s say they pay us maybe 10 years of profit in advance, what is after that?” he said. “And also, imagine if we grow over the next 5 or 10 years—if we sell, we can get a much better bargain.”

That expectation was confirmed a few years later when they received offers for their practice that were an order of magnitude higher. They bought back their junior partners’ shares at a good price, and they are still working at the clinic and happy with the new situation that is a triple-win for him and his partner, the investor, and, most importantly, his patients.

Horizons new

Dr Pande took a different route out of his surgical practice. Rather than selling his clinic, he embarked on a new chapter entirely—establishing Vision and Research Centre and founding (and serving as CEO of) CUSTOM LENS AI, an automated AI-based system for generating personalised refractive surgical prescriptions. He observed he was developing these projects while still running his clinic but realised continuing in full-time practice was interfering with his ability to pursue his longer-term ambition.

“My surgical practice was slowing down the progress of that project, which was the final trigger in the end. I wanted to move away from clinical practice to spend more time on this aspect and focus the next 10 years on teaching innovation in research. That is how I made my decision, and I don’t think that was difficult at all,” he said. “I didn’t sell my practice because I

didn’t think the financial offers that came through to me were going to make that much of a difference to me. But more importantly, I cannot hand on my heart recommend those options to my patients who have been with me for many years.”

Passing the torch

Dr Cummings is still very active as medical director of his surgical practice. In his exit plan, he has the prospect of handing over his practice to his son, an ophthalmologist currently doing a fellowship in refractive surgery and oculoplastics. His motivation to perform a high volume of refractive procedures would be crucial in covering the infrastructure costs of running a refractive clinic.

Meanwhile, given the current level of private equity (PE) interest in ophthalmology, a well-established practice will attract numerous offers from venture capitalists. Yet the decision to proceed involves more than just financial considerations.

He also stressed the importance of ensuring the smooth exit for one’s patients when selling or closing a clinic, citing a recent article in the Harvard Business Review reporting on a study showing that, within a few years of purchase, there was a 25% increase in the complication rates of clinics bought by private equity investors.1,2

“It is not just about looking after your patients and finding a place for them, but also the team you have built up over many years,” Dr Cummings emphasised. “If you want to try and extract some sort of value, my advice to any young physician would be [to] work your entire life to build a brand and take a huge amount of responsibility, and at the end of it all you should

be entitled to sell what you’ve built at some sort of value proposition where you can retire.”

For citation notes, see page 41.

Paul Rosen BSc, MB ChB, FRCS, FRCOphth, MBA is Consultant Ophthalmic Surgeon at the Oxford Eye Hospital, Oxford University Hospital Foundation Trust, UK. phrosen@rocketmail.com

Omid Kermani MD is co-founder and CEO/consultant at Artemis Eye Clinic am Neumarkt, Cologne, Germany. mail@Kermani-Vision.de

Arthur B Cummings MD, FRCSed, FWRCS is medical director of the Wellington Eye Clinic, Dublin, Ireland. abc@wellingtoneyeclinic.com

Milind Pande MBBS, BS, DO, FRCS, FRCOphth, CertLRS is founder of Vision Surgery & Research Centre and founder/CEO of CUSTOM LENS AI based in Hull, UK. mp@visionsurgery.co.uk

GLOBAL REACH

As a renowned authority in the field of cataract and refractive surgery, ESCRS facilitates global connections amongst ophthalmic professionals, fostering collaboration and the exchange of knowledge.

Our events span across continents, providing a platform for pioneering research, advanced surgical techniques, and continuous professional development.

Using the interactive map on our website, we invite you to explore our global presence by viewing upcoming events and academies.

Join us to network with esteemed experts, access the latest advancements, and contribute to the enhancement of eye care on a worldwide scale.

escrs.org/meetings-and-events/global-reach/

LENSAR receives EU MDR Certification

LENSAR has received certification under the European Union’s (EU) Medical Device Regulation (MDR) for their ALLY Adaptive Cataract Treatment System designed for femtosecond laser-assisted cataract procedures. With an ergonomic design, the system uses artificial intelligence to automatically determine cataract density, optimize fragmentation patterns and energy settings, and perform iris registration and surface identification of astigmatism management. LENSAR is commercializing ALLY through its distributor network in the EU and expects to place the first ALLY systems with European surgeons in the third quarter of 2024.

