CAKE Issue 19: The Anterior Segment Innovation Issue

From IOL advancements to AI, the anterior segment continues to push the boundaries in vision care

Are the Easy Wins Long Gone?

In terms of anterior segment surgery, are we at an innovation impasse at the moment? Haven’t all the low-hanging fruits been picked by now?

Dear Readers,

Remember when PRK, LASEK and LASIK were new, elective and akin to a miracle to a market that was essentially fresh to the field? Those were the good days…

While I wouldn’t call it the “wild west” back in the day, there was definitely a pioneering spirit and certainly an intense period of nomogram forming and procedure finessing. This quickly led us to a much better understanding of the cornea – and particularly its biomechanics – as well as a clearer grasp of the excimer laser’s capabilities and what was and wasn’t possible.

But as the technique became more widely adopted, the volumes rose, the margins dropped, the outcomes got better and better (albeit with diminishing returns) and the safety issues became rarer and rarer.

Today, an experienced surgeon with the best equipment can deliver some exquisite post-surgical optical outcomes. But I sometimes wonder if many patients will ever appreciate that. If a run-of-the-mill 5 D myope with no astigmatism went down to the local pile ‘em high, sell ‘em cheap LASIK center with a 10-year-old laser, they’d still probably be delighted with the results — and never know what they’re missing out on. Bullseye’s Jim Bowen would never have the opportunity to tell them, “Look at what you could’ve won.”

With cataract surgery, can we also say that most of the battlefield has already been conquered? Unless the holy grail of a truly universal and amazing accommodative IOL comes along, are we simply left finessing the optics of PMMA or silicone IOLs, preloading them into injectors, making phaco machines a bit more surgeon-friendly – and making the whole shebang a fair bit more efficient, to boot?

If you haven’t heard of Betteridge’s law, then let me enlighten you: It pertains to sensationalism in journalism, which reads, “Any headline that ends in a question mark can be answered by the word no.” I’ve asked three questions in the prose above. And I would argue “no” to almost all of them.

Just because a procedure is widely performed and isn’t as lucrative as it used to be doesn’t mean that small improvements are almost worthless. Small improvements add up — and as the number of procedures scales upward, so do the benefits.

So, whether the advance is a small improvement to corneal biomechanics assessments that once a year flags an additional patient that might be unsuitable for refractive surgery, that’s a win for everyone.

If the biometers all talk to the computer that does the IOL calculations, which saves a few minutes and avoids manual transcription errors, that’s a win.

If the phaco machine deals with

occlusion breaks that’s a little bit better than before and makes the procedure a smidgen safer than before, that’s a win.

When that multifocal IOL gives patients with large pupils fewer halos and glare than the older one you used to offer, you’re still going to manage patients’ expectations — but overdeliver a little bit more on them. It all adds up.

July 2023 represents my tenth year working in the field of ophthalmology, and I’ve seen some developments that were heralded as game-changers come to the fore over this period — MIGS being one great example.

It’s all white-hot excitement, to begin with, and much like refractive surgery with the excimer laser a few decades earlier, the field matures, and the fervor starts to die down. But actually, as we see time after time, like a fine wine or hard cheese, it’s really when it matures that we start to see the best of things happen.

Am I comparing refractive surgeons to artisan hard cheesemakers? Maybe a little. It’s at this point when the true — for want of a better word in this heavily data-driven field — “artists” really show what can be done. At this point, we have surgeons that have the skills and experience to truly excel, and an increasing repertoire of tools to achieve these outcomes.

Fortunately, we’re in a field that shares best practices, so anyone who wants to learn what needs to be done to achieve that can do so quite easily. Across all of the anterior segment — and beyond — there’s no better time to be a patient.

James Betteridge might be clearing his throat at the moment, but can we all agree (if pay/conditions and work-life balance are taken out of the equation) that there’s no better time to be an anterior segment surgeon?

Cheers, Mark Hillen, PhD Director of Communications

ELZA Institute, Zurich, Switzerland Editor-At-Large | CAKE

chelvin@gmail.com

george.beiko@sympatico.ca

boris.malyugin@gmail.com

Society Friends

jodmehta@gmail.com

wtrattler@gmail.com

Dr. Harvey S. Uy University of the Philippines; Peregrine Eye and Laser Institute, Manila, Philippines harveyuy@gmail.com

Dr. Boris Malyugin S. Fyodorov Eye Microsurgery Institution Moscow, Russia

Dr. Chelvin Sng Chelvin Sng Eye Centre, Mount Elizabeth Novena Hospital, Singapore

Prof. Jodhbir S. Mehta Singapore Eye Research Institute (SERI); Singapore National Eye Centre (SNEC) Singapore

Dr. George H.H. Beiko University of Toronto; McMaster University, Ontario, Canada

Dr. William B. Trattler Center For Excellence In Eye Care Miami, Florida, USA

Arunodaya Charitable Trust (ACT)

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Ahead of the Curve

In Egypt, copper needles or probes were found in 1900 in the tomb of King Khasekhemwy at Abydos. And in ancient Babylon, the code of Hammurabi specified the charges and penalties for making an incision that heals a man’s eye.1

Indeed, the history of cataract surgery is long and august, but the developments we are experiencing right now are unparalleled compared to any previous era.

by Andrew Sweeney

Experts reveal exciting innovations in the ever-evolving landscape of cataract surgery

Cataract surgery is enjoying remarkable advancements in the field of ophthalmology. We delve into the perspectives of two leading experts in the industry, who shared the cuttingedge innovations they utilize in their practice, their most anticipated developments, and their visions for the future.

Ophthalmology has come a long way. And when it comes to the anterior segment and cataracts in particular, the progress has been nothing short of breakneck — especially considering that for much of human history,

cataracts were known but poorly treated.

Some scholars have hinted that cataract surgery might have first taken place during the Bronze Age, but none of the evidence is definitive.

Thankfully, we don’t have to consult ancient hieroglyphic inscriptions to scry the latest in cataract surgery. At CAKE Magazine, we have our very own squad of oracles to help out.

Redefining phacoemulsification performance

Dr. William Trattler, a cataract, refractive and corneal surgeon enjoys any opportunity to take advantage of the latest technology medical science has to offer. And he was happy to share his experience with us.

He was particularly keen to point out the considerable promise of a device made by Car Zeiss

Meditec (ZEISS), the German manufacturing giant headquartered in Jena. The QUATERA®700 is a phacoemulsification system that measures and simultaneously controls both infusion and aspiration volumes during cataract surgery. It includes automated ultrasound power on demand, can be easily integrated into the other devices in the ZEISS portfolio, and, as the company states, “provides maximum efficacy during surgical procedures.”

“The QUATERA 700 does seem to be very promising for cataract surgery. It’s a device designed for phacoemulsification, one that has new fluidics, which helps provide a very stable chamber. We’ve had several advances in this area recently, but the QUATERA 700 appears to be another step up,” Dr. Trattler shared.

He enthused that he has been very fortunate to work with a number of great technologies, “and the QUATERA 700 is something that makes me very excited,” he said. “It works using a four-pump mechanism and it’s perfect at maintaining pressure throughout the surgical process, no matter how much energy or vacuum you’re using. As such, it provides a safe and efficient environment in which to perform cataract surgery,” he added.

Lenses are lit

Devices such as ZEISS’ highlight the impact of technology on cataract surgery. And that’s something that can be seen across the board, particularly in the realm of lenses.

Dr. Chelvin Sng is a leading cataract specialist and the medical director at the Chelvin Sng Eye Centre in Singapore. And when we asked her

about the new tech developments that excited her the most, her answer was clear: Lenses. Her excitement stems not only from her scientific interest but also from her practical experience in the field.

“Cataract surgery has evolved to become ‘refractive surgery,’ as patients expect not only to have a good clinical outcome but also good unaided distance and near vision,” Dr. Sng shared. “Cataract surgeons have to be wellversed in new technologies, such as new intraocular lens (IOL) implants and artificial intelligence-guided biometry, to improve their surgical and refractive outcomes. Preoperative patient counseling has become increasingly important so that the patient’s expectations are aligned with their choice of intraocular lens,” Dr. Sng explained.

She shared that she uses extendeddepth-of-focus (EDoF) IOLs in her practice. “These allow my patients to enjoy excellent distance and intermediate vision without compromising their contrast or night vision as much as conventional multifocal intraocular lenses do. Recently, more variations in EDoF lens designs have allowed a wider range of patients to enjoy a greater degree of independence from spectacles compared with monofocal lenses,” she continued.

Dr. Trattler was also keen to point out how lens technology has improved cataract surgery. In his case, he was focused more on the importance of lens placement, pointing to the Zepto IOL Positioning System™.

Created by Centricity Vision, Inc. (California, USA), the Zepto System is described by its maker as the world’s

“first and only device that creates an instantaneous capsulotomy for precise, 360-degree overlap and improved outcomes.” Dr. Trattler views it as an intuitive, easy-to-use device that can ensure considerable efficacy during the surgical process, especially for patients who represent more difficult cases.

“A lot of research has been focused on trying to automate the capsulotomy step, which can be difficult in certain patients. For example, if you have a patient with corneal scars, it’s going to be tougher to view their cataracts. Patients who have undergone radial keratotomy (RK) will also be more difficult to treat because the laser has to go through the cornea, and the RK scars can interact and affect the laser,” Dr. Trattler explained.

“This is why I’m excited about the Zepto device, as it goes directly inside the eye. Even if the patient has small pupils, you can use Zepto as an expansion device that will help make the pupils larger. I’m really looking forward to having access to that technology on a routine basis,” he shared.

The robots are coming

Of course, we would be remiss if we didn’t consider not only the current developments in cataract surgery that are making leading clinicians excited but also what innovations are on the horizon.

