It's great to see you. I know you presented yesterday on quality of life—yesterday afternoon. Could you tell me a bit more about the key takeaway points from your presentation?

 Yeah, so I'm a glaucoma specialist, and a cataract surgeon. And nowadays with advances in glaucoma surgery, there's a new type of glaucoma surgery that most ophthalmologists are familiar with called minimally invasive glaucoma surgery. And this is surgery that can be very easily and fits perfectly well when it's combined with cataract surgery.

 So, at the same time, as a patient having a cataract surgery, we can now do operations to better control or optimize their glaucoma.
I've been doing this for at least the last 10 years now. And what I've noticed—certainly in the last few years, as we're doing higher volumes of these patients—is that when patients come back to their post-op visit, the next day or one week later, you can see a big transformation in the patients. They are seeing better, so they're happy. The eye pressures are better controlled, they're taking less glaucoma medications, and they just feel less anxious about glaucoma.

Glaucoma is the leading cause of irreversible sight loss in the world. And a lot of patients worry about this in between the clinic visits, glaucoma can dominate their lives. And you see that once their pressures are better controlled, and you sort of told them their glaucoma is stable, that really allays a lot of their anxiety.

Then you've got the other patients, big group of patients, majority of patients that hate taking their drops. You know, imagine if you have to put drops twice a day for the rest of your life. That can isolate you, can limit your social interactions with others, and again, creates that insular approach that "I have a stigma of a disease or chronic disease."

 And they sort of dissociate themselves from society. So getting patients off glaucoma drops then frees them from that. So they have that sort of physical independence from not being on the drops. But on the other side, their eyes are a lot more comfortable.

Glaucoma drops are effective, or they can make the eyes red, sore, itchy, watery. So we've looked at a study essentially, as opposed to just seeing patients in the clinic, actually doing a study to look at patient-reported outcome measures, using some well-established patient reported outcome measures such as the glaucoma severity scale, glaucoma quality of life, the ocular surface disease index.

So we looked at all the these both before the surgery, four months after the surgery, and just recently 12 months after surgery. And we see a big improvement from before the surgery to four months. And that improvement has been maintained at 12 months.

 So and then when we examine their eyes, we look at the surface of the eyes, look at how healthy their tear film is, how healthy their eyes are in general. And that also has shown a big improvement.

So you know, it's nice to have post-op patients that are happy. They're—happy patients make happy doctors. And really, of course, glaucoma is about controlling the eye pressure, about preventing further visual field loss and keeping patients from visual disability in their lifetime.

But if patients are happier, more confident, less anxious, and have a better quality of life, then that's a that's a huge—

 A win-win. And it's something that probably as clinicians we underestimate, and hopefully these kinds of studies will help make it more commonplace to sort of start off thinking as there's a patient at the end of that eyeball.

 So one step towards that. Lots of more work to do. But yeah, very happy with the initial results.

What would be the next steps for this research?

So the next step would be to apply it to other glaucoma surgeries and not just the minimally invasive glaucoma surgeries but some of the bigger surgeries that we need to do for patients who are a little bit more advanced or the glaucoma is a bit more aggressive, and maybe potentially looking at at other types of surgery as well.

We know some stuff about cataract surgery, but you know, retinal surgery, and those sorts of things, so not just limited to glaucoma. And then within our own data, we've got 12-month data, but it'd be lovely to see whether this is maintained at two years, three years and five years. They're the next steps, really.

Yes. Oh, that sounds really good. Well, thank you very much for sharing your insights with Ophthalmology Times Europe.

Videos

Mr Gokulan Ratnarajan recaps his 2022 ESCRS presentation: "A Real World Comparison Of iStent Combined With Phacoemulsification And Endocyclophotocoagulation (Ice2) With Preserflo And Xen-45 Implants In The UK; Short- And Long-Term Outcomes."

Should endocyclophotocoagulation be considered part of MIGS? Mr Ratnarajan delves in

 This transcript has been lightly edited for clarity.