Lensar.com

CE mark for ViaLase incision-free glaucoma treatment

ViaLase announced it has received EU CE mark approval for the ViaLase laser system for treating adult patients with primary open-angle glaucoma using the femtosecond laser image-guided high-precision trabeculotomy (FLight) procedure. The ViaLuxe laser targets the iridocorneal angle with high-definition gonioscopic imaging to create customized drainage channels through the trabecular meshwork, thereby increasing aqueous outflow without opening up the eye.

Vialase.com

Vabysmo approved for retinal vein occlusion

Roche announced the European Commission approved Vabysmo (faricimab-svoa) for treating visual impairment caused by macular oedema secondary to retinal vein occlusion (RVO, branch RVO, or central RVO). RVO is the third indication approved for Vabysmo in the EU, in addition to wet agerelated macular degeneration (AMD) and diabetic macular oedema (DME). Bispecific antibody Vabysmo targets angiopoietin-2 (Ang-2) and vascular endothelial growth factor A (VEGF-A).

Roche.com

Genentech reintroduces AMD intravitreal implant

Genentech announced the reintroduction of Susvimo (ranibizumab injection) 100 mg/mL intravitreal implant to treat neovascular AMD. The device’s portal delivery system releases ranibizumab to the vitreous continuously and is designed to be refilled every six months. The company’s decision follows the FDA’s approval of a post-approval supplement to the Biologics License Application, which incorporates updates to the ocular implant and refill needle components.

Susvimo.com

Approval recommended for ciclosporin dry eye drug

The EMA’s Committee for Medicinal Products for Human Use (CHMP) have recommended approval of Novaliq’s Vevizye as a treatment for moderate to severe dry eye disease (DED) in adults. The positive opinion is based on the CHMP review of the comprehensive data package from more than 1,500 patients with moderate to severe DED. Vevizye, developed as CyclASol, is composed of ciclosporin 0.1% solution and is free of oils, surfactants, and preservatives.

Novaliq.com

SETTING STANDARDS FOR IOL CLASSIFICATION

The variety of IOLs with different optical designs and ranges of focus can be a source of confusion for surgeons when deciding which lens will suit which patient in their desired visual outcomes, notes Professor Thomas Kohnen. Updated requirements and recommendations from the International Organization for Standardization (ISO), advised by an American Academy of Ophthalmology (AAO) task force, provide physicians and patients with a consistent, measurable, and repeatable system of naming, categorising, and understanding any IOL. Among the new guidelines are definitions as to what differentiates an extended depth of focus (EDOF) IOL and a monofocal IOL: a monocular negative depth of focus at 0.2 logMAR of at least 0.5 D more than a monofocal IOL, a monocular photopic distance-corrected non-inferior intermediate VA (66 cm) should be superior to a monofocal control IOL, and at least 50% of eyes should achieve a VA of 0.2 logMAR (Snellen 6/9.6) or better.

T Kohnen, “Current and future nomenclature and categorization of intraocular lenses,” 50(8): 787–788.

EVIDENCE SUPPORTS ENHANCED MONOFOCALS AS STANDARD OF CARE

Enhanced monofocal IOLs fit the criteria for a standard of care lens for cataract patients, according to an evidence-based appraisal by the ESCRS Functional Vision Working Group. The team performed a literature review to analyse the level of scientific evidence on enhanced monofocal IOLs using three reviews and 66 articles published in the primary literature from 2020 to 2024. After excluding those not comparing conventional monofocal with enhanced monofocal IOLs, those not including a visual performance analysis, and those involving pathological eyes, there was one meta-analysis and systematic review, one scoping review, and 19 clinical studies for consideration. Most of the studies reviewed—including the randomised controlled trials—confirmed the superiority of enhanced monofocal IOLs in intermediate visual function and interchangeable results in distance vision compared with conventional monofocal IOLs.

