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High-Frequency Deep Sclerotomy A MIGS Procedure for Mild-to-Moderate Glaucoma

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Authors

Hovanesian is in private practice at Harvard Eye Associates in Laguna Hills, California, and is a clinical instructor at Jules Stein Eye Institute at the University of California, Los Angeles. Find him online @DrHovanesian. Hovanesian is a consultant for Ocular Therapeutix, EyePoint Pharmaceuticals, Omeros, and several other manufacturers of ophthalmic drugs and devices.

Drug delivery solutions to manage pain after cataract surgery improves adherence.

Removing opioid prescriptions from cataract surgery

Over the last 15 years, biosimilars have become a major feature of the health care landscape. Physicians in many disciplines, particularly oncology and immunology, have embraced biosimilars. However, access to educational resources on these powerful biologics can be inconsistent, and in turn, some ophthalmologists who could benefit from the adoption of biosimilars are left in the dark.

The real-world application of biosimilars was the focus of discussion for Martin Zinkernagel, MD, PhD, chair of the Department of Ophthalmology at the University Hospital of Bern, Switzerland, and Paolo Lanzetta, MD, professor of ophthalmology and chairman of the Department of Medicine-Ophthalmology at the University of Udine in Italy. In their discussion, the experts addressed several common questions, framed around the phase 3 clinical trial for biosimilar SB11 (BYOOVIZ) from Biogen. SB11 is approved in Europe and the United Kingdom. Like the reference product ranibizumab (Lucentis), SB11 is approved for the treatment of retinal disease including neovascular age-related macular degeneration (nAMD).

Addressing physicians’ levels of familiarity with biosimilars, Dr Lanzetta attributed much of the variation to regulatory discrepancies. “The uptake of biosimilars varies throughout Europe by country and by product,” he said. “Obviously, variation in the uptake of biosimilars [is] influenced by government involvement, reimbursement issues and tender procurement policies.” Recent survey data have revealed gaps in awareness across Europe and in the United States on the efficacy and safety of biosimilars for retinal diseases, Dr Lanzetta said, especially in terms of “real-world data.”

In a clinical application, Dr Lanzetta said, biosimilars may exhibit minor differences from the reference products, but they aren’t considered to have significant impact on the efficacy or safety profile. Typically, the biosimilar and reference medicine must have the same posology and route of administration, with few exceptions, he added.

Dr Lanzetta also said that in the last 10 years, the European Medicines Agency (EMA) has approved the highest number of biosimilars worldwide.

 “And this means, to us physicians, having both the possibility to have experience on their use in terms of safety and evaluating the efficacy after that,” he explained.

One common misconception about biosimilars is that these therapeutics are interchangeable with the idea of generic medicines. But there is a key indicator that biosimilars are unique: the cost. “While generic medicines are marketed at a significantly lower price than name brand ones, why do we not see the same level of cost savings with biosimilars?” Dr Zinkernagel asked.

Dr Lanzetta explained that biosimilars are developed via a rigorous, complex and highly regulated manufacturing process. “Generics are simple chemical medicines or agents, which is not the case for biosimilars and biologics,” he said. “Unlike generics, biologics, and therefore biosimilars as well, are very complex; they’re very difficult to copy. And the development processes are patented and proprietary to the originators.” The proprietary nature of biologic development, he added, is why biosimilars may have differences from their originators.

Prof Zinkernagel and Dr Lanzetta used data from the SB11 phase 3 trial to expand upon the capabilities of biosimilars. Prof Zinkernagel detailed the study: over 700 patients were included in the randomised, double-masked, parallel-group multicentre trial. Over 52 weeks, investigators evaluated the efficacy and the safety profile of this biosimilar SB11 in comparison with monthly ranibizumab for the treatment of nAMD.

“Patients with neovascular AMD were included, [with a] visual acuity range between 20/40 and 20/200,” Prof Zinkernagel said. “[Patients] were randomised in a 1:1 ratio to either have the originator or the biosimilar every 4 weeks from baseline up to week 48.”

Primary end-points were change from baseline in best corrected visual acuity at week 8 and change from baseline in central subfield thickness at week 4. The pre-specified secondary efficacy end-points included longer-term assessments of change from baseline in visual acuity, and the proportion of participants who lost fewer than 15 letters or who gained 15 or more letters in visual acuity from baseline at weeks 24 and 52.

“Other secondary end-points included, of course, change from baseline in central subfield thickness and central retinal lesion thickness at week 24, as well as change from baseline in choroidal neovascularisation [CNV] size and proportion of participants with active CNV leakage seen via OCT [optical coherence tomography] at week 24,” Prof Zinkernagel continued. Describing the results, he said, “When you look at the visual acuity improvements, it’s really equivalent. You have equivalence between the originator and the biosimilar, and the same holds true for a decrease in central retinal thickness. So the curves are basically the same, and also the secondary end-points.”

