Caroline Richards

The respiratory symptoms caused by the severe acute respiratory coronavirus disease (COVID-19) that has been sweeping the world since late 2019 are well documented, given the regularity and consistency with which they occur. However, the role of the eyes and tears both as entry routes for the causative virus, SARS-CoV-2, and as sources of contagion are still the subject of debate, and relatively less is known about the ophthalmic implications of the disease.

It would appear from some recent studies that patients who experience the more severe forms of COVID-19 and present with pneumonia commonly display ocular symptoms. However, the authors of a recent Chinese study of 38 patients concluded that although a third of patients with the disease had ocular abnormalities, there was a low prevalence of the virus in tears1,2.

Nevertheless, it is possible that contact with infected eyes could be a route of transmission of SARS-CoV-2, especially given the knowledge that it can be spread via direct or indirect contact with other mucous membranes (the mouth and nose), so ophthalmologists should err on the side of caution and ensure rigorous prevention protocols are put in place.

In a literature review recently published in 

, Prof. Jorge Alió and Dr Alejandra Amesty reported that when it occurred, conjunctivitis was the most common ophthalmologic sign related to coronavirus infection1. And there are clues from previous coronavirus outbreaks as to why this should be the case: inflammation of the conjunctiva was first associated with a human coronavirus back in 2004 when children started to fall prey to the symptoms during the severe acute respiratory syndrome (SARS) crisis.

Genetically speaking, SARS-CoV-2, the virus that caused SARS, is around 70% similar to SARS-CoV and uses the same receptor (ACE2) to insert itself into human cells. This is potentially quite significant when one considers that ACE2 receptors have been found in the aqueous humour3.

But could the fact that conjunctivitis is mainly being seen in the most poorly patients mean that the presence of the virus on the surface of the eye and subsequent ocular events are down to decreased immune function? The researchers do not think so: “Both viral diseases and immune problems can lead to ocular manifestations, such as conjunctivitis, uveitis, retinitis, among others. It is difficult to determine the pathology of the ophthalmic involvement. However, since the virus has been cultured from conjunctival secretions, COVID-19 ophthalmopathy is more likely to be related to the actual virus infestation rather than the secondary immune reaction that the infection may cause.”

Any sign of conjunctivitis in the clinical setting should be considered to be a “possible coronavirus conjunctivitis, especially when accompanied by other respiratory tract problems or fever”, the authors pointed out.

Thankfully, viral conjunctivitis usually amounts to no more than an uncomfortable nuisance, so treatment strategies are typically supportive in nature. That said, it is important to try to lessen the potential viral load on the ocular surface and some of the general ophthalmic recommendations for viral conjunctivitis could also apply to COVID-19 patients.

“These include hygienic measures (frequent hand washing, especially when eye drops need to be applied or contact lenses worn; avoiding touching or rubbing the eyes; changing pillowcases, sheets) … we should be meticulous when examining patients who have tested positive for COVID-19.”

The close face-to-face proximity of ophthalmologists to their patients and frequent exposure to tears and ocular discharge, as well as regular handling of equipment such as slit lamps, tanometers and lasers, means they are perhaps at a higher risk of contracting COVID-19 than other types of healthcare professionals, the researchers said, referring to recent guidelines that have been published in an attempt to minimise the chances of infection spreading in ophthalmology clinics and hospital departments.4,5

In the guidance, ophthalmologists are advised to impose limits on the number of attending patients and to adhere to strict appointment timetables to prevent people from gathering in clinic waiting rooms. Online platforms, such as hospitals’ official websites, should be readily used, whilst simply making more telephone calls could reduce the need for patients to visit hospitals, for example, by helping them to distinguish between urgent and nonurgent ocular problems.

The guidelines go on to recommend triage systems to help to flag up patients with symptoms consistent with COVID-19 infection such as fever, and online ordering and delivery of prescribed medication, especially for chronic eye diseases such as glaucoma.

Recommendations for handling a patient’s visit include:

Reducing the number of accessible entry points to the hospital/clinic;

Screening patients for COVID-19 symptoms and contact history with confirmed or suspected within the past 14 days;

Seeing patients with eye infections in separate clinics with their own waiting areas;

Testing patients more than twice for evidence of SARS-CoV-2 RNA in the conjunctival sac and tears;

Limiting numbers of people in examination rooms;

Ensuring rooms are well ventilated and instruments used disinfected immediately after a patient’s visit; and

In addition, slit lamps should be protected by shields and direct ophthalmoscope examination could be replaced by slit light lenses, optical coherence tomography or fundus photography.

For inpatients, the suggested adaptations include preoperative infection screening and use of local rather than general anaesthesia to avoid contamination. Negative-pressure operating rooms should be used for emergency operations on any COVID-19-positive patients.

Human coronavirus is believed to be able to remain infectious on inanimate surfaces for as many as 9 days6, so disinfecting surfaces with water, detergent and commonly used disinfectants is extremely important, Prof. Alió and Dr Amesty explained. In addition, they suggested that some ocular spray disinfectants that contain hypochlorous acid (usually applied to treat blepharitis in order to reduce bacterial and viral load on the skin and eyelashes) could be used as “a measurement of prevention for the facial area where many other chemical agents cannot be applied”.

However, more studies are needed to establish a specific antiviral product that could be used to reduce the viral load on infected patients’ conjunctiva and lower the transmission rate via the eyes/tears. The authors conceded that this is no easy task when “so many doubts still remain regarding the ophthalmic implications” of the infection.

Summarising, the authors have called for “well-designed trials” to be conducted “to rule out other ocular manifestations [besides conjunctivitis] that may result from COVID-19 infection and to better elucidate the mechanisms of transmission through the eyes.”

