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21 SEP 2018 PIE Ma ga zine’s D aily C ong re s s New s on the P o s t e rio r S e gment
HIGHLIGHTS Treatment and pg04 diagnosis of eye cancer
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Experts weigh in on AI’s role in ophthalmology
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Yes, there are myths in vitreoretinal surgery too! Find out what some of them are...
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Published by
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Call to ACTION on
Diabetic Retinopathy
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iabetic retinopathy (DR) should be a new focus for international efforts, a leading ophthalmologist said at the opening day of the 18th EURETINA Congress in Vienna yesterday (September 20). Professor Wong Tien Yin, Medical Director of the Singapore National Eye Centre (SNEC), took the opportunity after being awarded the congress’s Keynote Lecture Award to make a call to arms for action on what he described as the “global epidemic” of diabetic retinopathy. The event was a global conference, and the ideal place for cooperation to begin, he said, on what has become an international issue. Diabetic retinopathy is no longer an issue only for just wealthy western nations, he told the congress. Diabetes affects 153.3 million people in the Western Pacific region, 78.3 million in South East Asia, 49.6 million across Africa, and 29.6 million in South America, according to recent studies, he said. By 2030 there will be an estimated 400 million people worldwide with diabetes, he continued, with the condition growing significantly in countries where it was not traditionally considered a problem, such as India and China.
The impact could be greatest on less developed countries, which do not have the resources or attention to tackle a sudden increase in diabetes and its associated eye condition. Cont. on Page 3 >>
HOTSHOT
“Mozart” at his birth house in Salzburg. If Mozart were a surgeon today, what revolutionary tools would he use? Beyond in our PIE Magazine 07 issue Cover Story, we ask this same question daily during EURETINA. Today’s answer: Robotics, page 13.
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////////Science for a better life
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21 September 2018 | Vienna, Austria
Will old age stop us seeing our grandkids? 80 80 %
of visually impaired % people are over the age of 50
of all visual impairment can be prevented or cured
CanWeLiveBetter.com Source 1: GBVI – Global Disaggregation of Numbers for Gender and Age. IAPB Vision Atlas, 2017 Source 2: Vision Impairment and Blindness. World Health Organization, 2017 L.AT.MKT.09.2018.8551 September 2018
PIE Magazine’s Daily Congress News on the
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Cont. from Page 1 >>
By 2030 there will be an estimated 400 million people worldwide with diabetes, with the condition growing significantly in countries where it was not traditionally considered a problem, such as India and China.
For this reason, diabetic retinopathy requires “global action,” emphasized Prof. Wong. The focus of treatment is currently on tertiary action, treating diabetic retinopathy when it occurs, according to Prof. Wong, which the industry does well. Almost all congress sessions were on how the industry could provide better treatment to people already suffering with the disease, “but are we doing enough to prevent it?” he continued. Greater focus should be placed on preventative and secondary action, such as lifestyle changes, he added. “When we look at secondary prevention there have been many gaps,” he said. “That is maybe where our failings have been.” Diabetic retinopathy should be thought about as a systemic disease, not solely an ocular one, he said. Studies have shown that controlling blood pressure and glucose can significantly reduce the risk of developing diabetic retinopathy across ethnic groups and globally, but even in developed countries there is a lack of focus on that area. Ophthalmologists should be advising diabetic patients to take measures that will reduce their blood pressure and control glucose levels, he added. Efforts should also be made to increase awareness of the condition, particularly in developing countries where studies suggest the majority of people with diabetic retinopathy are unaware they have the condition, he explained. Screening could work as an early-stage measure to detect people with the disease or at risk of developing it, he said. Prof. Wong was instrumental in Singapore developing a screening programme for diabetic retinopathy, following in the steps of the United Kingdom. In both cases, from conception to the first screening took around ten years, he said, showing the level of commitment necessary to create momentum for change.
Looking at the developing global diabetes crisis, it could seem an impossible task to screen everyone, he noted, as there may simply not be enough ophthalmologists to conduct the work, particularly in developing countries. But, the future may hold hope in solving that issue, he added, via the development of artificial technology. “Artificial intelligence is something that is going to be on us very quickly in this generation,” he told the audience, and it could have a significant positive impact on tackling diabetic retinopathy. A “quantum leap” in terms of computer processing power and performance has allowed artificial intelligence to “take off,” he said, to the point where it is now outperforming humans. Artificial intelligence could make vast diabetic retinopathy screening more possible, he said, but there will remain challenges. First, artificial intelligence requires good, clean data, according to Prof Wong. It also needs to be tested in real world settings, he added. In addition, ophthalmologists will need to overcome their fear of artificial intelligence taking over the industry, he continued. Physicians “need to overcome fear of this black box phenomenon,” he said. It will be a useful technology for the industry, particularly in countries where there is a lack of ophthalmologists, he said, but its development will be curtailed if there is a push-back against it by physicians who fear losing their jobs if it becomes too prevalent. The future could see small, simple, portable artificial intelligence machines used for diabetic retinopathy screening, highlighted Prof. Wong. Widespread screening could have a significant impact on blindness caused by diabetic retinopathy, he concluded, as has been shown by the UK’s screening
all congress sessions “wereAlmost on how the industry could provide better treatment to people already suffering with the disease, but are we doing enough to prevent it? Greater focus should be placed on preventative and secondary action, such as lifestyle changes.