Prof Zinkernagel also spoke about the immunogenicity outcomes of the SB11 trial, as immunogenicity reactions have been a common problem in past assessments of anti–vascular endothelial growth factor (VEGF) agents. Along with detrimental effects to visual acuity, immunogenicity reactions can also lead to vasculitis and vitritis.

“Now, in this trial, the overall cumulative incidence of anti-drug antibodies, antibodies reacting against this specific drug up to week 52, was very low,” Prof Zinkernagel said. “For the SB11 biosimilar, it was 4.2%, and for the originator it was 5.5%. So very, very similar.”

He also noted that most antibodies were non-neutralising, which generally indicates a weak antibody response. “Furthermore, no statistical or clinically relevant differences in the incidence of anti-drug antibodies and neutralising antibodies were observed between treatment groups at any of the time points,” Prof Zinkernagel explained.

Dr Lanzetta highlighted the unique potentialities for anti-VEGF therapies as an area where physicians can consider treating patients with a biosimilar. “You can either switch a patient from the originator, obviously, or you can also consider treating with a biosimilar treatment-naive patients who may benefit…from being treated with that reference agent or originator agent,” he said. When to deploy a biosimilar will depend on many factors, including the locality where a patient is being treated. “Europe has different countries, different health care systems,” Dr Lanzetta said. “You may consider treating with the biosimilar patients who may not be strictly adherent to the cost of therapy and the frequency of treatment because of some cost issues.”

Just as education on biosimilars is vital to practitioners, awareness and education resources for patients are vital, too. “We spend a lot of time with our patients in letting them know that biologics did undergo a very rigorous approval process through studies, efficacy and safety studies,” Dr Lanzetta emphasised. This education is vital to getting patients on board with biosimilars, and it sparks enthusiasm about the potential benefits. “Once they do understand that, I think they will be very prone to receive a biosimilar; [it’s] in their interest and in the interest of the community, the whole community of patients, and in the interest of the health care system,” Dr Lanzetta said.

1. Biosimilars in the EU: information guide for healthcare professionals. European Medicines Agency. Updated December 2, 2019. Accessed October 3, 2023. 

https://www.ema.europa.eu/en/documents/leaflet/biosimilars-eu-information-guide-healthcare-professionals_en.pd

Editor’s note: A prior version of this article contained a misspelling of the product name BYOOVIZ. It has been corrected. We regret the error.

How biosimilars expand treatment options for patients with retinal disease

Founded in the 13th century, the Quinze-Vingts National Ophthalmology Hospital in Paris is commonly noted to be one of the oldest hospitals in France, but it is known to be equipped with the best in modern diagnostic and surgical technology. I truly appreciate having access to the latest advances in equipment and software that elevate my performance as a surgeon and serve to enhance outcomes for my patients. And, as a self-described geek I am always eager to trial new technology. Therefore, the launch of the AT ELANA® 841P hydrophobic trifocal IOL and the introduction of the ARTEVO® 750 and ARTEVO® 850 microscopes from ZEISS were exciting developments for me. After learning about the features of these new products, I looked forward to using them, and in my first real-world clinical experiences they are fulfilling my expectations.

Optical designs for presbyopia-correcting IOLs continue to evolve, but in my experience and according to findings of a recent meta-analysis, a trifocal optical design gives patients the best chance of achieving spectacle independence at all distances after cataract surgery.1 Going back to 2008, the first presbyopia-correcting IOL I implanted was the AT LISA® 809M (Carl Zeiss Meditec AG, Jena, Germany), a hydrophilic bifocal lens that provided high quality vision for distance and near, but often left patients needing correction for intermediate vision tasks. Thus, I was very happy when the trifocal AT LISA® tri 839MP became available because it combined the proven performance of the AT LISA platform with the functional benefit of a trifocal optic.

Now, with the AT ELANA 841P, the newest member of ZEISS IOLs, I can give my patients seeking presbyopia correction the advantages of a fully preloaded trifocal IOL with a glistening-free*hydrophobic acrylic biomaterial and heparin-coated** surface that ensures good optical clarity as well as smooth and controlled unfolding. Furthermore, the C-loop platform and step-vaulted, rigid optic-haptic junction found on the AT ELANA 841P facilitate centration and capsular contact to minimize posterior capsule opacification (PCO). The design of the AT ELANA 841P optic is based on the AT LISA tri 839MP, but it is modified to have increased light transmission efficiency and a higher allocation of light towards near vision to enhance near-to-intermediate vision without compromising far vision.***

Different surgeons favor different IOL biomaterials, but compared to hydrophilic acrylic, hydrophobic acrylic material has the advantage of being associated with a lower incidence of PCO.2 I inject the AT ELANA 841P through a 2.4 mm incision. As a fully preloaded lens, the AT ELANA 841P contributes to surgical efficiency, and the lens unfolds gently and easily, enabling precise positioning.