Until more light can be shed on the ophthalmic implications of COVID-19, ophthalmologists can only remain as up-to-date as possible on emerging disease findings, whilst maintaining a cautious approach when dealing with patients before, during and after appointments.

1. Amesty MA, Alió del Barrio JL, Alió JL. COVID-19 disease and ophthalmology: An update.

https://doi.org/10.1007/s40123-020-00260-y

Wu P, Duan F, Luo C, et al. Characteristics of ocular findings of patients with coronavirus disease 2019 (COVID-19) in Hubei Province. China 

https://doi.org/10.1001/jamaophthalmol.2020.1291

Holappa M, Vapaatalo H, Vaajanen A. Many faces of renin-angiotensin system—focus on eye. 

Lai THT, Tang EWH, Chau SKY, et al. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. 

Yong Y, Ruixue T, Xu S, et al. A comprehensive Chinese experience against SARS-CoV-2 in ophthalmology. 

Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents

Prof. Alió is professor and chairman of ophthalmology at the Miguel Hernandez University of Elche and scientific director at Vissum in Alicante, Spain. He has no financial interests in the subject matter.

Articles

Emerging data on conjunctivitis cases in COVID-19 patients necessitate high levels of caution and a meticulous approach during the pandemic.

The ophthalmic implications of COVID-19: What we know so far 

Caroline Richards, editor of Ophthalmology Times Europe®, interviews Dr Lamis Baydoun on how corneal transplantation has changed-and what has been learned-since the introduction of Descemet membrane endothelial keratoplasty (DMEK)

A high number of corneal diseases only affect the inner layers of the cornea, that is, the Descemet membrane (DM) and endothelium. Until a few years ago, full-thickness corneal transplants-or penetrating keratoplasty (PKP)-typically took place, irrespective of whether the disease affected one or all layers. However, surgeons can now replace just the diseased parts with corresponding layers from healthy donor tissue in posterior lamellar corneal transplantation procedures.

Dr Lamis Baydoun, former head of academy and corneal surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS) in Rotterdam, has been heavily involved in developments with posterior lamellar keratoplasty and the most recent type of corneal surgery to spring from this, Descemet membrane endothelial keratoplasty (DMEK). At NIIOS, she taught dozens of surgeons across the world how to perform DMEK surgery, and her research continues to push the field forward.

Gerrit Melles is the founder of NIIOS and is regarded the ‘Pope’ of lamellar endothelial surgery. For 100 years, corneal surgeons performed only full-thickness penetrating keratoplasty-there was no other option to treat patients who have only one diseased layer. 

The results of Dr Melles’ experiments and his first surgeries opened up the field of endothelial keratoplasty. This started with deep lamellar endothelial keratoplasty (DLEK), then Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) and, finally, DMEK, the latest and most precise innovation, where you can practically restore the normal corneal anatomy.

HOW HAVE OPHTHALMOLOGISTS’ PERCEPTIONS OF DMEK CHANGED OVER TIME?

Many corneal surgeons were reluctant to adopt it at first. They were very uncomfortable with the technique and the graft itself, and perceived several obstacles.

Firstly, it was very difficult to recover the DMEK graft from a donor cornea. Secondly, the possibility of the graft unfolding during surgery incited fear in learning this technique because every time the delicate graft is touched, the corneal endothelial cells that are required to clear the cornea may be damaged.

The management of a new post-operative complication such as graft detachment (i.e., separation of the DMEK graft from the posterior stroma) was another concern. Patients faced complications that just did not occur with full-thickness penetrating keratoplasty (PKP) transplants, so surgeons felt they were far more comfortable remaining with the older technique.

However, over the longer term, the benefits of DMEK over all previous keratoplasty techniques were so overwhelming that the method could not be ignored any more-you could actually reach a level of visual outcomes that were comparable to those seen following lens or even refractive surgery! We had some very happy patients following the procedures. And when the patient is happy, of course, us doctors are also very happy.

WHAT ARE THE CHALLENGES FOR OPHTHALMOLOGISTS WHO ARE NEW TO THE PROCEDURE?

It is worth mentioning that the technique is now becoming much easier to master. Dr Melles first performed the surgery in 2006, so we have 13 years of experience to draw on, and during this time period we developed a standardised procedure and learnt how to handle the graft and complications better.

However, it is, of course, a challenge for surgeons starting out with performing DMEK. This is why courses are offered in Rotterdam: to teach surgeons tips and tricks, and help them to get over common obstacles, thus enabling them to adapt to DMEK surgery more quickly.

The main issue beginner surgeons have is knowing which graft side is the right side up. This is a key step for a successful surgery, and certain intraoperative signs can help indicate the correct graft orientation.

An intraoperative OCT (iOCT) may be a useful tool during the DMEK learning curve to visualise graft orientation and positioning. Once the surgeons are familiar with the technique and the surgical set-up, they do not necessarily need to use it, although it may remain a helpful tool in eyes with very, very edematous corneas.

WHICH DISEASES ARE BEST TREATED WITH DMEK?

The answer to this is: all diseases that concern the corneal endothelium. So, the cornea normally consists of five layers. Going from the outside to inside, you have: the epithelium; the Bowman layer; the stroma; the Descemet membrane; and finally the endothelium-and these final two layers are replaced in endothelial diseases.

There is one disease-Fuchs endothelial corneal dystrophy-which is very common and effectively treated with DMEK, showing outstanding results. Then there is bullous keratopathy, which usually occurs when corneal endothelial cells are damaged during certain eye operations; for example, during surgery to treat glaucoma or remove cataracts. This is another disease that is well treated with DMEK.

WHAT SHOULD PATIENTS EXPECT WHEN THEY ARE TOLD THEY NEED LAMELLAR CORNEAL SURGERY SUCH AS DMEK?