For Dr. Sng, the way ahead is clear — thanks to advancements in imaging technology in the anterior segment and ophthalmology as a whole. Improvements to widely used technologies such as optical coherence tomography (OCT) will provide numerous benefits, especially as they are already commonly used around the world.

“I am most excited about innovations to improve the accuracy of predicting refractive outcomes for our patients. These include the new biometry techniques using total keratometry values and OCT-based imaging. Such innovations will enable us to achieve better refractive outcomes for our patients who want the best possible unaided vision,” Dr. Sng noted.

“This is particularly important to

“The QUATERA 700 does seem to be very promising for cataract surgery. It’s a device designed for phacoemulsification, one that has new fluidics, which helps provide a very stable chamber. We’ve had several advances in this area recently, but the QUATERA 700 appears to be another step up.”

Dr. William Trattler

me as it will help me maintain my clinical gold standards for cataracts. These are ensuring accurate biometry, which may require repeated measurements, and detailed preoperative assessment to detect subtle or early ocular pathology, including OCT of the macula. Specular microscopy is also important to detect early Fuchs endothelial dystrophy or low endothelial cell count,” she continued.

As for Dr. Trattler, he’s looking forward to a subject that will always pique everyone’s interest: Robots. While robotics in cataract surgery may be in its infancy, it’s not difficult to imagine how quickly AI-driven technology will become more common in the operating room — and anterior segment ophthalmology is no exception.

In particular, Dr. Trattler pointed to the work of Horizon Surgical Systems (California, USA) as promising. This company is a newcomer to the ophthalmology industry, having only been registered last year. But it is already generating considerable buzz.

website describes its current operations as being in ‘stealth mode.’ Luckily, Dr. Trattler was able to give us a glimpse into their work.

“Horizon Surgical Systems is developing robotic cataract surgery, which may sound far fetched. But consider how only a few years ago, driverless cars were thought to be impossible. Surgery will still require the supervision of an in-house ophthalmologist, just like many laser

Reference

Contributing Doctors

Dr. William B. Trattler is a refractive, corneal and cataract eye surgeon at the Center For Excellence In Eye Care in Miami, Florida, USA. He performs a wide variety of cataract and refractive surgeries, including PRK; all laser LASIK; no injection sutureless cataract surgery; as well as laser cataract surgery. He has been an investigator for next generation technologies (like the Tetraflex accommodating intraocular lens) and procedures like corneal collagen crosslinking (CXL). His involvement in the FDA-approval study for CXL led to its approval in 2016. In addition to his private practice, Dr. Trattler is on the Volunteer Faculty at the Florida International University Wertheim College of Medicine, as well as the University of Miami’s Bascom Palmer Eye Institute. He is board certified by the American Board of Ophthalmology and has been an author of several articles and abstracts. In 2016, Dr. Trattler received the Catalyst Award in Advancing Diversity in Leadership from the Ophthalmic World Leaders (OWL), an association of interdisciplinary ophthalmic professionals dedicated to driving innovation and patient care by advancing diversity in leadership.

wtrattler@gmail.com

techniques today, but this will allow it to become automated,” Dr. Trattler shared.

“This technology may not appear for five years, for example, but I believe Horizon is looking to start human trials in the next year or two. If they’re successful, cataract surgery could become all the more precise, with improved safety and efficacy,” he concluded.

Its mission is to revolutionize microsurgery by using advanced robotics along with AI. However, rather mysteriously, Horizon’s

Dr. Chelvin Sng , BA, MBBChir, MA(Cambridge), MRCSEd, FRCSEd, MMed, FAMS, is the medical director of Chelvin Sng Eye Centre at Mount Elizabeth Novena Hospital. She is also an adjunct associate professor at the National University of Singapore (NUS), a visiting consultant at the National University Hospital, Singapore, and an adjunct clinician investigator at the Singapore Eye Research Institute (SERI). A pioneer of minimally invasive glaucoma surgery (MIGS), Dr. Sng was the first surgeon in Asia to perform XEN, InnFocus Microshunt, and iStent Inject implantation. A coauthor of an open-access book on “Minimally Invasive Glaucoma Surgery”, Dr. Sng has also written several book chapters and publications in various international journals. Proficient in conventional glaucoma surgery and trained in complex cataract surgery, Dr. Sng co-invented a new glaucoma drainage device (currently known as the “Paul Glaucoma Implant”), which was patented in 2015. Dr. Sng has received multiple international awards, including the Asia Pacific Glaucoma Society Young Investigator Award and the Asia Pacific Academy of Ophthalmology Achievement Award. When not working, Dr. Sng can be found volunteering in medical missions in India and across Southeast Asia.

chelvin@gmail.com

1. Leffler CT, Klebanov A, Samara WA, Grzybowski A. The History of Cataract Surgery: From Couching to Phaecomulsification. Ann Transl Med. 2020;8(22):1551.

“I am most excited about innovations to improve the accuracy of predicting refractive outcomes for our patients. These include the new biometry techniques using total keratometry values and OCT-based imaging. Such innovations will enable us to achieve better refractive outcomes for our patients who want the best possible unaided vision,”

Dr. Chelvin Sng

Coping with Complications

From common to complex, cataract surgery complications can occur despite advancements in surgical technology by Hazlin Hassan

To enhance patient safety and outcomes during cataract surgery, surgeons and patients need to be prepared and understand potential complications. Prompt action is essential to prevent irreversible vision loss in cases of endophthalmitis, with intravitreal antibiotics and vitrectomy being potential treatments. According to a recent report*, surgeon experience, preoperative evaluation and postoperative care significantly lower complication rates.

Posterior capsule rupture (PCR) is one of the most significant complications that can occur during cataract surgery, which can result in vitreous loss. Serious morbidities, including retinal detachment, cystoid macular edema, uveitis, glaucoma and dislocated intraocular lenses (IOLs) are associated with PCR. Prompt surgical intervention and appropriate management are necessary to prevent any further complications.

Although rare, endophthalmitis is a serious complication that involves inflammation and infection inside the eye. It can cause vision loss and requires immediate treatment with intravitreal antibiotics. Strict adherence to sterile techniques, preoperative prophylactic antibiotics and proper wound care can help reduce the risk of this complication.

Cataract surgery can also occasionally lead to an increase in eye pressure, which can result in glaucoma. This can be managed with medications or additional procedures to control intraocular pressure (IOP). While these complications can occur,

the rate of occurrence is relatively low, and most cataract surgeries are successful without complications.

From common complications…

“Cataract surgery is the most common surgery performed by ophthalmologists,” said Prof. MaeLynn Catherine Bastion, professor of ophthalmology (vitreoretina) and senior consultant ophthalmologist at the National University of Malaysia (UKM). She noted that an increase in surgical experience is associated with a gradual decline in the rate of complications.*

The most common complication of cataract surgery is blurred vision, which is due to the temporary swelling of the cornea and should clear up by the next day, she explained.

A relatively common complication is posterior capsular opacification, which occurs when the capsule into which the lens is inserted becomes thickened due to a scarring reaction. This condition can be treated in the eye clinic with a low-risk laser procedure, which is painless and takes just five minutes to perform in a cooperative patient. For pain relief,

only eye drops are needed.

Another common complication is redness of the eye, which may be due to local anesthesia. “This clears up without specific treatment in one to two weeks. Eye redness and itching may also be a sign of an allergy to eye drop constituents or dry eye that tends to worsen after any eye surgery,” she continued. Both of these complications can be managed by discontinuing the use of the current eye drops and switching to a more well-tolerated type, or by using lubricating eye drops.

… To rare and complex cases

“Other complications are fortunately much rarer. These include a tear or break in the capsule, which the surgeon immediately treats by performing a vitrectomy. According to one published report,* this occurs in only 0.99% of all surgeries,” added Prof. Bastion.

“Most often, a vitrectomy is required (in cases of PCR), and prompt intervention is crucial to preserve visual outcomes,” shared Dr. Noor Aniah Azmi, medical director and consultant refractive surgeon at the Ikonik Eye Specialist and General Health Centre in Kuala Lumpur, Malaysia. Dr. Azmi once encountered a PCR that resulted in a dropped nucleus.

“As the vitreoretinal surgeon was retrieving the dropped nucleus, a retinal tear occurred. It was a long surgery, but the patient ended up with good post-op vision eventually,” she continued. “This showcases the importance of expertise and comprehensive management in complex cases.”

One of the many challenges cataract surgeons sometimes face is weak or missing zonules. This is when the lens becomes weak, causing it to wobble during surgery, said Prof. Bastion. In most cases, zonulysis is detected during pre-surgery examination by the doctor, but there is a possibility of it being easily missed.

“During surgery, if there is less than 180 degrees of zonular weakness, then the surgeon may implant a capsular tension ring to support the capsule. Then good outcomes are

possible,” Prof. Bastion chimed in.

Bleeding during cataract surgery is rare. However, some are at risk of experiencing a devastating type of bleeding from large vessels in the choroid. These vessels can bleed into the space above the choroid very suddenly during surgery, resulting in a blood-filled eye.

The surgeon should immediately close the operation wound and refer the patient to a vitreoretinal surgeon, who may be able to salvage the situation if the retina can be reattached, said Prof. Bastion.

Another less common complication that can occur after surgery is an unexpected discrepancy in the calculated power. This may occur despite careful lens calculation before the operation. This error is most common after refractive surgery and in patients with high eye power. In these cases, the patient may still need to wear glasses to correct the power difference. They could also exchange the lens, which is a risky procedure, or undergo further refractive surgery if not contraindicated.

Retinal detachment is another rare complication, which needs to be repaired by a retinal surgeon. The outcomes can be favorable, provided the macula is not involved or is quickly reattached.