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– Prof. Wong Tien Yin: EURETINA 2018 Keynote Lecture Awardee
programme, which began in 2007. “There’s been good news,” he said, as the United Kingdom for the first time has seen a decline in blindness caused by diabetic retinopathy. The “global epidemic” of diabetic retinopathy requires “international strategies” he concluded. “It’s not sexy. It is hard work.”
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21 September 2018 | Vienna, Austria
Treating and Diagnosing
Eye Cancer
by Hazlin Hassan
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he 18th EURETINA Congress’s main session on ocular oncology for surgical and medical retina specialists saw renowned specialists sharing important insights on eye cancer, from diagnosing to treating patients. Although ophthalmologists may not do ocular oncology all the time, this knowledge is necessary as some cases may crop up in their clinic from time to time. Dr. Norbert Bornfeld from the Department of Ophthalmology, University of Essen in Germany, presented on how to diagnose intraocular lymphoma, including clinical presentation and biopsy techniques. He touched on the three types of intraocular lymphoma: vitreoretinal lymphoma, uveal Lymphoma, and iridial lymphoma. The incidence of primary vitreoretinal lymphoma (PVRL) is increasing over the last 20 years, with a mean survival of 3 years after diagnosis. Typical symptoms include loss of vision, floaters, and metamorphopsia, and the typical clinical appearance are yellow nodular subretinal infiltrates. In about 60-80% of the cases, the central nervous system (CNS) is involved, he said, adding that the prognosis for PVRL involving the CNS is poor and most patients are dead within years. The gold standard for diagnosing PVRL is a diagnostic vitrectomy and steroids should be stopped at least two weeks prior to the procedure, he said, adding that it is best done under air after retinotomy using the suction of a 25-gauge or 27-gauge vitreous cutter.
Cases of uveal lymphoma are rare, and often affect men more, with a mean age of 50-60 years. Clinical features include yellow-white unifocal or multifocal choroidal infiltration. It also has a much better prognosis. Vitreoretinal lymphoma continues to have a poor prognosis, he concluded, advising that a transretinal biopsy is the gold standard to diagnosing such cases and that less invasive methods have yet to be evaluated. Professor Heinrich Heimann, consultant ophthalmic surgeon, from the Royal Liverpool University Hospital, United Kingdom, spoke on how modern imaging can aid in differential diagnosis of small intraocular tumors. The first point of call in such cases is the general ophthalmologists, medical and surgical retina specialists, he said. The incidence of choroidal lesions is around 6% among Caucasians aged over 50 years. “In this room there are probably about 20 choroidal nevi or pigmented lesions and probably none of you or one of you would know that it’s there. It is as common as diabetic retinopathy,” Prof. Heimann told delegates. He noted that there is a sharp increase in detection and referrals due to the popularization of digital fundus photography, with referrals rising 30% over the past five years at his hospital. Game-changers include wide-angle photo documentation, auto-flourescence, optical coherence tomography (OCT) and enhanced depth OCT which can document lesions.
Professor Bertil Damato, from the Department of Ophthalmology, Nuffield Department of Clinical Neurosciences, Oxford University spoke on prediction of metastatic disease in patients with uveal melanoma and screening recommendations. During his presentation he said that patients with uveal melanoma have about a 50% chance of metastases. Once metastasis has developed, the prognosis is usually poor, he said. In order to personalize prognostication to make it accurate enough for individual patients, doctors should find out if a tumor has metastatic potential by doing genetic typing. “Some people think that prognostication causes harm to patients. But I found very convincingly that patients are much angrier and more harmed if they are not given good prognostication with genetic testing.” However he cautions that prognostication requires counseling, emotional and psychological support, practical advice, speaking to family, friends and colleagues, and investigating medical care, including screening, therapy and treatment for metastases. Dr. Mandeep Sagoo, consultant ophthalmic surgeon at Moorfields Eye Hospital, United Kingdom, presented on critical evaluation of systemic, ocular and ophthalmic artery chemotherapy for retinoblastoma. The main goals of ocular oncology were to save life, save the eye, and save vision, he stressed. He noted that it would be easy to think small tumors would be treated locally, the biggest tumors would involve removal of the eye and for cases in between, doctors would prescribe chemotherapy. But the reality is very different, he said, with some overlap in many cases. “The treatment of retinoblastoma is complex. Local treatments include cryotherapy, thermotherapy, Argon laser photocoagulation, and plaque radiotherapy,” he said, adding that external beam radiation is no longer used. Factors in choosing a strategy include age, status of fellow eye, treatment availability, team expertise, complication profile, risk/benefit ratio and parental wishes.