So thank you for joining me, Professor Dirisamer. I understand you participated in an instructional course on refractive surgery. I'm Caroline, editor of Ophthalmology Times Europe, and I would love to hear more about the key takeaways from that instructional course.

Thanks for the kind invitation to talk to you. Yeah, what we tried to say or to transport in this instructional course, are, where are the limitations and indications for the specific treatment options we have in refractive, in modern refractive surgery, either with laser refractive surgery or lens based surgery like phakic IOLs or refractive lens exchange.

Excellent. And what would you say the main challenges are that people have to pay attention to?

Yeah, since we get more and more precise pre-operative assessments, we get nicer and very precise devices based on different technologies like OCT-based, or like, [audio unclear]-based, and also epithelial mapping, for example. So there are many, many parameters for refractive surgeons have to keep in mind and have to look into their decision whether the patient gets refractive surgery and which kind of refractive surgery. This is very important since this kind of an elective procedure. So there's no medical need for that. You have to be more precise, and rule out the suspicious cases. That sounds easy, but it's tricky.

Exactly, there's not really a certain rule. Now you can really say, Okay, this is safe or it's not safe. There are some, but it remains the decision by the surgeon what we do.

And I suppose with more experience, it becomes easier to...

And it's, of course, an individual decision for each surgeon because someone may feel more comfortable with this technology, the other one with the other techniques. So we try to cover the latest publication and latest scientific works and see what changed.

There are some changes. So we are very happy to have epithelial mapping. So this is a tool that it's getting more precise to rule out suspicious corneas.

Yeah, I think we are getting close to zero complication rates.

No, but close enough. I was going to ask you what you're most excited about in the field, but I would imagine it's epithelial mapping. Or is there anything else?

Well, in terms of diagnostic, I think epithelial mapping is pretty, pretty cool. But there was a biomechanical measurements, which are coming more and more in terms of surgical techniques. I think the SMILE technique, which is a femtosecond laser lenticule extraction, I think this becomes the future of cornea and refractive surgery. Yes. Many, many companies are now providing this technique. So let's developing tool we have in our armamentarium.

Yeah, yeah. How long, how long has that been around now? It's just a few years, isn't it?

More than 10 years. Yeah, we probably see next year or so hyperopic treatments for SMILE and cyclotorsion compensation and so on. So this, yeah I'm looking forward to that.

Professor Dirisamer, that was really interesting. Thank you very much for sharing your insight.

Prof. Martin Dirisamer speaks with Editor Caroline Richards about his ESCRS instructional course, "Mastering laser refractive surgery: Indications and outcomes."

Investigating better indications and outcomes in laser refractive surgery

This transcript has been lightly edited for clarity.

 Thank you for joining me today, Dr Lubeck, to discuss your presentation on endothelial cells, which I understand you just gave, in fact. It's lovely to meet you here in sunny Milan. I'm Caroline, editor of Ophthalmology Times Europe. Could you please tell me more about your presentation and what the key takeaway points were?

Caroline, we and surgeons who have done MIGs surgery have been drawn more and more to the possible consequences of damaging corneal epithelium as we do our procedures. There's much still to be learned about how these procedures affect the epithelium over the long term.

Canaloplasty, which is procedure I've been doing for about seven years, there was little to no data on its effect on the endothelial. Two years ago, Robert Noecker and I began a prospective study to determine the effects of canaloplasty on the cornea...

We found very, very strongly that canaloplasty has no negative impact on the corneal epithelium compared to cataract surgery alone. So essentially, it has minimal impact to no impact on the health of the cornea.

 Where do you see this research going in the future?

We hope to extend the current study up to 5 years, but we've also embarked on a much bigger data registry project called the iTrack Glaucoma [Global] Data Registry. It's being housed in the ISGR, the National Glaucoma Surgery Registry. And we hope to enrol up to 1,000 patients in that over a fairly short period of time, and then have a much more comprehensive look at knowing the efficacy, safety profiles and the nuanced elements of the procedure.

