EyeSee 3/2022 English version by Rivista Sfogliabile

ITALIAN NEWS MAGAZINE FOR EYE SPECIALISTS FGE S.r.l.-Reg. Rivelle 7/F - 14050 Moasca (AT) - Editorial board: Strada 4 Milano Fiori, Palazzo Q7 – 20089 Rozzano (MI) - Year IV - N. 3/2022 - Quaterly publication 3/2022YEARIV TOWARDS A CLEARER VISION Rethinking hi-tech lenses for presbyopia correction SURGICAL TECHNIQUES The Only Constant is Change, with Amar Agarwal ONSPOTLIGHTTHEEXPERT Marie-JoséTassignon INSIGHTS The Grey Zone, with Diego Ponzin

IMMEDIATELY SEQUENTIAL BILATERAL CATARACT SURGERY: YES OR NO?

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A ‘CONTINENT’ FULL OF OPPORTUNITIES nightmare Cases

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Marie-José Tassignon, MD, PhD, FEBO

THE ONLY CONSTANT IS CHANGE Controversies

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TOWARDS A CLEARER VISION spotlight on the expert AN INEXHAUSTIBLE MIND FULL OF IDEAS yos

Amar Agarwal, M.S., FRCS, F.R.C.Ophth Francesco Carones, MD

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ITALIAN NEWS MAGAZINE FOR EYE3SPECIALISTS/2022YEARIV TOWARDS A CLEARER VISION Rethinking hi-tech lenses for presbyopia correction SURGICAL TECHNIQUES The Only AmarChange,ConstantwithAgarwal SPOTLIGHT Marie-JoséTassignon INSIGHTS The Grey Zone, with Diego Ponzin 3634323026221442

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Forty-one years after its creation, the European Society of Cataract and Refractive Surgeons is one of the world’s leading associations. It covers many fields of ophthal mology, education, research, in novation, permanent updates on our professional life, and holds two major annual meetings where worldwide colleagues gather year after year. The society’s significant help to Ukraine is a new testimony of our growing roles and influence. Today we are more than a scien tific organisation, we are a vivid Howcommunity.wasit back in 1991? After Harold Ridley’s initial invention, intraocular lenses were more than reluctantly considered by the first users. In 1949, when he implanted the first IOL, there was no surgi

ESCRS, AND THE LEGACY OF ITS FOUNDERS AND LEADERS

All the www.eyeseenews.itbynumbercontainedinterviewsinthiscanbeconsultedconnectingtothesite:

cal microscope in our specialty, sutures were 5/0 silk, intracapsu lar extraction was the standard of surgery, carried out through a 180° incision. Ridley’s lens was relatively heavy, and serious com plications had been evidenced. Choyce’s and Strampelli’s anterior chamber modifications also met with problems regarding the cor neal Whenendothelium.in1962,Cornelius Binkhorst invented a second IOLs iris fixa ted generation, the academic world was not supportive, to say the least! The memories of iatro genic complications with the first implants were too imprinted. A few private practitioners, mainly European, followed that new trail, encouraged by their initial results, and Jan Worst’s fighting spirit and

by Professor Philippe Sourdille,former President of the ESCRS from 1994 to 1996

PhilippeProfessorSourdille

Editorial

based in Dublin, was remarkably Inefficient.1996,the merger of the European and the American Journal of Im plant and Refractive Surgery was another strategic change, initia ted and realized by Emmanuel and Steve Obstbaum. To date, this is still one of the few successful merging of American and European medical journals. Confidence and friendship were the leading forces in this ama zing adventure where the charisma of the two initiators played a major role in bringing together colleagues of different cultures.

That same year, during an ASCRS meeting in Seattle, Emmanuel and the society’s executives decided to create a winter meeting, focu sing on refractive surgery. The ra tionale was to propose an educa tional forum to gather experts and discuss the different approaches: keratotomy, lasers, implants.

As a President, as our journal edi tor in chief, and as an influential and active person throughout his life, Emmanuel Rosen deserves our gratitude and our loving memory.

In 1991, after a meeting in Pa ris, the local organisers, Dan Lebuisson and myself, debriefed the event with Emmanuel Rosen, Ulf Stenevi and Paddy Condon. Emmanuel’s question “should we reinvent the wheel every year?” was the initial movement towards creating a permanent office, a bo ard, and an official language. The ESCRS was born, and Emmanuel was declared its first President. ESCRS was Emmanuel’s lifetime achievement. From its very be ginnings until fairly recently, he created, managed and increased the influence of our society. The support of Agenda as our office,

In 1981 Cornelius Binkhorst foun ded the International Intra-ocular Implant Club, attracting new ta lents from different countries. The annual meeting gathered more and more colleagues, but a different lo cation every year and the absence of a permanent office did not faci litate the growing needs for educa tion and scientific recognition.

The first 4 Presidents of the ESCRS in chronological order: Emmanuel Rosen (1991-1993), Philippe Sourdille (1994-1996), Michael Blumenthal (1997-1999), Thomas Neuhann (1999-2001)

creativity were a considerable help at the time.

Cover Story

TOWARDS A CLEARER VISION

Trifocal, bifocal, EDOF lenses, monofocal plus, up to niche solu tions, such as the pinhole and the Light Adjustable Lens: according to Béatrice Cochener-Lamard, the arsenal continues to pile up, while the categories where these lenses are allocated tend to re main the same.

difficult,” she said. “because every time we try to pigeonho le a lens, be it trifocals, EDOFs or the so-called monofocal plus, or advanced monofocal lenses, we realise that in reality this ope ration is not possible as their cha racteristics often combine”. Béatrice Cochener-Lamard is Professor and Department Director of the Brest University Hospital in France. She is the President of the French Academy of Ophthalmology, the for mer President of the French Ophthalmological Society, ESCRS and the French Society of Cataract and Refractive Surgery, and an internatio nally recognized expert in intraocular lenses, especially in relation to the cor rection of presbyopia.

BéatriceProfessor Cochener-Lamard

If the question here were exclusi vely semantic, i.e. relative to the names given to lenses, it would probably not have the same re lapse. The problem lies mainly in the rigidity of the defining lines between different products posed by certain marketing strategies which, according to Cochener, ge nerate confusion in doctors and complicate, rather than facilitate, the selection process.

TOO MANY LENSES, TOO LITTLE CLARITY

Rethinking hi-tech lenses for presbyopia correction

“Defining each category is very

Interview with Professor Béatrice Cochener-Lamard, Brest University Hospital, Franceand Dr. Francesco Carones, Carones Vision, Italy

The constant growth of a sector such as that of presbyopia cor rection, therefore poses new chal lenges to the entire community of anterior segment surgeons and makes it necessary to encourage dialogue and collaboration with companies in order to proactively maximise the satisfaction of the fi nal consumer: the patient.

The origin of the term ‘presbyo pia’ is generally attributed to Ari stotle, albeit not without some debate on the matter. In fact, the union of the prefix πρέσβυς , whi ch indicates the elderly, and ὤψ , ‘eye’, gives us a good idea of the awareness of this condition that man has had since antiquity, that is, the inevitable aging of the eye. The correction of presbyopia has a very long history, beginning with the first spectacles introduced in Italy around the middle of the XIII century, up to the invention of intraocular lenses by Sir Harold Ridley after World War II. Since then, technology has made great strides, especially in the field of intraocular lenses, and has undergone rapid development in the decidedly short space of time of about two decades. For exam ple, the first diffractive bifocal was approved in 2005 by the Food and Drug Administration, a date which seems to us literally the day before yesterday. With 1.8 billion presbyopes in the world, accor ding to 2020 data from the World Report on Vision of the World Health Organization, the industry has worked tirelessly to market new products, different technologies and different concepts, in an extra ordinary proliferation of proposals in the field of intraocular lenses.

“Today in many European coun tries, from the arrival of multifo

“The problem here is that new len ses are developed that do not ful ly reflect the old classifications: for example, there may be lenses that are not categorised as trifocals, but are trifocals in terms of focus range. There is a lot of confusion in the world of high performance IOLs,” Francesco Carones added.

cals, the main survivors are the trifocals with some changes in biomaterials, the transition from hydrophilic to hydrophobic and some changes in the optical zo nes and extended focal zones, inducing some EDOF effect,” Cochener stated. “This made the distinction between EDOF and multifocal less clear.”

se implants are paid out-of-pocket by the patient if a clear lens is re moved. In case of cataract surgery, some countries have introduced a co-payment system, with rates that vary according to the manu facturer; this may also influence the choice of certain models as compared to others. In all cases, as soon as the patient presents a corneal astigmatism of 0.75D or more, a toric version is required”, Cochener remarked.

by Laura Gaspari and Timothy Norris

For Cochener, the nomenclature attributed by marketing and the massive presence on the market of different models has generated confusion and renders patient se lection challenging. “The confu sion is based on the fact that the EDOF family actually corresponds to different concepts but with the same objective, that is, quality of vision and the search for a conti nuous defocus curve. However, the category of diffractive implant with extended focal zones is the pioneering principle described as EDOF; just as aspheric modulation

She noted that the majority of sur geons who routinely implant pre sbyopia-correcting IOLs, choose trifocals in refractive lens surgery, with the aim of offering spectacle independence but with the need to achieve emmetropia. In other situations, such as with elderly pa tients, patients requiring quality of vision at night, patients who have already undergone corneal re fractive surgery, or with a particu lar focus on the pinhole implant for irregular corneas, EDOF implants are preferentially used. “All of the

Medical Director and CEO of Ca rones Vision, Doctor Carones is a pioneer in Italy of the implantation of high-tech intraocular lenses and is often present in international debates on the subject.

