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ay 2 of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) was when the convention really began in full earnest, with all the exhibitors’ booths set-up and even more attendees making their appearance. Similarly to the day before, Ukraine featured prominently, not just thanks to a large crowd of Ukrainians outside the venue all wearing their national costume and waving their famous blue and yellow flag. The ESCRS’s work in supporting Ukrainian ophthalmologists and medical staff featured prominently in today’s Opening Ceremony and Ridley Medal Lecture on
Cont.
Not all lasers are created equal ... some are ZEISSmade.
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0702HIGHLIGHTSMattYoung CEO & Publisher Hannah Nguyen COO & CFO Gloria D. Gamat Chief Editor Brooke Herron Editor Maricel Salvador GraphicWritersDesigner Andrew Sweeney Matt Herman Customer Care Ruchi Ranga InternationalDevelopmentBusiness Brandon Winkeler Robert Anderson Adam Angrisanio Media MICE Pte. Ltd. 6001 Beach Road, #09-09 Golden Mile Tower, Singapore 199589 Tel.: +65 8186 7677 Email:www.mediaMICE.comenquiry@mediamice.com Published cakemagazine.orgby
by Andrew Sweeney
2ISSUE 09 | 18 | 22 CAKE MAGAZINE’S DAILY CONGRESS NEWS ON THE ANTERIOR SEGMENT cataract • anterior segment • kudos • enlightenment
The future of digital medicine in ophthalmology is now ... and ophthalmic AI gurus showed a peek of how dazzling that future can be!
A Livestream Fireside Chat with the Johnson & Johnson Vision Leadership ended in an embrace at the company’s Lighthouse experience. [From L to R: Warren Foust, Matt Young (host), Christoph Vonwiller, Adam Toner]
Ophthalmology Has a Responsibility to Act on Climate Change
18 September 2022 | Issue #22
She also found that the VISUMAX 800 offered unparalleled predictability. After three months, 77% of patients were less than 0.5 D away from their target refraction, with 100% within 1.0 D. And for powerful features she loved like
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One doctor’s journey with the VISUMAX 800
by Matt Herman
On Day 2 of ESCRS 2022, practitioners from around the world shared a host of promising new insights on small incision lenticular extraction (SMILE) using the VISUMAX 800 from Carl Zeiss Meditec (Jena, Germany).
Dr. Madonna Al-Dreihi spoke on her journey with the ZEISS VISUMAX 800 in the first five months of using the device and how it checked boxes like patient satisfaction levels, visual outcomes, surgeon-supporting features and
ot all laser platforms were created equal, and speakers from an ESCRS 2022 lunch symposium showed why ZEISS devices are simply cut from a different cloth.
coerced, but in the end it’s the results that matter, and there’s no hiding from the Surgeonsdata.
Many things in life are a matter of opinion, and this was never more evident than in a spirited (pun intended) argument over Italian wine at a trattoria between sessions at the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) in Milan, Italy. Your correspondent is particularly partial to dry reds, but there was no convincing the table, and a semidry white was settled upon to accompany the risotto alla milanese
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Fortunately, medical devices like ophthalmic laser surgery platforms do not fall under this category. ‘Expert’ opinions can be dredged up, concocted and
Laser-focused on Next-level Refractive Surgery Outcomes with ZEISS
want refractive laser surgery platforms that are fast, reliable, and predictable with reproducible results that leave patients satisfied. And though you can’t have a wine that will please an entire table, the latest data is showing you can have it all with ZEISS’s cutting edge refractive laser platforms.
800 was the clear choice for her, and she explained exactly why. Fast performance was a major factor –at a pulse repetition rate of 2 MHz, she reported lenticule cutting times of less than ten seconds, pointing out to raucous laughter that this was less than the preparation time of a doppio espresso
As one of the most published refractive surgeons, Dr. Sheetal Brar had her own slate of data showing the superiority of the MEL 90. Safety-wise, 95% of myopic patients saw no change or a gain in CDVA lines, and in hyperopic patients it was a triumphant 91%. Only 3.17% of eyes in the hyperopic group had to undergo early enhancement for near vision after 3 months, and none of the eyes in either group had enhancement for distance and near vision after one year.