PIE Magazine’s Daily Congress News on the
Posterior Segment
Artificial Intelligence,
Will Transform and Disrupt
by John Butcher
A
rtificial intelligence will prove both disruptive and transformative to the ophthalmology industry, according to experts speaking on the opening day of the 18th EURETINA Congress in Vienna. Rapid advances in artificial intelligence (AI) driven by powerful computers and vast amounts of data will result in new models of care, financial savings, faster diagnoses, and improved patient services, experts told an audience on September 20. It will become an integral part of how the best in the profession operate, they added, and it could offer potential beyond human abilities. “AI will offer sustained benefits to the ophthalmology industry,” Dr. Adnan Tufail, a consultant ophthalmologist at Moorfields Eye Hospital in London, told the audience. Those benefits are already becoming apparent, according to Dr. Pearse Keane, a consultant ophthalmologist at Moorfields Eye Hospital, who also spoke at the same symposium. According to Dr. Keane, Moorfields Eye Hospital linked up with leading AI company DeepMind in 2016, to conduct research on the use of AI in ophthalmology in analyzing data from optical coherence tomography (OCT) scans. “OCT scans have transformed ophthalmology, but to some extent they have become a victim of their own success with too many now being performed to allow deep analysis to be carried out on them,” noted Dr. Keane. At Moorfields Eye Hospital on average 1,000 OCT scans are performed per day, and yet all the potential data within is not utilized, he said. The result is that Moorfields and other hospitals are only “scratching the surface in terms of clinical and scientific insights we could get from those scans.” He explained how the MoorfieldDeepMind collaboration had demonstrated how AI could be used to provide deeper analysis by taking it out of human hands to some extent. “It has shown the exciting potential of artificial intelligence,” he said, with it able to make referral decisions and well as recognize the full context of a disease.
Ophthalmology
OCT scans have transformed “ophthalmology, but to some extent they have become a victim of their own success with too many now being performed to allow deep analysis to be carried out on them. – Dr. Pearse Keane
”
AI will add speed and scope to ophthalmology work and studies, Dr. Ursula Schmidt-Erfurth, head of the ophthalmology department at the Medical University of Vienna, shared to the audience. “Models being developed will be able to identify disease features and classify them without interference, essentially conducting unsupervised anomaly detection,” she said. As well as enhancing the ability of ophthalmologists, AI could also go beyond human abilities, according to Dr. Tufail. Studies have been conducted on training AI with non-structural data, he said, demonstrating the technology’s ability to see “hidden information” in OCT scans. Studies at Moorfields looked into whether there was information on OCT scans that people cannot detect, but that AI can, which “infers flow.” “To everyone’s amazement it worked,”
Session on AI at EURETINA 2018 Congress.
he said, demonstrating a potential to “unlock a vast repository of OCT data to understand what is going on in these patients.” Another future use of AI could be in conjunction with robotics, he added, as a means of reducing error in work conducted by surgical robots. While AI will advance ophthalmology, it will also be disruptive, emphasized Dr. Konstantinos Balaskas, head of Moorfields’s Reading Centre. The advent of AI will change how, when and where ophthalmologists provide care, he said, adding that it was important “be clever about it and ensure that it is to the benefit of patients.” The infrastructure to do this already exists, he argued, in the form of reading centers, which can provide the technology, manpower and expertise, to analyze the benefits of AI and how best it can be used. “It is evident the developments in AI are likely to transform our models of care and to raise all sorts of questions,” he said, and it will require large amounts of data that is well curated. To get vast amounts of data all in one place, correctly labelled, is a “mammoth task” that requires knowledge and in many cases manual labor that reading centers can provide, he said. “Reading centers have the power to consider this new tool and its impact on the industry,” he added.
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Controversies in by Brooke Herron
Management of Endophthalmitis
E
ndophthalmitis is a serious, sightthreatening intraocular disorder, characterized by inflammation the intraocular cavities. “We found that the biggest predictors [for developing endophthalmitis] were complications at the time of cataract surgery,” said Dr. Christophe Chiquet, head of the ophthalmology department at Centre Hospitalier Universitaire de Grenoble, France. While cataract surgery is one of the most common intraocular surgeries worldwide, management of postoperative endophthalmitis remains controversial from lack of standardization of care. Current treatment includes antibiotics, and in some cases vitrectomy and use of steroids have been prescribed – but still the best first-line treatment remains debatable.
The vitrectomy debate Should we always do vitrectomy for cases of endophthalmitis? According to Dr. Jan van Meurs, owner of the Rotterdam Eye Hospital, The Netherlands, some doctors say yes – but that is not always the case. “There are some arguments for vitrectomy . . . the best one is for bad endophthalmitis,” he said. According to Dr. Chiquet, the first step to determine whether to do pars plana vitrectomy (PPV) is to identify if the patient is a good candidate or not. From there, doctors must get the timing right. This will reduce postoperative complications and fight against intraocular inflammation. “It’s best to go in early, but it can be hard to organize quickly,” added Dr. van Meurs. This is because the procedure needs to be done quickly – he says within four hours – and it may not be available everywhere. “After five hours, it doesn’t matter if you do the procedure or not.” PPV needs to be done by an experienced surgeon, which can pose difficulties of its own: the surgeon may not be onsite, or not in the best form to operate. “Patients must be managed in a vitreoretinal surgery center, and the clinical status must be evaluated twice daily if
Dr. Jan van Meurs
intravitreal injections are performed,” continued Dr. Chiquet. Like with any surgery there are complications – even with an “easy” vitrectomy procedure. “It can be dangerous to do vitrectomy on everyone due to postoperative complications. It depends also what you call vitrectomy . . . if it is core, it is recommended, but if it is large, it should be carefully considered,” explained Dr. Chiquet. “You can do vitrectomy at any time as long as you have a view, if you lose the view, you lose the eye as well. So, you should consider vitrectomy a little earlier – if you’re having difficulty seeing the fungus you will have a hard time.” However, Dr. van Meur notes that it does work: “Vitrectomy and antibiotics work best if treated very early. You might consider it early in some patients, in the very worst patients.”