According to Prof. Bastion, while endophthalmitis is a serious complication, it occurs very rarely at a rate of 0.01% due to effective prevention measures, including intravitreal antibiotics.

Time is of the essence when it comes to

prevention

Prevention includes paying attention to eye hygiene in the weeks leading up to surgery, as well as ensuring diseases that reduce immunity, such as diabetes, are well controlled before surgery. However, once the infection has occurred, time is of the essence. It usually develops within the first five days of the operation. Symptoms include pain, blurred vision with floaters, swelling, and increasing eye redness — which warrant an immediate visit to the

emergency department or the eye clinic. Early intervention can save a patient’s vision. Intravitreal antibiotics are prescribed, but if vision drops further, then a vitrectomy is performed.

Dr. Azmi agrees that swift and decisive action is essential to prevent irreversible vision loss in cases of endophthalmitis. “Prompt administration of intravitreal antibiotics is crucial. A vitrectomy may be necessary to effectively clear the infection and safeguard the vision,” she said.

“Surgeon experience, comprehensive preoperative evaluation, and postoperative care significantly influence the complication rates. By understanding the potential complications and taking appropriate measures, we can enhance patient safety and deliver positive outcomes for the patients,” concluded Dr. Azmi.

Reference

* Aaronson A, Viljanen A, Kanclerz P, Grzybowski A, Tuuminen R. Cataract complications study: an analysis of adverse effects among 14,520 eyes in relation to surgical experience. Ann Transl Med. 2020;8(22):1541.

Contributing Doctors

Dr. Noor Aniah Azmi earned her MBBCh degree from Cairo University, Egypt, in 2010, and completed her Doctor of Ophthalmology postgraduate studies at the National University of Malaysia in 2018. She is a medical director and consultant refractive surgeon at the Ikonik Eye Specialist and General Health Centre in Kuala Lumpur, Malaysia. Before that, she was a medical lecturer at Universiti Putra Malaysia from 2018 to 2021. A resourceful mom to three girls, Dr. Azmi shares parenting life hacks on social media. On weekends, she volunteers to give talks on eye health to raise community awareness about eye diseases.

draniah@ikonik.com.my

Professor Dr. Mae-Lynn

Catherine Bastion graduated from the University of Sydney, Australia with MBBS (First Class Honours) in 1999. In 2003, she received a fellowship in ophthalmology from the Royal College of Surgeons of Glasgow. The following year, she received the Doctor of Ophthalmology postgraduate degree from the National University of Malaysia (UKM). During her postgraduate training, she has received both Best Presentation and Best Poster awards. In 2007, she completed her clinical fellowship in vitreoretinal surgery at The Eye Institute, Singapore. She currently heads the vitreoretinal services of the Department of Ophthalmology at UKM. In 2009 she became the head of the Department of Ophthalmology for which she served two terms. She was appointed UKM Professor of Ophthalmology (Vitreoretina) in 2014 and received the Academy of Medicine (AMM) Fellowship in 2015. She is the head of the Quality Unit of UKM Ophthalmology Department. She teaches undergraduate and postgraduate ophthalmology while maintaining a private practice at UKM Specialist Centre. She has trained five fellows in vitreoretinal surgery since 2010. She currently serves on the committees of the Malaysian Universities Conjoint Committee of Ophthalmology, College of Ophthalmologists of the AMM, and Malaysian Society of Ophthalmology. She was the founding chairperson of the UKM Ophthalmology Researchers’ Society and continues to serve as advisor. Her research interests are in vitreoretinal diseases and vitrectomy, vitreolysis, diabetic keratopathy and stem cell therapy. She has several on-going research grants with over 50 peer-reviewed publications. She has been invited to speak at the Asia Pacific Vitreoretinal Society Meetings (APVRS) in 2017 and 2019; and is a member of the APVRS and AsiaPacific Ocular Imaging Society. She also contributes as a reviewer for numerous journals and serves as editor for the Medicine and Health Journal as well as the Malaysian Journal of Ophthalmology.

maelynnbdr7@gmail.com

Rayner Reaches Milestone: 4 Million RayOne IOLs Now Implanted Worldwide

Known as a global leader in ophthalmic innovation — and for manufacturing the world’s first intraocular lens (IOL) — Rayner is celebrating the success of its RayOne IOL with 4 million implantations worldwide.

The RayOne EMV, an enhanced monofocal developed in partnership with Prof. Graham Barrett, is one of the IOLs in the RayOne line earning this distinction. It was implanted by long-standing Rayner supporter and advocate Dr. Nathan Radcliffe. Following this landmark event, he said: “Given the rapid growth of the RayOne platform and RayOne EMV in particular, I can see that we are just at the beginning of the success of this fantastic surgical option for cataract patients.”

The RayOne IOL was introduced in 2016 and has nine available optics: Monofocal, toric, enhanced monofocal, and trifocal options. All RayOne IOLS come complete with Rayner’s fully preloaded IOL system, featuring an intuitive twostep injector and a 1.65 mm nozzle diameter.

Dr. Radcliffe continued: “As a surgeon, it has been a pleasure to bring RayOne technology to my patients and to my surgery center. We have all been extremely pleased with the experience and outcomes, and knowing that my peers and I have now implanted 4 million RayOne lenses confirms that I am not alone in recognizing the value of this fantastic IOL technology.”

This milestone closely follows

another accomplishment: Surgeons have implanted 10 million IOLs made from Rayacryl, Rayner’s hydrophilic material renowned for its glistening-free properties and the foundation for both legacy and newer RayOne IOLs.

These milestones showcase Rayner’s dedication to spearheading breakthrough technologies. With a robust pipeline of research and development projects, the company is wellpositioned to introduce additional groundbreaking IOLs to advance eye care in the coming years.

For more information on Rayner IOLs, go to rayner.com/en/iol/ overview.

A Helping Hand for MIGS Surgeons

Can the OCULUS GONIO ready® help surgeons stay ahead of the curve?

by Matt Herman

An ever-growing roster of MIGS devices is pushing outcomes in glaucoma patients to previously-unimaginable heights. But progress comes with a price. As devices get smaller and procedures more delicate, the onus is on surgeons to keep up with an increasingly steep learning curve. The new GONIO ready® (OCULUS Optikgeräte GmbH, Wetzlar, Germany) claims to help surgeons beat the MIGS heat with a slew of technical innovations, and MIGS expert Prof. Fritz Hengerer, chief physician at the Bürgerhospital Frankfurt Augenklinik, explained why that just might be the case.

The adage in skill-intensive endeavors has long been to blame the carpenter and not the tools. And in the high-stakes world of ophthalmic surgery, glaucoma procedures — and specifically MIGS, are about as skillintensive as it gets. Small devices, delicate anatomical structures and maneuvers that demand intense, one-handed fine motor skills are all in the cards for MIGS surgeons. And all this with patients’ sight at stake makes for a daunting task.

Despite the aforementioned carpenter aphorism, OCULUS believes that it has made a tool that can literally lend MIGS practitioners a hand. The GONIO ready® is an intraoperative gonioscopy lens with an innovative pressure-sensitive design that allows surgeons to keep both hands free during MIGS operations. The device is already drawing rave reviews from some of the best in the glaucoma subspecialty, including Prof. Ike Ahmed. And in a recent video review of the GONIO ready®, Prof. Hengerer, a long-time MIGS maestro, added his voice to the chorus.

Flexing its muscles

At the heart of the GONIO ready® is the device’s patented Flex System, which, when combined with an adjustable height mechanism, allows the gonioscopy lens to float securely on top of the eye without being held in place by the surgeon.

In a MIGS operating room, surgeons know that everything is in perpetual motion. From the patient’s head to the gonioscopy lens and the eye itself, the resultant microadjustments that must be constantly made by the surgeon are a major reason for the high skill cap of these procedures. And minimizing these is what the GONIO ready® is all about.

Prof. Hengerer acknowledged the massive impact this has had on his own surgeries. “The Flex System is able to respond a little bit to eye movements, and is able to absorb pressure and some of the small movements of the patient’s head during the procedure,” he noted. “[This] provides you, as a surgeon, a stable situation without having to readjust the whole system.”

The power of position

The knock-on effects of this added stability are noteworthy in their own right. In the video review, Prof. Hengerer reflected on how critical this is in the game of inches that is MIGS surgery. “The lens position is a very important part of [MIGS] surgery… When the lens is tilted, you lose your view of the anterior chamber angle and you cannot see where you want to place your device,” he related.

This was another area that the GONIO ready® really made an impression on Prof. Hengerer. “With the GONIO ready®, it’s easy to get the lens into place and maintain its position during surgery,” he explained. And mise en place in the OR is a recipe for success, as the surgeon is then free to focus their attention on more important things.

Safety over all

When it comes to any ophthalmic surgery, results are quite literally in the eye of the beholder. Any procedure is done in the name of preserving vision, and MIGS is no exception. Glaucoma surgeons around the world are always on the hunt for novel techniques, procedures, and devices that can give them the edge in their mission to save sight. In Prof. Hengerer’s view, the Gonio ready® and its technical wizardry can provide such an edge.

Under it all, however, there is one concept underpinning the design philosophy of the GONIO ready®. The stability, the extra hand, the enhanced viewing angle — for OCULUS and its international sales manager Sascha Ruecker, these all fall under the umbrella of safety. And in the end, that’s what the GONIO ready® is all about, with the next generation of MIGS offering unprecedented opportunities — and challenges that will define the future of glaucoma surgery. “It’s all about one word,” commented Mr. Ruecker. “Safety… for the patient.”

Prof. Hengerer

All hands on deck

One such thing that surgeons equipped with the GONIO ready® can use this extra bandwidth on is what to do with their other hand. The GONIO ready®’s primary calling card is the device’s ability to free up the surgeon’s other hand by autonomously keeping the lens safely in place. And after its introduction, the minds of surgeons around the world are flush with the endless possibilities an extra hand can provide.