 It sounds like it will be really valuable data when that comes through.

It's essential. We don't have for this procedure. We don't have a single, large database, and it's been around for a long time.

 Well is anything else you would like to add, anything you're really excited about at present? Or have we covered everything?

The procedure is attractive in the beginning because it's non-destructive, there's no stents left behind. And from a Bayesian standpoint, or reasoning, it makes sense in terms of what it does for glaucoma, and the treatment. It has tremendous implications for the future.

Once we understand not only the biomechanics, but the bio-physiology of glaucoma, I believe that this technology is going to have a future application to different modalities of treatment.

 Oh really? Oh, that sounds excellent. Well, thank you very much for your insights today, Dr Lubeck.

It's a pleasure. Thank you very much, Caroline.

Dr David Lubeck talks with Caroline Richards of Ophthalmology Times Europe about his ESCRS presentations, touching on surgical effects on corneal epithelium and the iTrack Global Registry for glaucoma.

Investigating the effects of canaloplasty on corneal epithelium

 So thank you for joining me at this year's ESCRS, Professor Dirisamer. I understand tomorrow you're due to present on DMEK. I would love to hear more about that. Could you tell me the key takeaways from the instructional course?

 Yeah, thank you for the kind invitation. Yeah, we are having a course about DMEK and how to avoid mistakes in converting to DMEK because it was like a kind of transformation from PK and DSAEK. And, you know, obviously, mistakes we made, we try to [make it so] the younger people do not have to do the same mistakes. Well, it's about the indication, how to start and what are the key points where I can avoid complications, and to get together the perfect outcomes.

So it's, I think, very important for a beginner to start with DMEK, to pick up easy cases. So not start with challenging cases. But pick easy cases. And from there, follow certain rules. So if you follow these rules, and these suggestions, I think it could do this transformation pretty easily.

 And so do you think that'll be a good uptake on DMEK in and amongst the younger ophthalmologists?

 Yes, I think it's, at least in German-speaking countries, I think the most popular transportation. And so I think the younger colleagues, they started with us; in my case, it was the same thing. So I think you can kind of overtake the other data procedures that don't have to DSAEK anymore. They can start right away with DMEK.

And, yes, so we tried to give them a kind of stepwise approach to solve problems we have to face in the beginning with DMEK. And, yeah, I think this could work out for most people. Of course, you need some surgical skills, you need some surgical training as well. But you also should be aware of the theory behind.

 Yeah, that's I think that for younger people and younger colleagues, I think this might be a good basis.

 Yeah. And what would you say the main challenges in performing this procedure? What goes wrong most often?

 I would say the most the most challenging part is that it's basically a two-step surgical procedure, so you have to prepare your graft, sometimes on your own. Of course, there's prepared tissue available, but in many parts of the world, there is not. So you have to prepare the tissue both by yourself; this is the first challenge. You have a challenge already, and the surgery part hasn't even started.

 Of course, you have to know how to store this tissue, how to stain it. And so it's a combination of many things. I would say complication number one, if you make a sealed [audio unclear] detachment. But on the other, the other side, it's not a big complication. You can solve it pretty easy. But it's better to avoid it. So we do everything that we can to not get a complication, and there's some tips and tricks, how you can do that.

 All right. Well, it sounds like it would be a great course for ophthalmologists to attend tomorrow. I'm sure they're very much looking forward to learning more.

 Yeah, oh well, I can imagine. It sounds really interesting. Thank you very much for sharing that with me here.

Prof. Martin Dirisamer discusses his instructional course on common mistakes when performing DMEK and how to avoid them at ESCRS.

Avoiding errors when converting to DMEK

 So thank you for joining me here Professor Bostanci. I understand you've given quite a few presentations at this year's ESCRS, and it's lovely to meet you here in Milan. I'm the editor of Ophthalmology Times Europe, and I would love to hear more about EDOF lenses and the key takeaway points from your presentation.