Despite this, there are interesting newcomers in the advanced-te chnology IOL arsenal. “The most interesting advancement is the monofocal plus technology: these lenses are not only likely to repla ce the traditional monofocal IOLs,

The confusion is based on the fact that the EDOF family actually corresponds to different concepts butwith the same objective, that is, quality of vision andthe search for a continuous defocus curve Béatrice Cochener-Lamard

“The debate is all about marke ting and how the companies sell their lenses,” Cochener-Lamard remarked. “Indeed, the fact that, according to the laboratories, the categorisation of implants varies, for an identical principle, between advanced implants and non-reim bursed ‘premium’ implants makes their positioning more difficult, and the cost can become a crite rion of choice”.

Dr. Francesco Carones

can be combined with refractive multifocality,” Cochener explai ned. “The limit is therefore not clear-cut and the final choice is ba sed on the personal opinion and experience of individual surgeons. When EDOF IOLs are used for mini-monovision, induced myopia may cause a halo effect, similar to what occurs with diffractive multi focal implants.”

➧

ach spectacle independence with good visual quality, that is, being spectacle-free in daylight, at ni ght, in the sun, driving at night, at the computer or while reading in dim light conditions. If this target is reached, the patient would be really happy. However, surgeons should give precise information about IOL performance in order to make patient expectations reaso nable”.

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How do we define happiness for an ophthalmic patient? “Happi ness for patients is to ‘forget about their eyes’,” Cochener replied. “The ultimate goal would be to re

but they are also used for refracti ve purposes in the correction of presbyopia. In combination with micromonovision, they give very interesting results, correcting pre sbyopia without optical sophistica tion and without sacrifices in night vision,” Carones explained. However, the main point of the question raised, in particular by Cochener, is basically this: the pa tient turns to an ophthalmic surge on to see well in every condition of life, night and day, and althou

THE DILEMMACOMPROMISE

Presbyopia typically occurs in the mid-forties, an age in which peo

Francesco Carones

The problem here is that new lenses are developed that do notfully reflect the old classifications: for example, there may belenses that are not categorised as trifocals, but are trifocals interms of focus range. There is a lot of confusion in the world ofhigh performance IOLs

gh companies are looking for so lutions that allow them to see wi thout glasses, each of them often offers a compromise which does not fully satisfy the concept of pa tients’ happiness.

niche,” Francesco Carones said. “In a hypothetical future, there could be a reference center that purchases the laser and takes care of the lock-in procedure. I do not really see it as a routine approach”.

➧

According to Béatrice Cochener, although the concept is fascina ting, the Light Adjustable Lens is a solution that has not yet found a market and, despite the promises of greater customisation, it is only suitable for specific cases. “The re are many limitations: the high cost of the laser for the surgeon and of the IOL for the patient, and the limited amount of correction you can provide,” Cochener said. “It may have a role in specific si tuations where IOL power calcula tion is complicated and not even supported by AI optimisation, like high ametropia and implantation post-corneal surgery.”

European countries will have to discuss with their healthauthorities whether from a certain level of opticalperformance the implant should continue to be paid outof pocket by patients. In other words, if patients shouldcontinue to pay the cost of progress

Even with the best of current mul tifocal technology, enhancemen ts are often necessary to provi de full spectacle independence, Cochener pointed out. “It is qui te common after the implantation of trifocal lenses to take a further step using the laser if you do not arrive at perfect zero on the refrac tometer,” she explained. “Howe ver, the advent of toric versions is a huge improvement and allows us to correct corneal astigmatism starting from 0.75D with presbyo pia-correcting IOLs.”

“In hyperopic patients, which are very complicated cases due to very small eyes, you need to have a very high lens power and there are not always multifocal lenses suitable for these patients on the market. The only advantage is that they can undergo surgery without significant risk compared to myo pic eyes under 55 years of age. So what’s the solution?” Cochener wondered. “Piggyback implan tation is potentially an option.”

Suitable options are also needed for patients with anatomically nor mal eyes, but with personal or fa mily retinal risk factors. “Finally, another unmet need is a diffracti ve EDOF lens suitable for sulcus

Today, the market offers solutions also for patients who are not su itable candidates for multifocal technologies. These are pinhole lenses and the Light Adjustable Lens (LAL, RxSight). “Pinhole is an exceptional lens for reducing higher-order aberrations in irre gular corneas due to previous surgery, trauma, post-transplant, or keratoconus,” Carones explai ned. “The therapeutic approach of these lenses is highly suitable for these eyes”. However, the se lenses also have limitations. “Pinhole IOLs are a fine option in my experience, especially for irregular corneas, but are limited in that monocular implantation is recommended. It is difficult to im plant them in both eyes, because patients may be disturbed by poor quality binocular vision, and we must remember that we are dea ling with patients who are already difficult to treat,” Cochener said. LAL also has severe limitations and is still a niche solution. “It is an in teresting lens, and may catch on eventually, but it will never beco me the standard. There are addi tional costs involved for implan ting, adjusting and locking-in the lens with the laser. It can work well in cases of extreme myopia and hyperopia, but still a very narrow

Béatrice Cochener-Lamard

are primarily suitable for the cor rection of presbyopia on the basis of anatomical consideration, pre sence of ocular pathologies, and personal needs,” Carones explai ned. “The toric component is cru cial: astigmatism must always be addressed and there is no reason for not doing so. In my opinion, everything above half a diopter of expected residual astigmatism should be corrected”.

ple are still very active. The choice of a lens must be made according to individual needs, taking into account the patient’s ocular con dition and anatomy, past history, and any potential risk factors.

“The question I ask my patients is how much would it matter to them, in the context of a necessary compromise, to have night vision disturbed by the presence of halos and glares. Patient satisfaction is crucial,” Carones explained “and this discussion on the maximum advantage over the compromise is fundamental, where the advanta ge is full spectacle independence and the compromise is the quality of night vision. If night vision di sturbances are definitely percei ved as a problem, then I opt for the compromise, choosing a lens that is simpler from an optical point of view”.

There are extreme cases for whi ch there is no suitable option on the market. Hyperopia treatment, for instance, is still an unmet need.

The choice of the most suitable lens for each patient is a com plex process in which there are no indications and criteria that fit everyone. “The selection criteria are many and can be customised according to the individual patient and individual surgeon: my appro ach is to assess whether patients

implantation in eyes where the capsular bag is not perfect or un stable, or for piggyback implanta tion. The companies should think about this; it is a message that we are trying to put across”.

Market Scope Graph from 2022 Market Report on global PC-IOL Growth

A NEW PROPOSALCODIFICATION

Cochener agreed on the need for companies to adopt new criteria and said that we should forget the marketing term ‘premium’ and fo cus on optical properties and the objective targeted. “Standardisation of criteria and prices should facilitate the objective ranking of implants,”

lenses, which refer to the old trifo cal, and increased range of focus, which are the old EDOF”. Accor ding to Carones and AECOS, this new terminology should help to classify even those lenses that ori ginally did not fall into either ca tegory. “In this way, we may over come the problem of categorising high-performance lenses by giving each of them their own pigeonho le where they can sit comfortably.

The offer of advanced-technology IOLs is wide but, as already sug gested, penetration is still low. “The numbers are still very low everywhere. At the last AECOS congress we have learned that the penetration of high-performance lenses at this time is 6.3-6.4% and rises to 11.5% if toric IOLs are also considered,” Carones said. “From my personal perspective, which is that of a private clinic, I can say we have high numbers. However, this is just a niche, nothing like the vo lume of usage in public hospitals”. What are the reasons for this poor penetration of high-tech lenses in presbyopia correction? “The main reason, in my opinion, is definitely the cost, which is borne by the pa tient, and this is not acceptable in countries like France, which has a strong social security system. Fur thermore, surgeons are the actual sellers of these lenses in that the re is no intermediary between us and the industry, and this puts us

“The new terminology is essen tially based on two main criteria: optical characteristics and per formance properties,” Carones explained. “The optical characte ristics are divided into diffractive and non-diffractive while, based on performance properties, IOLs are divided into full range of focus

Cover Story

Terminology is therefore beco ming a matter of extreme im portance, since the criteria used by companies to categorise and name the lenses on the market do not seem to meet the needs of ophthalmologists and whatsmore, tends to generate confusion in the selection process. A revision of IOL terminology was proposed at the last European meeting of the American-European Congress of Ophthalmic Surgery (AECOS) in order to provide clarity and make IOL categorisation unequivocally simpler and more understandable.

out of pocket by patients. In other words, if patients should continue to pay the cost of progress.”

OF LOW NUMBERS, FUTURE PROSPECTS AND RADICAL CHANGES

At first, it may be difficult to in troduce the new terminology,” he explained “but we hope that we will reach consensus on uniform definitions, both from a methodo logical and scientific standpoint, as well as from that of dissemina tion and information by the manu facturing companies”.