The steroid discussion According to Dr. Catherine Creuzot-Garche from the Centre Hospitalier Universitaire de Dijon, France, the rate of endophthalmitis is decreasing, but it remains a trauma for patients. She says that steroids are used to treat endophthalmitis with the rationale that they limit leucocyte recruitment, stabilize the blood-brain (retinal) barrier, modify the expression of inflammatory cytokines and stimulate the production of cytoprotectants. “Corticosteroids have been used in endophthalmitis as in meningitis (pneumococcal infection),” said Dr. Garcher. “They were used the first time in 1974 and positive effects were found in some animal models, including low inflammation rate,
preserved tissue integrity and improved retina function. Although some pros and cons were raised from these animal models.” “In the old days, clinical trials were slightly in favor of steroid use, but this was only done in a few trials,” she continued. “In clinical practice, there is a very frequent empiric steroid use, but the timing (immediate versus delayed) is still controversial.” To learn more, Dr. Garcher and her team conducted a study to determine visual acuity with prompt intravitreal injection of betamethasone versus delayed treatment (48 hours) in patients with presumed endophthalmitis.1 The main objective was to determine the proportion of patients with visual acuity of greater than 20/40 at 12 months. Secondary objectives were to study the rate of delayed vitrectomy (more than three days) and the rate of complications, like retinal detachment and phthisis bulbi. Patients were randomized into two groups: both received intravitreal vancomycin and ceftazidime, while one group also received intravitreal betamethasone injection (early-IVB) or no immediate injection (delayed-IVB). After 48 hours, a second intravitreal antibiotic injection associated with intravitreal betamethasone was given to all patients. They found that overall, 62.9% of patients achieved a visual acuity (VA) of ≥20/40 at 12 months. In patients with severe endophthalmitis or clinical deterioration, a prompt or delayed vitrectomy was performed. The rates of delayed vitrectomy, retinal detachment and phthisis bulbi were not significantly different between the two groups (p=0.42, p=0.37 and p=0.44, respectively). This led the investigators to conclude that early intravitreal betamethasone had no clear advantage versus delayed injection in the management of presumed postoperative endophthalmitis. 1
Koehrer P, Bron AM, Chiquet C, et al. Early versus delayed intravitreal betamethasone as an adjuvant in the treatment of presumed postoperative endophthalmitis: a randomised trial. Br J Ophthalmol. 2016;100(8):1076-1080.
PIE Magazine’s Daily Congress News on the
Posterior Segment
Population Level Action Needed on
Myopia Crisis
by John Butcher
R
ising levels of high myopia in Asia and Europe warrant population level action to tackle the issue, a leading ophthalmology professor has said. Speaking on the opening day of the 18th EURETINA Congress in Vienna yesterday (September 20) Professor Wong Tien Yin, Medical Director of the Singapore National Eye Centre (SNEC), warned myopia levels had reached “quite astounding” levels with an estimated one billion people globally likely to suffer from the condition by 2027. Dramatic measures should be considered to counter this trend including government action on national levels, he said, and individual ophthalmologists should also do more to address it. High level myopia, an advanced form of the condition, has long been considered an Asian problem, Prof. Wong told the audience, and it is a significant and growing concern for the region with rising levels of blindness due to the condition along with increasing amounts spent on tackling it ($1 billion a year in Singapore alone). However, it will become an increasingly urgent issue for Europe too, he warned, as recent population studies have shown rising myopia levels among Caucasians. “If it is not a problem in Europe now, it will be quite soon,” he said.
The myopia crisis is so “pressing that action should be considered at a population level, by governments.
”
– Prof. Wong Tien Yin
Tackling this developing crisis on both continents will require a change of mindset among ophthalmologists, according to Prof. Wong. The industry as a whole concentrates on late stage issues and generally considers myopia as someone else’s problem, he said. There must be a shift towards prevention and engagement with the issue if progress is to be made, he added.
Prof. Wong questioned why atropine, administered as eye drops, is not widely prescribed as a treatment for the condition, despite it having a significant demonstrated impact on slowing its progress. Its widespread use is held back because there is no pharmaceutical company behind it and therefore “no money to be made,” he said. The myopia crisis is so pressing that action should be considered at a population level, by governments, he added. He cited the case of China, which last month announced plans to control video gaming in order to tackle myopia levels. That followed a statement earlier in the month by Chinese President Xi Jinping, who called for greater attention on optical health. Measures that the authorities plan to take include limiting the number of new online games allowed to market, restricting playing time and setting age restrictions. That was done despite it having a negative impact on gaming companies. Internet-based technology companies Tencent, which is based in the southern Chinese city of Shenzhen, saw a significant impact on its share price as a result of the announcement. Population level action could have an impact and should be considered, according to Prof. Wong. “Some population level policies can have an impact,” he said. “It is something we probably need to do.”
Key members of the Asia-Pacific Vitreo-retina Society (APVRS) share perspectives in the management of pathologic myopia.