Prof. Hengerer shared one way that he makes use of another hand to push patient outcomes beyond. For him, it’s all about one word that appears time and time again. “When I first used it and thought about my left hand, I thought, better to have a side port incision 60-degrees available from the main port,” he shared. “That way I can use a second instrument to stabilize the eye — and the results are better.”

“[With the GONIO ready®] when I’m entering [the anterior chamber] with my devices, I have a brilliant view of the structures inside without touching the lens or the cornea. Then I can move on further viewing the chamber angle, focusing down with the microscope with this brilliant view of the structures I want to access,” concluded Prof. Hengerer.

OCULUS GONIO ready®

“The Flex System is able to respond a little bit to eye movements, and is able to absorb pressure and some of the small movements of the patient’s head during the procedure,” he noted. “[This] provides you, as a surgeon, a stable situation without having to readjust the whole system.”

From IOL advancements to AI, the anterior segment continues to push the boundaries in vision care

by April Ingram

Anterior segment is a thriving hub for progress and innovation, all dedicated to achieving better patient outcomes. Imaging advancements have enabled us detailed and comprehensive visualization of all the anatomic complexities of the eye, leading to more accurate diagnoses and effective treatments. The introduction of innovative IOLs demonstrates a paradigm shift in presbyopia compensation. Furthermore, the significant impact of AI in the anterior segment is expanding, with AI applications integrating with imaging modalities for enhanced detection and diagnosis of various eye conditions.

The evolution of treatment and refractive precision is highly impactful for patients. And as we know, patients nowadays do not hesitate to share their high expectations –and even more so when not met.

“Cataract and refractive surgery has always been a sub-specialty with numerous innovations and paradigm shifts in recent years. Besides the development of new intraocular lens (IOL) designs several times a year, IOL calculation and diagnostics are continuously evolving.”

The current available technology and treatments, as well as those in development, allow us to deliver the most effective solutions and achieve the most refined visual outcomes like never before.

The ever-evolving IOLs

Dr. Florian T. A. Kretz, the founder, owner, and lead surgeon at Precise Vision Augenärzte in Rheine, Germany, has witnessed firsthand the rapid evolution of anterior segment medicine.

“Cataract and refractive surgery has always been a sub-specialty with numerous innovations and paradigm shifts in recent years. Besides the development of new intraocular lens (IOL) designs several times a year, IOL calculation and diagnostics are continuously evolving,” shared Dr. Kretz.

Despite ongoing refinements to IOL design, undesirable dysphotopsias remain one of the most common complaints following cataract surgery. The latest developments in IOL design aim to address such issues, including unwanted bursts of light and halos in the central or mid-periphery of the visual field. These innovations involve shifting the optical power more anteriorly than posteriorly, rounding the anterior portion of the square edge, reducing the thickness of the square edge and leaving the edge unpolished.

Recent additions to the range of Johnson & Johnson’s extendeddepth-of-focus (EDoF) IOLs includes the Tecnis Symfony OptiBlue

and Tecnis Synergy, which have InteliLight technology. InteliLight’s latest advancements boast a violetlight filter that reduces halo, glare, and starburst effects. Additionally, the echelette design minimizes light scatter and halo intensity, while achromatic technology corrects chromatic aberration, allowing for better contrast in both bright and dark lighting conditions.

Sometimes, innovation can take the form of revisiting something familiar and exploring how it can be enhanced with the technology available today. While the focus has been on developing premium IOLs, with all the bells and whistles, looking back to the good old reliable monofocal — with its almost perfect uncorrected distance vision and minimal photic phenomena — may be worth another look.

“More of a trend or paradigm shift than innovation are the so-called monofocal plus IOLs. Just a decade ago, everyone was focusing on the compensation of corneal spherical aberration to increase contrast and achieve a sharper image, especially under scotopic pupil sizes. Now we find ourselves going back where we came from by using inverted spherical IOLs with a higher dioptric power in the center to increase the range of focus for additional presbyopia compensation,” Dr. Kretz explained.

The updated design is based on a continuous refractive optical surface that results in a progressive increase in power from the periphery to the center of the lens, delivering true intermediate vision.

The latest in imaging and diagnostic technology

Prof. Jodhbir Mehta is the executive director of the Singapore Eye Research Institute (SERI) and a distinguished professor in the Corneal & External Eye Disease and Refractive Department at the Singapore National Eye Centre (SNEC). He shared that among various advancements, imaging and diagnostic innovations have had the most significant impact on his clinical practice.

“The combination of the Corvis ST (OCULUS Optikgeräte, Wetzlar, Germany) and Pentacam (OCULUS Optikgeräte, Wetzlar, Germany) analysis providing a tomographic biomechanical index (TBI) score has made a huge difference in the preoperative assessment of refractive patients,” Prof. Mehta said. “The Pentacam provides tomographic data integrated with biomechanical data from the Corvis ST to improve sensitivity and specificity in the detection of patients who could possibly develop ectasia after refractive surgery,” he added. “This technology has also been extremely valuable in the assessment of patients with presumed unilateral keratoconus.”

“The combination of the Corvis ST (OCULUS Optikgeräte, Wetzlar, Germany) and Pentacam (OCULUS Optikgeräte, Wetzlar, Germany) analysis providing a tomographic biomechanical index (TBI) score has made a huge difference in the preoperative assessment of refractive patients.”

Dr. Kretz also acknowledges the impact of advancing technology in diagnostics.

“The biggest trend over the last five years is the implementation of optical coherence tomography (OCT) technology in anterior segment diagnostics,” he said.

— Dr. Florian T. A. Kretz

— Prof. Jodhbir Mehta

To demonstrate the progress of anterior segment OCT (ASOCT), early devices had a penetration depth of 7 mm and captured between 200 and 2000 scans per second. In comparison, current Fourier-domain OCT devices designed for anterior segment imaging offer scan depths of 2 to 3 mm and scan speeds ranging from 26K to 110K scans per second.

This large volume data capture allows for a 360-degree assessment of the anterior chamber angle and quantifiable parameters, such as iris volume and anterior chamber volume. Intraoperative ASOCT has also been integrated into femtosecond laser platforms and operating microscopes. This technology allows for real-time intraoperative guidance during cataract surgery, visualization of wound morphology, lens hydrodissection, trenching depth during phacoemulsification, and IOL positioning.

Today, OCT devices can also incorporate epithelial thickness mapping technology. Dr. Kretz explained its added value: “Epithelial mapping is helping us to understand remission after refractive laser surgery and to detect corneal diseases like keratoconus quicker than with front surface topography. But in biometry, this technology also offers even better outcomes in corneal astigmatism treatment.”

By mapping the epithelium and quantifying epithelial thickness, we can achieve accurate measurements of the stromal surface, leading to a revolutionary approach to managing astigmatism.

Real game-changers in the anterior segment

We asked our experts about the latest anterior segment innovations currently in development that they believe will be true game-changers in clinical practice.

“There are several innovations on the way that we are all eagerly looking forward to. Probably one of the biggest is the possibility to treat hyperopia with lenticule extraction in the near future,” Dr. Kretz shared.

This was an intriguing technique, originally proposed over a decade ago. However, the technology

available at the time was not sufficient for the task. Since then, innovations to the small incision lenticule extraction (SMILE) technique, including an improved nomogram, modifications to the lenticule geometry, an increased transition zone of 2.0 mm, and optimization of the energy settings on the VisuMax (Carl Zeiss Meditec, Jena, Germany) femtosecond laser have successfully resolved earlier challenges.

The SMILE for hyperopia trial had remarkable results. They reported that 83% achieved corrected distance vision of 20/20 or better after 12 months. And for those with a plano target, at 12 months, 68.8% had an uncorrected distance visual acuity of 20/20 or better, and 88% had at least 20/25.1

Prof. Mehta has been watching the ongoing trials of drug-eluting IOLs. “This could be an interesting technology with the potential to have far-reaching applications, especially for the patients we treat with chronic diseases, such as glaucoma, who are undergoing cataract surgery,” he shared.

SpyGlass Pharma (California, USA) is evaluating their single-piece, hydrophobic acrylic IOL with drug-

eluting pads, which in early studies demonstrated significant intraocular pressure lowering in patients with glaucoma or ocular hypertension. The ultimate goal would be to enable cataract surgeons to use existing IOL techniques to improve the patient’s vision due to cataracts and deliver multiple years of bimatoprost therapy for those who also have glaucoma. This may also be the solution to the ongoing challenges associated with adherence to daily drop regimens, a significant issue in treating glaucoma and other ophthalmic diseases.

Other drug-eluting IOL investigations have included hydrophilic modification of the IOL surface using heparinization or pegylation as a method to decrease initial cellular adhesion and inhibit posterior capsule opacification.

Companies like VisusNano (London, United Kingdom) are also developing biodegradable polymer-based drug elution systems that can be attached to the IOL. These systems allow controlled and slow release of antibiotic, anti-inflammatory and anti-proliferative agents to prevent cell proliferation — thereby reducing infection and inflammation risk and avoiding the need for eye drops or postoperative laser treatment.

Regenerative medicine using cell-based therapies is also a hot topic in corneal disease innovation as a way to replace or enhance damaged tissue. The challenge with these types of therapies is that for delivered cells to integrate with the host tissue, they need to stay at the site of delivery. The team at Emmecell (California, USA) has developed a magnetic cell delivery nanoparticle platform, effectively localizing and integrating cell therapies to the appropriate target tissue. The evaluation of this technology in eyes with corneal edema is currently in clinical trials in the United States.

AI to the rescue

When it comes to innovations in the anterior segment, discussions would not be complete without acknowledging the significant impact of artificial intelligence (AI) technology in clinical practice.