The refractive and functional outcomes from my first use of the AT ELANA 841P have been as favorable as my initial intraoperative experience. While there is always uncertainty about achieving the targeted refractive outcome when implanting a new IOL with use of the manufacturer’s recommended IOL constant, my analysis of data from the first 10 patients who underwent bilateral implantation showed excellent accuracy. At 3 months after surgery, spherical equivalent averaged +0.09 D and was <1.0 D in all eyes; mean residual astigmatism was 0.86 D. Mean (decimal) monocular best corrected distance visual acuity was 0.9, all eyes had a best corrected intermediate visual acuity >0.7, and best corrected near visual acuity was >0.8 in 90% of eyes. The defocus curve for my patients was consistent with the published findings from bench tests that showed the AT ELANA841P has good optical performance across an extended range of distances.3

I have been very happy operating with the OPMI LUMERA® 700 optical microscope because I find it provides high clarity images with excellent contrast and color. In addition, I appreciate the microscope’s connectivity with other ZEISS diagnostic, planning, and surgical platforms, which I find increases workflow efficiency.

Yet, when it comes to technology, it seems that there are infinite possibilities for innovation and advancements, and ZEISS proves that point again with the introduction of two new surgical microscopes – the ARTEVO 750, an optical microscope with traditional oculars, and the ARTEVO 850, a hybrid device with both a 3D monitor for digital visualization and traditional oculars.

I recently had the opportunity to trial the new ARTEVO 850. The image quality of the LUMERA 700 was already outstanding according to my experience, making the improvement I found with the new ARTEVO 850 microscope even more impressive. I personally found that the ARTEVO 850 improves surgical visualization with the new RGB LED illumination. Equipped with a mix of red, green, and blue LEDs, the RGB illumination technology allows surgeons to adjust light color temperature from warm to cold (3000K to 6000K), offering the opportunity to finetune the surgical view according to personal preferences. I also found this feature may help to highlight specific anatomical details. For example, I noticed that switching to a warmer temperature during capsulorhexis made the red reflex even more stunning, aiding visualization of the capsule edge. 

The ARTEVO 850 captures the surgical image with 2 4K 3-Chip cameras and displays it in 3D with true colors on the system’s 55-inch high dynamic range (HDR) monitor. Viewing the surgical image on the 3D HDR monitor was an amazing experience for me because I actually felt immersed inside the eye. In my experience and as demonstrated by multiple studies, operating with a heads-up configuration while viewing the 3D monitor is more ergonomic and comfortable than bending over the microscope, and it also gives other OR personnel a real-time view of the surgical procedure. However, the ARTEVO 850 is also equipped with a Hybrid Mode that allows surgeons to view the surgical field through the microscope’s oculars at any time during the procedure with just a simple switch of a button.

In addition, integrated intraoperative optical coherence tomography (OCT) is available as an optional add-on. In my opinion, the OCT image has excellent quality in high definition, and the OCT scan quality can be adjusted as desired. For example, after reducing the noise during a Descemet membrane endothelial keratoplasty case, I was able to better visualize the side of the graft (Figure). As another new feature, size indicators are displayed in the OCT image, and I am looking forward to applying this tool in Implantable Collamer Lens (ICL) cases so that I can estimate the size of the vault intraoperatively.

The ARTEVO 850 is digitally connected to the ZEISS Premium Cataract Workflow. Options for data overlays during cataract surgery include cataract assistance functions, e.g., for toric IOL alignment, and phaco parameters from QUATERA® 700. Along with the new ARTEVO 850 microscope, ZEISS introduced a redesigned CALLISTO eye user interface that I found to have a spectacular, intuitive touchscreen. Enhancing workflow efficiency, preoperative biometric data collected with the IOLMaster® 700 and planning data created using EQ Workplace® can be seamlessly transferred to the QUATERA 700 and the CALLISTO eye of the ARTEVO 850.

Innovation brings novelty to technology, but it must also provide value. Based on my early experience, the AT ELANA 841P IOL and ARTEVO 750 and ARTEVO 850 microscopes are true innovations offering important benefits that serve both me as a surgeon and my patients.

1. Li J, Sun B, Zhang Y, et al. Comparative efficacy and safety of all kinds of intraocular lenses in presbyopia-correcting cataract surgery: a systematic review and meta-analysis. 

2. Donachie PHJ, Barnes BL, Olaitan M, Sparrow JM, Buchan JC. The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 9, Risk factors for posterior capsule opacification. 

3. Labuz G, Yan W, Khoramnia R, Auffarth GU. Optical-quality analysis and defocus-curve simulations of a novel hydrophobic trifocal intraocular lens. 