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YAMANE
21 September 2018 | Vienna, Austria
DOUBLE-NEEDLE STABILIZER
Must-see Places In and Around
Vienna
by Ruchi Mahajan Ranga
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s the joint EURETINA and 36th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS) congress brings its attendees to Reed Messe, Vienna, it also gives many reasons to its attendees to find out what makes Vienna an absolutely festive and magical city. Just like a city of fairy tales, Vienna is a stunning city that relishes its past and has some of the most famous attractions in the world to prove it. Stylish taste, rich culture and marvelous architecture all reflect the spectacular legacy of Vienna in a graceful style. Being the largest city and the capital of Austria, Vienna has given the rest of the world some very precious things – the Viennese waltz, great classical composers,
sinfully delicious pastries, being an epitome of European history, impressive buildings, and much more… Whether you are on the look to discover more about the long-reigning Habsburg family or wish to enjoy the classical music composed by Wolfgang Amadeus Mozart, the city offers enough to keep you entertained. Here are some of the not-to-be missed attractions for anyone visiting Vienna… St. Stephen’s Cathedral Also known as Stephansdom, this massive cathedral is truly a centerpiece in Vienna. This Gothic architectural marvel standing tall today was built in early 12th century. St. Stephen’s
VIDEOS Watch the videos and see how the technique works.
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St. Stephen’s Cathedral
PIE Magazine’s Daily Congress News on the
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ESCRS Satellite Symposium Optimizing Your Clinical Practice With OCT and OCT Angiography Sunday, September 23, 2018 from 1pm - 2pm SPEAKERS
Salzburg
Cathedral is the mother church of the Roman Catholic Archdiocese of Vienna and the seat of the Archbishop of Vienna, Christoph Cardinal Schönborn, OP. The cathedral has borne witness to many important events in Habsburg and Austrian history, with its multi-colored tile roof, and has emerged as the city’s most recognizable symbols. House of Music This interactive place allows you explore the world of music in the most unique and comprehensive way. From composing music to creation of sound and voice to musical instruments, House of Music is a perfect gateway to the world of music. Piano enthusiasts can play on a piano in the lobby where kids will love the musical stairs and virtually conducting the Vienna Philharmonic Orchestra. The place can totally spice up your family’s musical experience while in the town. Walk through Naschmarkt Your visit to Vienna isn’t complete without taking a walk through the multicultural bustle of Naschmarkt. It is known as Vienna’s main food and produce market. Whether you want to go for lunch, an after-work cocktail, or just wish to unwind after a hectic day, Naschmarkt offers you delightful array of options to see, eat, drink, shop and enjoy. Even if you are not a foodie or an avid shopper, it’s a great place where you can admire the surrounding art nouveau buildings.
Lainzer Tiergarten If you are on the look to find a getaway from all the hassle and bustle of your day, Lainzer Tiergarten is undoubtedly the place for you. It is a famous wildlife preserve in the 13th district of Vienna. About 80% of this preserve is covered by woodland, making it an ideal place for long walks. If you are a fan of nature and wish to find a serene space, Lainzer Tiergarten’s floral and green beauty will mesmerize you. Twin City Liner Vienna and Bratislava are the two capital cities with shortest reaching distance in Europe between them. So, if you are staying in Vienna, be sure to hop on the Twin City Liner to take a cruise to Bratislava, the capital city of Slovakia. This will allow you to check out two European capital cities in just one day as it takes only 75 minutes from each direction to reach the other. Salzburg The birthplace of Mozart, located at the border of Germany, is less than 2 hours and 30 minutes away from Vienna by train. This fourth-biggest city in Austria is dominated by churches, palaces, and castles. When in Salzburg, you will find yourself immersed in countless personal stories about the city’s rich 12-century history. An internationally acclaimed World Heritage listed city, there is always so much to say about Salzburg. This city, popularly known as Mozart’s town, is filled with striking architectural wonders, museums, Cont. on Page 10 >>
Vincent Borderie, MD, PhD France - Moderator
Maria Cristina Savastano, MD Italy
Luca Di Antonio, MD, PhD Italy
Frank Goes Jr., MD Belgium
Reed Messe Congress Center, Room: Lehar 2 Lunch Boxes Provided Discover Optovue’s latest technology at EURETINA & ESCRS stand N° B203 To register for this event: www.optovue.com/escrs-symposium
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21 September 2018 | Vienna, Austria
and much more that will perfectly stun you with a unique experience. Even if you are visiting Vienna for a short duration, stick with paying a visit to Salzburg and you’ll realize how special of a place it is. Schönbrunn Palace and Gardens Schönbrunn Palace has been Vienna’s major tourist attraction since 1960s. One of the country’s most important cultural assets, the palace is an eye treat. You can opt for a tour of the imperial apartments that will include the residential suite of rooms formerly occupied by the royal family, all furnished in 19th century style. The 1,441-room Baroque place is one of the very popular architectural, historical, and cultural monuments in Austria. One of the most visited tourist attractions in Vienna, the place conveys an authentic
“Mozart” looks out upon Salzburg, his birthplace.
House of Music
impression of the imperial lifestyle with its original furnishings and decorations. The gardens and park surrounding the palace make it a good recreational area for people belonging to all age groups. Architecture from across the ages complements the natural beauty of the mountains and green landscapes that surround it.
meet up with giraffes. Watching the dwarf mongoose in a playful mood, the mighty hippopotamus in a spacious bathing pond, and hornbills bustling around is sure to amaze and entice you and your family. The zoo will enrich your experience by offering you a glimpse of animals from around the world.