The potential value of AI in anterior segment ophthalmology is expanding, particularly for the areas that involve big data and image-based analysis. With growing populations and limited ophthalmic care in remote communities, there is a growing value in AI-based telehealth applications.

AI applications have integrated with imaging modalities, complementing the detection of keratoconus, preoperative screening for risk of post-refractive surgery ectasia, diagnosis of infectious keratitis, and prediction of post-corneal graft complications.2 AI algorithms have been used to help clinicians detect and differentiate clinical diagnoses with high sensitivity, specificity, and accuracy. As an example, a trained artificial neural network accurately classified bacterial and fungal keratitis with a rate of 90.7% compared with the clinician’s prediction rate of 62.8%.3

Once adequately trained, AI excels in image analysis. Remarkable examples include AI conducting semiautomatic analysis of corneal ulcers from photographs and providing reliable automated detection of Descemet membrane endothelial keratoplasty graft dislocation.

Furthermore, AI has been applied to predict treatment outcomes for eyes with keratoconus. It has also been used to screen refractive patients at high risk of developing progressive post-LASIK ectasia and visual disability after any laser vision correction with >90% accuracy.2

With that said, the deployment of AI into everyday clinical practice still has several hurdles to clear. Many of the reported achievements are based on algorithms trained using limited samples, with relatively few being validated in real-world scenarios.

References

Contributing Doctors

Dr. Florian T.A. Kretz (FEBO), MD, is the founder, owner, and lead surgeon at Precise Vision Augenärzte in Rheine, Germany. He specializes in cataract and refractive surgery, but he also treats patients for glaucoma and medical retina. Beyond his professional interests, he also likes waterports, but his passion lies in work and research, especially seeing patients happy and satisfied after successful treatments.

Dr. Kretz and his wife share a commitment to philanthropy, regularly embarking on missions to support and offer free eye care where it is needed. As a medical board member of the Khmer Sight Foundation, their current focus is in Cambodia, where they find immense fulfillment in witnessing patients experience improved vision. His greatest passion is living in a patchwork relationship with two children and his wonderful wife.

mail@florian-kretz.de

Innovation is driven by the desire to deliver safe and effective sight-saving opportunities, ultimately improving the lives of clinicians and patients alike. Dr. Kretz emphasizes the importance of staying updated on cutting-edge advancements to deliver the best possible care to patients. Moreover, he is supportive of the latest innovations, always keeping an eye on the future of eye care.

“As anterior segment surgeons, we are very happy that there is continuous innovation in our field. And I look forward to seeing what comes out next,” Dr. Kretz concluded.

Prof. Jodhbir S. Mehta , MBBS, FRCOphth, FRCS(Ed), FAMS, PhD (UK), is the executive director and head of the Tissue Engineering and Cell Group at the Singapore Eye Research Institute (SERI), head of Cornea External Disease and senior consultant in the Refractive Service at Singapore National Eye Centre (SNEC), deputy executive director at Singapore Eye Research Institute (SERI), as well as a full tenured professor with Duke-NUS Medical School in Singapore. With a main interest in corneal transplantation, he completed a corneal external disease and refractive fellowship at Moorfields Eye Hospital in London and at SNEC. He has co-authored nearly 20 textbooks and 333 citations, and holds 16 patents, six of which have been licensed. Prof. Mehta has won several awards from the AAO and ARVO, among others, the latest of which was from the ASCRS in 2018. Prof. Mehta is also a favorite keynote speaker and presenter in several international conferences.

jodmehta@gmail.com

1. Reinstein DZ, Sekundo W, Archer TJ, et al. SMILE for Hyperopia With and Without Astigmatism: Results of a Prospective Multicenter 12-Month Study. J Refract Surg. 2022;38(12):760-769.

2. Ting DSJ, Foo VH, Yang LWY, et al. Artificial intelligence for anterior segment diseases: Emerging applications in ophthalmology. Br J Ophthalmol. 2021;105(2):158-168.

3. Saini JS, Jain AK, Kumar S, et al. Neural network approach to classify infective keratitis. Curr Eye Res. 2003;27:111-116.

A Balancing Act

How oculoplastic surgeon Dr. Livia Teo successfully juggles her busy practice, young family and eye care education

by Chow Ee-Tan

Dr. Livia Teo’s passion for oculoplastics stems from its unique blend of functional and aesthetic aspects, which allows her to offer comprehensive eye care to a diverse range of patients. In an exclusive interview with CAKE Magazine, the petite doctor opened up about the setbacks she faced in medical school, the challenges in her career and the rewarding experiences of balancing her thriving practice and young family – all while remaining dedicated to eye care education.

Dr. Livia Teo, senior consultant ophthalmologist at Gleneagles Hospital in Singapore, stumbled upon the field of oculoplastics while she was training to be an ophthalmologist at the Singapore National Eye Centre (SNEC) and assisting in the plastic surgery department there.

“I came to realize through my mentors that there was a field in ophthalmology called oculoplastics, and that subspecialty is the perfect combination of ophthalmology and plastic surgery. That was when I decided to embark on a career in ophthalmology and worked towards joining the oculoplastics fraternity,” enthused Dr. Teo.

From fascination to passion

She realized her dream and today, she is practicing as a fellowshiptrained oculoplastic surgeon and runs a private practice at Nobel Eye and Vision Centre located within Gleneagles Hospital.

“I chose to do oculoplastics as it is the only subspecialty in ophthalmology that allows me to achieve both functional and aesthetic aspects of a patient’s eye condition,” she said, adding that many of the conditions span both adult and pediatric age groups, and Dr. Teo also has a special interest in pediatric oculoplastic cases.

According to Dr. Teo, there are various eye conditions with a wide range of surgeries to manage, including eyelid, orbital, and lacrimal conditions. Many of these conditions span both adult and pediatric age groups. Dr. Teo also has a special interest in pediatric oculoplastic cases.

“For instance, if they are tearing, I could offer them tear duct surgery to relieve any blockage. If they had cataracts, I could restore their vision through cataract surgery. And if they complain of droopy eyelids affecting their vision, I can further improve their vision or appearance through lid surgery,” she continued.

It runs in the family

Born in Singapore to parents who were from Malaysia, Dr. Teo completed her undergraduate studies at the Yong Loo Lin School of Medicine at the National University of Singapore. She then trained at SNEC for her ophthalmology postgraduate residency training and further subspecialized in oculoplastics at Severance Hospital (Yonsei University, South Korea), and Massachusetts Eye and Ear Infirmary, (Harvard Medical School, Boston, Massachusetts).

Dr. Teo shared that her career choice was inspired by her father, an obstetrician and gynecologist.

“I was greatly influenced by his passion and dedication to his work,” she said. “He would always share the rewarding aspects of medicine with me — about making his patients feel better and the joy of bringing life into the world when he delivers babies. He inspired me to enter medical school, and I haven’t looked back since.”

Dr. Teo had always been a high achiever in her academic journey and received training from many prestigious institutions. However, she admits that there have been setbacks along the way.

“I failed one of my exams in the middle of my residency training and I started questioning myself if I had chosen the right path. I even considered if I should give up ophthalmology,” she recalled.

Thankfully, she had the support of her fiancé (now her husband) and wonderful parents, who helped her work through that challenging time.

Dr. Teo has always been passionate about education, having been influenced by her mother, a former teacher. When she was working fulltime in the restructured hospital in Singapore, she served as the program director of the SingHealth Ophthalmology Residency Program. Even after setting up her own private practice, Dr. Teo remains committed to teaching as a visiting consultant at the National University Hospital.

“Teaching allows me to get to know the younger generation, understand their challenges, and share my clinical experience with them,” she happily shared. “I am also very enthusiastic about public education on eye health and eye care. There are so many eye diseases that are detectable and treatable in the early stages. I believe that everyone should have access to this information and should be entitled to the opportunity to have their eyes screened. This will allow us to work towards the prevention of blindness,” she added.

Career highlights and challenges

One of the highlights of her career is running her own practice

and successfully managing a great team of staff.

“My team is like my second family! It has been great working with likeminded individuals who do [their] best to give the patient a good experience when they come to see us. It also allows me to fulfill my dream of reaching out to patients and their family members, and educating and empowering them to take care of their eye health,” shared Dr. Teo.

With her accomplishments and dedication, Dr. Teo has received several accolades from the industry over the last decade. The award that is most meaningful to her is the SingHealth Service Star she received in 2018.

“It is awarded to individuals based on positive feedback and compliments from patients. It meant a lot to me to receive it as it felt like a shared gift from my patients for taking care of them. It brings me great joy to be able to help them to see better and feel better about themselves,” she shared.

However, it wasn’t always smooth sailing in her practice, as she faced various challenges along the way.

“As a petite female, I often meet patients who feel that I might not be able to perform the necessary surgery or meet their expectations. Some would comment that I look too young to be a specialist or that I just graduated from university and might lack the necessary experience. I still receive comments like these, even after I have been an ophthalmologist for more than 10 years,” she laughed.

Dr. Teo would usually take time to explain to patients their conditions and the surgeries necessary, often showing them videos of her past surgeries and their results to help patients understand.

“I chose to do oculoplastics as it is the only subspecialty in ophthalmology that allows me to achieve both functional and aesthetic aspects of a patient’s eye condition.”

“They are usually convinced thereafter that I can do the job. I believe a good rapport and trust from the patient is of utmost importance in a doctor-patient relationship,” she shared.

Balancing work and family life

Dr. Teo is married to a vitreoretinal surgeon, whom she met during her first year as a medical officer in the ophthalmology department of SNEC. They have been happily married for 15 years now and have two beautiful daughters, aged six and three.