* Grade 1 (traces) or better for 85% of the patients up to and including 12 months according to Christiansen scale and based on internal clinical trial outcomes and on published clinical data.

** Fragment of heparin used in IOL surface coating with no pharmacological, immunological or metabolic action.

*** Compared to AT LISA tri in photopic conditions in virtual implantations and optical bench tests.

Liem Trinh, MD is an ophthalmologist at 15-20 National Ophthalmologic Hospital in Paris, France, specializing in refractive and cataract surgery. He is a paid consultant for Carl Zeiss Meditec.

Enhancing cataract surgery with advanced optics

My first experiences with AT ELANA 841P and ARTEVO 850

For a patient undergoing cataract surgery, the primary post-operative expectation is improved vision. As a surgeon, achieving the desired refractive outcome involves several critical steps: conducting precise preoperative measurements, selecting the appropriate IOL technology and power, and performing surgery with accuracy.

Heidelberg Engineering’s advanced diagnostic imaging solutions support you in enhancing the cataract patient journey, from initial assessment and diagnosis to preoperative planning and postoperative monitoring. Throughout this interactive supplement, leading surgeons share their experiences with and discuss the advantages of these advanced diagnostic imaging solutions, as Dr. James Lewis does in this video 

A major challenge for cataract surgeons is the vast number of patients. Addressing this backlog is crucial to prevent vision impairment and improve the quality of life for those affected. The electronic medical record, Heidelberg Eye Explorer 

, helps to streamline the cataract workflow by optimising patient data management, enhancing communication, and improving surgical planning.

Dr. Hackl from Hanusch Hospital in Vienna recalls how HEYEX EMR streamlined their workflow and provided access to patient records across more than five locations.

“There was a need to have a paperless medical record which could be seen in all five locations and met our main requirements: a continuous medical record, a patient summary for a quick overview, as well as planning and documentation…when a system like HEYEX EMR supports structured data the possibilities to use the data are unlimited." 


Read the full story on how Hanusch Hospital, Vienna, used HEYEX EMR to streamline their workflow.

 image and data management platform into your clinic workflow allows for improved efficiency. All patient information is centrally recorded and can be accessed anywhere in the clinic. Images and data are immediately available on your desired device, viewing station, and in the patient record.

Visualising all relevant data and images from the cataract workup contributes to an optimal diagnostic workflow, facilitates confident decisions, and assists you in easily identifying potential sources of complication.

Precise ocular biometry is critical for determining the power of IOLs being implanted. Leveraging advanced Swept-Source OCT technology, 

 provides you with a comprehensive, all-in-one solution for optical biometry and IOL power prediction. In a single imaging session, the Cataract App provides precise and accurate measurements traditionally delivered by several devices, including axial length, cornea topography and tomography, anterior chamber depth, lens thickness, white-to-white, and central corneal thickness.

“I was looking to upgrade my methods and equipment, especially in intraocular lens calculation, explains Dr Arturo Chayet, ophthalmologist and founder of CODET Vision Institute in Tijuana, Baja California, Mexico. At the time, I was using the IOLMaster500 for calculations, but I was looking for a bridge to swept-source OCT technology. We knew it was crucial to not only measure axial length and various parameters of the eye but also to understand the anterior chamber, specifically the effective lens position. I was struck by the capability of ANTERION and was very impressed with the expertise Heidelberg Engineering has in the field. Our experience with SPECTRALIS was excellent as well.” 
- Dr. Arturo Chayet, M.D. 

For refractive IOL procedures, where presbyopia-correcting IOLs are implanted, and in challenging cases, accessing additional data is essential for patient selection and satisfaction. ANTERION provides a comprehensive analysis of the cornea and includes details on astigmatism and corneal wavefront. 

Learn more about the significant role ANTERION plays in premium IOL selection here.

ANTERION’s high-resolution imaging of the anterior segment can help you prevent unexpected results by identifying complex ocular properties relating to anatomy, visual quality, and atypical geometry of the anterior segment. The high-quality images also provide visual aids that can be used to explain your patient’s condition and the planned surgical procedure, enhancing their understanding and compliance.

Listen to Dr. Pooja Kumar, Consultant, Khetarpal Hospital, New Delhi, India 

, as she explains how she uses ANTERION’s high-resolution swept-source OCT images to identify complex cases like posterior polar cataracts. She also explains how she utilizes these images to counsel her patients in preparation for surgery.

OCT imaging of the retina before cataract surgery lets you assess pathologies that may limit visual outcomes. 

 allows you to choose between 20kHz, 85kHz and 125KHz depending on your needs. 20 kHz scan speed offers high-quality retinal imaging also in eyes with media opacities often caused by cataracts. 