The Vienna Zoo Located in the heart Schönbrunn palace, Vienna Zoo is the oldest and best zoo in Europe. If you are travelling with kids, this is a must-see place where your little ones will enjoy seeing the cutest of pandas, elephants, orangutans, and also the fiery Siberian Tigers. Each year more than two million visitors come to see the newborn elephants, lions, polar bears, panda babies, and many other animals. The new giraffe park introduced in May 2017 offers the visitors a face to face
Vienna is symbolic of culture and refinement for its visitors. Its heritage buildings, diverse culinary delights, stunning architecture, amazing coffee houses, long lasting tradition, way of living, and classical music are sure to make your visit a memorable one. After or before the congress, when you go visit these places, you would not be able to stop yourself from being mesmerized and awed by not only the beauty but also how well everything has been maintained for centuries.
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Busting Myths in Vitreoretinal Surgery by Brooke Herron
Unicorns are another myth (that have nothing to do with ophthalmology).
A
lthough ophthalmology is a science, myths can still creep in. So how do we differentiate between facts, and what is simply not true? According to Dr. Ramin Tadayoni, Professor of Ophthalmology at OphtalmoPôle in Paris, France it comes down to research, studies and experiments. Knowledge comes from sensory experiences . . . after all, a hypothesis begins as a thought and evidence is discovered through experience – or in this case, experiments.
Myth #1 One such myth concerns childbirth, which is that patients with a history of retinal detachment (RD) should not push – and myopes should not push either. The myth comes from the statistic that 10.5% of maternal subconjunctival hemorrhage occurs following normal vaginal delivery. And according to a 2008 survey, 76% of surveyed obstetricians advocate interventional labor in patients with a history of RD – and 38% believed that raised intraocular pressure (IOP) during contractions would cause RD. According to Dr. Alistair Laidlaw, this could be attributed to the Valsalva maneuver – although he notes this is not a recognized risk factor for RD and is very rare. He notes that statistics show that 1 in 500 45-year-olds who have a baby will have RD, while 1 in 1,500 30-year-olds will have
one. He notes that in the United Kingdom, 1 retinal problem was observed per 137,000 normal vaginal deliveries, for an incidence of 0.0007% – none of which were RD. He says based on these numbers (and other research), this myth is based more on belief than evidence and there is an insufficient risk to modify childbirth.
Myth #2 Another myth is that LASIK increases the risk for RD. But is that really so? Dr. Thomas Wolfensberger, Director of Vitreoretinal Department at Jules Gonin Eye Hospital, University of Lausanne, Switzerland, says that when you Google “myths in retinal surgery” what comes up is not anything to do with retinal surgery, but instead with refractive surgery. What?! We know that refractive surgery can be divided into two categories: intraocular and extraocular. For one intraocular procedure, phakic posterior chamber intraocular lens (PPCIOL), the retinal detachment rate is 0.8 to 1.2% ̶ meaning that the incidence appears to be below average for RD. A 2008 study hypothesized that if the PPCIOL is too large in diameter, it will irritate the ciliary body leading to inflammation with peripheral contraction of the vitreous. “It’s not so much the technique, rather that the size of the implant isn’t right,” said Dr. Wolfensberger. In this case, the refractive surgery would not lead to RD.
For extraocular procedures like LASIK, a 2001 study reported that the incidence of RD was low (0.06%). Another study, this one published in 2006, found that there was a yearly incidence of RD following LASIK of 0.032%. The authors concluded that the incidence of RD was not increased by LASIK. “In an apple tree, the apples hang on the tree and fall at some stage. But if you go in and kick the tree the apple might fall before it normally would,” said Dr. Wolfsenberger. “So, what happens with LASIK [in incidences of RD], is you accelerate a physiological event that would have happened later anyway.” What about LASIK after RD and vice versa? “If you apply LASIK after RD surgery, you may have problems with suction or regression of refractive changes,” he explained. On the other hand, vitreoretinal surgery after refractive surgery comes with its own set of problems. Dr. Wolfsenberger notes that there can be LASIK flap displacement during RD surgery, among other issues. So, while these procedures can have an effect on the other and cause complications, LASIK alone, wouldn’t be solely responsible for RD.