Patients can expect a minimally invasive treatment. Rather than excising the whole cornea and having the eye open during surgery, the surgeon will make only minimal, small incisions, entering  the eye with small instruments to remove the diseased layers before inserting a healthy donor graft.

Following this, the surgeon unfolds the graft before attaching it with an air bubble to the posterior stroma of the patient. This was actually how this surgery became so successful: previously, the graft was attached with sutures. These sutures can irritate the eye and induce inflammation, leading to possible transplant rejection.

Attaching the graft with an air bubble eliminates this problem, providing patients with a less traumatic surgery, and, after that, faster rehabilitation with better visual outcomes. From our experience at NIIOS, the graft can detach in about 10% of cases; however, not all cases may need a re-bubbling procedure. In my experience, graft detachment has become a controlled complication.

WHAT LESSONS HAVE YOU LEARNT SINCE THE FIRST PROCEDURE WAS PERFORMED?

What I have learnt is to no longer be afraid of the graft! This is something that at first is quite frightening. You are afraid of touching the graft and fearful because it behaves how it wants to behave. However, with experience, you realise that you can tell it what to do, and in most of the cases it will do what you want.

I have also learnt that not every surgery that is difficult necessarily ends up producing a bad result (it is often the other way around)-it can be surprisingly good even though it was a difficult surgery. These are mysteries that we still need to understand.

WHAT ARE THE BENEFITS OF QUARTER-DMEK SURGERIES?

Quarter-DMEK surgery was invented at NIIOS and the first series was recently published. The surgery was offered to patients with central Fuchs dystrophy and not those with bullous keratopathy. The rationale for this is as follows.

Fuchs dystrophy is a disease that sometimes only causes central guttae with mild or localised corneal oedema, but still-functioning peripheral endothelial cells. So, in a similar way to how Dr Melles invented DMEK, to offer a selective treatment for the patient that only treats the diseased endothelium and DM, we took that thinking a step further. We asked: is standard DMEK, with its 9.0 mm descemetorhexis (i.e., removal of the DM and endothelium) and round 8.5–9.5 mm graft, really the most selective treatment for all forms of Fuchs dystrophy?

If you have a patient with Fuchs disease but only central guttae that cause visual disturbances such as stray lights during activities such as driving, it would seem sensible to remove just this small diseased central portion and provide the person with a small graft piece for quick visual rehabilitation while sustaining his/her own peripheral cells. This is the idea with quarter-DMEK; you can use endothelial donor tissue more efficiently, hence instead of one standard graft, you can recover four quarter DMEK grafts from one donor cornea.

Endothelial keratoplasty brought us new understandings in cell biology and physiology. Further innovations are possible because of how the endothelial cells react and how they migrate after DMEK surgery. It is not just simply a case of placing some graft tissue in the eye: much more than this takes place.

WILL YOU BE ABLE TO USE PATIENTS’ OWN CELLS TO TREAT CERTAIN DISEASES IN THE FUTURE?

Potentially, yes. A lot is happening in this field at the moment. For example, in ‘Descemet stripping only’ or ‘Descemet stripping without endothelial keratoplasty’ for Fuchs disease, foreign tissue is not used, so there is no transplant. As a consequence, there is no risk of tissue rejection and so you avoid the problem of repeated transplants.

In this procedure, surgeons remove the DM and the endothelial layer in the centre of the cornea, which allows the cells from the periphery to migrate inwards to the centre and clear up the cornea. However, we still don’t know which cases should be treated without a transplant (and still profit from this treatment with fast visual recovery), so we currently feel that if we transplant a smaller quarter DMEK graft just in the centre of the optical axis and use it for these kinds of patients, then we will have combined the benefits of the migration approach, use less graft tissue with the chance of further reduction of rejection, and still give the patient fast visual rehabilitation.

In addition, a lot of research is being carried out on approaches with cell injections and cell carriers. I think we will still be doing some DMEKs for a couple of years, but it is likely such innovations will shake up the field again.


	DR LAMIS BAYDOUN, MD
	E: lamisbaydoun@hotmail.com
	Dr Baydoun is a consultant ophthalmic surgeon at the ELZA Institute, Zurich/Dietikon, Switzerland and at the Department of Ophthalmology at the University Hospital Muenster, Germany.

Being the ‘boss’ of the graft

The Congress of the European Society of Cataract and Refractive Surgeons (ESCRS), now in its 36th year, is just around the corner, and this time, the Reed Messe in Vienna, Austria, will be hosting the event.

From the 22nd until the 26th September, a variety of symposia, poster sessions, instructional courses and workshops will showcase the latest advancements in ophthalmology, alongside a daily exhibition providing delegates with information on new technologies.

It is becoming something of an expectation that the ESCRS takes place in some of the most interesting cities in Europe, and this year is no exception, with the beautiful Vienna providing attendees with impressive sight-seeing opportunities when they venture out from the congress.

’s exclusive preview of the ESCRS, we have asked two of our respected Editorial Advisory Board members, Professor Jorge L. AliÃ³, chairman of ophthalmology at Vissum in Alikante, Spain, and Dr Albert Augustin, professor of ophthalmology and chairman of the Department of Ophthalmology at the Klinikum Karlsruhe, Germany, to provide their input on the sessions. Read on to find out more!

Clinical Research Symposia
8.30am–5.30pm
The first symposium on Saturday will be on the topic of myopia. Chairpersons Prof. Oliver Findl of Austria and Dr Rudy Nuijts from the Netherlands will host presentations that will delve into epidemiology, genetics, biological mechanisms and scleral cross-linking, among other subject areas. Dr Augustin notes the “very high quality of the moderators and speakers” in this session, which he believes will guarantee high-level science and clinical relevance.

