 of cataract surgeons and nurses found that most are concerned about operating theatre waste and believe that having more re-usable products in the operating theatre is a step in the right direction. The survey was developed by the Ophthalmic Instrument Cleaning and Sterilization Task Force, which has representatives from the American Society of Cataract and Refractive Surgery, the American Academy of Ophthalmology (AAO), the Outpatient Ophthalmic Surgery Society and the Canadian Ophthalmological Society. The survey was disseminated to the members of all four societies.

Some impetus for the survey came from two published studies from the Aravind Hospital System in India. The first report in 2017

 found that their carbon footprint for phacoemulsification was one-twentieth of that in the United Kingdom and the United States, largely because they re-use as many surgical supplies and drugs as possible. A second study in 2019

 found that despite such widespread re-use, the rate of endophthalmitis in the Aravind system was 0.01% – lower than that in the United States, with the AAO IRIS registry rate of 0.04%.

Combined MIGS and cataract surgery option offers positive results

“The results suggested that much of our surgical waste due to single use of everything is excessive and of unproven benefit for preventing endophthalmitis,” said Dr David F. Chang, clinical professor of ophthalmology, University of California, San Francisco, US. Dr Chang co-authored the survey report with Dr Cassandra Thiel, assistant professor, New York University School of Medicine, US.

The respondents felt that the major factors accounting for operating theatre waste were wasteful packaging of single-use items (71%), hospital/regulatory policies (74% and 82%, respectively) that limit surgeon discretion in re-using supplies, manufacturer mandates in instructions for use (IFU) for single-use products to limit liability (70%) and manufacturers driving the market towards more profitable single-use products (77%). Surgeon or patient preference for single-use products was felt to be a driver by only 26% and 7%, respectively.

Support of re-use of devices and supplies

The 23-question survey was completed in full by 1,317 of the 1,563 respondents; more than 1,050 of those who completed the survey were doctors.

The surgeons strongly/somewhat agreed that manufacturers of devices and supplies should use recycled content in packaging of medical supplies (90%) and that they should consider the environmental/carbon footprint in product design (92%). “However,” Dr Chang said, “the real impact would be to offer more re-usable instruments and supplies as options (94%) and allow surgeons greater discretion within their IFUs for re-using supplies (93%).”

Other areas with which surgeons strongly/somewhat agreed were more surgical discretion in the re-use of supplies by regulatory bodies (95%) and advocacy by medical societies to reduce the carbon footprint in operating theatres (87%).

Regarding the use of topical pharmaceuticals and intra-ocular pharmaceuticals, 98% and 95%, respectively, would consider using them in multiple patients; there was also strong agreement for re-using compounded pharmaceuticals (86%). Most surgeons are or would consider sending pharmaceuticals home with patients from the operating theatre (93%).

Investigators analyse factors associated with patient satisfaction after refractive surgery

Surgeons were very willing to re-use phaco tips (92%), phaco tubing and irrigation bottles (77%), cystotomes (72%), single-use cannulas and metal blades (74%), iris retractors (72%) and the unused halves of sutures (59%). During cataract surgeries, 91% are or would consider using short-cycle sterilisation and 56% would consider simultaneous sequential bilateral cataract surgery, although 34% would not be willing to do so.

Among other conservation proposals, eliminating the full-body drape was supported by 95%, not having the patient wear a hospital gown was supported by 90% and operating theatre staff using the same surgical mask all day was supported by 95%. Two-thirds of respondents were open to not changing surgical gowns between every case, but 77% would not be willing to re-use surgical gloves. Endophthalmitis (48%) and toxic anterior segment syndrome (43%) risks and malpractice liability (51%) were factors that decreased willingness to use supplies and medications on multiple patients.

Let’s throw everything away…except the patient and the surgeon

Factors potentially driving single-use instruments included reduced staff processing requirements (45%) and improved operating theatre efficiency (37%). “However, the main factors driving manufacturers to promote single-use instruments were felt to be increasing profit (62%), reducing liability (66%) and an easier regulatory approval pathway (65%),” Dr Chang said.

According to Dr Chang, the findings showed that more than 90% of surgeons are concerned about global warming; excessive operating theatre refuse; the need for more re-usable and multi-use options; strong preference for re-usable over disposable instruments; discretion from regulatory agents and manufacturers in re-using materials; and greater manufacturer consideration of carbon footprint.

This article is adapted from Dr Chang’s presentation at the American Academy of Ophthalmology’s 2020 virtual annual meeting. He has no financial interest in this subject matter.