Cochener said. “European countries will have to discuss with their heal th authorities whether from a cer tain level of optical performance the implant should continue to be paid

of what we offer. We must stop car rying on optical concepts that are too difficult to understand, we must rethink the marketing strategies and focus on providing patients with top-level care. Patients should always be encouraged to ask for the best for their eyesight. For this purpose, registers that collect data on the patient’s needs and on the aspects to be considered in order to create increasingly better lenses in the future would be useful”. The revolution lies in the hands of companies and surgeons, but it is the mentality that must chan ge, above all, to ensure that num bers continue to increase and that more and more patients can enjoy good vision and maintain a fully active life as they age. “We need to make the ‘cake’ become bigger and bigger by reducing the num ber of monofocal IOLs and getting more and more people interested in improving the quality of their eyesight,” Carones concluded.

in 2006-2007,” Carones said. “The increase is not so much given by the increase in cataract procedures with correction of presbyopia, but by the growing number of patients who have surgery for refractive pur poses only. COVID has accelerated this trend, with problems brought on by wearing masks, the fogging of spectacles, the unwillingness to wear contact lenses, the visual fati gue due to long stays in front of the screens, and the desire to get rid of the glasses”.

Rethinking cataract surgery for Cochener is also a key issue. “With ESCRS we are producing guidelines, and there are two working groups: one on cataract and one on refractive sur gery. Not surprisingly, the two groups overlap when it comes to discussing intraocular implants for cataract and for presbyopia; that notwithstanding, for this indication it is still recommen ded to remove the lens only when the opacification process has begun” Cochener observed. “The key mes sage is to remember that cataract surgery has evolved to become a refractive surgery, with the capability of minimising or even eliminating the need for spectacle correction, and that it is the surgeons’ duty to deploy all means to offer the best for their patients, in accordance with scientific progress,” she concluded.

We need to make the ‘cake’ become bigger and biggerby reducing the number of monofocal IOLs and getting more and more people interested in improving thequality of their eyesight

Cover Story

in a very uncomfortable and deli cate position of having to guaran tee that the product we provide will lead to certain results, that is, reaching the intended target re fraction which patients expect,” Cochener explained. “But since there are visual compromises inhe rent to all of these lenses, this goal is very difficult to achieve. Many surgeons don’t have enough trai ning, and too many concepts con tinue to generate confusion”.

Across Europe the trend is growing more or less uniform ly, albeit at different speeds. “In many European countries, lens re placement for refractive purposes is now accepted and approved, especially in northern European countries: Sweden, Norway, Fin land and Denmark. The countries of southern Europe, apart from Spain, are more conservative, but we are moving in this direction,” Francesco Carones said. So how can the situation be im proved and move more and more towards pure emmetropia without getting lost in a myriad of con cepts? “It is urgent to educate all cataract surgeons regarding the evolution of IOL optics by simpli fying the principles and by ad vocating the need to align their practice with the state of the art, integrating the advanced-techno logy IOLs. This awareness can be reinforced by informing patients who must now know what they can expect from cataract surgery, which has become refractive surgery, with the goal of not only regaining clear distance vision but also being less dependent on glasses.” Béatrice Cochener said. “We need to stop thinking in terms of patient num bers, focusing rather on the quality

According to Cochener, recent de velopments in anterior segment surgery have led to a new cate gorisation of anterior segment surgeons rather than lenses. “In my opinion there are two types of surgeons,” she said. “On the one hand there are those who normally perform cataract surgery at stan dardised levels and opt for the quick and easy choice, without dwelling on the optical characte ristics of IOLs and without discus sing different options with the patient, therefore not making pro mises and avoiding additional co sts. On the other hand, there are the refractive surgeons: those who are trying to provide their patients with emmetropia and independen ce from glasses.” Cochener said. “They are familiar with advanced IOL optics and with the criteria for patient information and selection, and are eager to offer optimised outcomes, having spectacle inde pendence as a common goal in their daily practice.”

However, there is an upwards trend in the sales of advanced-technolo gy IOLs for purely refractive pur poses. “Market Scope data show a 2.1% increase in the penetration of this type of technology in 20202021. This is the highest percenta ge since the launch of these lenses

Francesco Carones

When I was still in training, I often used to say to myself “Wow, those people on stage at congresses, I wish I had their knowledge and expertise!”. My career has also developed, thanks to people to whom I am still grateful be cause they have helped me a lot. The first of these is Professor Jan Worst. He was a strange person, but he was talented and innovative. He had a peculiar and unconventional way of thinking, but I understood him without problems because we were very simi lar in that respect. I think this similarity was the reason we got on so well. He taught me a lot, and it was thanks to him that we discovered that Berger’s space was so important. His teachin gs were essential to my development.

Interview with Professor Marie-José Tassignon, University of Antwerp,Belgium

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ternationalis. Still active at the Univer sity Hospital of Antwerp, Belgium and elsewhere, Marie-José Tassignon told us her story, her successes and her wi shes for the future in this beautiful and interesting interview given to EyeSee.

Marie-José Tassignon is one of those pillars of international ophthalmology, a protagonist in innovation, who has witnessed and breathed the most si gnificant moments of recent decades. Interviewing such a fundamental per sonality could be intimidating at first, because the task seems beyond the capabilities of a simple journalist. In stead, Marie-José Tassignon is an easy person to approach, a person who lo ves to tell about her life and achieve ments by explaining every detail with simplicity while treating her interlocu tor as an equal. And yet, behind this kindness and willingness, we perceive the strength and intellectual stature of an extraordinary innovator, a resear cher, a highly skilled surgeon, a teacher and a guide for the new generations of ophthalmologists, a woman who has collaborated with the greatest of ophthalmology, who was President of the European Society of Cataract and Refractive Surgeons (ESCRS), the Euro pean Board of Ophthalmology (EBO) and of Academia Ophthalmologica In

Who have been the most influential people in your career? Who do you consider your teachers and mentors?

Professor Tassignon, what are your subspecialties and areas of interest?

Professor Marie-José Tassignon

Spotlight on the expert

In our career as ophthalmologists we tend to move from one subject to another depending on the circumstan ces. I started as a vitreoretinal surge on and then moved on to the anterior segment. Then, I went more and more “anteriorly” from the lens to the cor nea. Now I have returned to the po sterior segment, but between the lens and the retina. So, at the moment my main interest is the vitreous, the pedia tric cataract with its associated malfor mations of the anterior vitreous.

The incredible innovative energy and personal story of a great master of international ophthalmology, Marie-José Tassignon AN INEXHAUSTIBLE MIND FULL OF IDEAS

I had the opportunity to meet Sir Ridley, the inventor of intraocular len ses. Although he had a complex per sonality, he was also very humble and could explain in a simple way what his ideas were. Unfortunately, he was he avily criticised at the time, as is often the case with someone who introduces something new.

Another very influential person for me was another Belgian, Charles Schepens, who did a wonderful job in the Resistance during World War II, saving many people lives. Then he went to Boston via London and du ring his journey he met an engineer named Oleg Pomerantzeff, with whom he worked to develop the indirect ophthalmoscope. These are the most important people in my career.

vents the proliferation and migration of epithelial cells, and over time there would be no posterior capsular opa cification. I am convinced that some ophthalmologists do not perform it because they would lose their income from the YAG laser. Okay, it is their re sponsibility. Regarding the use of this technique in children, the evidence for its safety is very strong. However, I believe that those who do not at least try to learn this technique do so for an ethical question.

Marie-José Tassignon

My career has been a turning point for the role of women in ophthalmology. I do not really like the ideaof being chosen because I am a woman. I prefer to bechosen for my merits

What have been your greatest achieve ments and contributions to the advan cement of ophthalmology?

My career has been a turning point for the role of women in ophthalmology. I do not really like the idea of being chosen because I am a woman. I pre fer to be chosen for my merits. For example, when I was proposed for the position of Head of Department in Antwerp, I was the only woman out of ten candidates. I thought I had little chance but in the end, I got the job and not because I am a woman. This also happened when I became President of ESCRS and EBO: it was not because of my gender, but because I worked for the society for many years. The number of women in ophthalmo logy is growing, and many of them are actively working, even taking on re ➧

Another very significant person in my career was Charles Kelman, the inven tor of phacoemulsification. I was very young compared to him, but we wor ked a lot together. I used to go to New York every year to give courses on ca taract surgery in complicated cases, something that has helped me a lot in my career.

The greatest achievement of my life was to develop a technique to sol ve the problem of posterior capsular opacification (PCO) in cataract sur gery, that is: the bag-in-the-lens. It is a challenging technique. Surgeons used to be afraid of damaging the po sterior capsule, so I came up with a so lution to the PCO problem by doing a surgeon-controlled capsulorhexis and inserting the edge of both capsules into the groove of the lens. This pre

You are present on the international scene and are involved in the great ad vances in ophthalmology. How much of what you do and have learned finds space in your daily clinical practice? The answer for me is very strai ghtforward. I use everything I have developed because I believe in it,

otherwise I would not do it. So cer tainly, what I have developed and le arned I apply in my daily practice, ab solutely.

by Laura Gaspari

Marie-José Tassignon at the University Hospital of Lubumbashi (Congo) in 2018

You are one of the best known and most praised specialists in internatio nal ophthalmology: what do you think of the scarce presence of women in this specialty?