Prof. AliÃ³ also comments on the topic: “Myopia is one of the top topics today, worldwide, due to the emergence of an immense increase in the epidemiology of this problem. Myopia should not be considered always to be a disease but rather only in exceptional cases. However, it draws the attention of society because it limits the activities of those people who cannot use spectacles (including security forces, and port and professional dedications); it has a mysterious genetic background; and it has no treatment other than the correction of the refractive error by refractive surgery. This symposium promises to be one of the most interesting as myopia affects, in Europe, over 30% of the population and in other countries like Israel and the Far East, over 50%.”

‘Measuring Near and Intermediate Quality of Vision’ will be the theme of the second morning/early afternoon symposium, which will be chaired by Dr BÃ©atrice Cochener from France and Dr Nino Hirnschall, Austria. Topics discussed will include assessing reading patterns, and methods for quantifying various factors such as halos and accommodation, all of which are “very important for your daily clinical routine”, remarks Dr Augustin.

Prof. AliÃ³ notes that “most studies on visual outcomes have been focused on refraction and best corrected visual acuity”, explaining that quality of vision also relates to a person’s perception about their vision: “These psychological issues are still difficult to measure and are the subject of this symposium.” He believes this will be a leading topic in the future: “As a surgeon, I consider most important the adequate quality than the quantity of vision because nobody complains about quantity but we have many patients with J1 20/20 syndrome who have good vision but feel negative about their perception of visual quality.”

Dr Thomas Kohnen of Germany and Prof. David Spalton, the UK, will chair the afternoon’s ‘Blue Sky Lens Research’ symposium, featuring a variety of topics from femto lentotomy to stem cell regeneration of the lens. When considering cataracts, Prof. AliÃ³ remarks that preventative measures or even therapies could become important in the future “both to delay the appearance of this problem, avoid surgery, or, more importantly, lead to preservation of accommodation for a longer period of time”. The final series of talks will be on ‘Femtosecond Surgery’, from 3.30pm, hosted by Dr Guy Kleinmann of Israel and Dr Mario Nubile, Italy. Overall, Dr Augustin believes this symposium will touch on many interesting clinical topics.

Instructional Courses
8.30am–6.00pm
Like last year, a series of free-to-attend instructional courses will be offered throughout ESCRS, beginning on Saturday 22nd September; it is not necessary to register for these. Catering for all levels, from basic to intermediate and advanced, the courses aim to inform attendees about all manner of surgical techniques, including microsurgical suturing techniques; vitrectomy and IOL implantation; glaucoma surgery; corneal cross-linking; and phacoemulsification.

Dr Augustin highly recommends attending as many courses as possible, pointing out the importance of learning from experts in the field, improving skills and avoiding mistakes. Also emphasising the attractiveness of this “very diverse programme” is Prof. AliÃ³, who advises choosing three or four of the courses according to the topics and directors, in order to find specialised tracks that might improve continuous medical education of each doctor on a particular topic.

Exhibition Hall
The exhibition schedule will be open from 9am to 5.50pm on Saturday.

Poster Sessionsâ¨
2pm–4.30pm
A moderated poster session will be held from 2pm for one hour on Saturday, while presented poster sessions will follow.

ESCRS/EuCornea Symposium: Corneal Cross-Linking: Current Status and Future Perspectives
11am-1pm
One of the two main symposia on Saturday will focus on the biomechanics of cross-linking, techniques surrounding it, and its use with LASIK and for keratoconus. Dr Roberto Bellucci of Italy and Dr Jesper Hjortdal, Denmark, will chair, and three short discussions will be interspersed throughout. Prof. AliÃ³ comments that this symposium will update the attendee on recent advancements on the “many varieties and diverse techniques of crosslinking, some of them with a lack of adequate evidence and some with strong evidence in favour”. Echoing his thoughts, Dr Augustin states: “Cross linking is still an evolving field and techniques are rapidly changing.”

ESCRS/EuCornea Symposium: The Diabetic Eye
2pm-4pm
Dr Cochener and Prof. Sebastian Wolfe, Switzerland, will chair the second of Saturday’s main symposia, which will put the spotlight on diabetes treatments, epidemiology of diabetic eye diseases and preparing for cataract surgery, among other topics. Dr Augustin remarks that the symposium will provide the attendee with “further insight into both anterior and posterior segment alterations induced by diabetes”. Prof. AliÃ³ adds: “The diabetic eye affects a huge amount of people around the world with the complications that are related to this metabolic disease. Diabetic retinopathy is one of the leading causes of blindness worldwide and is still the subject of strong medical actions and wide research leading to its prevention and early detection. Other problems related to the diabetic condition of the patient will be reviewed.”

Refractive Surgery Didactic Courseâ¨
8.30am–5.30pmâ¨
This course will address a range of subject areas, with chairpersons Dr David Epstein of Switzerland and Dr Jose Guell, Spain, taking the reigns.

Young Ophthalmologists Programmeâ¨
8.30am–4pm
Providing an opportunity to ‘learn from the learners’, ophthalmologists at the beginning of their careers will demonstrate what they have learnt through video cases, so this session will be useful to fledgling physicians. The first presentation will address the issue of ‘Preparing for the first operation’, with subsequent video cases focused on biometry; incisions; capsulorhexis; hydrodissection; IOLs ‘tricks’; and phacoemulsification. Taking charge as chairpersons again this year will be Dr Oliver Findl, Italy’s Dr Simonetta Morselli and Dr Kaarina Vannas of Finland. Dr Augustin notes the “well-known course directors” in this programme. “You can expect a high didactic level and many tips and tricks for young physicians,” he adds.