1. Chang DF, Thiel CL. Ophthalmic instrument cleaning and sterilization task force. Survey of cataract surgeons’ and nurses’ attitudes toward operating room waste.J Cataract Refract Surg. 2020;46:933-940.

2. Thiel CL, Schehlein E, Ravilla T, et al. Cataract surgery and environmental sustainability: waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg. 2017;43:1391-1398.

3. Haripriya A, Chang DF, Ravindran R. Endophthalmitis reduction with intracameral moxifloxacin in eyes with and without surgical complications: results from 2 million consecutive cataract surgeries. J Cataract Refract Surg. 2019;45:1226-1233.

Articles

Cataract surgeons and nurses would support having re-usable equipment and supplies to reduce operating theatre waste and carbon footprint. 

Cataract surgeons on operating theatre waste: Less is often more

Physicians in New Delhi reported a rare case of bilateral immune-mediated keratolysis (corneal melting) after administration of one dose of the ChAdOx1 nCoV-19 (Covishield, AstraZeneca) vaccination.

This case may demonstrate a temporal association between this severe ocular adverse event after one dose of any of the available SARS-CoV-19 vaccines, according to first author Dr Tanveer Alam Khan and colleagues from the Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

The patient was a 48-year-old man who presented to the ophthalmic emergency department with what was described as progressive bilateral corneal melting 5 weeks after he received the first dose of the COVID-19 vaccine.

The patient reported having experienced fever, diarrhea and vomiting during the first 2 weeks following the vaccination, which then subsided before the ocular symptoms began 3 weeks after he received the vaccination.

Ocular examination showed a visual acuity of light perception bilaterally with features of bilateral corneal melting with choroidal detachment on ultrasonography. Culturing was negative for microorganisms.

The patient underwent tectonic penetrating keratoplasty and the host corneal tissue was sent for analysis that included histopathology; bacterial and fungal cultures; polymerase chain reaction for herpes simplex virus; varicella zoster virus; cytomegalovirus; adenovirus; and SARS-CoV-2.

“Microbial culture was sterile and viral polymerase chain reaction reports were negative. Histopathological examination revealed dense inflammatory cell infiltration,” the investigators wrote.

According to the investigators, a detailed systemic workup revealed no underlying systemic or autoimmune pathology.

“Immune-mediated keratolysis after the ChAdOx1 nCoV-19 (Covishield) vaccination is a rare entity, and we believe that this is the first report of a temporal association between a serious ocular adverse event after a single dose of any SARS-CoV-19 vaccine,” they concluded. “It may be included as a possible adverse event associated with this vaccine.”

1. Khan TA, Navneet S, Livia K, et al. Bilateral immune-mediated keratolysis after immunization with SARS-CoV-2 recombinant viral vector vaccine. 

. P P 4 September 2021. DOIi:10.1097/ICO.0000000000002844.

Telemedicine ushers in new chapter in eye care

Managing retinal disorders: Lessons learned from COVID-19 (video)

Navigating COVID-19 with ophthalmic patients in the hospital setting

A 48-year-old male patient presented to an ophthalmic emergency department with what was described as progressive bilateral corneal melting 5 weeks after he received the first dose of a COVID-19 vaccine.

Bilateral cornea melting may be linked to AstraZeneca COVID-19 vaccine

Key to beating diabetes is better understanding for ophthalmologists

Health systems are challenged to provide appropriate care for the ever-increasing number of patients with diabetes and its complications, such as diabetic retinopathy and diabetic macular oedema.

Should NPDR patients be treated with anti-VEGF agents?

Dr Jennifer Sun explores the question of whether ophthalmologists should be using anti-VEGF agents to treat patients with nonproliferative diabetic retinopathy (NPDR)

Comparison of suitable naïve versus pretreated DMO patients

Dr Javier Zarranz-Ventura discusses the key highlights from his presentation on a clinical investigation of suitable naïve versus pretreated DMO patients, and what it means for future research.

Providing optimal care for patients with diabetic eye disease

Prof Tunde Peto discusses her presentation on providing the best virtual care for patients with diabetic eye disease at EURETINA 2021.

Optogenetic therapy for retinal degeneration shows potential of gene-independent therapeutic strategies

Dr José-Alain Sahel explains that optogenetics involves the use of artificial photoreceptors from specific retinal cells to restore vision by transferring a gene that encodes for a light-sensitive protein that causes neuronal cells to respond to light stimulation.