 Thank you, I will be more than glad to answer this question. So I am Basak Bostanci, an associate professor of ophthalmology from Istanbul, as you said, and here in Milan, there was a great discussion about EDOF lenses as an option for presbyopia correction.

So, in the past, these trifocals diffractive, optic trifocal lenses, were only given as a solution to people who had the most wonderful ocular surface and ocular anatomy. So people with some dry eye issues and people with compromised corneas were not eligible. With EDOF lenses, we have a slight chance to offer them a premium solution for giving them a functional vision, which is arm-length vision.

So intermediate vision is very important in our daily lives, we are checking our telephones, we are cutting something on the table, we are preparing meals for our children. So functional vision is really depending on how we see far and how we see at arm distance. So these EDOF lenses provide us intermediate vision.

And because most of them are not verging on a refractive principle, we can offer them also to our dry eye patients, to our patients who had received refractive surgeries.

So what I love about these lenses are if the patient doesn't have a fully compromised cornea, or geographic atrophy in the retina, or severe glaucomatous damage, now we can offer them a premium lens option to make their lives easier.

 Yeah, yeah. Oh, that sounds really good. I mean, there's so much information in the field at this conference. And is there anything that you would say you're most excited about going forward to the future?

 Yeah, I like walking through the technology. So these EDOF lens technologies are very different from one another. So I love in those congresses, the best part of those congresses is we can go ahead, meet the inventors of these wonderful intraocular lenses, and we can compare one to another and find a good option for our particular patients. So thank you for asking me this question.

 Oh, no problem. You're welcome. Well, it was really lovely to speak to you and I'm sure our readers and subscribers to OTE will be very interested to hear what you have to say. And thank you very much.

Assistant Prof. of ophthalmology Basak Bostanci discusses her ESCRS presentation, “Extended Range Of Vision In Unusual Cases” and how EDOF lens technology is evolving to include a wider pool of candidates.

EDOF lens tech is evolving to help more patients with intermediate vision

Prof. Ioannis Pallikaris discusses his 2022 ESCRS presentation: "Peripheral Capsule Reconstruction And IOL Centration With The Fixoflex Ring".

Fixoflex ring: Prof. Pallikaris describes how to utilise the device during IOL implantation

The European Society for Cataract and Refractive Surgery (ESCRS) plans to welcome delegates to the Milano Convention Centre in Milan, Italy, for the fortieth time this year, and, judging by the preliminary online programme overview, there is a great variety of ophthalmology sessions on offer.

A range of symposia, programmes, video sessions and workshops will be on offer and are discussed in this brief preview article. There will also be a daily exhibition, enabling delegates to learn about the latest technological advancements in ophthalmology and providing networking opportunities.

editorial advisory board members about their anticipations for the Congress:

Prof. Dr Martin Dirisamer, FEBO, cornea consultant at University Munich, University Graz and Wels-Grieskirchen

Dr Frank Goes, consultant at the Goes Eye Center, Antwerp, Belgium

Dr Anastasios G. Konstas, Professor of Ophthalmology at Aristotle University of Thessaloniki, Thessaloniki, Greece

H. Burkhard Dick, Chair of Ophthalmology, University of Bochum, Germany

New this year are the “Cornea Day” and “Glaucoma Day” streams that are due to take place throughout the day. Cornea Day topics will include cataract surgery in patients with ocular comorbidities; ocular surface and anterior segment surgery; and developments in posterior lamellar keratoplasty, keratoconus and cross-linking, whilst Glaucoma Day will cover profiling glaucoma patients, hints for cataract surgeons who are considering MIGS, surgical complications and surgical controversies.