Digitization is the key word here, with data-driven, integrated workflows powered by AI leading the way to save the clinician time and delivering highly optimized patient outcomes. But it’s not just the top end that the ZEISS Refractive Workplace has an outsized impact on.
The MEL 80 and MEL 90 has been shown to excel in the full suite of excimer laser functionality – from myopia, hyperopia and mixed cylinder to wavefront-guided, topo-guided, PTK, TE-PTK, wet PTK and post-SMILE enhancements. And while the MEL 90’s success in these areas is well documented, its trump card lies in something else entirely. “Most excimer lasers can do all of these applications,” Dr. Reinstein admitted. “But only the MEL 90 can do “Scientificallypresbyopia.”speaking,
Patient satisfaction is similarly off the charts – Dr. Andrea Russo found 100% of myopic patients scored a grade 0 in dysphotopsias and glare, and for
Fads and fashions come and go in the streets of Milan and the world at large, but with excimer lasers the science shows the timelessness and indispensability of the MEL 90. For prestigious cataract and refractive surgeons Drs. Dan Reinstein and Sheetal Brar, the proof is in the pudding – the data pudding, that is.
CAKE Magazine’s Daily Congress News on the Anterior Segment 3
All in all, there’s no turning back for Dr. Guldenfels. Besides excellent day 1 postoperative VA and a short learning curve (20 patients) to home in on the ideal settings, Dr. Guldenfels also noted the benefits of the VISUMAX 800’s significantly reduced lenticule extraction times (around 8 seconds) like reduced suction loss risk and postop inflammation.
On the other side of the coin is, well, coin, and Dr. Brar also laid out the financial case for the MEL 90 and PRESBYOND. Femtolaser PRESBYOND showed a 71% profit margin per surgery, compared to 25% for FLACS trifocal IOL and 27% for phaco.
From the experiential to the empirical
centration support with CentraLignTM and cyclotorsion alignment with OcuLignTM, only a slight learning curve was necessary to get in the groove.
It was then time for a titan of refractive surgery to take over, and Dr. Yves Guldenfels then talked about his approach with the VISUMAX 800. He began his use of the VISUMAX 800 with an energy setting of 30 to avoid difficulty dissecting the lenticule and fixed spot spacing and line spacing on the cap at 4.20, sidecut at 1.80, lenticule at 4.0, and incision at 1.5.
Though 1 month visual outcomes were superb and refractive outcomes accurate (96% within 0.5 D), day 1 postoperative uncorrected visual acuity was still not up to snuff. A simple adjustment saw the energy lowered to 28 (140 nanojoules) and cap spot spacing and line spacing to 4.1, which did the trick. Only 6% of patients were less than 8/10 on day 1 postoperatively, decreasing to only 2% after 1 month.
this is the optimal current way of treating presbyopia in the absence of cataract,” he continued, and then layed out the data proving that the MEL 90’s PRESBYOND laser-blended vision is king of the hill. For presbyopia in emmetropic patients, 95% reach 20/20 and J2; in hyperopic patients up to +5.65 D, 20/20 and J2 in 77% of patients; in myopic patients up to an astonishing 8.50 D, 20/20 and J2 in 95% of patients.
hyperopic patients 94% reported a grade 0. Spectacle independence was spectacular, too – 100% of myopic patients were spectacle independent at distance, 97% at intermediate, and 93% at near; for hyperopic patients, it was 98% at distance, 97% at intermediate, and 94% at near.
The excimer laser at the end of the rainbow
Workflow has the final word
The superior clinical results, patient satisfaction and profitability with the VISUMAX 800 and MEL 90 are clear from the data, but there is another crystalclear advantage to using these devices. Life is good in the ZEISS ecosystem with the ZEISS Refractive Workplace, and Holger Ruchatz showed why.