Brolucizumab injection improves vision in eyes with neovascular AMD

Dr Cristina Cristian noted that an injection of brolucizumab treatment in patients with neovascular age-related macular degeneration led to a median improvement in visual acuity (VA) of 10.5 letters and the drug was well-tolerated.

AI for nAMD: Capturing more information from OCT

Dr Anat Loewenstein discussed how artificial intelligence can optimize optical coherence tomography.

Exploring the clinical and humanistic burden of geographic atrophy

During a presentation at the EURETINA 2021 Virtual Congress, Dr Daniel Jones discussed GA and emphasized the need for additional study to gain a better understanding of the burden experienced by patients.

LIGHTSITE II study: Photobiomodulation treatment improves vision in eyes with dry AMD

During a presentation at the EURETINA 2021 Virtual Congress, Prof. Ben Burton detailed how dry AMD patients treated with photobiomodulation therapy have seen improvements in best-corrected visual acuity 9 months after treatment.

Worldwide pathological myopia discussed by panel

Dr Ramin Tadayoni discusses the myopia panel at the EURETINA 2021 virtual meeting.

Addressing roadblocks of treating peripheral hemorrhagic polypoidal choroidal vasculopathy

Treating the disease can be a challenge, and at the EURETINA 2021 Virtual Congress, Dr Chekitaan Singh discussed a case study detailing the care of a patient who had already lost vision in one eye from a similar issue.

Exploration of new biological treatments in posterior uveitis

Professor Quan Dong Nguyen speaks on the highlights of his presentation regarding new biological treatments of posterior uveitis.

Analysis of macula dystrophy classifications

Study investigates PCR risks associated with intravitreal injections for AMD

Dr Marta Belmonte-Grau discussed the potential risk for posterior capsular rupture during cataract surgery.

Role of anterior vitreous, managing retinal folds in retinal detachment cases

Dr Grazia Pertile discusses the highlights of her presentations on the management of retinal folds after retinal detachment and the role of the anterior vitreous as a cause of recurrent retinal detachment.

A post-conference guide for ophthalmologists after the conclusion of EURETINA 2021.

EURETINA 2021 Virtual Congress in review

Retinal degenerative diseases are a major cause of visual impairment and blindness in humans. The retinal degenerative processes that result from genetic mutations generally affect the retinal pigment epithelium (RPE) and retina. The development of a new animal model for gene therapy may make studying these genetic mutations easier.

With the development of hypoxia, the photoreceptors progressively apoptose, and metabolic changes in the retina develop. Microglial cells that are activated by the dead photoreceptors can alter their location in the retinal tissue, resulting in further photoreceptor degeneration due to the release of proinflammatory cytokines.

Elif Ozgecan Sahin, MS, under the supervision of Salih Sanlioglu, VMD, PhD, from the Department of Gene and Cell Therapy at Akdeniz University in Antalya, Turkey, explained during a presentation at the American Society of Gene & Cell Therapy 2021 Virtual Annual Meeting that because the type of mutation present controls the photoreceptor degeneration, the pathologies seen in the hereditary retinal dystrophies are similar.

Realization of this similarity sparked the need for development of a new animal model of retinal degeneration that exhibits the pathologies seen in all the inherited retinal dystrophies, she said.

The investigators then set out to create an in vitro retinal degeneration model by treating ARPE-19 cells with cobalt chloride (CoCl2), an agent that triggers hypoxia. Western blot analysis confirmed the hypoxia and degeneration using antibodies against HIF1A. The next step then was generation of hypoxia in vivo by injecting CoCl2 intravitreally into Wistar rats.

Sahin pointed out that evaluation of their efforts via hematoxylin and eosin staining and TUNEL assay results “indicated that progressive retinal degeneration initiated in the outer segment of the photoreceptors and then further extended into the other retinal layers over time.” Changes began to be observed in the first 48 hours following the CoCl2 injection.

She also reported that the CoCl2 activated microglia cells that were visualized by CD68 immune staining; the cells were scattered throughout the retinal layers.

“All these results indicate that this chemical agent–induced animal model can be used successfully for gene therapy studies targeting retinal degeneration,” she concluded.

This article is adapted from Sahin’s presentation at the 

American Society of Gene & Cell Therapy 2021 Virtual Annual Meeting

. She has no financial interest in this subject matter.

Sanlioglu has no financial interest in this subject matter.

Development of new animal model enhances study of genetic mutations.