I enjoy designing and developing tools to improve surgery and its results. I am working on new surgical devices and new techniques. It is very important to me - it is an improvement that helps us build from generation to generation.

did not think so years ago when I was a younger teacher, it took me some time to learn it. Also, students remem ber the little stories you told while you were teaching them - it is a good tech nique for understanding and remem bering better. I think I have students all over the world and it is very pleasant when I travel and find people who gre et me. Sometimes I do not remember where and when I met them: then I re alise who they are and that they have not forgotten me. It is a good feeling.

I have to say, I do not know if I am a good teacher or not. I have never had any complaints from my students, and that is a good sign. On the other hand, teaching is definitely something I love to do. I want to be able to teach things in a simple way. If you are able to understand things easily, then you are able to convey them just as easily. Telling stories of things and people is also important. How did I get to where I am now? We need to know the past because each of our goals is built on the legacy of those who precede us. I

I would like to already have the bagin-the-lens technique with the option of providing accommodation or pseu do-accommodation for the patient. The patent is ready, and I hope it will be accessible soon, also for compa nies, because it is truly a solution to avoid posterior capsular opacification, avoid possible dislocation due to fi brosis, and the alignment of the lens to the patient’s visual axis.

sponsible jobs. We are getting closer and closer to gender equality. Howe ver, it is also true that not all women are interested in positions of respon sibility early in their careers, and for various reasons, including having a family. You can never know what a per son’s responsibilities will be in a new job so everyone makes their choices and has their reasons. But if you deci de to have a role of responsibility, it is better not to do it just for personal and material reasons, but to carry forward an idea. Responsibility consumes time and must be taken into account. It is not a question of popularity, but of re asoning.

Would like to see fully implemented techniques totreat patients complaining of floaters, by using more advanced lasers than we now have, that have greater visibility and the ability to dock and stabilize the eyeto treat floaters in a complete way

Spotlight on the expert

What do you think of yourself as a tea cher? How important is it to give space to your students?

I know this is a cliché, but it is true that making a hobby out of your profession makes life easier! When I was younger, I liked to paint. I really liked fashion and wanted to become a fashion de signer, but then I realised that it would be a real profession and doing it as a hobby would be impossible. You must choose in life. It is important to be fully involved in your profession so, yes, it is a big part of my life. Then of cour se, there is my family: I have children and grandchildren and I love spending time with them. Having grandchildren made me better understand what happens when you are a young pa rent. Everything has its role in life and nothing should be neglected.

Marie-José Tassignon

Then I would like to see fully imple mented techniques to treat patients complaining of floaters, by using more advanced lasers than we now have, that have greater visibility and the ability to dock and stabilise the eye to treat floaters in a complete way. This would reduce the number of vitrecto mies in the case of severe floaters.

How important is your profession in your life? What are your passions and hobbies outside your profession?

The Aladdin’s Lamp. A desire, a tur ning point that you would like to see ready for your patients.

I would also like to collaborate with companies to develop new devices to facilitate ophthalmologists in ocular surface, sclera, and corneal flap sur gery. It is something I would really like to see implemented in the daily practi ce of the ophthalmologist.

Leisure is very important to me: you have to relax, or you do not go on. The fact is that I relax in my work. Of course, there are really crazy moments where I say to myself: “Why have I ac cepted so many jobs together again?”. It is the moment I realise I have to step back and breathe, but I am still thin king about developing stuff because it is my Havinghobby.ahobby just to have one is not interesting in my opinion: for example, golf is interesting because you have to build strategies and make choices while playing, but I already do it in my job. I know how to do it, I do not necessarily have to learn it by running after a little ball, even if it is very he althy. However, I practice sport at an amateur level because I understand it is good for having a healthy life.

Marie-José Tassignon with Professor Jan Worst at ESCRS in Vienna (2000)

Myopia control effect sustained over 6 years In a 6- year long-term follow-up study 1 , results in the group of children wearing MiYOSMART spectacle lens showed that myopia control effect was sustained over time. Children who stopped wearing MiYOSMART spectacle lens show no rebound effect1 . 1 Lam CS, et al. Myopia control in children wearing DIMS spectacle lens: 6 years results. Invest Ophthalmol Vis Sci. 2022;63:ARVO E-Abstract 4247 2 Jong M, Jonas JB, Wolffsohn JS, et al. IMI 2021 Yearly Digest. Invest. Ophthalmol. Vis. Sci. 2021;62(5):7. https://doi.org/10.1167/iovs.62.5.7 Reported as an effective managementmyopiaoptionbytheInternationalMyopiaInstitute2

ATLAS OF ANTERIOR SEGMENT OCT

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Michele Fortunato

A ‘CONTINENT’ FULL OF OPPORTUNITIES

“No man is an island entire of itself; every man is a piece of the continent, a part of the main”. The famous ope ning by the British poet, religious and essayist John Donne, in which the in dividual is seen as part of ‘the main’, is the perfect metaphor for a society like the European Society of Cataract and Refractive Surgeons (ESCRS): a network of specialists who create a whole, which supports dialogue beyond borders and which promotes progress and advancement in anterior segment surgery.

YOs

22 “

Young Ophthalmologists are very simi lar. “I joined ESCRS in 2016 and I was a member of the Young Ophthalmo logy Committee, which changes every four years and organises and schedu les content for young ophthalmologi sts,” Stefan Palkovits explained, now a specialist in glaucoma, cataract sur gery and ocular surface disease. “The committee is made up of several peo ple from various European countries, ideally one young person per country. I am now a member of the Education Committee.” Doctor Artemis Matsou is specialised in corneal transplant and anterior segment surgery. “I joi ned ESCRS as a member in 2015, and I have been part of the Young Ophthalmologists Committee since 2020. I am also part of the Education Committee, bringing the point of view of young ophthalmologists.” she said. As a large European scientific and spe cialist society, ESCRS offers many op portunities for its young members to grow as professionals in an internatio nal environment. “The opportunities are many, from following the society annual congresses, to the symposium for young ophthalmologists organised at each meeting, video sessions, wet labs, courses: it starts from the basics and leads to more complex topics. Everything is tailor-made for young ophthalmologists at all levels, inclu ding those still in residency,” Matsou said. “The participation of YOs in con gresses is essential and they should be encouraged to be more active. For example, as a resident, I always aimed to submit research projects and pre sent at every congress in which I parti cipated. This gave me the opportunity to get involved in high quality research projects and practice presenting to my peers at an international level.”

In a world made up of “islands”, ESCRS YOs wants to create a “Pangea” that is a home for all young European specialists

All the greats have been young once and many of the young people today will be great tomorrow. For this rea son, none of them should be left to be an island in itself but must be culti vated in a context that gives opportu nities and possibilities to anyone who wants to get involved. On this basis the ESCRS Young Ophthalmologists (YOs) programme is founded, where young specialists themselves come to gether to give each other support on the path to a brilliant career. We talked about ESCRS and its young ophthal mologists with Dr Artemis Matsou, a Greek ophthalmologist who currently works at Queen Victoria Hospital, East Grinstead in the UK and Dr Stefan Palkovits, from Hanusch Hospital in Vienna, both of whom have been wor king for years within ESCRS. They have shared with EyeSee all the opportuni ties that a young European ophthal mologist can choose in order not to be limited to being an island in itself, but actively being part of the ‘main’.

Dr. Artemis Matsou

Interview with Dr Artemis Matsou, Queen Victoria Hospital, East Grinstead, UK and Dr Stefan Palkovits, HanuschVienna,Hospital,Austria

YOUNG PEOPLE FOR YOUNG PEOPLE: OPPORTUNITIES AROUND EVERY CORNER The experiences of Artemis Matsou and Stefan Palkovits within ESCRS

IT DOES NOT EVEN STOP WITH A PANDEMIC

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One of the biggest opportunities that ESCRS gives to its members, espe cially the younger ones, is to com pete for fellowships and grants and to encourage mobility and research.

Stefan Palkovits

ght us to always be ready to change and adapt very quickly. The younger generations have perhaps been fa ster to absorb these changes by using technology and social media to stay informed and connected,” Artemis Matsou explained. “The important thing was not to lose contact with our field; we had to maintain the mindset of our profession, and not seeing each other in person and not having access to wet labs and face-to-face conferen ces, there was a risk of losing contact.”

Dr. Stefan Palkovits

“There are three grants available: the Pioneer Research Grant, the Clinical Research Grant, and the Systematic Review Award. The first two refer to clinical research and reward the best proposal, while the third aims at finan cing the revision based on the Cochra ne Library methodology on empirical data relating to the anterior segment,” Stefan Palkovits explained. “Then the re is the Peter Barry Fellowship which supports the winner for a year of trai ning and clinical research in a foreign facility. All great opportunities for a young specialist to acquire new skills and experiences.”

Enrolment in ESCRS for trainees is free for the first years.There is really no excuse not to be a part of it and I really recommend it to all young ophthalmologists

The fellowships and observerships made available by ESCRS are huge opportunities for young specialists from various European countries to

establish a network. “The service made available by ESCRS is very ge nerous, but obviously we must go through very competitive selection processes. However, these oppor tunities help young ophthalmologi sts to get in touch with their peers abroad, create a network, and get to know other people directly,” Artemis Matsou added.