Read more about the benefits of retinal OCT before cataract surgery here

 provides a comprehensive overview by combining data and images from all devices 

. This consolidated information ensures you have all relevant diagnostic details, enhancing your confidence in surgical planning.

 delivers next-generation image technology to revolutionise your surgical practice. It brings together innovative design and 3D technology to set new standards in surgical precision and surgeon comfort during procedures.

 as he shares his initial impressions and discusses the benefits of SeeLuma, explaining why he eagerly anticipates incorporating it into his practice soon.

High-Resolution Imaging for Postoperative Evaluation

 supports you in visualising the success of surgical procedures by comparing pre- and post-op images and measurements. Detailed anterior chamber information from high-resolution SS-OCT images helps you assess cataract surgery outcomes, including IOL placement, ensuring optimal patient care and satisfaction 

Watch this Healio video interview with Dr. Mitchell W. Dul, OD, 

where he explains how he uses the ANTERION Metrics App to show his patients their pre-op and post-op configurations, helping them become more invested in their care.

Leveraging Heidelberg Engineering's advanced diagnostic tools and technologies, including high-quality OCT imaging, precise biometry, and corneal topography and tomography, enhances your diagnostic accuracy, surgical planning, and postoperative evaluation. Whether dealing with standard, refractive IOL, or challenging cases, these tools and technologies can help you improve patient outcomes and engagement, streamline workflows, and flag potential surgical complications.

Enhancing the Patient Journey: Solutions for Streamlining Success in Cataract Surgery

Glaucoma specialists worldwide face numerous challenges daily, from early detection to accurate diagnosis and ongoing patient management. The Heidelberg Engineering Glaucoma Workflow Solution is designed to provide the tools you need to deliver the best care to your patients. It offers dynamic visualization of parameters, efficient data management, precise imaging, and robust monitoring capabilities. Find out how glaucoma experts around the world are leveraging these advanced technologies to enhance the patient journey, increase diagnostic confidence, streamline workflows, and improve patient outcomes.

“It was a surprise as I didn’t feel my vision had been hindered in any way. At that point, I didn’t know that glaucoma was rampant in my family on both my mother’s and father’s sides. When I shared the news of my glaucoma with my late mother, she did not miss a beat, replying, ‘Oh honey, your father and I have had glaucoma for years’. To which I could only say, ‘Really Mom, maybe you and Dad could’ve mentioned that […] like 20 years earlier.” PHILLIP VAN LEAR, diagnosed at 48 

One of the most significant challenges in glaucoma management is detecting the disease early, as it often progresses without symptoms. “

Early glaucoma has no symptoms,” explains Christian Mardin, Consultant Ophthalmologist at Friedrich-Alexander-Universität, Erlangen, Germany. “Every person over 40 should go to their optometrist or ophthalmologist to get their optic nerve head checked

Continue reading Prof. Mardin’s insights on early glaucoma detection here.

The electronic medical record platform HEYEX EMR helps streamline this process by managing and presenting comprehensive ophthalmic patient records through an intuitive interface. It provides access to high-quality, structured data, aiding in efficient reporting and auditing. Dr. Hackl of Hanusch Hospital, Vienna, recalls how HEYEX EMR helped the hospital streamline their workflow and allowed access to patient records in over five locations.

“There was a need to have a paperless medical record which could be seen in all five locations and met our main requirements: a continuous medical record, a patient summary for quick overview, as well as planning and documentation…when a system like HEYEX EMR supports structured data the possibilities to use the data are unlimited.

Read the full story on how Hanusch Hospital, Vienna, used HEYEX EMR to streamline their workflow.

As early detection becomes more efficient, the next step is ensuring accurate diagnosis, where the 

The Glaucoma Module Premium Edition (GMPE)

 provides detailed imaging and analytics of the optic nerve head and retinal nerve fiber layer. Using the Anatomic Positioning System (APS) ensures an accurate anatomical setup for optimal comparison with the normative reference database. These tools equip you with the information needed to support confident diagnostic decisions. 

Download the SPECTRALIS Glaucoma Toolkit here.

 allows for non-contact assessment of iridocorneal angles and anterior segment anatomy, providing precise measurements and automatic identification of the scleral spur to enhance your early detection capabilities. 

Dr. Benjamin Xu, Chief of the University of Southern California's Glaucoma Service, presents a webinar on using non-invasive anterior segment imaging, including ANTERION® technology and AI, to detect and treat angle closure glaucoma. 

Once a confident diagnosis is achieved, effective management relies on seamless referrals and data sharing, which is where the integration of HEYEX EMR with the 

 platform becomes indispensable. Effective glaucoma management necessitates streamlined referrals and data sharing throughout your clinic. This system centralizes patient information, minimizing duplication and manual data entry errors.