Gene therapies studied as potential treatment for retinal diseases

Videos

UK researchers reported that photobiomodulation (PBM) (LumiThera Inc.) therapy in patients with dry age-related macular degeneration (AMD) resulted in significant improvements in the best-corrected visual acuity (BCVA) 9 months after treatment and that retreatment at intervals of 4 months provided consistent improvements in visual function and morphologic signs of dry AMD activity and maintenance of clinical outcome benefits, according to first author Ben Burton, an honorary professor at the University of East Anglia in Norwich, England.

The LIGHTSITE II trial, designed to assess the safety and efficacy of PBM in dry AMD, is being carried out in the UK, Germany, France, Spain, and Italy.

Burton, speaking at the EURETINA 2021 Virtual Congress, explained that this technology uses wavelengths of light to target cytochrome c oxidase of the mitochondrial respiratory chain to activate energy production and improve metabolic output.

By improving cellular activities, the anatomic and clinical endpoints benefit. PBM improves cellular activities that in turn positively impact the anatomic and clinical endpoints.

The PBM treatment is delivered using a light delivery system (Valeda Light Delivery System, LumiThera Inc.), which is CE marked in the EU. A growing body of evidence, Burton noted, supports PBM in the 500- to 1000-nm wavelength spectrum as a novel treatment for dry AMD.

A total of 44 patients (53 eyes; 17 men, 27 women; mean age, 74.1 years) with dry AMD were enrolled.

However, this enrollment did not meet the original goal of 96 patients (144 eyes) because of the COVID-19 pandemic.

The study extended the positive findings of the LIGHTSITE I trial by treating earlier, intermediate dry AMD subjects with 3 rounds of PBM, Burton explained.

Patients, with vision ranging from 20/32 to 20/100 and no central geographic atrophy, were randomized to either PBM or sham using the Valeda Light Delivery System delivered 3 times weekly over 3 to 4 weeks. The light treatment is applied for 4 to 5 minutes/treatment/eye.

“PBM-treated eyes showed significant (p=0.02) improvement compared with baseline in the BCVA at 9 months in the modified intention-to-treat group (n = 51 eyes),” according to investigators. “The patients had sustained BCVA improvement at 9 months (p = 0.01) with an approximate gain of 4 letters in the PBM-treated group versus a 0.5 letter gain in the sham group (p=0.1) for patients that underwent all 27 PBM treatments (29 eyes).”

More than 33% of PBM-treated eyes gained 5 letters at 9 months. The AMD converted from dry to wet disease in 3.1% treated with PBM compared with 5.6% in the sham group and 4.8% in non-study eyes.

The investigators pointed out that that eyes at high risk for conversion to wet AMD, i.e., the fellow eye had exudative macular neovascularization, showed a 0% conversion rate after PBM treatment.

PBM treatment also was associated with no significant drusen growth at 9 months in contrast to the sham group.

A 44% decrease in growth of geographic atrophy after PBM was observed at 9 months.

No safety concerns or phototoxicity were associated with PBM.

Physicians and health systems are challenged to provide appropriate care for the ever-increasing number of patients with diabetes and its complications, such as diabetic retinopathy (DR) and diabetic macular oedema (DMO). Tunde Peto, MD, PhD, Professor of Clinical Ophthalmology, Queen’s University Belfast, Belfast, Northern Ireland, and Clinical Lead for Diabetic Eye Screening in Northern Ireland and Medical Retina Consultant, offered some practical advice to address some of these challenges.

Diabetes and DR: Making progress in the global epidemic

The Diabetic Retinopathy (DR) Barometer Study

 analyzed data from over 4,000 patients and 2,000 doctors worldwide showing just how difficult living with and managing diabetes can be. The study results showed that almost 40% of patients describe the long wait times for an appointment as a barrier to eye examinations. 

About 80% of responders said that diabetes and DR and DMO impacted their ability to function in daily life, making driving, working, and completing the most basic household tasks difficult to impossible. Twenty percent reported that their visual impairment resulting from DR and DMO made managing diabetes difficult; and 69% described days during which they experienced poor physical/mental health. 

These difficulties in some settings might be compounded by the fact that as high as 1 in 5 ophthalmologists said that they did not receive specific training in diagnosing DR and DMO; and 44% of care providers did not have or use written protocols for managing diabetic eye disease and related visual loss. 