Dr Matsou at ESCRS Winter Meeting in Portugal 2022

Virtual space has therefore become fun damental. “ESCRS in general has been able to adapt to the virtual space. We have seen that it works, even if it is more satisfying to see each other in person, especially for those activities that cannot be online, such as the wetlabs and other hands-on courses,” Palkovits added.

by Laura Gaspari

It goes without saying that COVID-19 has also greatly impacted the op portunities offered to young ESCRS ophthalmologists, who nevertheless, endeavoured to continue, trying to adapt to the difficult challenges that the pandemic was posing to ophthal mology worldwide. “COVID has tau

The participation of YOs in congresses is essential and they should be encouraged to be more active

LEARN FROM THE MASTERS

According to both Artemis Matsou and Stefan Palkovits, it is essential for young ophthalmologists to join a society like ESCRS from the very be ginning of their careers, even while still in residency. “There is so much educational material, and there are so many activities and networking op portunities that every ophthalmologist can benefit from! Participating actively in activities expands the mind. The so oner you join and start taking advan tage of them, the better,” Matsou no ted. “I highly recommend to all young ophthalmologists to join ESCRS, even those who do not specialise directly in anterior segment surgery, as cataract surgery is one of the basic procedures for all ophthalmologists irrespective of their subspecialist interest.”

“In this regard, there is the Journal Club project, in which youn ger ophthalmologists of ESCRS host the experts and focus discussion on the critical appraisal of recently publi shed articles through questions that stimulate often fantastic dialogues,” Artemis Matsou explained. “They are always available, they dedicate their free time to us and answer our questions, they leave us pearls of wisdom in very interactive sessions in which, in reality, everyone can participate and which are useful for any level of expertise.”

Artemis Matsou

“NO EXCUSES”

However, ESCRS has always continued to focus on learning, including online material. “Not only does ESCRS have one of the most attended annual con gresses, it also focuses significantly on online educational opportunities, than ks to the launch of the new website,” Palkovits explained. “you have online access to recordings of previous pre sentations, to review content on de mand, videos with surgical tips & tricks. There is also the ILearn platform, with high quality anterior segment inte ractive courses that give CME credits. In addition, members have access to exclusive content from the Journal of Cataract and Refractive Surgery.”

The reopening of congresses in pre sence in times of pandemic has also seen the decrease of seats in venues during the symposia, and this has gi ven rise to less crowded sessions such as Meet The Expert, now a widespre ad practice in almost all meetings. “These sessions host around 15-20

people and are very useful, especially for young ophthalmologists becau se they have the freedom to ask the experts questions without perhaps feeling intimidated by a full room. I think it is helpful in making them feel comfortable,” Matsou said.

The great ‘ESCRS continent’ not only offers so many opportunities to young people from an educational and practical point of view, but also encourages both the old and the new guard to meet and break down that often-perceived impression of the unreachable expert, who a young person may have difficulty in appro aching and who knows of him or her only on paper. “When you take part in

A screenshot a virtual meeting of ESCRS

The encouragement to join the ‘con tinent’ is very strong and the possi bilities are there for everyone. Being isolated islands in the sea does not benefit anyone. “Enrolment in ESCRS for trainees is free for the first years. There is really no excuse not to be a part of it and I really recommend it to all young ophthalmologists,” Palkovits concluded.

the activities of a society like ESCRS, suddenly all the names you had only seen on the scientific papers become reachable: you can talk to them in per son, you can get to know them and you can work with them. Perhaps for me it is one of the greatest experien ces,” Palkovits said.

Even the symposium programme dedi cated exclusively to young ophthalmolo gists during the annual ESCRS meeting has always given them the opportunity to meet the experts and discuss openly with them. “The symposium program me dedicated to YOs allows everyone to present their case directly to partici pating experts and have their opinion and feedback. This interaction allows for greater personal and professional growth,” Palkovits added.

24 YOs

Matteo Forlini, MD

“This is the case of a severely myo pic woman in her sixties from a small town of Tuscany, Italy. In the hope of improving her visual acui ty, she underwent PRK in ‘98, and that should have been the end of the story. One eye went very well, the other, instead, soon began

“The eye doctor was an anterior segment surgeon, and considering the high risk of iatrogenic retinal detachment he decided to opt out of the responsibility of operating.”

Inaction, however, is not an op tion: “An aphakic patient general

the QR code

manifesting early complications,” Forlini Matteosaid.Forlini, MD, is consultant of vitreoretinal surgery at San Marino State Hospital. Active in many clinics scattered around the Emilia-Romagna region of Italy, Forlini has always distinguished himself for his skills in complex surgical cases.

Stuck in an unlucky series of events, this is the case of a patient and her ten-year misadventure full of turning points, but eventually with a happy ending

One year later, the same surgeon decided to correct the residual myopia with an add-on ICL IOL in the sulcus.

Sometimes in life you can become one of those unlucky patients in which practically everything from a medical point of view goes tra gically wrong. Though at first you hope for a better lifestyle, sud denly you find yourself struggling through the bitter consequences of an unexpected chain of events. Sometimes coping with such pro blems really feels like a snowball rolling downhill, growing bigger in size, and becoming more and more of a burden. At times, tor mented journeys such as these end up in the clinic of Dr. Matteo Forlini, MD.

Interview with Dr. Matteo Forlini, San Marino State Hospital

“The bag was already damaged, and the lens was very precarious,” said Forlini. “A simple small blunt trauma would have been suffi cient to push the lens through the crack and into the vitreous cham ber. The patient’s sudden loss of vision would have been a tell-tale sign indicating that something was going very wrong.”

“A refractive residue remained in the left eye following the PRK procedure,” Forlini said. “This obliged the surgeon to undertake multiple follow-up interventions to correct the defect, resulting in a cataract that had to be removed with phaco. To make matters wor se, a small capsule tear occurred during cataract surgery, but the surgeon chose to insert the lens in the bag anyway.”

Nightmare Cases THE UNLUCKY CHAIN

To video, scan

Visiting her eye doctor, the patient soon had to face up to her predi cament. “High myopia means a frail retina,” Forlini pointed out.

connect to the

Matteo Forlini in the operating theatre of the Domus Nova hospital in Ravenna.

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tocoagulation was also performed for this reason,” he said. “At this point, removing the ICL still linge ring in the anterior chamber was a necessary manoeuvre.” Unfortuna tely, however, the patient still had one last unlucky trump card up her sleeve. During a very delicate sta ge in the surgery, the ICL slipped from the surgeon’s grip, and pas sed through the capsule tear right into the vitreous chamber, ending up next to the other lens.

“The ICL was virtually hanging onto nothing, and a minimal pres sure would have been enough to make it disappear. Not such a big deal, really,” Forlini said. “But in

An intraocular lens slipping into the vitreous could be comparable to a stone thrown into a pond. In this example, however, replace the stone with a whole yachtand you may have a better idea of the kind of damagethat one would have to deal with

ly needs thick and old-fashioned 13D spectacle lenses for the eye in question,” Forlini explained. “Mo reover, leaving an intraocular lens inside the vitreous chamber would have been unwise. It would have been just a matter of time before the IOL triggered a chain reaction, relentlessly leading to retinal de tachment, and leaving the surgeon to deal with the resulting perma nent damage.”

by Timothy Norris

At this point surgery was inevi table. For the patient, finding the right surgeon was imperative and while searching for a second opi nion, she eventually got into con tact with Matteo Forlini’s clinic in

the town of Ravenna.

“An intraocular lens slipping into the vitreous could be comparable to a stone thrown into a pond. In this example, however, replace the stone with a whole yacht and you may have a better idea of the kind of damage that one would have to deal with” Forlini pointed out.

Matteo Forlini

“We immediately opted for pars plana vitrectomy to remove the altered vitreous, thus preventing unwanted tractions and severe consequences for the retina such as proliferative vitreoretinopa thy, and the risk of a tractional or rhegmatogenous retinal detach ment. Prophylactic 360° laser pho

lens, an easy-to insert IOL with a great safety profile and a won derful tool to cope with unlucky chains of events, according to Matteo Forlini.

In the end, the outcome was suc cessful. The patient had BCVA of 7/10 in the left eye at one month postoperatively and no sign of reti nal damage. “Despite some initial worries, the patient’s retina was perfectly intact. She had to deal with a slightly longer recovery pe riod due to a mild corneal swelling that resolved itself in less than a month after surgery. Furthermore, some Descemet membrane folds improved at every weekly follow up,” said Forlini.

The ICL escapes the grasp and slips into the posterior segment through the rupture of the posterior capsule.

Surgical skills apart, an optimal outcome had also been made possible thanks to the iris claw

“The ICL was fortunately very fol dable, and that made it possible to pass the largest lens through the pupil without damaging the iris,” Forlini said. “Finally, I was able to insert a retropupillary Iris Claw IOL.”

“Let sleeping dogs lie”. Vitrectomy is a necessary procedure in these cases to prevent the risk of a retinalvitreoretinopathyproliferativeoradetachment.

“Between vitrectomy and the re moval of both the intraocular len ses, surgery dragged on for more than ninety minutes,” he said. “I also needed a lens that would not trigger adverse effects such as corneal decompensations, secon dary glaucoma or cystoid macular edema, so the Artisan Iris Claw was the faster and more efficient option at my disposal for the case in question,” Forlini concluded.

Nightmare Cases

that very moment the patient’s pu pil began to shrink, thus gradually limiting my visual field while I was trying to remove two large-sized lenses through the iris.”