Ridley Medal Lecture
10am–10.50am
Dr Rudy Nuijts, associate professor of ophthalmology and director of the Cornea Clinic and the Centre for Refractive Surgery at the Department of Ophthalmology, University of Maastricht, the Netherlands, will give a one-off lecture on Sunday morning. The title of his presentation is ‘Facts first!’

Exhibition Hall
The exhibition schedule will be open from 9am until 5.30pm on Sunday.

Glaucoma for the Cataract Surgeon Symposium
11am-1pm
The main symposium on Sunday will be chaired by Dr Simonetta Morselli and Prof. David Spalton. Topics discussed will be: ‘Imaging aqueous outflow’; ‘Eagle eyes’; ‘Intracanalicular and suprachoroidal devices’; ‘Subconjunctival devices’; ‘New drugs and slow release devices’; and ‘Trabeculectomy revisted’. As with all other symposia throughout ESCRS, discussion opportunities will be present throughout.

Prof. AliÃ³ states: “Dealing with the glaucoma and cataract is one of the most conflictive topics that faces the practical surgeon. The different model approaches with mini glaucoma shunts (MIGS), the benefits of cataract surgery over IOP control and the implications of some topical medication in the outcome of cataract surgery will be reviewed. This symposium will be interesting for all cataract surgeons attending the meeting.”

Journal of Cataract and Refractive Surgery

 Symposium
2pm–4pmâ¨
On Sunday afternoon, ‘Controversies in Cataract and Refractive Surgery’ will be the theme of an informative symposium chaired by Dr Kohnen, the JCRS European Editor, and Dr William Dupps of the USA, the US Associate Editor, both of whom Dr Augustin remarks are well-known experts in the field of corneal and refractive surgery. Three subject areas will be: ‘Intraoperative OCT for the anterior segment’, ‘Cataract and corneal transplantation’ and ‘Corneal refractive surgery’. There will be ten-minute discussion periods following each topic. Dr Augustin believes it important for all anterior segment surgeons to attend this symposium.

Young Ophthalmologists Session
4pm–6pm
Dr A Panico, Italy, and Dr Filomena Ribeiro, Portugal, will chair a one-off session entitled ‘Targeting Emmetropia in Cataract Surgery’ on Sunday afternoon, which will address issues to consider before surgery. ‘What is emmetropia?’; ‘Let’s measure the eye’ and ‘Choosing the best IOL for each patient’ will be among the presentations.

Workshop on Visual Optics
8.00am–5.45pmâ¨
In what Dr Augustin sees as an “interesting format”, this three-part programme will explore ‘Visual Behaviour’ (Part 1), ‘Visual Optics (Part 2)’ and ‘Imaging the Human Eye’ (Part 3). Part 1, moderated by Prof. Raymond Applegate of the USA and Prof. Pablo Artal from Spain, will include a break at 10.40am to allow participants to attend the ESCRS/EUCornea symposium entitled ‘Corneal Cross-Linking: Current Status and Future Perspectives’, which will take place in Hall A1, before the workshop resumes following lunch. Moderators for Part 2 are Dr Ioannis Pallikaris of Greece and Dr Marie-JosÃ© Tassingnon of Belgium. Overseeing Part 3 will be Drs Damien Gatinel, France, and Dr Pallikaris. Dr Augustin adds that this workshop is important to attend and “highly recommended for all doctors who are interested in optics and physiology”.

Poster Sessionsâ¨
Various times
Poster sessions will be held throughout the day, with presented posters being available from 9.30am until 11am, a moderated poster session from 2pm for one hour, and further presented poster sessions between 2.30pm and 4.30pm.

Exhibition Hall
The exhibition schedule will be open from 9am until 5.30pm on Monday.

Extending Depth of Focus
11am-1pm
Monday’s main symposium, chaired by Dr Michael Amon, Austria, and Dr T Kohen, Germany, is entitled ‘Extending Depth of Focus’; optical principles, small aperatures and corneal techniques will be among the variety of topics on offer to members of the audience. Prof. AliÃ³ comments: “Some lenses and corneal procedures have been trying to implement this type of multifocality, which implies the induction of some aberrations on purpose to increase the ability of the eye to focus. The issue is how much we gain and how much we lose in using these lenses. This symposium will deal with this issue.” 

Poster Sessionsâ¨
Various times
Moderated and presented poster sessions will be held at various times throughout the day, beginning at 9am until 11am with presented sessions, a moderated posted session from 2pm until 3pm, and further presented posters straight afterwards until 4.30pm.

Exhibition Hall
The exhibition schedule will be open between 9am and 5pm on Tuesday.

Refractive Surgery for High Ametropia
11am–1pm
During Tuesday’s two-hour main symposium, attendees will be treated to talks on anatomical limitations, the ever-popular SMILE versus LASIK debate and intraocular surgery in short versus long eyes. The chairpersons will be Dr Alex Day, UK, and Dr Jose Guell.

Poster Sessionsâ¨
Various times
Poster presentations will take place in the morning on Monday, from 9am, and there will be one moderated session at 2pm.

Presbyopia Workshop
2pm–4pm
Following lunch time on Tuesday, attendees can visit the ‘Presbyopia Workshop’, which will include a range of topics, including laser correction, corneal inlays, and the pros and cons of extended depth-of-focus lenses and multifocal IOLs. Switzerland-based Dr David Epstein and Dr I Pallikaris of Greece will be the chairpersons. Presbyopia is “always an interesting topic”, Dr Augustin says, and will help attendees stay up-to-date in the field of presbyopia correction.

Best of the Best Review Session
8.30am–10.30amâ¨
To round up the meeting, a selection of the most interesting videos and presentations given during the Congress will be reviewed by a panel of physicians, in the ‘Best of the Best’ session on Wednesday morning, which, like last year, will be chaired by Drs Oliver Findl and Boris Malyugin.