HEYEX 2 Cloud Exchange facilitates secure, peer-to-peer transfer of images and data over the internet, eliminating the need for VPN connections. This feature enables efficient and encrypted data transfers, ensuring timely communication with other healthcare providers and enhancing your referral process. Learn to start using Cloud Exchange and transfer data after setting it up on 

 enhances your diagnostic workflows by enabling side-by-side review of images and reports from both eyes, consolidating all pertinent data for comprehensive analysis, in one single view.

“I have chanced upon signs which masquerade as glaucoma on an OCT scan. Branch retinal artery occlusions or cotton wool spots — small infarcts or blood vessel closures — can result in an initial swelling in the nerve fibre layer. They are transient and disappear in a few weeks, and are often caused by high blood pressure or kidney disease.” 

PROF. SANJAY ASRANI, Duke Eye Center, North Carolina, USA 

Accurate glaucoma diagnosis hinges on comprehensive examination techniques. The SPECTRALIS GMPE provides accurate measurements and visualization of key parameters involved in glaucoma diagnosis such as the optic nerve head, retinal nerve fibre layer, and macular ganglion cell layer, via OCT imaging. Tools like Bruch’s Membrane Opening – Minimum Rim Width (BMO-MRW) offer objective, geometrically accurate measurements of the neuro-retinal rim, aiding your early detection efforts. The reference database further guides your analyses.

Learn to integrate the power of OCT imaging and SPECTRALIS GMPE in your daily practice in this educational webinar by Dr. Swarup Swaminathan. 

Sometimes glaucoma needs to be differentiated from other conditions with similar presentations. Recognizing these nuances ensures your accurate diagnosis and effective treatment planning.

Regular monitoring is critical for managing glaucoma patients. The HEYEX 2 Multimodality Viewer supports ongoing data sharing and displays follow-up examinations across multiple locations, allowing you to access previous images and reports easily. Post-surgery, the ANTERION Metrics App provides precise measurements and visualizations of the anterior chamber and the anterior chamber angle, crucial for effective patient management.

Integration with the SPECTRALIS core technologies, such as TruTrack Active Eye Tracking and AutoRescan, ensures accurate monitoring of disease progression. These tools enable follow-up scans in the exact anatomical locations as previous exams, allowing you to detect minute changes with high precision.

, the world's first fully digital microscope, offers unparalleled precision through its 3D visualization technology. It provides exceptional image quality, ergonomics, and educational features, significantly benefiting your surgical practice.

The Heidelberg Engineering Glaucoma Workflow Solution is designed to integrate seamlessly into your patient care routine, supporting unparalleled diagnostic confidence and efficiency. By leveraging these advanced tools and technologies, you can overcome the challenges in glaucoma management, improving patient outcomes and engagement.

Delve deeper into how these solutions can transform your practice.

Enhancing the Patient Journey: Solutions to Overcoming Challenges in Glaucoma Management

A study that explored the effects of caffeine on systolic and diastolic blood pressure (SBP and DBP) and retinal vessel density (VD) assessed by optical coherence tomography angiography (OCTA) found that 200 mg of caffeine elevated the BP after 2 hours but did not impact the retinal VD, according to first author Mitchell Jacobs, MD, from the Department of Ophthalmology and Visual Sciences, University of Kentucky, Lexington, KY, and colleagues.

Previous studies, according to the investigators, have reported contradictory findings, with some suggesting adverse effects on the BP and cardiovascular risk, while meta-analyses proposed potential cardiovascular benefits.

 In contrast, the vascular and anti-inflammatory effects of caffeine are associated with a 65% decreased risk of dementia and Alzheimer disease.

In the eye, caffeine can temporarily increase the intraocular pressure and reduce blood flow in critical ocular regions.

 Other studies using OCTA reported that caffeine consistently leads to decreased VD, suggesting a vasoconstrictive effect on the retinal circulation,

In light of these conflicting findings, the investigators used OCTA to determine how 200 mg of caffeine affects the SBP and DBP and VD in a prospective, randomised, double-blind placebo-controlled study. The study included 59 healthy coffee drinkers who ingested less than 136 mg of caffeine daily. Forty-two participants were randomly assigned into the caffeine group and received a 200-mg caffeine pill, and 17 were assigned to the placebo group.

OCTA was performed at 60 and 120 minutes after the intervention. The VD was measured in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) after the SBP and DBP measurements were recorded before each imaging session.

The findings showed that 2 hours after the intervention, the caffeine group had a significantly higher SBP (123 ± 7 mmHg) and DBP (81 ± 5 mmHg) compared to the control group (118 ± 7 mmHg, 77 ± 6 mmHg, respectively) (p =0.012, 0.023, respectively).

No significant differences were seen in the VD between the caffeine and placebo groups, regardless of whether the scans were centered on the macula or optic nerve head.