With the help of a pair of crocodile forceps, both lenses were carefully pulled through the very tight pu pil, and eventually removed throu gh a clear corneal incision.

www.itallenti.com

Lente per il controllo della progressione miopica nei bambini ed adolescenti

Per rispondere a questa problematica Ital-lenti ha sviluppato MYOPKIDS, un’innovativa lente con defocus periferico, con lo scopo di limitare lo sviluppo della progressione miopica nei bambini e negli adolescenti.

La miopia sta diventando un problema sempre più diffuso a livello planetario.

InsIghts

One hundred and seventeen years have passed since the first kerato plasty was performed on a human patient. This first attempt, succes sfully carried out by Edward Zirm in 1905, was both a gamble and an act of reverence to all previous failures that marked the nineteenth century, as well as an auspicious beginning to what the future of corneal tran splantation would become. Nowadays, the original penetrating keratoplasty has been mostly aban doned in favour of the more refined transplantation of corneal layers. Te chniques such as DALK and DMEK are in fact, a product of brilliant minds of both past and present –from Arthur Von Hippel right up to Gerrit Melles – but have just recent ly gained their place in worldwide operating theatres. It is a fact that, when compared to other surgical te chniques in ophthalmology, corneal transplantation is still far from being a perfectly standardised procedure, and that there is still much to rese arch, unveil and discover in terms of safety and efficacy. It is nonetheless, a thrilling global race for progress, with a clear path and important goal.

Diego Ponzin is President of the Italian Society of Eye Banking (SIBO). He is also Director of the Veneto Eye Bank Foundation (FBOV), an inter national and national excellency not only in the procurement of corneal tissue, but in the field of medical R&D and ocular physiopathology. What happened at the end of 2021 is a perfect example of how much the road to hell is paved with good intentions. It all started in 2006, with the institution of biobanks and especially the new guidelines is sued by the Council of Ministers of the third Berlusconi Government. In these new guidelines it was decreed that all tissues ineligible for clinical usage could be used for research with a disclosure of voluntary, free of charge and anonymous partici pation. This was made possible by asking the immediate family for ful ly informed consent. According to Ponzin, this was a widely accep ted and approved procedure. “The Veneto region of Italy was pionee ring this practice,” said Ponzin. “For twenty and more years we were asking close relatives for permis sion to use the donor’s tissue for alternative usage, provided that it was unsuitable for transplant, and that it was all in compliance with law, privacy, traceability and safety. Everything started to change after

A dramatic setback in November 2021, however, is threatening to put Italy out of this exciting deve lopment.

THE GREY ZONE

Interview with Dr. Diego Ponzin, Veneto Eye Bank Foundation.

Diego Ponzin is President of the Italian Society of Eye Banking (SIBO). He is also Director of the Veneto Eye Bank Foundation (FBOV).

“It happened at the end of last year, and since then we have en tered an era of uncertainty”, said Diego Ponzin. “Suddenly, our op portunities of using human tissue drafts ineligible for transplant be came severely limited, as we had been told that we no longer have the authority to ask for consent for medical research purposes.”

How medical research in Italy is crippled by government bureaucracy, desperately looking for alternatives

by Timothy Norris

This is a wide spectrum problem, involving not just ophthalmology, but medical science as a whole. In an attempt to solve this crippling situation, many scientific societies made their voices heard, at times, as strongly as possible.

“We are very aware of how much living procurement can benefit us, not only for surgical procedures such as lamellar or addition kerato plasty, but also for how easily it can give us a vital supply to keep me dical research going,” said Ponzin.

red this a defect of form and a lack of regularisation in the procedure of consent. Given that there is no norm regulating the indirect con sent of close relatives in this area, it immediately became illegal to posthumously donate tissues to science,” Ponzin explained. “To put it simply, in trying to understand if the deceased ever manifested his or her consent during their lifetime, for the Ministry of Health this was not enough. This immediately tied our hands, as it were, thus reducing our chances of obtaining an inva luable resource for medical resear ch, and limiting our overall activity to just validation and education.”

It happened at the end of last year, and since then we have entered an era ofuncertainty. Suddenly, our opportunities of using human tissue drafts ineligiblefor transplant became severely limited, as we had been told that we no longerhave the authority to ask for consent for medical research purposes

“We all protested loudly,” said Ponzin. “All the scientific societies involved used up a lot of ink on the matter, and yet we are still wai ting for an answer, or a change of pace,” said Ponzin. “In the meanti me, nothing is happening.” One of the temporary solutions to this pro blem could be the use of corneal tis

a series of interpellations, which prompted the National Transplant Centre to ask the Ministry of Health for a formal inquiry into the lawful ness of this procedure. What hap pened next was an absolute kick in the teeth,” Ponzin said. According to an editorial issued by the FBOV and written by Ponzin, Fasolo and Ferrari, in November 2021, the Legislative Office of the Ministry of Health banned the use of organs and tissues ineligible for transplantation without the direct consent of the donor, with the exception of activity of research and formation strictly re lated to transplantation. The reason for this was that, according to the Legislative Office, there is no lawful basis for the surviving close relatives to mandate the will of the decea sed for research purposes. A blatant downside of the Italian law “Norme in materia di disposizione del proprio corpo e dei tessuti post mortem a fini di studio, di formazione e di ricerca scientifica” (Rules on the disposition of one’s body and post mortem tis sues for study, training and scientific research purposes) that on one side gave people the right to donate their body to science, and on the other, created a massive loophole.

Diego Ponzin

“The preservation of SMILE lenticu les, in particular, could give us the opportunity to create living donor tissue banking. That’s an invaluable resource given that tissue for medi cal research is soon going to be very scarce,” he added. While agreeing with the idea of alternative procu rements, finding a way out from the regulatory grey zone is nonetheless essential to ensure a future for me dical research, Diego Ponzin stres sed. Broad information could be key for a positive resolution. “A very useful suggestion would be to invi te ophthalmologists to inform and sensitise patients on this subject, particularly on the possibility of be coming donors for research purpo ses,” Ponzin said. “This, however, must be followed by the creation of biobanks here in Italy to ensure the preservation of priceless tissue spe cifically for medical research,” he concluded.

sue from living donors. “The SMILE technique is still not well-rooted in the ophthalmological community,” observed Ponzin, “but it might give us the opportunity to obtain stromal lenticules, human tissue from heal thy corneas that can be immensely useful for us, and that are invaluable for medical research,” he said. “Mo reover, these portions of tissue may not be useful for patients anymore, so there is no point in preserving it other than for research purposes.” It is widely known that the first corneas implanted by Eduard Zirm came from a living donor, an eleven years old boy sadly destined to enucleation due to bilateral trauma. The child’s name was Karl Brauer, and his corne as stand as an emblem for both sur gery and research in ophthalmology.

The Research Center of the Veneto Eye Bank Foundation (FBOV) is a national and international excellence in scientific and medical research in transplantation, rare diseases and stamina cells.

“The Ministry of Health conside

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President and Director of Dr. Agarwal’s Eye Hospital and Eye Research Centre, Amar Agarwal is a renowned ophthalmologist and a pioneer in surgery for both the anterior and posterior segment.

IOL in the eye while it is still in the injector. For this reason, we pre pare the injector with one of the PC IOL haptics slightly protruding out of it,” Agarwal explained.

Surgical TechniqueS THE ONLY CONSTANT IS CHANGE

This is a story of constant chan ge, of how a complex and chal lenging procedure of PC IOL fixa tion can lay the foundation for a simpler, yet efficient and versatile technique that was designed to become an extension of the sur geon’s hands.

How a simple and easy to learn technique can really make the difference in complicated surgery

Interview with Professor Amar Agarwal, Dr. Agarwal’s Eye Hospital and Eye ResearchChennai,Centre,India

The Handshake Technique was developed in 2008 by Dr. Amar Agarwal along with his team, to maximise surgeon’s manoeuvrabi lity during the Glued Intrascleral Haptic Fixation of an Intraocular Lens; a procedure for the implan tation of a three-piece PC IOL in eyes with absent or insufficient capsule support. “First of all, we need to make it easier for us to take hold of one of the tips of the haptics of the three-piece foldable

Amar Agarwal, M.S., FRCS, F.R.C.Ophth, is President and Director of Dr Agarwal’s Eye Hospital and Eye Research Centre, counting more than 103 hospitals in eleven countries around the world. Along with the first implan tation of a glued IOL, he is a true pioneer of countless anterior and posterior segment surgical techni ques such as Phakonit and Single pass 4 throw pupilloplasty, Pinhole Pupilloplasty, IOL Scaffold and many more. “As the injector is introduced through the sclerotomy into the anterior chamber, we take hold of

of the second haptic”, he said. “Now the second haptic is held through forceps by both the sur geon’s hands. Like a handshake passing the haptic from hand to hand it is now possible to safely lead the haptic through the se cond sclerotomy.”

“In the case of a dislocated IOL I carry out a vitrectomy, passing the tip of the haptic from hand to hand, and finally pulling the lens out. This can reduce the risk of trauma to the corneal endothe lium,” Agarwal explained. “The only exclusion criterion is that the procedure is not feasible with a single-piece foldable IOL, whe reas it is fine with a three-piece foldable or with a single-piece non-foldable IOL.”

Change is something that is con stant. A remarkably simple te chnique can make surgery more effective even in complicated scenarios and compromised eyes.