F Ribeiro, T Kohnen, et al., “Should enhanced monofocal intraocular lenses be the standard of care? An evidence-based appraisal by the ESCRS Functional Vision Working Group,” 50(8): 789–793.

FUNCTIONAL CLASSIFICATION OF SIMULTANEOUS VISION IOLS

The ESCRS Functional Vision Working Group has developed a functional classification system for simultaneous vision IOLs according to the endpoints described in the most recent International Organization for Standardization update (ISO 11979-7, 2024). The classification system is based on an objective, comprehensive review of the scientific literature, using data extracted from various studies for various functional endpoints. The cluster analysis found that two metrics were enough to classify IOLs: (1) a VA increase from intermediate to near in the event of a non-monotonic VA decrease from far to near and (2) the range of focus from CDVA to 0.2 or 0.3 logMAR VA cut-offs.

F Ribeiro, T Kohnen, et al., “Evidence-based functional classification of simultaneous vision intraocular lenses: seeking a global consensus by the ESCRS Functional Vision Working Group,” 50(8): 794–798.

Upcoming Events

October 18–21

American Academy of Ophthalmology

Chicago, United States

November 20–24

The 58th TOA National Congress Antalya, Turkey

November 28–29

UKISCRS

75th Anniversary of the IOL London, United Kingdom

18 Oct

28 Nov 20 Nov

Cited in this Issue

The Burnout Factory

Page 10

Alotaibi AK, Alsalim A, Alruwaili F, et al. “Burnout during ophthalmology residency training: a national survey in Saudi Arabia,” Saudi J Ophthalmol, 2019; 33(2): 130–134.

ArtsSEC. (2020, June 12). “Burnout, de qué se trata? Reflexiones y aprendizaje,” Medium. https://medium.com/@ ArtsSEC/burnout-reflexiones-y-aprendizaje-1b85d6141ebb

Cheung R, Yu B, Iordanous Y, Malvankar-Mehta MS. “The prevalence of occupational burnout among ophthalmologists: a systematic review and meta-analysis,” Psychol Rep, 2021; 124(5): 2139–2154.

Cruz OA, Pole CJ, Thomas SM. “Burnout in chairs of academic departments of ophthalmology,” Ophthalmology, 2007; 114(12): 2350–2355.

Feng S, Taravati P, Ding L, Menda S. “Burnout in ophthalmology residency: a national survey,” Journal of Academic Ophthalmology, 2018; 10(1): e98–e107.

Martínez Pérez, A. “El síndrome de Burnout. Evolución conceptual y estado actual de la cuestión,” Vivat Academia, 2010; 0(112), 42–80. doi: 10.15178/va.2010.112.42-80.

Méndez Iglesias SM. “Reflexiones sobre el burnout de los profesionales de atención primaria tras la pandemia,” Atencion Primaria, 2022; 54(6): 102314. doi: 10.1016/j. aprim.2022.102314.

Panagioti M, Geraghty K, Johnson J, Zhou A, et al. “Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis,” JAMA Intern Med, 2018; 178(10): 1317–1330.

“Strategies to avoid burnout,” (n.d.). CRSToday. Retrieved June 14, 2024, from https://crstoday.com/articles/2019-june/strategies-to-avoid-burnout.

Nurturing Resilience: Alleviating Burnout in Ophthalmology

Page 12

1. Fromm, Erich. Haben oder sein. München: Deutsche Verlags Anstalt, 1976.

2. Chang TC, A R, Candelario C, Berrocal AM, Briceño CA, Chen J, Shoham-Hazon N, Berco E, Valle DS, Vanner EA. “LGBTQ+ Identity and Ophthalmologist Burnout,” Am J Ophthalmol , 2023 Feb; 246: 66–85. doi: 10.1016/j. ajo.2022.10.002. Epub 2022 Oct 14. PMID: 36252675.