Streamlined workflows and procedure optimization can lower the cost for provider and patient alike, bringing refractive surgery to the masses. According to Mr. Ruchatz, 50 milion people every year with treatable significant myopia reach treatment age, but only 5% get treatment. Laser vision correction is thus a massively underserved market, and with the costoptimization features that come with the ZEISS Refractive Workplace, surgeons can get to work delivering next-level outcomes by the millions.
argely as a result of the COVID-19 pandemic, the use of telemedicine— and specifically, teleophthalmology — has accelerated, resulting in a viable means of delivering care when access to resources is Digitalizationlimited.andthe use of related technologies like electronic medical records (EMR) and artificial intelligence (AI), among others, have the potential to elevate patient care through increased efficiency and improved clinical workflow. For some, the rise of utilizing digital resources to optimize patient care came as no surprise — especially in the retinal space, a subspecialty known for its continued innovation and development.
based in Teltow, Germany. Known for the Navilas 577s, a laser system for retinal indications that require threshold or subthreshold treatment, the company is supporting digitalization through the laser system’s teleguidance feature. It’s an all-digital laser system with integrated eye tracking for computer-assisted treatment.
have not been overlooked as renowned ophthalmologists from around the world have embraced the Navilas 577s with teleguidance to optimize the digital workflow of retinal laser treatments.
by Brooke Herron
18 September 2022 | Issue #24
One company leading the charge is OD-OS, a retina navigation company
In an increasingly digital world, the benefits of the teleguidance advanced remote access features for Navilas 577s are numerous: surgeons can log-in remotely, pre-plan treatments and observe live procedures by novice users — making expert knowledge and resources available anywhere, at any time. Further, this feature also facilitates tele-education: Students can view treatments remotely without the need to be in the classroom. And these benefits
Digitalization and remote access create new opportunities to elevate care and training
Find More Flexibility in Navilas Teleguidancewith
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The rewards of remote planning
Who doesn’t want more flexibility and efficiency? Indeed, the ability to preplan a treatment remotely independent from a specific location and time is a major advantage of Navilas, according to Dr. Simo Murovski from Augenzentrum Erzgebirge in Germany. At his clinic, they have fully embraced digitalization, so using Navilas with teleguidance was a natural fit.
The opportunities and flexibility that digitalization can offer in applicable areas of ophthalmic practice are numerous. From freeing up time from already jam-packed schedules; to helping guide young surgeons through their first photocoagulation treatments safely and without risk to the patient; and the ability to allow students to observe and learn from live laser treatments — digitalization is paving the way forward in patient care. And fortunately, companies like OD-OS (and laser systems like Navilas with teleguidance) are on the forefront of advancing both medical technology and patient care.
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CAKE Magazine’s Daily Congress News on the Anterior Segment 5
Undoubtedly, with this type of virtual expert supervision the learning curve of students can not only be controlled, but potentially shortened as well.
In the end, patients win
Dr. Murovski added that this is a radical change from the previous method of training, where although an expert provided guidance, the responsibility was in the hands of a young surgeon. “Laser photocoagulation was always a procedure in training that was approached with great caution,” he shared. “The Navilas tracking ability gives me certainty that as a trainer that risk is almost zero when a young colleague is treating patients,” said Dr. Murovski.
Share expert knowledge at a distance
that planning laser coagulation treatments can take time, and Navilas with teleguidance offers the unique ability for flexibility: “We are not forced to create the plan at the same time as the treatment and we can check all the findings without being in a hurry, whenever we have time — in the afternoon or from home,” said Dr. Murovski, adding that this flexibility is very important in a busy clinical environment. Further, the added ability to pre-plan provides ample opportunity for the physician to determine the best approach to treatment.
Distant guidance is another feature that makes expert knowledge digitally available — and this flexibility to share knowledge virtually has the potential to reach (and treat) more patients where access to retina specialists is limited.