“Every surgeon should learn this technique,” Agarwal said. “It is a technique, a skill, which can really and effectively take the surgeon to the next level,” he concluded.

Amar Agarwal

With a successful Handshake Technique, the glued IOL can then be completed by inserting both haptics through a 26-gauge intrascleral tunnel with a Scha rioth tuck and sealing the flaps with some fibrin glue.

The spacewithinmanoeuvrabilityallowsTechniqueHandshakeforeasytheclosedoftheeye.

10 ofpostyearsOPaGlued IOL.

I developed the Glued Intrascleral Haptic Fixation procedure withmy team in 2007, and soon realised that we needed a specifictechnique to make it better, easier and more efficient

The Handshake Technique allows for easy manoeuvrability within the closed space of the eye. Ac cording to Dr. Agarwal, this te chnique can be extremely useful in the case of subluxated IOLs.

this leading haptic with an MST forceps through a side port and hold it like this while the optic is injected. Holding the haptic from the tip and not anywhere else, is crucial for keeping the integrity of the haptic itself,” Agarwal explai Whilened. the first haptic held with the forceps is introduced through the sclerotomy port, the injector must be removed, leaving the second haptic trailing outside the wound. “An assistant keeps the first haptic steady outside the port, while the surgeon enters through a second side port with MST forceps near the first haptic port and flexes the second haptic into the anterior chamber,” Agarwal said. “At that point we are almost ready to per form what I call ‘the handshake’: the surgeon takes hold of the se cond haptic with the forceps, and keeping the haptic flexed, enters the eye through a second sclero tomy port on the other side of the eye with a second pair of forceps, reaching and then holding the tip

by Timothy Norris

“I developed the Glued Intrascle ral Haptic Fixation procedure with my team in 2007, and soon reali sed that we needed a specific te chnique to make it better, easier and more efficient,” said Agarwal. “The following year we developed the Handshake Technique and a few years later were able to publi sh an article about it in the Journal of Cataract and Refractive Surgery, also winning the Best Film Festival Award at the 2012 ASCRS-ASOA Congress in Chicago.”

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ral cataract surgery, Professor Jorge Alió, Professor and Di rector of the Department of Ophthalmology of the Univer sity of Alicante, Spain and Di rector of the Vissum Clinic of Alicante. Instead, Dr. Arthur Cummings, of the Wellington Eye Clinic in Dublin, Ireland, defends the contrary opinion. Which side will you take?

Controversies

In this regard, EyeSee hosts two international names with different but not entirely op posing opinions: in defense of immediately sequential bilate

One of the most lively debates in the field of the anterior seg ment is certainly on the possi bility of having cataract surgery on both eyes on the same day or not.

IMMEDIATELY SEQUENTIAL BILATERAL CATARACT SURGERY: YES OR NO?

Essilor® Stellest™ lenses slow down myopia progression by 67% on average** ** Compared to single vision lenses, when worn by children at least 12 hours per day every day. Bao, J., Huang, Y., Li, X., Yang, A., Zhou, F., Wu, J., Wang, C., Li, Y., Lim, E.W., Spiegel, D.P., Drobe, B., Chen, H., 2022. Spectacle Lenses With Aspherical Lenslets for Myopia Control vs Single-Vision Spectacle Lenses: A Randomized Clinical Trial. JAMA Ophthalmol. 140(5), 472–478. https://doi.org/10.1001/jamaophthalmol.2022.0401 India.China,Brazil,Canada,US,Spain,Italy,Germany,UK,France,-2019FebruaryinCSAbyECPsindependent958ofsamplerepresentativeaamongconductedresearchQuantitative-worldwideprofessionalscareeyebyrecommendedBrandlens#1*Essilor,Essilor® Stellest™ lenses slow down myopia progression by 67% on average,** compared to single vision lenses, when worn 12 hours a day. #1ESSILOR® LENS BRAND RECOMMENDED BY EYE CARE WORLDWIDE*PROFESSIONALS

• Liposomes (Phospholipids S75 Nio lip) that deliver the functional sub stance (Biosecur®) ensuring the

36 Industry news

Oftasecur ophthalmic solution and Oftasecur ocular spray are Medical Devices based on liposomes of Biosecur® and hypromellose. Biosecur®, used for the first time in ophthalmolo gy, is a natural and patented complex of bioflavonoids and polyphenols, with a broad-spectrum antimicrobial activity. Its antibacterial action can be attributed to several mechanisms:

Both are well tolerated even during prolonged treatments, and they pro tect and relieve the irritated eyes and eyelids1,2

• Hypromellose, with its viscoelastic and hygroscopic properties, that moisturizes the eyelids and region around the eyes.

product persistence, tolerability and manageability

• inhibition of nucleic acid synthesis

• inhibition of energy metabolism. Bioflavonoids and natural polyphenols have demonstrated synergic effect with antibiotics by increasing the sen sitivity of multi-resistant bacteria. Biosecur® is extracted from citrus fru its with organic certified origin and extracting processes. It is approved by the Food and Drug Administration (FDA) as a safe antimicrobial additive and preservative in food and care. Oftasecur ophthalmic solution and Oftasecur ocular spray contain:

• alteration and direct damage of the structure of the cytoplasmic mem brane of bacteria and consequently the inhibition of its main functions

Bibliografia:

OFTASECUR: SECURITY IN OPHTHALMOLOGY

Oftasecur ophthalmic solution and Oftasecur ocular spray have a paten ted formulation, that can help control ling the bacterial load and reduce the risk of occurrence of infections even in ocular surgery1,2

(1) Vagge A, Ferro Desideri L, Car nevali A, Del Noce C, Campo sampiero D, Agrusta M, Ponzin D, Pellegrini M,Vaccaro S, Nicolò M, ScorciaV,TraversoCE,GiannaccareG. Efficacy of a New Commercial Ocu lar Spray Containing Oftasecur Ci trus Extract for Reducing Microbial Load in the Conjunctiva of Patien ts Receiving Intravitreal Injections. Ophthalmol Ther. 2021 Sep 8. doi: 10.1007/s40123-021-00384-9

(1) Mencucci R, Ghelardi E, Ce landroni F, Mazzantini C, Vec chione A, Pellegrini-Giampie tro D E, Favuzza E, Landucci E. Antiseptics and the Ocular Surfa ce: In Vitro Antimicrobial Activity and Effects on Conjunctival and Corneal Epithelial Cells of a New Liposomal Ocular Spray Contai ning Biosecur ® Citrus Extract PMID: 35284982 PMCID: PMC9114213 DOI: 10.1007/ s40123-022-00492-0

thanks to exclusive technologies designed to improve their lives. Ergonomic t and large support surface. Brand "shortenablenewandinterchangeable"templetips!

#kidspremium A strong and durable XINOX® core with the soft outer touch and gentle touch of ToEVO®request the LOOKKINO TEST PACK write to ciao@lookocchiali.it

LOOKKINO frames child-friendly, those of youngest children,

are

the

conceived with strong ethical and functional values, designed and manufactured exclusively in Italy following precise rules of ergonomic use. They adapt to the physiognomy of faces, even

Nanex multiSert +™ is the world’s smallest injection system for hydrophobic preloaded C-loop intraocular lens and designed for incisions up to 1.8 mm. With its innovative design it allows the surgeon to perform cataract surgery with sub-2.2 mm incisions without compromise.

NANEX multiSert+TM

HOYA SURGICAL OPTICS: INNOVATIVE SOLUTIONS DEDICATED TO CATARACT SURGERY

38 Industry news

Among our flagship products, we present the two novelties Vivinex™ Impress™ and Vivinex™ Gemetric™ in addition to the well-known NANEX multiSert +™.

Flavio HOYADirectorBusinessLongatoDevelopmentEMEASurgicalOptics

HOYA Surgical Optics, whose products are used by eye surgeons around the world, is a world leader in the development of preloaded intraocular lenses to meet different surgical needs and methods. Always at the forefront with a range of products with unique features, HOYA Surgical Optics works closely with surgeons and patients to better

understand their needs. With over 10 million intraocular lenses sold worldwide, HOYA Surgical Optics has won the trust of surgeons thanks to its quality and dedication.

Thanks to its active oxygen surface treatment system, the material of which Nanex multiSert +™ is made demonstrates strong capsular adhesion and a significant reduction in PCO compared to an untreated surface. Nanex multiSert +™ is a 4-in-1 preloaded system that provides several options available to the surgeon: push injection and screw injection in a single device, designed to allow fluid release of the lens compared to other injection systems and to mitigate the possibility of abrupt release.

Sight as a primary interest for HOYA Surgical Optics

At HOYA Surgical Optics, we empower eye surgeons to improve the vision and quality of life of millions of people with cataracts, to help them celebrate life, visually. Our products are known for offering safety, relia bility and easiness of use. Quality, trust, dedication and attention to detail are deeply rooted in our Japane se heritage and in the HOYA brand.

Among the benefits of this innovative trifocal IOL we could report the material of which it is composed, acrylic, hydrophobic and glistening free, the proprietary aspheric design of the optics, which greatly improves image quality.

In the presence of decentration, coma is less in HOYA Vivinex™ Gemetric™ than in leading competitor IOLs for a pupil diameter of 4.0mm. It is also possible to precisely calculate the power of the cylinder with the help of the new HOYA Toric Calculator 4.3.

uses the preloaded multiSert +™ 4-in-1 system which provides several options available to the surgeon: push injection and screw injection in a single device, designed to allow fluid release of the lens compared to other injection systems and to mitigate the possibility of abrupt release.