Prof Peto believes education, timely diagnosis, and treatment are the key components for preventing visual loss and preserving vision. Working together with patients and patient organization and co-developing education material will raise awareness of the disease. Diabetic eye screening programs can significantly address the problems associated with late diagnosis of DR and DMO leading to timely treatment and consequently better quality of life.

Diabetes during pregnancy linked to high refractive error in offspring

Complications associated with diabetes develop over a long period and regular monitoring can identify most patients at a stage in which treatment is most beneficial. DR and DMO lend themselves to image-based monitoring.

Physicians have an excellent understanding of diabetes-related eye changes, starting with the Airlie House Classification of DR.

 Landmark studies such as the Early Treatment Diabetic Retinopathy Study and the Diabetes Control and Complications Trial established a good understanding of the disease process.

 DR classification has been based on the presence of characteristic features in the eye or color fundus imaging of microaneurysms, hemorrhages, vascular abnormalities, and new vessels, and for DMO on these changes and exudates and macular fluid.

Diabetic macular edema: Treatment overview

“With advances in imaging technologies, we now have the opportunity to refine these and add further disease features to match our current understanding of the disease, its progression, and the potential response to treatment. Diabetes-related blindness still increases by 8% annually, so working with patients, care givers, public health agencies, and the healthcare sector, our patients with diabetes will have a better chance of retaining their vision and live a productive life,” Prof Peto concluded.

1. Cavan D, Makaroff L, da Rocha Fernandes J, et al. The Diabetic Retinopathy Barometer Study: Global perspectives on access to and experiences of diabetic retinopathy screening and treatment. Diabetes Res Clin Pract 2017;129:16-24; DOI: 10.1016/j.diabres.2017.03.023

2. Wu L, Fernandez-Loaiza P, Sauma J, et al. Classification of diabetic retinopathy and diabetic macular edema. 

3. Early Treatment Diabetic Retinopathy Study Research Group. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Ophthalmology 1991;98:786–806.

Diabetes Control and Complications Trial Research Group

 S, Lachin J, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med1993;329:977-86; doi: 10.1056/NEJM199309303291401

Myopia is the most common refractive defect of the eye, affecting substantial proportions of adult populations; in one UK study, it was found to affect 49% of adults.

 The exponential increase in the prevalence of the condition is sparking increased interest in the geometric properties of the conjunctival-scleral tissue.

Generally referred to as short sightedness, myopia is an ametropia characterised by an eye that is too long for its optical system (cornea and lens). In recent years, there has been growing concern about the sharp rise in the prevalence of myopia in the juvenile population, and this has increased the need for research and development of new techniques to control axial elongation of the eye.

Myopia progression can be slowed with multifocal and orthokeratology lenses

 and post-mortem studies in humans have shown that the sclera is more extensible in high myopes than emmetropes, and that weakening of the scleral structure is related to the elongation of the eye, 

 examination of the geometric properties of the anterior sclera in eyes with different levels of myopia may improve our understanding of the variations in the anterior eye properties associated with increased ocular length.

The risk of suffering from diseases such as glaucoma or maculopathies increases very significantly as myopia increases. Therefore, it is important to understand the weakening procedure that takes place in the sclera, leading to progressive eye elongation, and to see whether this process also generates changes in the anterior portion of the structure (covered by the conjunctiva), which can be measured clinically. In this way, geometric factors at the level of the sclera might predict which cases are more susceptible to scleral changes.

OCULUS joins International Myopia Institute in mission to raise myopia awareness

Considering the existing technology for the clinical evaluation of the corneo-scleral geometry,

 as well as the comparison and validation of the main technologies applied in the clinic,

 Fourier domain profilometry (Eye Surface Profiler [ESP], Eaglet-Eye) stands out as being a reasonable way of studying the relationship between myopia and corneo-scleral geometry. Measurement with this device is minimally invasive and quickly captures all the data necessary to characterise such geometry with high levels of precision.

We recently conducted a prospective study to analyse the relationship between corneo-scleral geometry, measured with this type of technology, and the axial length of the eye, defining the differential aspects existing in myopic eyes and developing prediction models of the axial length of the eye based on clinical data.

In total, 64 eyes of 32 healthy participants (mean age 33 years) were evaluated in the Optometry Clinic of the University of Alicante, Spain, including complete analysis of the anterior segment, analysis of visual function and evaluation of the corneo-scleral topographic profile with the ESP system. The study methods adhered to the tenets of the Declaration of Helsinki and were approved by the ethics committee of the University of Alicante (Exp UA-2019-08-28).