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21 September 2018 | Vienna, Austria
Keep Your Gloves On and Other Tips on How to Manage Retinal Diseases
Professor Francesco Bandello by Hazlin Hassan
L
eading specialists shared their guidelines for the management of retinal diseases yesterday at the 18th EURETINA Congress, going over some basic issues such as hygiene as well as which anti-VEGF worked better. Among the speakers were Dr. Andrzej Grzybowski, Professor at the Department of Ophthalmology, University of Warmia and Mazury, Poland, who briefed the session on state-of-the-art endophthalmitis prophylaxis in anti-VEGF therapy. Endophthalmitis (EO) is an inflammation of the interior of the eye, with possible loss of vision and the eye itself. The topic was important due to a “huge increase in intravitreal injections in recent years globally,” he said. He outlined the latest 2018 EURETINA Expert Consensus Recommendations on intravitreal injections. Among them were that office-based and operating room-based injections have very low EO incidence, topical antisepsis (povidoneiodine or chlorexidine) was the most important intervention to reduce risk of postoperative endophthalmitis, and frequent use of topical antibiotics promoted increasing antibiotic resistance and growth of pan-drug resistant bacteria which would lead to more severe endophthalmitis cases. Sterile instruments and gloves were recommended, and equipment should not be reused, he added. Wearing face masks or remaining silent during the procedure lead to a significantly decreased bacterial contamination on culture plates. Francesco Bandello, Professor and Chairman of the Department of Ophthalmology at University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy, shared ten key messages on diabetic
Professor Anat Loewenstein macular edema (DME). He pointed out that one mistake the industry was making was that it was using an old classification system, and that proper classification was crucial for treatment choice. He talked about the different types of DME, which range from vasogenic, nonvasogenic, tractional and mixed, and noted that vasogenic appeared to be the most frequently occurring. He said that laser was no longer recommended for DME with “classic” indications. Anti-VEGF remained the first choice in treating both focal and diffuse DME, unless contraindicated, he said. On the question of which anti-VEGF is best, he said all appeared to be equal. Based on Protocol T’s two-year results, bevacizumab, ranibizumab and aflibercept were equal in restoring visual acuity at two years follow-up. “All of these anti-VEGF produces some good results at the level of ischemia and proliferative diabetic retinopathy,” he added. Steroids, in particular dexamethasone, are a first-choice in the event of recent cardiovascular events, or if the patient is vitrectomized, pseudophakic or simply noncompliant, he said. He also pointed out that doctors in Europe appear to use more steroids than in the US. “In many cases the capability of steroids to act against all the different pathogenic mechanisms is able to guarantee some better results compared with anti-VEGF and we must remember that 30 to 40% of our patients are not sensitive to anti-VEGF,” he said. Steroids were second-choice in diffuse DME with a few exceptions, he said.
In the event of an unresponsive tractional DME, he said central vitrectomy must be performed with epiretinal membrane removal and possibly internal limiting membrane peeling. He reminded delegates at the session that metabolic control was important and to refer to a diabetologist and not to delay retinal therapies in the event of uncontrolled diabetes. He concluded by saying that there have been dramatic improvements in diagnostic and therapeutic care of DME during the last few years. “Individualized therapy – choosing the right therapy for the right patient – is the most effective approach to maximize results.” Dr. Anat Loewenstein, Professor and Director, Department of Ophthalmology, Tel Aviv Medical Center shared her ten key messages on retinal vein occlusion (RVO). Among them were that systemic evaluation should be minimal, to treat early in the course of the disease, to treat with anti-VEGF in the case of macular edema (ME), that there were no differences found between anti-VEGFs, and that visual acuity may be improved even in patients with bad visual acuity at baseline. Dr. Daniel F. Martin, Chair of the Cole Eye Institute, USA, shared on future directions in the evolution of anti-VEGF therapy.” The notable speaker administered the first anti-VEGF intravitreal injection in January 1999. Among his suggestions on what could possibly improve outcomes in age-related macular degeneration (AMD) would be better prevention of macular atrophy, although there is no treatment known to date, and reduced treatment burden.
Mozart Says
PIE Magazine’s Daily Congress News on the
Posterior Segment
Robotics The Future of
Posterior Segment Surgery by Brooke Herron
F
rom studying Mozart, we know he was credited for advancing the technical sophistication of classical music in his time – which didn’t come without controversy. If he were an ophthalmologist, he would have been looking toward the future as well . . . pushing the science ahead with intelligent debate (see PIE Magazine issue 07 for full “Dr. Mozart” coverage). Today, the advent of robotics in surgical procedures is set to not only advance the technical sophistication of the field, but perhaps create a revolution in the way we operate. One such robotics system is the PRECEYES Surgical System from Preceyes BV (Eindhoven, The Netherlands). Featured at EURETINA 2018 (Booth #C238), this surgical platform can operate with an accuracy of better than 10 microns, meaning it can perform procedures in the vein of the retina. “Our goal is to get to stage where a micro robot could do eye surgery,” said Prof. Marc de Smet, CMO of Preceyes BV. “A surgeon is like a pilot in a plane . . . a robot it 10 times better, if you can feed video information it would be 100 times better.” Of course, this doesn’t mean that the robot takes over everything – the surgeon can define the planes in which they want to work. The surgeon is still present at the patient’s head, and still at the microscope. The robot can be brought in (with a micro mechanical arm) when precision is needed,
or to accomplish certain tasks. Overall, Prof. de Smet says this promotes a safer surgery and facilitates teaching. One main idea was to make the instrument intelligent. For example, it could anticipate whether a retinal detachment could occur as you approach the retinal surface. “If you want to penetrate through retinal tissue, you could decide to depth you want to go. You could preprogram how far you want to go within the tissue and into subretinal space,” he continued. Another example, Prof. de Smet explains, is putting a limit to how deep to go during a vitreous hemorrhage. “It makes it safer as you work faster.”