The Enigma of Pseudoexfoliation
11am–1pm
What is pseudoexfoliation? The answer to this question will be posed in the first talk of Wednesday’s main symposium, which will also enable attendees to discover more about the epidemiology, genetics, intraoperative complications and other elements of this enigma. Dr David Epstein and Dr Oliver Findl will chair.

“Pseudoexfoliation is still a mystery. So, this lecture is of interest for all anterior segment surgeons and glaucoma specialists as well as glaucoma surgeons,” Dr Augustin comments. Prof. AliÃ³ also describes pseudoexfoliation as still being a mystery, and one that affects many people according to ethnicity and geographical location. “Even though important investigations have been performed, the reasons that lead to this problem and its implications and prevention are still unknown. This symposium will deal with the basic knowledge about this problem and how to deal with it on practical terms,” he adds.

Video Symposia
On Saturday, Sunday and Monday afternoons, surgical videos will be played, aimed at helping ophthalmologists navigate sticky situations. Saturday’s session is on ‘Challenging Cases’, Sunday’s symposium handles ‘Surgical Complications: You Make the Call’, and on Monday, the topic is ‘Getting Into Trouble’. Dr Augustin points out that video symposia are a highly recommended format to learn from peers.

On Sunday and Monday, Practice Management Masterclasses will be held throughout both days, from 9am to 6pm on the Sunday and from 8am until 6pm on the Monday.

Hands-on wetlab courses will be available to ESCRS attendees, providing them with the opportunity to practice surgical techniques on porcine eyes. The small classes utilise two-way audio and video as teaching tools.

The cost for all wetlabs for trainees is fixed at 100 Euros per course. For regular delegates the cost will vary between 100 and 150. Some of the course topics this year are: ‘Basic Phacoemulsification’, ‘Basic Surturing Techniques’, ‘Boston Keratoprosthesis’, ‘Corneal Cross-Linking Therapy’, ‘Glaucoma Canaloplasty’ and ‘Modern MIGS techniques enhancing Schlemm’s Canal’. Pre-booking online is necessary.

A meeting of minds at the 36th Congress of ESCRS

As another year comes to an end, five members of 

 Editorial Advisory Board reflect and share their perspectives on the exciting opportunities that lie ahead for ophthalmologists in 2018, whilst also considering the potential challenges.

Dr Hollo: In the field of glaucoma clinical research and practice, considerable development has been seen in several areas in 2017. In terms of diagnostics and research, optical coherence tomography (OCT) angiography is one such area, and there has also been progression in the understanding of the role of the Bruch membrane opening in optic nerve head OCT imaging.

With regards to surgical treatment, substantial new information has become available on an ab interno implantable microstent for glaucoma filtration surgery, while the popularity of using completely preservative-free topical glaucoma medication, including fixed combinations, has surged. We also see some new molecules in the Rho kinase inhibitor family moving closer to clinical application.

However, when it comes to patient referrals, European research has revealed that using an intraocular pressure (IOP) reading of between 21 and 25 mmHg as a sole criterion for referral to a glaucoma specialist may increase the number of false positive referrals and does not increase the detection of true glaucoma cases.

Although this situation has no direct influence on clinical practice in the upcoming year, I hope that a better or more established referral system will be rolled out in the future, as this will make glaucoma clinics more efficient, allow ophthalmologists to spend more time with those patients who really need it and prevent incorrect glaucoma diagnoses and the negative effect this has on patients.

Dr Augustin: Traditional glaucoma surgery has a significant lowering effect on IOP. However, this approach is not necessary in all patients and leaves patients at risk from several complications that are difficult to manage.

A less traumatic option is micro-invasive glaucoma surgery (MIGS), which is gaining in popularity. This technique uses different devices, allowing the complications seen with traditional techniques to be avoided and giving surgeons the opportunity to reduce IOP more easily and safely.

However, both techniques have advantages and disadvantages, and the major challenge in 2018 will be the decision-making process involved in choosing either MIGS or conventional surgery as the best treatment for the specific patient.

Thoughts on optical coherence tomography angiography (OCTA)

Dr Augustin: Optical coherence tomography angiography (OCTA) is fast becoming an essential tool in the evaluation of retinal diseases. It removes the need to use a dye and provides immediate visualisation of the retinal and choroidal vascular bed. It also helps to visualise the superficial, deep and choroidal vascular network simultaneously. Therefore, by combining dynamic and morphology data the ‘road’ to the diagnosis becomes less complicated.

However, image artifacts, which are common in OCTA and can lead to incorrect interpretations of images, need special attention and require further evaluation. Having a standardised way of evaluating OCTA and a clear listing of all kinds of artifacts to avoid misinterpretation of the results would be helpful. 

Dr Hollo: OCTA in the macula area and in the peripapillary region has repeatedly been shown to have good diagnostic accuracy in glaucoma detection. In addition, a case series showed that very significant IOP reduction (at least a 50% reduction to 18 mmHg or less) in high-pressure open-angle glaucoma and ocular hypertension may lead to considerable recovery of the decreased peripapillary circulation.

Another report presented a glaucoma case in which progressive deterioration of the visual field and thinning of the retinal nerve fibre layer was accompanied by progressive reduction of peripapillary perfusion with OCTA.

Thus, OCTA may potentially be applicable in the follow-up of glaucoma patients. Prospective studies addressing this area, however, are not yet available. I hope that the first studies investigating the role of OCT angiography in the detection of glaucomatous progression will be available in 2018.

Thoughts on optical coherence tomography (OCT)

Dr Augustin: The eye is a window to the brain. The relationship between neurodegenerative diseases and ocular structures such as the optic nerve and retina is well established for many disease entities, such as multiple sclerosis (MS).