“My husband has been my pillar of strength throughout my career. There were many points when I doubted myself, but he always believed in me and would support me through the toughest times,” shared Dr. Teo. “He is quieter and more reserved compared to my chatty and bubbly self. I am the emotional half, and he is my rational and intelligent better half. I would like to think we complement each other well.”

Being a mother of two young children while successfully managing a thriving career is Dr. Teo’s most significant achievement to date. “It’s always difficult trying to find that work-life balance. Running my own practice means I have clinics and surgeries from Monday to Saturday. I have to actively find pockets of time to spend with the kids,” she noted.

Dr. Teo makes the effort to send her daughters to school every day and occasionally drops by the playground

on the way to school. She always tries to make it home for bedtime to tuck the kids into bed, and they would exchange stories about the day.

“Now that I have my own practice and a more flexible schedule, I make it a point to block my schedule to attend my children’s school performances and gatherings. I always have to rush to catch up on work before and after, but the effort is so worth it when I see their little faces light up when I show up,” she happily shared.

A rewarding learning journey

Dr. Teo is indebted to the many great mentors and teachers who inspired and motivated her throughout her career.

“I had the privilege to be trained by many accomplished experts in the oculoplastics field, particularly at the SNEC. I am also grateful to have had the opportunity to learn from international experts under the Ministry of Health Manpower Development Program Scholarship. And I am still learning every day,” she said.

Dr. Teo pays tribute to an outstanding mentor, Prof. Barry Cullen, who taught neuro-ophthalmology at SNEC until his retirement in 2015 when he was 87.

“He was approachable and wellloved by the doctors, nurses, and allied health in the Singapore ophthalmology scene. He loved

teaching and would make the effort to hold tutorials for all the residents to prepare us for the examinations. Sadly, he passed away in 2020. It was an honor and privilege to have crossed paths with him. It was a lifelong calling for him to contribute to the community, and I aspire to have the same passion that he had,” Dr. Teo concluded.

Contributing Doctor

Dr. Livia Teo is a senior consultant ophthalmologist at Gleneagles Hospital. Before joining Nobel Eye and Vision Centre, she was a senior consultant at the Singapore National Eye Centre with more than 15 years of experience. She graduated from the National University of Singapore on the Dean’s list and was awarded Book Prizes in surgery and dermatology. She obtained Fellowships from The Royal College of Surgeons (Edinburgh) and the Academy of Medicine (Singapore), securing Gold Medals as the top candidate in Oculoplastic & Adnexal Disease as well as Corneal & Refractive Surgery. Being granted a Ministry of Health HMDP postgraduate scholarship, she further advanced her training and completed fellowships at Massachusetts Eye and Ear Infirmary, Harvard Medical School, and Severance Hospital, Yonsei University in Seoul. Committed to mentoring the next generation of ophthalmologists, she served as the Program Director of the Ophthalmology Training Program in SingHealth and won the Best Teaching Faculty Award in 2019 and 2016. Dr. Teo is a member of the Singapore Medical Association, Singapore Society of Ophthalmologists, and Association of Women Doctors, and is a council member of the Singapore Society of Ophthalmic Plastic and Reconstructive Surgery. She has expertise in managing a range of eye conditions and has a special interest in pediatric and adult ptosis and related eyelid conditions, ophthalmic plastic, and reconstructive surgery of the face and orbits. drliviateo@gmail.com

“My husband has been my pillar of strength throughout my career. There were many points when I doubted myself, but he always believed in me and would support me through the toughest times.”

Sharpening the Focus

In his talk, Prof. Ecosse Lamoureux from Singapore shared how AIassisted, patient-centered evaluation could make eye care more holistic. He noted that collecting patientreported outcome measurements (PROMs) data is important and aligns with global value-based care initiatives in which incorporating the patient’s voice and experience of clinical care is central. However, current “fixed-length” PROMs are problematic as they are paper-pencil scales, burdensome, resourceintensive, and require manual data entry and scoring.

To overcome this problem, his team developed a suite of eyespecific computerized adaptive tests (CATs) for nuanced and sensitive measurement of patientreported outcomes. “These are fast, precise, and fully integrated into the electronic medical record (EMR), allowing real-time feedback,” he said.

Experts share cutting-edge anterior segment innovations at the 35th APACRS Annual Meeting

by Tan Sher Lynn

At the 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) annual meeting, held recently in Singapore, experts shared breakthrough innovations in anterior segment that are revolutionizing the field, promising a brighter future for ophthalmology.

Following a successful pilot implementation at Singapore National Eye Centre (SNEC) in 2021, he and his team are currently scaling up their CAT implementation across selected retinal, glaucoma and refractive clinics at SNEC using a detailed implementation science approach. This AI-assisted approach is important to eye clinics as it repositions their mission to incorporate holistic as well as clinical care. “We treat the patient, not just the organ,” he quipped.

Artificial intelligence is already here. In ophthalmology, AI’s potential is reaching optimum level. The growing role of AI in diagnosing and treating anterior segment diseases was one of the highlights during the meeting, with predictions of its increasing importance in healthcare. A smart shape memory polymer was introduced for safe and efficient pupil expansion in cataract surgery. Anterior segment optical coherence tomography (OCT) was

also highlighted for its benefits in pre- and postoperative evaluations. And last but not least, biomarkers were explored as tools to predict and improve refractive surgery outcomes.

An increasingly AI-driven world

The rise of AI is permeating every aspect of human lives, including how the eyes are treated.

Meanwhile, Dr. Daniel Ting, also from Singapore, said that the global trend for AI application in anterior segment diseases includes keratoconus detection, infectious keratitis detection, refractive screening (for suitability and entasis risks), pterygium detection, corneal transplant (detection of DSAEK/ DMEK graft detachment), cataract (severity grading) and IOL calculation.

He foresaw that in the future, areas that will become increasingly important are AI implementation science (e.g., health economics, perception studies, AI health guidelines), AI education and social determinants of health, privacy-preserving technology (e.g., federated machine learning, blockchain), metaverse and nonfungible tokens, explainable AI, synthetic AI (with human in the loop)

and generative AI (e.g., ChatGPT and large language models).

“I think, in the next five, 10, 15 or 20 years, the use of robots together with deep learning and generative AI could actually be one of the mainstreams in healthcare,” he said, pointing out that governing framework and safety regulations need to be in place to govern these technologies.

Smart tool for efficient pupil expansion

With 32 million cases per year, cataract surgery is the mostperformed surgery worldwide, emphasized Dr. Shamira Perera from Singapore. To facilitate successful cataract surgery, it is necessary to achieve pupil expansion. While pharmacologic drops are usually used to dilate the pupil, they can be ineffective in about 5% to 10% of cases, prompting the need for pupil expanders, added Dr. Perera.

Nevertheless, there are problems associated with the use of current pupil expanders, which include insufficient expanded dilation, high iris stress, and lack of protection to the pupil margin.

To address these problems, Dr. Perera and his research group developed a smart shape memory polymer named Spiralis, which expands the pupil safely and easily for cataract surgery. Made from biocompatible polyurethane, this product has a compact shape at low temperatures and deforms to an expanded shape at body temperature.

In 2020, the technology was licensed to Geuder, a Germanybased multinational ophthalmic product company. After taking over the product, the company has taken steps to refine it, including the finalization of the product design, analysis of usability with other instrumentation required for surgery, as well as the development of assistive instruments to improve usability and function. Samples for human use are set to be available this year.

“Ultimately, we would have this potentially best-in-class expander for rapid commercialization,” said Dr. Perera.

Advantages of the anterior segment OCT

Since the development of the world’s first swept-source anterior segment optical coherence tomography (ASOCT) device by Tomey (Nagoya, Japan) in 2008, this technology has witnessed a surge in clinical applications. Its ability to penetrate deeper and provide enhanced tissue visualization has contributed to its growing utilization.

During his talk, Dr. Yoshihiko Ninomiya from Japan shared the preand postoperative benefits of ASOCT in cataract surgery.

According to him, preoperative identification of corneal irregular astigmatism and zonular dehiscence is critical for the success of cataract surgery. Tomey’s CASIA2 ASOCT platform has effectively addressed such preoperative evaluation needs. “Having access to the lens analysis provided by CASIA2 enables surgeons to anticipate potential complications and develop alternative strategies or techniques to address dehiscence,” he said.

CASIA2 is also useful in both pre- and postoperative clinical settings of intraocular lens (IOL) dislocation in terms of measuring and describing the position of IOL.

In addition, CASIA and CASIA2 come in handy with IOL power calculations, providing accurate predictions of the postoperative IOL depth. “CASIA2 can transform previous approaches of toric IOL calculations and IOL power calculations,” he noted.

Biomarkers-enabled refractive surgery

According to Dr. Rohit Shetty from India, despite the use of current diagnostics modalities which help to decide the appropriate refractive surgery and predict postoperative outcomes, 20% of all outcomes are still unpredictable and undesirable, including postoperative haze, dry eye, neuropathic pain, and epithelial remodeling. All these are due to an altered immune profile.

When looking under the microscope, he and his teammates saw that a healthy epithelium actually gulps up dead cells, while unhealthy

epithelium is unable to digest dead cells. This becomes the primary source of inflammation. With tear collection using Schemer’s strips and the fluorescence reader (Bio-M Pathfinder), they were able to build a point-of-care diagnostic kit to evaluate inflammatory factors in tear fluid. The entire process takes about 90 minutes.

Dr. Shetty shared the reasons they chose certain biomarkers to be included in the test. “Interleukin-17A is a common cause of neuropathic pain, tumor necrosis factor-α is a very strong predictor of postoperative corneal haze and ICAM-1 (the itch factor) plays a role in dry eyes,” he said.