PRECEYES Surgical System
“It does demand a fair amount of programming . . . we have to break down into components to make sure the robot carries out what we want it to do,” he said. “It can be seen as an assistant – it can take over parts of surgery to make it more efficient.” The system was first used two years
ago on a patient in Oxford. Since then, they have performed procedures using the system on additional patients. Currently, two robots have been sold, plus one simulator. “We need to get industrialization of our device so we can go to a mass market,” continued Prof. de Smet. He expects that to happen by 2020. He says they are focusing on vitreoretinal surgery because it is such a varied surgery. “There’s precision in different areas, so it made sense,” explained Prof. de Smet. He says most people who develop things like this would like multiple systems – dedicating specific robots for a specific indication, but from a macroeconomic standpoint it doesn’t make sense: “It makes more sense to have a few systems that are a generic platform where specific tools make it useful for vitreous or anterior segment.” He says that in the future, they will also develop the platform to work in the anterior segment. This Mozart-approved innovation will undoubtably create more specialized care in specific areas. “I think we’re ahead of the curve,” said Prof. de Smet. “Others are coming along – I would assume that within five years, there will be competition.” He notes that a true adoption can take longer and that perhaps in 10 years robots will be present in hospitals. Certainly, this is an advance that Mozart would embrace.
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21 September 2018 | Vienna, Austria
Alcon Allows Surgeons to
Focus on What’s Important –
the Patient
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lcon, the global leader in eye care, provides surgeons with the latest in cutting edge technology in surgery tools in order to allow surgeons to focus on what’s most important – the well-being of the patients. Here, we interviewed renowned surgeons who have tried Alcon’s ophthalmic tools to share their experiences. Ramin Tadayoni, Professor of Ophthalmology at OphtalmoPôle in Paris, France, described the integration of NGENUITY 3D Visualization System and the CONSTELLATION Vision System which allows surgeons to view data on one screen, through DATAFUSION software, as a step forward in the surgical field. “It helps the surgeon to better control the parameters and concentrate on what matters: performing the surgery,” he said. Professor Tadayoni noted that the vision on NGENUITY is also improved and the use of the whole system made easier with the integration of the tools. Also, he shared that he enjoyed using the Advanced Ultravit 10k Beveled Tip Probe Cutters. “I like the Beveled Tip as it helps us to work close to the retina. The 10k decreases the distance of action of the probe and increases security. He said it also increases efficacy, by allowing the surgeon to reduce aspiration which in turn improves
by Hazlin Hassan
stability. “In the end, the vitrectomy is safer and still efficient,” he added. Talking about the 27+ Portfolio, Professor Tadayoni emphasized that: “It is probably the best on the market I have used in terms of maintaining efficacy and stiffness. The smaller gauge allows working with precision close to the retina.” Professor Tadayoni also tried the new additions to the Grieshaber portfolio (e.g. the Finesse SHARKSKIN ILM Forceps) and was impressed by the improvement especially in small gauge instrumentation. Furthermore, Dr. Carl Claes, Head of Vitreoretinal Department, Sint-Augustinus Hospital, Antwerp, Belgium, said that the integration of the Constellation and NGENUITY is a “winning combination” boosting both efficacy and userfriendliness. “The NGENUITY is a real eye opener and facilitates the life of the surgeon tremendously together with the new improvements on the Constellation,” he said. According to Dr. Claes, the Advanced Ultravit 10K Beveled Tip Probe Cutters are another leap forward in less traumatic and faster vitreous and membrane removal. He noted how the miniature instrument possessed an incredible cutting power and made it easier for surgeons during the procedure as frequent instrument exchange
can be avoided thanks to the multifunctionality of the instrument. “The complete 27+ Portfolio also allowed tackling the most advanced cases with good control of very complicated intraoperative surprises,” he added. As for the Finesse SHARKSIN ILM Forceps, Dr. Claes noted that the design provided better visibility of the tissues to be peeled and the improved grip holds membranes and ILM tighter. “In this way, allowing easier and complete peeling,” he explained. Finally, Dr. Khalid Al-Sabti, CEO of Kuwait Specialized Eye Centre, said that the NGENUITY has improved its performance since its introduction in 2016 in both hardware and software, providing retina surgeons a wide variety of options in digital enhancements, which have changed the way of doing retina surgery. “With digitally-enhanced 3D technology we have seen the inside of the eye like never before,” he said. “For example, enhanced depth perception provided us with better insight of fine surgical maneuvers that were very difficult or even impossible few years ago. In addition to enhanced depth we do have a large selection of color filters that help retina surgeons highlight different structures,” he further explained. Of Alcon’s latest release in integrating NGENUITY and CONSTELLATION, displaying surgical parameters on the NGENUITY screen, Dr. Al-Sabti noted that it is a big step towards safer surgery. “I have used this feature and found it very helpful during surgery,” he said. “The next step of integration with V1.3 which will allow bidirectional integration will be released in Q1 2019. This feature will emphasize the concept of surgeon customized setting making both machines work as one platform in a new concept for retina surgery which is surgeon-focused,” Dr. Al-Sabti shared. He also commented on the Vektor Articulating Illuminated Laser Probe, a new addition to Alcon’s retina surgery portfolio. “It provides a wide range of treatment zones through one entry with a minimal need to exchange sites. It also provides anterior treatments that other laser probes may not offer,” he said.
PIE Magazine’s Daily Congress News on the
Posterior Segment
Visit Us at ESCRS-EURE TINA at Booth #C 518A
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