Dr Jacobs and colleagues concluded that 200 mg of caffeine elevated the BP after 2 hours but did not impact the retinal VD. “This underscores the intricate relationship between caffeine, BP and retinal vascular dynamics, prompting further exploration of their implications for ocular health, especially in subjects with vascular disease,” they commented.

Jacobs M, Demas N, Hemesath A, et al. Optical coherence tomography angiography: investigating vessel density changes induced by caffeine in healthy subjects. 

Zhou A, Hyppönen E. Long-term coffee consumption, caffeine metabolism genetics, and risk of cardiovascular disease: a prospective analysis of up to 347,077 individuals and 8368 cases. 

James JE. Chronic effects of habitual caffeine consumption on laboratory and ambulatory blood pressure levels. 

https://doi.org/10.1177/174182679400100210

Vlachopoulos C, Hirata K, Stefanadis C, Toutouzas P, O’Rourke MF. Caffeine increases aortic stiffness in hypertensive patients. 

Wilson PWF, Bloom HL. Caffeine consumption and cardiovascular risks: little cause for concern. 

Caldeira D, Martins C, Alves LB, et al. Caffeine does not increase the risk of atrial fibrillation: a systematic review and meta-analysis of observational studies. 2013;99:1383-1389; doi: 10.1136/heartjnl-2013-303950

Miller PE, Zhao D, Frazier-Wood AC, et al. Associations of coffee, tea, and caffeine intake with coronary artery calcification and cardiovascular events. 

https://doi.org/10.1016/j.amjmed.2016.08.038

Vercambre MN, Berr C, Ritchie K, Kang JH. Caffeine and cognitive decline in elderly women at high vascular risk. 

Eskelinen MH, Kivipelto M. Caffeine as a protective factor in dementia and Alzheimer’s Disease. 

Ajayi OB, Ukwade MT. Caffeine and intraocular pressure in a Nigerian population. 

https://doi.org/10.1097/00061198-200102000-00006

Avisar RR, Avisar E, Weinberger D. Effect of coffee consumption on intraocular pressure.

https://doi.org/10.1345/1542-6270(2002)036%3A0992:eoccoi%3E2.0.co;2

Tugan BY, Subasi S, Pirhan D, et al. Evaluation of macular and peripapillary vascular parameter change in healthy subjects after caffeine intake using optical coherence tomography angiography. 

https://pubmed.ncbi.nlm.nih.gov/35225536/

Karti O, Zengin MO, Kerci SG, Ayhan Z, Kusbeci T. Acute effect of caffeine on macular microcirculation in healthy subjects: an optical coherence tomography angiography study. 

Caffeine has been shown to temporarily increase intraocular pressure and reduce blood flow in critical ocular regions

Study: caffeine does not impact retinal vessel density, despite effects on blood pressure


As a young ophthalmologist in my early years of practice, I am always asking myself, how I can do my best for my patients. Improving my skills in performing cataract surgery has been one area of focus for me, and there are a variety of modalities that I could consider to help me achieve my goal. The ZEISS Surgery Optimizer offers a new option, and I was excited when I was asked to trial it in my practice.

Cataract surgeons certainly know that reviewing personal intraoperative videos is a useful method for improving efficiency and skill because it allows us to see what we are doing well and identify areas where there is room for improvement. In addition, watching recordings from surgeries performed by recognized experts can be a powerful learning tool. Based on the concept of “monkey see, monkey do”, the hope is that after observing cases done by the hands of leading surgeons, we will be able to replicate their tricks and techniques and improve our skills.

The process for reviewing intraoperative videos requires that surgeons have a good microscope, a good recording system, and technology for transferring and watching the videos. Surgeons operating in modern facilities have access to the first two components of this triad, but exporting the recordings to a device where they can be reviewed has been a cumbersome, multistep task that discouraged surgeons from taking advantage of the benefits that could be gained from video review. Once recorded, the video file needs to be transferred to a USB drive and then to a desktop or laptop computer, but that transfer could be slow and time consuming considering the large size of the video files.

The ZEISS Surgery Optimizer revolutionizes the entire process by providing a way for surgeons to access their surgical videos anytime on their personal devices without having to manually export and import the files. With the click of a button, videos are imported from ZEISS CALLISTO eye, a digital navigation and data management system of ZEISS ophthalmic microscopes, to a cloud-based software system. Once imported, the videos are directly available for viewing on a computer via a web browser or on a mobile device using the dedicated ZEISS Surgery Optimizer app (VIDEO 1). Case documentation and database creation are easy, enabling surgeons to be selective about what videos they add to the application. The descriptive documentation also has the benefit of enabling searching for cases based on specific characteristics, such as biometry measurements.

Importantly, the app also gives users access to unedited videos provided by highly experienced surgeons from countries all around the world with the opportunity to review those recordings side by side against their personal videos so that they can learn by comparing their own techniques against those of leading surgeons.