The innovative Vivinex™ Gemetric™ hydrophobic glistening-free trifocal lens preloaded into the proven multiSert™ injector, offers unmatched patient vision and exceptional rotational stability. Equipped with proprietary technology, it is available in two versions (Gemetric™ and Gemetric™ Plus) to adapt to the visual needs of different patients and is also available in a toric version.

Vivinex™ Impress™

HOYA Surgical Optics introduces Vivinex Impress™ the new preloaded “Enhanced Monofocal” intraocular lens. Vivinex Impress™ is a monofocal lens with an extended depth of focus to allow a better vision at intermediate Vivinexdistance.Impress™

As our claim defines, we are focused on the individual needs of the surgeon and patient. At the same time, we have a global reach by engaging in the distribution of our preloaded lenses throughout the world.

Vivinex™ Gemetric™

fotoselettive a protezione controllata L’uso di lenti fotoselettive FLOOX® oltre ad essere protettive nei confronti delle radiazioni UV, eliminando e/o riducendo le basse lunghezze d’onda del visibile (radiazione blu), riducono sia la diffusione davanti alla retina che il velo di distanza, ottimizzando il contrasto. STANDARD POLARIZZATE FLOOX 450 FLOOX 450 FASHION FLOOX 450 FLOOX 450 FLOOX 480 FLOOX 480 FASHION FLOOX 450 FASHION FLOOX 480 FLOOX 500 FLOOX 500 FASHION FLOOX 480 FLOOX 500 FLOOX 520 FLOOX 480 FASHION FLOOX 540 FLOOX 500 INDICATE PER LE PATOLOGIE QUALI: • CONGIUNTIVITI • CHERATITI CON ELEVATA FOTOFOBIA • CATARATTA • DISTROFIE CORNEALI • EDEMA CORNEALE • POST VITRECTOMIA RETINOPATIA DIABETICA • DEGENERAZIONE MACULARE • GLAUCOMA • FARMACI FOTO SENSIBILIZZANTI • TERAPIA FOTODINAMICA LENTI DISPONIBILI NEI MATERIALI: www.flooxlenses.it

LENTI

ITALIANE

LENTI

All LOOKKINO frames are also traceable because they’re deve loped, designed and produced in Italy by LOOK-made in Italia.

Super lightweight and soft to the touch – the new LOOKKINO NIL KIDS series 3880 eyewear, specifi cally for kids 4 years and up, focus on their joy and vitality.

NIL KIDS, NEW LOOKKINO STYLES DRESS CHILDREN’S EYES IN LIGHTWEIGHT NIL

42 Industry news

In order to produce ultralight eyewear that hold up under the active use of small children, the front of the new styles is made of NIL (Natural Injection Light), a sta te-of-the-art technopolymer who se particles are molded into the most unique and balanced shapes. The innovative ingenuity of this product lies in the temples, where the internal part is in EVO (EVO lution polymer), derived from the development of its RUBBER EVO “big brothers”. Especially suited to children’s frames, EVO is soft to the touch, so it also ensures grea ter wearing comfort during active use without sacrificing the huge cool-factor of iconic NIL products. By combining the two materials

– both 100% non-toxic and hypo allergenic – NIL KIDS eyewear are the perfect answer to children’s needs for quality, safety and ima ge. Thanks to exclusive technolo gies, the new styles adapt to smal ler faces, based on designs meant to improve kids lives from the time they’re infants. In the quest to de liver a superior product, each style is developed in collaboration with ophthalmologists, specialists and parents.TheLOOKKINO production cycle maintains excellent standards throughout its entire process. This translates to strict control of each production phase, in com pliance with specific provisions for eyewear applicable to medi cal devices.

I tuoi occhi si muovono più di 250.000 volte al giorno. Vivi in ogni momento l’esperienza di una visione nitida mai provata prima con B.I.G. EXACT®, le lenti biometriche di Rodenstock create esattamente per te. UNA VISIONE PIÙ NITIDA

250.000 VOLTE X

ESSILOR®: CHILDREN’S VISUAL HEALTH IS…ON THE FIRST ROW

Finally, the work in progress section “where to go” lets paren ts find and contact ophthalmo logists who joined the project to book for an appointment or ask for a consultation.

2021 has been a starting point for the Guardiamo Lontano! project. The 4000 classroom already en rolled will continue their journey throughout the academic year that has just began, thanks to new initiatives, materials and wor kshops. In addition, new schools are selected and involved in the project, so to be close to even more teachers and families.

1Journal of Behavioral Optometry. Chil dren’s Vision Care in the 21st Century & Its Impact on Education, Literacy, Social Issues & the Workplace: A Call to Action

THE PROJECT

80% of all learning occurs through vision, an inefficient vision could therefore limit the scholastic suc cess of students (1). A 2020 Sight Defence Committee survey reve als that 20% of parents of children between 4 and 10 years have ne ver took their child for an eye exa mination, in most cases this is mo tivated by the fact that the child “sees well”.

Reading, writing, looking at the blackboard and using the com puter are the visual activities that daily engage children and Theirteenagers.eyesare constantly stressed, at school as during the game.

44 Industry news

Teachers are provided with 25hour training program divided into 6 modules and accredited by the Ministry of Education: the goal is to deal with issues such as the relationship between sight and learning, research on myopia and its progression and the role of the teacher and the school in the prevention of refractive defects. The training also provides sugge stions to facilitate the dialogue between the short-sighted stu dent and his family.

The involved classroom received an informative and educational kit comprehensive of a poster contai ning 10 good visual habits: thus, students have a steady reminder of the behaviours necessary to preserve visual health, such as maintaining correct reading di stance and illumination, the 2020-20 rule and the need to submit to periodic eye examination.

Essilor ® is a trademark of Essilor International

Find out more on the website (only in italian language) scan the qr code

The Guardiamo Lontano! project enters schools with the aim of exploring the theme of visual he alth, raising awareness on the re cognition of the first symptoms of myopia and driving parents to the ophthalmologists in their territory.

In 2021, thanks to the project Guardiamo Lontano!, Essilor has hired over 4000 primary and se condary classes throughout the Thecountry.project has involved teachers, students and families through an exciting and complete educatio nal path.

To inform and raise awareness in families and children, the dedi cated website www.guardiamo lontano.it has been realized. A section called “the world of the eye” explain to the parents what ocular health is, refractive defects and corrective solutions. Throu gh tests and play that reproduce daily activities, kids have moreo ver the chance to learn actively what the correct visual habits are, regaining and strengthening the notions received at school.

Redazione: Strada 4 Milano Fiori, Palazzo Q7 – 20089 Rozzano (MI) Sede operativa: FGE srl − Regione Rivelle 7/F − 14050 Moasca (AT) Tel. 0141 1706694 – Fax 0141 856013 e-mail: info@fgeditore.it − www.fgeditore.it HISTORY OF REFRACTIVE SURGERYHISTORY AND EVOLUTION OF MODERN CATARACT SURGERY Lucio Buratto, Richard Packard

Lucio Buratto, Richard Packard

To order: www.fgeditore.it Stand 2W01 MiCo North - Level +1 Hall B

References: 1. Data on file, HOYA Medical Singapore Pte. Ltd, 2018. 2. Matsushima H, et al. Active oxygen processing for acrylic intraocular lenses to prevent posterior capsule opacification. J Cataract Refract Surg. 2006; 32:1035-1040; (PCO study in rabbit eye). 3. Comparative porcine eye study: study result. David J Apple International Laboratory for Ocular Pathology, University Hospital Heidelberg. Report on file. 4. Data on file, HOYA Medical Singapore Pte. Ltd, 2019. 5. Data on file, HOYA Medical Singapore Pte. Ltd, 2019.

Sistema precaricato con 4 possibilità di impianto: iniezione a stantuffo o a vite, beccuccio in 2 modalità di elongazione in funzione della preferenza del chirurgo e del singolo caso chirurgico.

Iniettore ProtezionemultiSert+TMdell'incisione:3

Il sistema precaricato NanexTM multiSert+TM elimina i compromessi tradizionalmente associati alla chirurgia della cataratta con incisioni sub 2,2 mm DELLA CATARATTA SENZA COMPROMESSI

IOL NanexTM

Collaudato materiale acrilico idrofobo: più di 10 milioni di lenti impiantate nel Mondo in 15 anni 1

Signiﬁcativa riduzione della PCO: processo di produzione brevettato che include un esclusivo trattamento all'ossigeno attivo della superﬁcie posteriore della lente.2

NanexTM multiSert+TM CHIRURGIA MICROINCISIONALE

Impareggiabile prevedibilità e controllo di iniezione: un rilascio della lente controllato grazie al sistema di iniezione precaricato unico e brevettato da HOYA.5

il più piccolo iniettore disponibile per un sistema di lente intraoculare C Loop idrofoba precaricata.4

FROM THE SURFACE INTO THE DEEP OF THE PROBLEM 2 MONTHS IN-USE SHELF LIFE COMPATIBLE WITH CONTACT LENS USE SELF-PRESERVED INTERNATIONALFORMULA,PATENT MULTIPLE ACTION COMBINATION THAT SIMPLIFIES THE MANAGEMENT OF DRY EYE PATIENTS