Optical coherence tomography (OCT) provides an important tool to accurately analyse modifications in the eye that have been induced by inflammation and neurodegeneration. Using the new OCT software platforms we can evaluate every single retinal layer and, above all, ganglion cells layer.

Taking MS as an example, several studies have demonstrated the correlations between GCL and clinical disability in this disease. The value of OCT is currently evaluated in many neurological diseases for both diagnosis and follow-up. The major challenge will therefore be the establishment of a network between neurologists, specialists in internal medicine and ophthalmologists.

Dr Kermani: Cataract and refractive imaging platforms based on swept-source OCT will increase confidence in the measurements, since this technology enables you to actually see what you measure and measure what you see. In 2018 we can expect IOL biometry (including axial length measurement), corneal topography/tomography, anterior segment biometry and anterior segment imaging to be combined in one instrument. 

Productivity is one of the central challenges in today’s cataract and refractive world.  An important characteristic of the new platforms is the fact that all measurements and analysis are based on high-resolution diagnostic images. This mitigates the effects of confounding factors such as coexisting abnormalities, which often cannot unambiguously be identified without diagnostic imaging. 

Processing the ray tracing algorithm with valid patient data is also near to hand. I am sure this will lift us to an even higher level of predictability and success. Such technology should be available in 2018. 

Thoughts on cataract & refractive surgery

Dr Kermani: Quality and safety in cataract and refractive surgery is better today than ever before. Femtosecond laser-assisted cataract surgery (FLACS) and premium IOLs are my gold standard now. Usually, I can perform what I have promised to my patients and this is a real game changer. However, the number of patients is significantly increasing and so the main challenge ahead, beside consolidation of results, is improving the perioperative set-up at all levels.

With challenges come opportunities and some of the new therapeutic technologies that have recently been introduced promise to revolutionise surgery. For example, the company Avedro, which develops corneal crosslinking (CXL) products, has developed the ‘Mosaic’ technology, which offers both customised remodeled vision (CuRV) and photorefractive intrastromal crosslinking (PiXL).

CuRV is a procedure that allows advanced cross-linking options to be offered to keratoconus patients. This treatment is customised to a patient’s specific corneal topography. Clinical studies have demonstrated that the CuRV procedure can result in greater flattening of K-max, improved corneal regularisation and reduced epithelial healing responses, compared with standard CXL. 

The PiXL procedure applies cross linking to a selective part of the cornea to flatten the cornea. It results in the cornea being reshaped, thus having the potential to provide non-invasive vision improvement.

Dr Fazio: In my practice, I have only had two ectasia cases: one after LASIK and the other after photorefractive keratectomy (PRK). Each patient was around 30-years-old and neither was showing an abnormal topography; the amount of refractive error was in the mid-range. In my eyes, it is evident that the Randlemann rule is largely inadequate to protect patient and surgeons from late complications after refractive excimer treatments.

Tomography software claims to give useful clues. Lately, the Corvis instrument (Oculus) has been proposed as a means to analyse corneal biomechanics in order to rule out patients at risk of ectasia. We are in need of strongly validated ways to decide if a patient is truly a good candidate for LASIK or PRK.

There are also challenges with toric IOLs. Since the advent of toric IOLs, astigmatic correction of the refractive error after lens replacement has seemed possible. However, even though they are a very powerful means of correcting astigmatism, a certain degree of disappointment still weighs on the procedure.

Despite the eventual acknowledgement of the role of the posterior corneal curvature on the amount of corneal astigmatism, the goal of a consistent precise astigmatism correction remains elusive.

There are three reasons for this: firstly, unlike optical or laser correction of refractive error, which relies on a subjective test or precise wavefront analysis, astigmatic correction via toric IOLs rely on shape analysis of the cornea and effective lens position in terms of antero-posterior shift as well as centration. Believe it or not, shape analysis of the central anterior and posterior cornea is still an art to refine.

Secondly, even if the surgeon has determined axis and amount of toric correction, perfect alignment of the lens is a far from easy. And techniques using automated surface recognition or even intraoperative wavefront analysis seem to offer no more precision than manual techniques.

Finally, toric IOLs occasionally exhibit a tendency to rotate. I personally believe that anterior capsule fixation, instead of capsular fornix fixation, is worth exploring in order to ensure better IOL stability and centration.

Another challenge in 2018 and in the years to come is achieving emmetropia in 100% of postoperative cases. Both with laser vision correction and refractive or cataract lens exchange, this is often achieved. However, something is missing in our anatomical analysis of the eye.

Moreover, effective lens position, that is to say, where exactly your artificial lens will decide to sit into the eye of your patient, is still guess work. The impact strategy of our excimer laser has yet to be improved.

In a setting of premium surgery, 0.50D of emmetropia is considered a failure. The challenge is to reduce such a small error to zero, every time.

Dr Alio: Multifocal trifocal IOLs have shown excellent results, becoming the gold standard for the majority of patients receiving a multifocal lens after refractive lens exchange (RLE) or cataract surgery, due to its better defocus curve for intermediate vision (nowadays critical) and greater tolerance.

It is now a common treatment option for all hyperopic patients of >45-years-old who ask for refractive surgery. Knowing this, is it coherent to perform LASIK in a 40-year-old patient with +6D of sphere considering that this option will preclude him from receiving multifocal lenses in the future? Many surgeons decide to wait until presbyopia appears in those patients before performing an RLE, but does it make sense to wait?

On the other hand, where should we place the cut-off age limit? With the current performance of new multifocal lenses, this age limit will probably change, although we still do not know what adverse events might appear with such lenses in the very long term (for example, 30 years’ time). We might see glistening and opacification, for example.

Age limits for multifocal lenses probably need to be redefined today, although not forgetting the expected long survival of these lenses in such young patients.