In essence, he noted that biomarkerenabled refractive surgery helps to determine which eye drop to use for diabetic eye disease (DED) subjects, monitor subjects with irritation and for treatment responses, discover and stratify clinically healthy eyes with abnormally high levels of inflammation and treat them before the disease worsens or before surgery.

As for the future, Dr. Shetty foresaw that there will be an expansion of the present biomarker panel by the incorporation of more molecules, testing the validity of the panel in the diagnosis and prognostication of systemic diseases.

Editor’s Note

The 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) annual meeting was held on June 8 to 10, 2023. Reporting for this story took place during the event.

Revolutionary On-the-Move Femtosecond Laser

Ziemer’s FEMTO LDV Z8 mobile platform provides added advantages in lenticule extraction

by Tan

Dr. D. Ramamurthy, a renowned cataract and refractive surgeon from India, shared his perspective on Ziemer’s all-in-one FEMTO LDV Z8 femtosecond laser. The platform claims to offer a more efficient and cost-saving way on performing lenticule extraction while catering to the requirements of both cataract and refractive surgeries.

Since its introduction in ophthalmic surgery in 2001, the femtosecond laser has been increasingly used in anterior segment surgeries. However, most of the femtosecond lasers available today are large and bulky, falling into two categories: Those designed for cataract surgery and those used for creating corneal flaps and lenticules in refractive surgery.

The launch of the FEMTO LDV Z8 by Ziemer Ophthalmic Systems AG (Port, Switzerland) has ushered in a new era for femtosecond lasers. Its multipurpose surgical functions can be used for refractive, cataract, as well as therapeutic surgeries — all while being compact, mobile and customizable.

An all-in-one platform for lenticule extraction, refractive and cataract surgery

“I truly believe that the FEMTO LDV Z8 is a game changer [in the industry],” shared Dr. D. Ramamurthy,

who had been performing laser procedures for about 15 years on the femtosecond laser platforms. “The FEMTO LDV Z8 covers a wide spectrum of anterior segment applications, such as procedures that require the creation of a flap, lenticule-based procedures like CLEAR (corneal lenticule extraction for advanced refractive correction), cataract surgery, as well as creating pockets for implanting inside the corneal stroma,” he added. Patient outcomes using CLEAR have been found excellent and comparable with well established similar procedures.

Dr. D. Ramamurthy is the chairman of The Eye Foundation, a leading eye hospital with centers in major cities in South India, such as Coimbatore, Tirupur, Bangalore, Kochi, Ooty, Mettupalayam, Erode, and Pollachi, with a track record of treating millions of patients over nearly three decades. The hospital is one of the pioneers in introducing the use of lasers in refractive and cataract surgeries, which significantly enhanced the precision of these operations.

He noted that what made the FEMTO LDV Z8 stand out from other femtosecond lasers is its ability to combine the capabilities of femtosecond lasers in both cataract and refractive surgeries.

“Compared to other laser platforms, the FEMTO LDV Z8 can be used for multiple procedures across multiple sectors. We can treat almost the entire gamut of cataract and refractive surgeries with the accuracy of the laser.

“In terms of laser cataract surgical procedures, I find that the incisions or keratotomies created by the FEMTO LDV Z8, as well as the capsulorhexis, are extremely good and comparable to or better than any other platform that I have used in the past,” he continued. “Fragmentation of the nucleus is also very good. In terms of flap-based and lenticule procedures, it’s an extremely versatile and easyto-use platform.”

Compact, mobile and versatile

Another distinct advantage of the FEMTO LDV Z8 is its compact size and mobility, noted Dr. Ramamurthy. The FEMTO LDV Z8 only weighs 210 kilograms, which is way lighter than

Sher Lynn and Ruchi Mahajan Ranga

any other femto laser in the market. Due to this, the FEMTO LDV Z8 can be easily transported and used across multiple venues, making it more cost efficient.

For Dr. Ramamurthy, he used the FEMTO LDV Z8 in six Eye Foundation centers, which are between 50 and 150 kilometers apart. Small modifications were done in some centers for easy transfer of the machine. Two technicians, who always travel with the machine, were trained to operate it. “Instead of buying, say, two laser machines for each center, I can buy one machine and use it across six centers,” he said.

Dr. Ramamurthy mentioned that the distributor of the FEMTO LDV Z8 machine in India, Care Group Sight Solutions, has been exceptional in providing support in terms of transporting the machine between his six centers, which includes identifying and modifying the vehicle for transportation.

“Flap and cataract procedures don’t need calibration of the machine after it is moved. In lenticulebased procedures such as CLEAR (corneal lenticule extraction for advanced refractive correction), it’s the dimension of the lenticule (the posterior cut) that determines the accuracy of the refractive correction,” Dr. Ramamurthy said.

“Say, in one center, we do laser cataract surgery and laser refractive

surgery in the morning. In the afternoon, the machine will travel to the next center and reach there around 6 pm where the technicians will set it up to ensure optimal performance. And soon after, it is ready for use,” he shared.

Dr. Ramamurthy believed that the FEMTO LDV Z8 has created a multifunction platform that will become the future trend for femtosecond lasers.

“We are glad to have a fruitful, long-term association with Care Group Sight Solutions. It is important to have a competent partner in this sense,” he enthused.

Besides providing full support in machine mobility, Vipin Duggal,

Advantages of the CLEAR procedure

• Easy centration and the possibility of centering after docking

• Guiding tunnels to facilitate the access to the upper and lower plane of the lenticule

• Venting channels to evacuate any gas formation

• Operative OCT for a better/ safer visualization of the lenticule in the applanated area

• Patented scan pattern with overlapping spots

• Easier lenticular extraction

• Cyclotorsion compensation

• A new surgical method in which only a femtosecond laser is used without the need to ablate the cornea with an excimer laser

• Flap-free method

• A proven mobile concept for lenticule extraction

the director of Care Group Sight Solutions (Vadodara, India), also noted that the company provides warranty coverage and comprehensive maintenance contract (CMC) even when it’s mobile. Insurance is available for the movement of the machine to ensure peace of mind.

Contributing Doctor

Dr. D. Ramamurthy completed his M.B.B.S from JIPMER, Pondicherry, India, and M.D. in Ophthalmology from R.P. Center, AIIMS, New Delhi, India. At present, he is the chairman of The Eye Foundation, a chain of state-of-the-art eye hospitals in South India. His areas of interest include cutting-edge technology in cataract and refractive surgery. He was the chairman of the scientific committee of the All India Ophthalmological Society (AIOS) for six years and the past president of the same organization. He has been awarded 21 named orations both in India and abroad. He has been an invited speaker and has performed live surgeries in most parts of India and several countries worldwide. In addition, he has 31 publications in peer-reviewed journals and was conferred the APACRS Asia Pacific Certified Educator (ACE) Award, the APAO Distinguished Service Award, APAO Senior Achievement Award, and the AAO Achievement Award.

drramamurthy@theeyefoundation.in

From Innovation to Precision

Eye specialists at APACRS 2023 highlighted the innovations and dynamic landscape of refractive surgery

According to him, surface ablation has a good safety profile and allows for customized treatments (e.g., topography-guided). “However, these procedures can cause a lot of pain and discomfort, slow visual rehabilitation, significant dry eyes for several months and some optical side effects. They are also irreversible,” he said.

by Tan Sher Lynn

From phakic IOLs to SILK and ray tracing, experts discussed the latest offerings and the ever-changing paradigm in refractive surgery during the recently held 35th Annual Meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2023).

Meanwhile, laser lenticule extraction has a good safety profile, fast visual rehabilitation period, and fewer dry eye symptoms than LASIK or FemtoLASIK. He also noted that there are some optical side effects and the procedure is also not reversible. Also, since corneal aberrations limit vision, especially at night, corneal laser vision correction should be limited to moderate myopia due to potential losses in vision quality.

At the 35th APACRS held in Singapore, eye specialists discussed options for moderate myopes such as phakic intraocular lenses (IOLs) and laser vision correction procedures. They also shared other innovative lenticular techniques, including the ray tracing approach for improving refractive predictability, the Smooth Incision Lenticule KeratomileusisTM (SILK) procedure, and the SmartSight protocol.

The best procedures for the moderate myope

When it comes to myopia correction, Dr. Michael Knorz from Germany, believed that the moderately myopic patient can opt for either phakic intraocular lenses (IOLs) or laser vision correction procedures, which include surface ablation, FemtoLASIK and small incision lenticule extraction (SMILE).

On the other hand, phakic IOLs provide better improvement in contrast sensitivity compared to LASIK or Femto-LASIK. “Visian ICL [a phakic IOL] has a good safety profile, provides faster visual recovery, no dry eye symptoms, as well as fewer optical aberrations resulting in significantly better night vision than corneal laser surgery. It is also fully reversible and future procedures are not compromised,” Dr. Knorz said.

“So, to me, the first choice for treating the -5 D myope is the phakic IOL due to the vision quality it brings and its reversibility. Second is laser lenticule extraction because it causes less dry eyes than LASIK.

Third is Femto-LASIK as it provides higher patient comfort than surface ablation, which is the last option. These four procedures are effective, reasonably safe, and are suitable for those less than 40,” he concluded.

The ray tracing approach

For decades, the focus of refractive surgery has beento reshape the cornea so that light that enters the eye can focus on the fovea. Nevertheless, Dr. Chandra Bala (Australia) thinksthat there should be a paradigm shift in refractive surgery.

“The purpose of refractive surgery is not to remove a thin lens from the cornea, but to change the angle of incidence at the front surface of the eye, which would correct the pathway of the light so that it will end at the fovea,” Dr. Bala shared. “In order to do that, we need to know what’s happening behind the cornea, and that requires us to know the journey of the light from the fovea to the front surface of the eye and from the infinity to the front surface of the eye. This is the concept behind Alcon’s Innoveyes ray tracing algorithm,” he added.