Bi-sphere corneo-scleral topographic map obtained in an emmetropic eye (left) and a myopic eye (right).

(Figure courtesy of Dr Laurent Bataille, Dr Ainhoa Molina-Martín and Dr David P. Piñero)

A statistically significant and moderate-to-strong negative association was found between the axial length and the difference between temporal and nasal sagittal heights for different chord lengths (from 

 < 0.001 for 15-mm chord length). This suggests that nasotemporal sagittal height asymmetry has potential as a biomarker of myopic changes.

It is possible that the decrease in nasotemporal sagittal height asymmetry in myopic eyes is due to different insertion of the medial rectus muscle and the lateral rectus muscle

 combined with the noticeably lower rigidity of the sclera in such eyes.

 Specifically, there is a rearward displacement of the insertion site of the medial and lateral rectus muscles in myopic eyes,

 with rotation of the eyeball around the same nasal and anterior point to its geometric centre regardless of the axial length of the eye.

Exploring possibilities of myopia prevention and control in the US

A multiple linear regression analysis showed that the axial length could be predicted with acceptable levels of precision by means of a linear equation relating refractive, corneal and corneo-scleral variables, although the variables involved for the prediction seem to differ in right and left eyes. Specifically, the following linear equations for predicting the axial length (AL) were obtained:

< 0.001, adjusted R2: 0.843): AL=15.62-0.27 ×SE+0.99 ×CD+2.77 ×HOA RMS-1.77 ×MinSH14; and

< 0.001, adjusted R2: 0.730): AL=37.20-0.40 ×SE-0.33 ×Km+0.086 ×CD-3.96 ×HOA RMS

where SE is spherical equivalent; CD, corneal diameter; HOA RMS, high order aberration root mean square; MinSH14, minimum sagittal height for a chord length of 14 mm; and Km, mean keratometry.

SMILE procedure offers low enhancement rate after nomogram adjustment

The slight difference between the linear models used to predict axial length from the anterior segment parameters for the right and left eyes may be related to differences in the ocular globe between eyes: the asymmetry of the axial length between them has been shown to increase with increasing axial length.

These models should be considered as a preliminary approach that provides information on the potential value of the geometry of the anterior sclera for the prediction of axial length. Future studies should validate and refine these models in large samples including subjects with different ethnicities.

Multifocal lenses for presbyopia in eyes with previous corneal surgery

The analysis of the relationship between the corneo-scleral geometry measured with Fourier domain profilometry and the axial length of the eye has shown that nasotemporal sagittal height asymmetry may be a good biomarker of myopic changes. More studies are needed to clarify this issue as well as determine how these corneo-scleral parameters change during myopia progression.

Laurent Bataille, PhD, Ainhoa Molina-Martín, PhD, and David P. Piñero, PhD

Dr Bataille and Dr Molina-Martín are post-doctoral researchers from the Group of Optics and Visual Perception of the Department of Optics, Pharmacology and Anatomy, University of Alicante, Spain. Dr David Piñero is a senior researcher and lecturer from the same group and is responsible for the advanced optometry unit of the Department of Ophthalmology of Vithas Medimar International Hospital, Alicante, Spain. The authors have no proprietary or commercial interest in the medical devices that are mentioned in this manuscript.

1. Pan C-W, Ramamurthy D, Saw S-M. Worldwide prevalence and risk factors for myopia: Prevalence and risk factors for myopia. 

2. McBrien NA, Jobling AI, Gentle A. Biomechanics of the sclera in myopia: extracellular and cellular factors. 

3. Backhouse S, Gentle A. Scleral remodelling in myopia and its manipulation: a review of recent advances in scleral strengthening and myopia control. 

4. Vurgese S, Panda-Jonas S, Jonas JB. Scleral thickness in human eyes. PLoS One 2012;7:e29692.

Characterization of the geometric properties of the sclero-conjunctival structure: a review.

6.Bataille L, Molina-Martin A, Piñero DP. C

omparative analysis of two clinical diagnostic methods of the corneoscleral geometry.

. 22 Mar 2021. DOI:10.1097/ICL.0000000000000785.

Bataille L, Molina-Martin A, Piñero DP. Intrasession repeatability of corneal, limbal and scleral measurements obtained with a Fourier transform profilometer.

 23 Nov 2020. DOI: 10.1016/j.clae.2020.11.002.

8.Bataille L, Molina-Martín A, Piñero DP. 