Meanwhile, many extended depth-of-focus (EDOF) lenses are currently being launched. These lenses offer the theoretical advantage of reduced adverse visual symptoms compared with the usual diffractive lenses. However, we will have to define where such EDOF lenses fit in our clinical practice and be sure on their supposed advantages (it has been reported with some models that they can still induce significant halos and equivalent visual symptoms). Their safety and efficacy for post-refractive surgery patients (either myopic or hyperopic) still needs to be properly defined.

Dr Augustin: In recent years, developments in corneal surgery have increasingly been directed towards lamellar keratoplasty instead of penetrating surgery, especially for diseases involving the endothelium of the cornea.

Nowadays, Descemet membrane endothelial keratoplasty (DMEK) enables surgeons to transplant just a part of the corneal tissue (the Descement membrane and endothelium), which is proving to offer better postoperative visual acuity and also reduces the risk of graft rejection.

DMEK enables patients’ vision to recover more quickly after surgery and, therefore, patient satisfaction has grown, while surgeons have access to a fast, effective option. Thus, this type of surgery has been revolutionary for both surgeons and patients.

A further improvement might come from the opportunity to have pre-cut donor flaps. However, this technique is not easy to learn. In addition, tissue preparation requirements mean that new facilities will be needed.

Dr Kermani: Dry eye is a real problem in refractive and premium cataract surgery. It needs to be seriously addressed. Today there are many ways to do so and we are building up the armamentarium both in diagnostics and therapy. We are not letting dry eyes spoil our surgical results. We will fight back and we will prevail.

Dr Alio: Surgical management of presbyopia is both innovative and challenging and is constantly being renewed. However, there are many factors in the development of presbyopia, making it difficult to adequately manage it.

Most surgical techniques that have been proposed for the surgical correction of this age-related disease are based on the acquirement of pseudoaccommodation. Accommodative intraocular lenses would be the ideal solution for presbyopia, having the power to resolve the inconvenience of the disease and the side effects produced by current surgical options.

However, despite many attempts to restore accommodation via the use of IOLs, none of the lenses have demonstrated sufficient long-term efficacy, even though they initially created a stir in the scientific community. Some new models and ideas are arriving and we should pay attention to their first clinical results, but we should do so carefully to avoid repeating the same mistakes of the past.

Dr Fazio: Presbyopia will probably remain the number one ophthalmic challenge in the refractive area for many years to come. These days the debate is about the new category of extended-depth-of-focus (EDOF) IOLs.

These lenses claim to make it possible for patients to have a continuous or almost continuous range of focus, from far to intermediate, without (or almost without) visual disturbances. Lenses competing in the increasingly crowded EDOF market include Symfony (Technis), Lara (Zeiss) and the Mini WELL IOL (SIFI Medtech).

With these lenses, worse near correction is traded for better far vision. But the question remains: how much worse does the near vision become and how big are the improvements to far vision?

If these lenses could really compete shoulder to shoulder with a standard aspheric lens in order of far quality of vision, that would be really good. However, since even an EDOF IOL manipulates the incoming light, a certain amount of visual disturbance is to be taken into account. 

Thoughts on small-incision lenticule extraction (SMILE)

Dr Alio: Treatment of hyperopia remains challenging for refractive surgeons. Hyperopic small-incision lenticule extraction (SMILE) performed using a proprietary femtosecond laser has recently been proposed and developed as a new treatment option. Clinical data from the first clinical trials are now being reported, bringing the technique closer to the clinic.

However, although encouraging results have been seen and will likely lead to a change in hyperopia management in the near future, there are still some important concerns, such as central haze, that need to be addressed. Further light might be shed on this in the coming year, as long-term outcomes and regression rate data become available.

Dr Alio: There are still some concerns regarding the available surgical options for SMILE enhancements. Important evidence has recently been published regarding the efficacy and safety of photorefractive keratectomy (PRK) after SMILE.

Visual recovery takes a little longer with SMILE (sometimes longer than acceptable) than with LASIK, and to convert into LASIK by opening the interface is not always feasible. We should be aware of future SMILE improvements such as cyclotorsion control to improve astigmatic outcomes; reSMILE standardisation to improve enhancement outcomes; and software optimisations to reduce the tissue comsumption per diopter.

Dr Fazio: SMILE is a relatively new treatment that has been proposed as a means to overcome the troubles encountered with the old and trusty LASIK and PRK. But will it be able to honour this promise?

SMILE has its limitations, including a slower recovery time compared with LASIK; difficult hyperopia treatment; and complications such as retained lenticule fragments. Moreover, it is not an open technique; it is a machine-linked procedure requiring the surgeon to use a femtosecond laser system (for example, Zeiss’ Visumax) if he or she wants to embrace the philosophy within.

Since there is not yet a validated way to analyse the biomechanical impact of a SMILE procedure compared with a PRK- or LASIK-guided procedure, the jury is still out. It is true that corneal analysis by the Corvis ST (Oculus) reveals a lesser impact of SMILE on the stiffness of the cornea but it is not yet clear if Corvis ST’s results can powerfully predict eventual ectasia.

Dr Kermani: An ongoing challenge is knowing when to take a break! I am not a workaholic but I recognise that I have to take care not to burn out by the enthusiasm I have of my work.

Every now and then I have to reflect on my work-life balance. In Germany, they say “you live to work” and in France they say “you work to live”. I want to do both with the same passion and attention. This is my personal challenge for 2018.

As another year comes to an end, five members of Ophthalmology Times Europe’s Editorial Advisory Board reflect and share their perspectives on the exciting opportunities that lie ahead for ophthalmologists in 2018, whilst also considering the potential challenges.

Author | Caroline Richards

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