The ray tracing algorithm involves measuring all the elements of the eye — namely, the anterior and posterior cornea, anterior chamber depth, corneal thickness, lens thickness and axial length, noted Dr. Bala. By considering all optical surfaces of the eye, ray tracing offers the highest possible accuracy to improve the refractive predictability of corneal procedures.

“I believe that ray tracing technology is a new era in our thinking and ability to correct refractive error. We now recognize the need for an individual eye model — an ‘eyevatar’ for creating a personalized treatment plan,” he said.

Innovative procedures in lenticular surgery

As lenticular surgery becomes increasingly popular throughout the world, we are seeing more advancements in procedures and lasers. More recent varieties include the Smooth Incision Lenticule KeratomileusisTM (SILK) procedure (Johnson&Johnson Vision, California, USA) and the SmartSight protocol

(SCHWIND, Kleinostheim, Germany), presented by Dr. Mahipal Sachdev from India and Dr. Thomas Kohnen from Germany, respectively.

Sharing his experience, Dr. Sachdev noted that the SILK procedure provides outstanding patient outcomes and highly accurate flap thickness with smooth stroll beds and easy lifts. This is largely due to the J&J Vision’s ELITATM femtosecond laser used in the procedure, which delivers low-energy treatment through a combination of ultrashort pulse frequency (10 Mhz) and small focus spot size (1.3 micron), creating fast and smooth cuts and inducing minimal tissue disruption in the stroma.

“My personal impression of this regime, which we started during the pandemic, is that it lives up to the name of smooth incision leticule extraction. There are minor or no tissue adhesions,” he shared. “All cases had a complete lenticular removal — none had cold spots, uncut areas, or bridges. None of the cases had any difficulty with the entry cut, and plane identification is relatively easy. Corneal biomicroscopy was unremarkable in all Day-1 and Week-1 postoperative visits, and visual recovery was fast. Patient satisfaction is great,” he added, noting that the procedure provides accurate refractive correction with tight outcomes and tight standard deviation for sphere and cylinder.

He also provided tips and pearls for best outcomes, which include having a good centration of the suction ring and a good approach in identifying the anterior plane, identifying the right type of patients, proper positioning of the patient head, as well as the use of proper instruments.

Meanwhile, the SmartSight procedure utilizes the SCHWIND ATOS® femtosecond laser and features intelligent eye tracking with pupil recognition and cyclotorsion compensation, providing a precise and gentle treatment method.

“The possible optical zone diameter of 5.5 mm to 7.5 mm creates a transition zone. The anterior cut has

a diameter between 6 mm and 9 mm and a selectable cap thickness from 100 micrometers to 160 micrometers. Edge cut has an angle between 45º and 135º, and an arc length between 2 mm and 5 mm,” said Dr. Kohnen.

He shared Dr. Kishore Pradhan’s (Nepal) experience with the SCHWIND ATOS device after 12 months of follow-up, in which there was only one event of suction loss. According to Dr. Kishore, dissection was easy even in the presence of opaque bubble layers (OBLs), the bed cut was smooth, optical zones seemed larger than planned, and there was no immediate post-op wrinkling.

Also, Dr. Kohnen and his colleagues performed a study on 60 fresh pig eyes using the SmartSight procedure and found that the SCHWIND ATOS laser provides accurate and predictable cap thickness (CT), slight deviations in cap diameter (CD), and lenticular thickness (LT).

“Results are comparable with already established systems and procedures. However, provided settings seem to be challenging even with semiautomated algorithms, which could be due to the experimental setting of

The 35th Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS) annual meeting was held on June 8 to 10, 2023. Reporting for this story took place during the event.

A Prelude to ESCRS 2023

This year, expect a Congress jam-packed with scientific sessions and interesting content

by Brooke Herron

The 41st Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2023) takes place in Vienna, Austria, from September 8 to 12 at the Messe Wien Exhibition & Congress Centre.

sponsored satellite sessions, where experts offer the latest data on the newest tech.

Make sure to mark your calendar for some of these informative events.

Day 1: Friday, Sept. 8

Delegates can attend subspecialty sessions during Focused Friday. Coorganized with ESCRS and other groups, these presentations feature deep-dives into key subject matter at an additional cost. Check out Cornea Day by ESCRS and EUCornea, Glaucoma Day by ESCRS and EGS, and WSPOS Day by the World Society of Paediatric Ophthalmology and Strabismus.

There’s also the Who Owns Ophthalmology? main symposium from 17:00 to 19:00, which is sure to be an interesting talk. Plus, the industry exhibition opens at 12:00. Head to the hall to experience the newest technology and innovations from ophthalmology’s leading companies.

Day 2: Saturday, Sept. 9

From new scientific sessions and content to a traditional Viennese ball, ESCRS 2023 offers attendees a conference experience unlike any other. In addition to the impressive scientific program, prestigious award lectures and ample networking opportunities, this Congress also marks an important step in

ESCRS’s overall journey toward sustainability.

Scientific program highlights

This year’s program features the latest updates in anterior segment surgery and practice, new specialty sessions and workshops — as well as industry-

The second day of ESCRS 2023 packs a powerhouse of must-view content. Begin your day at the Opening Ceremony with the Binkhorst Medal Lecture on Corneal Regeneration: The Future of Corneal Surgery by Dr. Jorge L. Alió. Here, Dr. Alió will share his insight and involvement in the emerging topic of corneal regeneration. As a thought leader in this arena, he has conducted the first

worldwide clinical trial for the treatment of corneal dystrophies with autologous mesenchymal stem cells and has published a series of key scientific papers on this innovative type of corneal surgery.

On Day 2, the Congress is also excited to share a new format: The ESCRS Near-Live Surgery Programme from 14:00 to 16:00. To produce this program, the ESCRS video team visited operating theaters and filmed surgeons during procedures. Each video focuses on critical surgical steps to allow for discussion — plus a selection of more challenging cases.

Other highlights include the day-long Refractive Surgery Didactic Course and the Young Ophthalmologists Programme

Day 3: Sunday, Sept. 10

As ophthalmology strives for more sustainability across the board, you can learn more about greener surgical practices yourself during the main symposium on Day 3: Making our Surgery Greener from 11:00 to 13:00. There will also be a Young Ophthalmologists For Sustainability (YOFS) event from 14:30 to 15:30.

ESCRS embarked on a journey to become more sustainable in 2022 — and in 2023, these efforts continue. According to ESCRS President Prof. Oliver Findl, “We [ESCRS] are increasing our momentum and investment in this area to achieve the very lofty goal of having a congress with zero waste to landfills, zero net carbon emissions, and placing ESCRS as a role model for social responsibility.”

Other highlights include the IME session on refractive surgery lenticule extraction, workshops on visual optics, as well as instructional courses and satellite symposia.

Day 4: Monday, Sept. 11

Rightfully dubbed Smart & @ctive Monday, Day 4 features a plethora of can’t-miss content — so much so, that you’ll likely wish you could be in two spots at once! So, double-check the program. Many of these sessions take place concurrently, so plan in advance.

Start your day off with the CSCRS symposium Continents Going Digital, followed later by the main symposium Automating Eye Surgery — or head over to one of the day’s workshops on presbyopia or dry eye.

However, you’ll want to make time from 10:30 to 11:00 to attend the Heritage Lecture on The Enigma of the Anterior Interface by Dr. Marie-José Tassignon. She is the emeritus head and chief of the Department of Ophthalmology of the Antwerp University Hospital and University of Antwerp, and a past president of the ESCRS.

Alternatively, you might also want to check out Brush-Ups: What An Anterior Segment Surgeon Needs To Know, featuring topics on retina (by Euretina), glaucoma (by EGS), and oculoplastics (by ESOPRS).

What’s more, there’s a host of other new content you might be interested in, such as the Medical Writing Workshop for Researchers and the Ophthalmic Anaesthesia Symposium. (It is important to note that the four-hour medical writing workshop is limited to 40 attendees, so register early to secure your seat.)

Day 5: Tuesday, Sept. 12

Last but not least, Day 5 offers attendees a final bit of crucial content — and tough decision-making. Kick off your day with one of these three presentations: The Austrian Symposium (8:30-10:00), the IOL Exchange Workshop (8:00-10:00), or Orbis Symposium (8:00-10:00).

The final main symposium of ESCRS 2023 also promises to be a good one: Taking Care of Postoperative Complications, happening from 10:30 to 12:30.

Waltz the night away

We love a good networking opportunity, and ESCRS has really outdone itself with this one: A first-of-its-kind, traditional

Viennese Ball. Taking place in the iconic Hofburg Imperial Palace on Saturday, Sept. 9, this is a truly unique opportunity to connect with peers and colleagues. This event comes at an additional cost and registration is available online. (Note: Dinner is not included and make sure to mind the dress code. It will be strictly enforced.)

For a less formal affair, check out Networking in the Exhibition Hall on Sunday, Sept. 10, from 18:15 to 19:30. This is the perfect opportunity for casual networking with industry partners and ESCRS faculty. Plus, there’s no additional cost for this event.

On Sunday, there’s also the ESCRS Charity Concert for Light for the World held at Porgy & Bess, Jazz & Musical Club. The headliner is JAZZMED 4 Life, a group of dedicated physicians who perform for charity. Proceeds of this benefit concert will be donated to Light for the World, an international organization that saves sight and empowers people with disabilities in Africa. (Note: For more info, visit www. jazzmed.at. Tickets are priced at €28,00 and are available at www.porgy.at.)

Plan accordingly and enjoy ESCRS 2023 promises to be a spectacular anterior segment congress — so, take advantage of the numerous sessions (and variety of events!) to elevate and enhance your own personal practice.

There’s so much more than we could cover here, so check out the program online and ensure you’re registered for any key events. We’ll see you there!