Dr. Kozak explained that the physician allows remote observation and then performs the laser photocoagulation; in addition, the physician is in charge of who can observe the treatment and students must use a secure log-in with ID-protected access to sign in. Up to 99 students can observe a laser treatment at one time. Information on the monitor is shared digitally, and students can watch the energy and power settings, along with the full treatment, said Dr. Kozak.
He illustrated an example: A colleague in the next room performs a navigated retinal laser treatment while he observes online. “The remote access program gives me an overview of everything,” he explained, “the planning below and the current execution of the laser coagulation
He continued: “I know that the device delivers [the laser treatment] at the point where we planned it.”
For more information, www.od-os.com/Teleguidancevisit
“Going digital was important from the beginning, our records are completely digital and all of our locations are networked,” he shared. “We are the first practice in Germany that has been granted permission to perform teleophthalmology … so we already had the ability to collect and evaluate findings remotely. Now we are also pleased to have the opportunity to view patients’ live laser treatments via remote observation.”
Since incorporating Navilas into his practice, Dr. Murovski has not only seen improvements in the quality of treatments delivered but in the integration of processes and procedures — which ultimately benefits patients, too.
The benefits of distant guidance were noted by another renowned expert, Dr. Igor Kozak from Moorfields Eye Hospital Abu Dhabi in United Arab Emirates, who helped define the clinical applications of teleguidance with Navilas. He shared his experience in distant guidance using the system’s user-friendly interface: “[In distant guidance], the consultant will be creating a treatment plan at a distant site and this will be executed by a student who is in the room with the patient.
“That takes away the pressure,” he said, “and we can focus on what’s important, namely the efficient targeted treatment for the benefit of the patient.”
Digitalization can offer additional benefits beyond the flexibility of remote pre-planning and the access to expert resources distance guidance provides: Navilas with teleguidance facilitates distance learning, too.
‘No Free Lunch’ and Much Ado About IOLs
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ne of the key themes of Day 2 of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) was constant improvement whether that be in medical sustainability, increasing the female voice at the top level of ophthalmology, or in providing the best quality of care to patients with intraocular lenses (IOLs).
This, said Dr. Nanavaty, emphasized how ophthalmology can indeed go further in IOL research, as IOL treatment success remains dependent on pupil size.
Of course, this is not to say that progress has not been made, a point made by French ophthalmologist Dr. Damien Gatinel, head of the Anterior and Refractive Surgery Department at the Rothschild Foundation in Paris, France. He emphasized that extended-depth-offocus (EDOF) lenses with small apertures have proven to be effective and have pushed development forwards in this field.
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Dr. Nanavaty cited a study he had overseen to validate his argument, one that was funded by the ESCRS, where patients with monofocal IOLs were screened to discover how many did not require glasses to see 20/40
by Andrew Sweeney
Dr. Mayank Nanavaty from Nuffield Health in Brighton, United Kingdom spoke about his research into enhancing monofocality among his patients, and how newer, enhanced monofocal IOLs that could “play with spherical aberration to improve depth of focus and are not pupil-sized dependent” are required to advance IOL optics across the board.
There is a growing demand for presbyopia-correcting IOLs, Dr. Gatinel said, and multifocal lenses are beneficial in this regard as they offer the bestuncorrected vision possible, despite the higher rates of photic phenomena. There is “no such thing as a free lunch,” he said, and that in these cases, EDOF IOLs can still bridge the gap between monofocal and multifocal, and help presbyopic
18 September 2022 | Issue #26
was given by Prof. Dr. Ehud Assia, the medical director of Ein-Tal Eye Center (Tel Aviv, Israel), who argued that opthalmology has much further to go to reach the limits of lens technology. He postulated that a combined approach, mixing and matching technologies like blending refractive/diffractive and diffractive/EDOF in the one lens, is an idea worth investigating.
post-implantation. Unfortunately, the percentage results were marred due to the outbreak of COVID-19. However, he still was able to conclude that “patients are likely to not require glasses if they have a minimally myopic spherical equivalent, smaller mesopic pupil size, and total spherical equivalent close to zero,” based on the results of his work.