Relationship between axial length and corneo-scleral topography: a preliminary study.

9.Haładaj R. Normal anatomy and anomalies of the rectus extraocular muscles in human: A review of the recent data and findings. 

10. McBrien NA, Gentle A. Role of the sclera in the development and pathological complications of myopia. 

11. McMonnies CW. An examination of the relation between intraocular pressure, fundal stretching and myopic pathology: The relation between IOP, fundal stretching and myopic pathology. 

12.El-Fayoumi D, Bahgat N, Khafagy M, et al. Horizontal extraocular muscle insertion site in relation to axial length using swept-source anterior segment OCT. 

13. Clark RA, Demer JL. The effect of axial length on extraocular muscle leverage. 

14. Rajan MS, Bunce C, Tuft S. Interocular axial length difference and age-related 

A recent prospective study analysed the relationship between corneo-scleral geometry and the axial length of the eye to develop preliminary prediction models of the axial length of the eye based on clinical data.

The relationship between myopia and conjunctival-scleral geometry

The 39th Congress of the European Society for Cataract and Refractive Surgery (ESCRS) plans to open its doors for the first time since the COVID-19 pandemic began at the RAI Congress Centre in Amsterdam, the Netherlands, from 8–11 October 2021. In-person attendance at this much-anticipated yearly event is sure to be an appealing prospect to many. And for those who are unable to attend in person, the Congress will also be held virtually, making the chance to participate in some capacity a reality for all.

So, what is in store for attendees this year over the four action-packed days? At the time of going to press, the ESCRS had not released the full, in-depth programme, however, a range of symposia, programmes, video sessions and workshops will be on offer and are discussed in this brief preview article. There will also be a daily exhibition, giving people the chance to experience the latest technologies in ophthalmology and providing the ideal location for ophthalmologists and researchers to network with their peers.

editorial advisory board members: Dr Albert Augustin, professor of ophthalmology and chairman of the Department of Ophthalmology at the Karlsruhe Municipal Hospital, Germany, and Dr Paolo Fazio, head of the refractive surgery service of the Catanese Centre of Medicine in Catania, Italy, to gain their insights into the topics on the agenda at this year’s event. Read on to find out more!

The Main Symposium to be held in the morning of the opening day of the Congress will be on the interesting-sounding topic “Managing Herpetic Keratitis”. There will also be a Clinical Research Symposium entitled “Stem Cells: Basics and Clinical Perspectives”, taking place after lunch. Two further symposia planned for the afternoon are the “JCRS” (Journal of Cataract and Refractive Surgery) and the “ISRS” (International Society for Refractive Surgery) sessions.

A Video Session due to be held between 5.15pm and 6.45pm will showcase “Challenging Cases”, a topic that proves popular every year at the ESCRS, as ophthalmologists seek to learn how to manage the more difficult patients and/or surgeries. Learning opportunities will also present themselves during the three courses planned for Day 1, whose topics have yet to be disclosed. Friday also marks the day the Exhibition Hall will open (between 9am and 5pm).

The more junior ophthalmologists among attendees will have the chance to network and learn tips and tricks in the “Young Ophthalmologists Programme”, which begins on the Saturday. Dr Augustin comments: “This format is becoming increasingly popular, since young ophthalmologists, and especially young surgeons, now have a new platform to discuss problems or situations in the clinical practice which are unique for beginners and may not be a topic suitable for other formats. This is true for both scientific and surgical questions.”

Meanwhile, the Clinical Research Symposium will be on “Advances in Corneal Cross-Linking”, which is currently a very hot topic. “Corneal crosslinking is an increasingly standardised procedure, with new accelerated protocols that reduce the duration of treatment with similar results to standard ones,” says Dr Augustin.

Emphasising the importance of the “Selecting Advanced IOLs” Main Symposium taking place, Dr Fazio comments: “This is a Symposium that will probably be held for several ESCRS meetings to come since the list of advanced IOLs is becoming more crowded by the day.”

“MIGS: The Evidence-Based Approach” will be the topic of the second of the Main Symposia taking place on the Saturday. Dr Augustin says: “The introduction of MIGS has simplified the approach to glaucoma surgery. A review of recent evidence is important to improve the outcomes in terms of both IOP reduction and complication rate.”

For those wishing to participate in courses, attendees will have the option to either do so in person or virtually, with both types (seven in-person and two virtual) being on offer on Saturday. Free Paper sessions are also expected to place before the day wraps up with a video “Award Session”, between 6.30pm and 8pm.