Video 1: Reviewing your surgical performance with ZEISS Surgery Optimizer


Tabs on the opening page of the ZEISS Surgery Optimizer screen show available videos divided into 3 categories: 1) Institution cases, which are cases performed at the user’s institution; 2) Featured cases, which represent a video gallery of cases from leading surgeons around the world; and 3) Favorites, which are institution cases individual users have chosen for easy access.

The videos are supported with datasets from ZEISS integrated devices, such as IOLMaster 500 and 700, and when a selected video plays, the patient’s biometric and some other preoperative data are displayed on the lefthand side of the screen. Using an AI-based segmentation algorithm, the ZEISS Surgery Optimizer automatically divides each case into its multiple phases (ie., incision, OVD injection, capsulorhexis, hydrodissection, phacoemulsification, irrigation/aspiration, IOL implantation, etc). As a very useful feature, the phases appear both as a list on the lefthand side of the screen and below the video timeline so that with a single click, surgeons can advance the video to focus on a particular maneuver. To designate a video as a “favorite”, users click on a star that appears at the righthand bottom corner of the screen, and a tab in the upper righthand corner gives users the capability to compare their case with a featured case. The cases chosen for comparison play side by side and can be watched from the beginning or at any selected phase. Users can adjust brightness, contrast, and playback speed without downloading the video. Videos can also be downloaded for editing with a professional software program.

My personal experience using the ZEISS Surgery Optimizer is testament to the appropriateness of its name. In a series of 200 routine cases that I performed before using the app, my total surgical time averaged about 12 to 13 minutes. Over a period of 30 days, I reviewed my videos using the app and compared them with selected “featured” videos to see where I could improve my techniques and increase my efficiency for completing various steps in the procedure (Video 2). I chose cases from my mentor, Dr Sri Ganesh, as my featured cases. I knew that Dr Ganesh completes a routine cataract surgery case in about 2.5 minutes, which left me eager to see what he does differently. My goal was not simply to increase my speed, but rather to improve my skills. Dr Ganesh always advised me that I should focus on the economy of movements and surgical efficiency and that faster speed would follow as a happy coincidence. He was right!

Watching his videos side-by-side with mine, I identified multiple ways to improve my approaches for completing a variety of steps. In particular, I implemented new techniques for performing capsulorhexis, hydrodissection, and direct chop/phacoemulsification, and I was amazed by the impact my time spent with the application had on reducing my average case time. Analyzing cases performed in my “post Surgery Optimizer era”, I found that I had cut my average surgical time by about 50% to just 6.5 minutes compared to my “pre Surgery Optimizer era”, I found that I had cut my average surgical time by about 50% to just 6.5 minutes compared to my “pre Surgery Optimizer era”. The largest contributors to this change were decreases in my average times for capsulorhexis (40 to 27 seconds), hydrodissection (40 to 9 seconds), and direct chop/phacoemulsification (3 minutes 10 seconds to 1 minute 52 seconds).

Video 2: AI driven comparison of the own surgical performance with expert-level cases

I believe that my experience with the ZEISS Surgery Optimizer is compelling proof of how this tool can help young ophthalmologists refine their cataract surgery skills and efficiency. In addition, I am certain that it has value as a remote teaching tool for residents and fellows and can help these ophthalmologists-in-training shorten their cataract surgery learning curve.

According to my mentor, Dr Ganesh, the ZEISS Surgery Optimizer can also be a useful tool for surgeons training young ophthalmologists because it enables mentors to evaluate current skills and provide guidance for modifications. Furthermore, I expect that experienced cataract surgeons wanting to implement a new technique can accelerate their learning phase by using the application.

The AI- and cloud-based ZEISS Surgery Optimizer provides cataract surgeons in practice and ophthalmologists in training an innovative new way of utilizing surgical videos. It allows users quick and easy access to the material at any time and on any personal device they choose along with the opportunity to review their procedures and compare their techniques directly with those of leading surgeons. Based on my personal experience with this self-training tool, I am convinced of its value and highly recommend its use by anyone wanting to take their cataract surgery skills to the next level.

Dr Supriya Samak Sriganesh is an ophthalmologist on staff at Nethradhama Super Specialty Eye Hospital, Bangalore, India, specializing in cataract and refractive surgery. Dr Sriganesh is a consultant of ZEISS.

The statements of the author reflect only her personal opinion and experiences and do not necessarily reflect the opinion of any institution that she is affiliated with. The author alone is responsible for the content of her experience reported and any potential resulting infringements. Carl Zeiss Meditec AG and its affiliates do not have clinical evidence supporting the opinions and statements of the author nor accept any responsibility or liability of the author's content. Surgery Optimizer is a non-medical device and not intended for diagnosis and therapeutic purposes, only for education, learning & review purposes

Dr John A. Hovanesian

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