Prof. Assia also called for more customizable and personalized IOLs, taking into account various aspects of angle kappa, visual axis, corneal axis, and pupil center, when creating lenses for specific patients. He added that clinicians should consider the development of more artificial intelligence technology in ophthalmology, and how that can be used to affect change in the designs of IOLs.
Such an increase in image quality will smooth the baton-pass to AI over timeintensive manual flesh-and-bone image analysts, and Mr. Virmani took it from there. Echoing Dr. Romano, he explained how image quality is more critical than quality in training machine-learning algorithms. AI performance begins to plateau around 50,000 images with diseases like diabetic retinopathy, and this can be improved on.
Artificial intelligence (AI) is an allconsuming data glutton, and not a picky one at that – or so the layman is led to believe. But human data chefs would do well to use finer ingredients in the fare they cook up for AI consumption, and Dr. Vito Romano of the University of Brescia (Italy) and Sunny Virmani of Google Health have the hows and whys.
Dr. Romano thinks the biggest limitations with anterior segment imaging lies in a lack of standardization, lack of reproducibility and an overly complex workflow. When images are not standardized, experimental data becomes unreliable, among other things, and diseases that require high-quality images that change slightly over time like dry eye disease become even tougher to tackle. New lens designs are in early stage clinical trials, and solutions in this area will also bleed over into simplifying workflows to become image-first.
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Humanitas ex machina
This was the theme of Dr. Pearse Keane’s talk, who spoke of a future of code-free artificial intelligence wizards. According to Professor of Artificial Medical Intelligence, Dr. Pearse Keane of the University College London, deep learning and its potential must not be limited to those with technical expertise; innovation must be able to come from all sides, and developing a paradigm which allows ideas to flow without the constraints placed by specialized knowledge is a massive cog in the wheel generating progress in the field.
And finally, Prof. Farhad Hafezi, professor of ophthalmology at the University of Geneva and medical director of the ELZA Institute in Switzerland, gave a glimpse of what bringing advanced tech to the everyman could look like. Using recently-discovered massive unmet needs in keratoconus as an example, he explained the power and potential of the smartphone with the smartphone-based keratographer (SBK), a cheap, portable, and accurate device that can prove invaluable in screening for keratoconus. These devices will be taken on a field trip to remote regions of Nepal this year, and the world will be watching as devices like this turn the tide on a new era in medical imaging and diagnostics.
CAKE Magazine’s Daily Congress News on the Anterior Segment 7
Quality over quantity
Beyond this, Mr. Virmani noted that we need to build a human-centric model for AI. Ultimately, this is a tool deployed by humans to help humans, and we need to build trust in results and ensure that we can deliver the promises of machine learning to the vulnerable people who need it most.
Another limiting factor in AI performance is labeling; a more systematic approach to how we communicate to AI will help deliver us into an age where computers can spend seconds telling us our risk of developing potentially sight-robbing diseases from a simple photograph.
Day 2 of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) saw the ‘official’ kickoff of the core programming, and with it the more traditional forward-looking content that doctors from across Europe and the world came to see.
by Matt Herman
Our Digital Future in Ophthalmology
The future of ophthalmology, and medicine in general is in bits and bytes, and an early Saturday morning session from some rockstars in the datadriven medicine biz showed a smitten audience why. The ever-increasingly productive marriage of advanced imaging technologies and artificial intelligence is on the march, and the benefits reach beyond the limits of even the wildest of imaginations.
he future of digital medicine in ophthalmology is now, and speakers at an ESCRS 2022 Day 2 symposium showed just how dazzling the path forward can be.
“What can you do? Attend courses and symposia, both at ESCRS and afterward, and ask for national initiatives in your own countries as global collaboration is what is needed,” he added.