Sunday is shaping up to be a very busy day at the ESCRS, with two Symposia taking place in the morning—on “Imaging Techniques of the Anterior Segment and Beyond” and “Practical Digital Ophthalmology”—and a couple taking place after lunch.

Referring to the afternoon’s Research Symposia on “Cost Effectiveness and Value-based Healthcare: Have They Entered Ophthalmology?”, Dr Augustin points out: “Limitations on resources make the cost-effectiveness of any procedure very important for all of us. The information in this session should help ophthalmologists to engage with both payers and hospital administration staff.”

Regarding the Main Symposium covering “Enhancements after Refractive Surgery”, he comments: “Enhancement of refractive surgery is also a hot topic because refractive patients have very high expectations, which very often cannot be met with the first procedure. Thus, enhancement procedures can be necessary to produce superior results.”

“Euro Times Satellite Education Symposia” also appear in the schedule at various times throughout the day and there is also a Symposium entitled “IIIC” (Intraocular Lens Implant Club) at the end of the day. The IILC is a group of international specialists which will, no doubt, present the newest developments in IOL design. Dr Augustin believes that development in the field of IOLs is in “constant turmoil, with the introduction of ever more precise lenses for the correction of refraction errors and the management of presbyopia”.

With educative opportunities remaining a major theme at the Congress, nine courses, two of which are offered virtually, are planned to be held at varying times. The Video Session will cover surgical methods, which is always a good opportunity for ophthalmologists to hone their techniques and learn from peers. Sunday also marks the last day the Exhibition is open.

On the final day of the Congress, glaucoma is the subject of the two “Masterclasses” in the morning, which demonstrates the importance that cataract and refractive surgeons need to have a high level of understanding of this disease entity. There will also be a “Hyperopia Workshop”, a total of five in-person courses and a session discussing the work of the non-profit organisation Orbis Flying Eye Hospital; a teaching hospital on board a flight, which delivers eyecare to low- and middle-income countries.

“Don’t miss the ORBIS session,” Dr Augustin advises. “This charity project was established many years ago. You will see and hear the newest activities of this group.”

Dr Augustin also strongly advises attending the “CSCRS Symposium”. “This symposium of the ‘united cataract surgeons of the world’ will provide you with latest news on cataract surgery from a global perspective,” he says.

The final day will be rounded up, as has become something of a tradition at the ESCRS Congress, with the “Best of the Best”, a session that will enable attendees to go away with the main pearls of the event.

The 39th Congress of the European Society for Cataract and Refractive Surgery (ESCRS) will meet at RAI Congress Centre in Amsterdam, the Netherlands, from 8–11 October 2021. The Congress will also be held virtually, making the chance to participate in some capacity a reality for all.

Opportunities lie ahead at the 39th ‘hybrid’ ESCRS

Reviewed by William R. Bloom and Colleen M. Cebulla, MD, PhD.

The posterior segment is not readily visible in patients implanted with a Boston type I and II keratoprosthesis (KPro, Massachusetts Eye and Ear) when using standard fundus examination and photography.

However, ultra-widefield imaging scanning laser ophthalmoscopy seems to have remedied this and facilitates noninvasive monitoring of pathologies in the retina and optic nerve, according to William Bloom and Colleen Cebulla, MD, PhD, both of the Department of Ophthalmology and Visual Sciences at The Ohio State University Wexner Medical Center in Columbus.

The quest for topical treatments for the posterior segment

The investigators conducted a retrospective chart review of 15 eyes of 14 patients who received either the Boston type I (n=14 eyes) or II (n=1 eye) KPro between 2009 and 2020 at the Wexner Medical Center.

The Optos ultra-widefield imaging system was used during 35 patient visits. A single masked reader graded image quality as poor, fair, good, or very good. The images were assessed for clinical pathologies of the retina and optic nerve. Poor image was defined as one in which the structure of the optic disc or posterior segment was incomplete without meaningful clarity; fair image was defined as providing moderate structural resolution but not showing the complete posterior pole; good image was defined as providing a clear view of the entire posterior pole; and very good image was defined as excellent resolution with a field of view to the equatorial retina, Bloom explained.

Scanning laser ophthalmoscopy offers improved view of posterior segment.

The relationship between myopia and conjunctival-scleral geometry

Opportunities lie ahead at the 39th ‘hybrid’ ESCRS

Ultra-widefield imaging improves visibility of retina and optic nerve in KPro patients