3. Sedhom JA, Patnaik JL, McCourt EA, Liao S, Subramanian PS, Davidson RS, Palestine AG, Kahook MY, Seibold LK. “Physician burnout in ophthalmology: U.S. survey,” J Cataract Refract Surg , 2022 Jun 1; 48(6): 723–729. doi: 10.1097/j. jcrs.0000000000000837. PMID: 34596630.

Know Thy Enemy

Page 14

1. GMC’s 2023 annual training survey shows progression improving for ophthalmologists in training, alongside concerns over burnout and access to independent sector | The Royal College of Ophthalmologists. https://www.rcophth. ac.uk/news-views/gmcs-2023-annual-training-surveyshows-progression-improving-for-ophthalmologists-intraining-alongside-concerns-over-burnout-and-access-toindependent-sector/.

2. Cheung R, Yu B, Iordanous Y, Malvankar-Mehta MS. “The Prevalence of Occupational Burnout Among Ophthalmologists: A Systematic Review and Meta-Analysis,” Psychol Rep , 124, 2139–2154 (2021).

Surgeons Split on Post-Surgery Inflammation Control

Page 16

1. Shorstein NH, McCabe SE, Alavi M, Kwan ML, Chandra NS. “Triamcinolone Acetonide Subconjunctival Injection as Stand-alone Inflammation Prophylaxis after Phacoemulsification Cataract Surgery,” Ophthalmology . 2024 Apr 4: S01616420(24)00206-9. Epub ahead of print.

2. Lu AQ, Rizk M, O’Rourke T, et al. “Safety and efficacy of topical vs intracanalicular corticosteroids for the prevention of postoperative inflammation after cataract surgery,” J Cataract Refract Surg . 2022; 48(11): 1242–1247.

3. Donnenfeld ED, Hovanesian JA, Malik AG, Wong A. “A Randomized, Prospective, Observer-Masked Study Comparing Dropless Treatment Regimen Using Intracanalicular Dexamethasone Insert, Intracameral Ketorolac, and Intracameral Moxifloxacin versus Conventional Topical Therapy to Control Postoperative Pain and Inflammation in Cataract Surgery,” Clin Ophthalmol . 2023; 17: 2349–2356.

4. Gira JP, Sampson R, Silverstein SM, et al. “Evaluating the patient experience after implantation of a 0.4 mg sustained release dexamethasone intracanalicular insert (Dextenza™): results of a qualitative survey,” Patient Prefer Adherence. 2017; 11: 487–494.

Limits and Complications of Cross-linking

Page 24

1. Raiskup F, et al. “Corneal Crosslinking with Riboflavin and UVA Light in Progressive Keratoconus: Fifteen-Year Results,” American J of Ophthal, 2023 June; 250: 95–102. doi: 10.1016/j. ajo.2023.01.022

2. Mazzotta C, et al. “Ray-Tracing Transepithelial Excimer Laser Central Corneal Remodeling plus Pachymetry-Guided Accelerated Corneal Crosslinking for Keratoconus,” Cornea, 2024 Mar 1; 43(3): 285–294. doi: 10.1097/ICO.0000000000003380

CRISPR Vision

Page 28

1. E A Pierce, et al. “Gene Editing for CEP290-Associated Retinal Degeneration,” N Engl J Med, 2024; 390: 1972–1984.

Bag-in-Lens for Ectopia Lentis

Page 34

1. Van Os L, Hildebrand GD, Tassignon MJ. Klin Monbl Augenheilkd. 2021 Oct; 238(10): 1058–1064.

Thinking of Selling Your Practice?

Page 36

1. J Miller, “What Happens When Private Equity Takes Over a Hospital,” Harvard Business Review, December 26, 2023.

2. S Kannan, “Changes in Hospital Adverse Events and Patient Outcomes Associated with Private Equity Acquisition,” JAMA, 2023; 330(24): 2365–2375.

Research. Education. Innovation.

ESCRS’s vision is to educate and help our peers excel in our field. Together, we are driving the field of ophthalmology forward.