Telehealth remains here to stay
Prof. Dr. Oliver Findl, president of the ESCRS, professor of ophthalmology and chair of the Department of Ophthalmology at Hanusch Hospital (Vienna, Austria) spoke in detail about his organization’s efforts to help the Ukrainian medical community. He reported that two storage locations had been set up for medical supplies in Krakow, Poland, and Lviv in Ukraine’s western region. Medical equipment has been delivered throughout the country; the total amount of this aid reached over EUR 1 million, and was primarily comprised of equipment donated by industry partners.
Dr. Elferink spoke passionately about the importance of practicing sustainability as the medical industry is one of the leading global contributors to man-made climate change. He reported that it is responsible for 5% of all global emissions and that if it was a country it would be the world’s fifth most polluting state.
18 September 2022 | Issue #28 >> Cont. from Page 1
in how much waste is produced per phaco procedure in each country. As an example, Dr. Elferink showed the room two similar piles of medical waste, one from the United States, and the other from India. He revealed that the level of wasted procedures in America by one procedure was identical to that from 37 such surgeries in India.
The Ridley Medal Lecture is one of the highlights of the ESCRS congress and this year the speaker’s place was awarded to French ophthalmologist and former president of the ESCRS, Prof. Dr. Beatrice Cochener-Lamard. Her presentation, How the Digital World is Entering Our
Cochener-Lamard.witheyeteleconsultationandare“GovernancegovernmentalofHersheTéléassistancetele-expertise,teleconsultation,remotemonitoring,andmedicalregulation,saidpatientscanbenefitgreatly.argumentalsocoincidedwiththatDr.Elferink’sbycallingformorelobbyingandsupport.andgovernmentsupportcrucialtoestablishingtransparency,newplayersinthemarketlikeplatformsandremoteexamsolutionscanbesupportedtheirassistance,”concludedProf.
We’re all tainted by climate change
“Climate change has an effect on health ranging from mobility to malnutrition, disease susceptibility etc. COVID-19 made us see what a crisis on a planetary scale looks like, and that’s what climate change is, it’s a public health crisis too,” Dr. Elferink said.
“In particular, two Solaris machines designed for vitreoretinal surgery have been delivered to hospitals in Ukraine, as have three endoscopes for traumatic surgery. In addition, 24 travel grants worth EUR 1,000 were granted for Ukrainian ophthalmologists to travel to Milan, and 577 free passes were distributed,” shared Prof. Findl.
“AI technology is advancing faster than public health measures and legal approvals, and we are facing key limits with regards to bioethics and data protection, as well as the medical community’s distrust. They are on the whole afraid of doctor replacement and the loss of key skill sets,” she said.
Prof. Cochener-Lamard emphasized that the key benefit to adopting new technologies is that they represent a solution to ‘medical deserts’, areas where patients find it difficult or impossible to access treatment. By creating systems where ophthalmologists can maintain control over the five key components of telehealth;
“There will also be a trauma symposium, Ocular Trauma in 2022, which will be held as part of the Ukrainian Support Session. It will start at 9 am on Monday, September 19 in the Auditorium and I encourage all of you to attend,” Prof. Findl added.
Ukrainian visitors at ESCRS 2022 received a warm welcome.
“Surgery is for a large part responsible as it causes 30% of medical waste and is between 3-6 times more energy consuming than other healthcare sectors. This obligates us to do something about it,” he said.
Overall, the session has two other important themes, the Ridley Medal Lecture itself and sustainability in the ophthalmology industry. A key address was given by Dr. Sjoerd Elferink, a Dutch ophthalmologist, cataract surgeon, and chair of the ESCRS Young Ophthalmologists (YO) Green Group.
This is a general problem with the global medical industry as well as with ophthalmology specifically he said, as cataract surgery has the world’s highest surgical volume with major disparities
Practice, offered a full examination of how technological developments like telehealth and artificial intelligence (AI) are changing ophthalmology. Many clinicians adopted tech like telemedicine during the COVID-19 pandemic, and she said this is neither something to be abandoned now that the pandemic is over, nor to be feared.