Prof Konstas remarks: “The Glaucoma Day format provides an enticing and practical platform aiming at both young as well as more senior ophthalmologists who have been many years in clinical practice. Attendees will gain greater insight into recent developments in glaucoma diagnosis and management. In particular, the surgical management of glaucoma has been revolutionized by the introduction of MIGS, which aim to meaningfully lower IOP with a better safety profile than traditional glaucoma surgery. Cumulative data suggest that MIGS offer tangible clinical benefits to selected glaucoma patients. The Glaucoma Day will cover the role and emerging potential of several novel antiglaucoma options enabling a better understanding of their future value in clinical practice.”

The Main Symposium to be held at the end of the afternoon will be on the topic of “Emerging Treatment Options for Corneal Endothelial Disease”. There will also be an IME Symposium with the title “Phaco complex cases.”

“A very promising symposium, a bunch of new treatment options for endothelial diseases are on the way, probably also with a paradigm shift (treatment options without need for transplants, cell injection, etc.) Mid-term and long-term data expected of DSO (Descemetorhexis only),” said Prof Dirisamer.

"A highlight for me will be the session on Cataract Surgery in the patient with ocular comorbidity", says Dr. Dick, and adds: "We're seeing patients with a variety of corneal afflictions which just a couple of years ago would have been called 'challenging', if not outright 'desolate'. Today, cataract surgery can in many cases benefit these patients - who value even moderate visual improvement - to an often astonishing degree."

Three instructional courses to be held at the end of the day will cover the topics of “Different Ways of Secondary IOL Implantation without Capsular Support”; “DALK: From Basic to Advanced”; and “Endophthalmitis after Cataract Surgery”. Finally, the Exhibition Hall will open at 13:00 on Friday and remain open until 18:00.

“It’s an exciting topic with several new approaches on the market (IOL, Yamane technique, etc.). I’m excited to hear more about the femto-second laser technology supporting this highly challenging procedure,” Prof. Dirisamer said.

“Assisting my colleagues in medical legal matters I am regularly confronted with endophthalmitis cases, so the topic ‘Endophthalmitis after cataract surgery’ and specifically the analysis of eventual differences between inpatient and outpatient surgery may be of practical use,” said Dr Goes.

Saturday sees the Opening Ceremony of the Congress take place at 10:00, which should provide attendees with a feel of what to expect during the yearly event. This is due to be followed at 11:00 by the Main Symposium on “Demystifying IOLS optics”.

“There is a strong need for a new and clear classification of different IOL’s and technologies on the market,” said Prof. Dirisamer.

Elsewhere, the “Young Ophthalmologists Programme” is running “Starting Phaco” which includes video cases submitted by young ophthalmologists. This programme also offers junior ophthalmologists the chance to network and pick up useful information.

"This is one of the most encouraging events of the meeting," according to Dr Dick, "since we all once again are going to recognize what a huge potential and bright future ophthalmology has - and needs to have given the demographic development in our countries - in these fine young colleagues!"

Prof. Konstas points out: “This session will offer a first-class introduction to all young ophthalmologists to the key steps and pitfalls of the surgical procedure that dominates daily clinical practice in our profession. Understanding the rules of engagement with this procedure is crucial to all junior ophthalmologists.”

Throughout the day, Clinical Research Symposia will be held on: “Digital Medicine – 6 Steps for a Better Future”; “Ocular Tissue Engineering”; “Advancement of IOL Optic – How Far Can We Go?” and last-but-not-least, on the very hot topic in ophthalmology at the moment: gene therapy.

“Gene therapy is certainly a hot topic, with huge chances of big changes in the treatment of genetic caused diseases,” explained Prof. Dirisamer.

"I'm so excited, especially in my function as the Chairman of the ESCRS Research Committee", exclaims Dr Dick, "since we hopefully will learn a lot in these sessions, that finally - finally! - we will be able to cure or at least influence to a hitherto unknown degree the course of terrible diseases, including Morbus Stargardt and Fuchs."

Prof. Konstas underlines: “the topic of gene therapy truly represents a hot topic! With recent advancements in the discovery of specific disease mechanisms, it is even conceivable that future therapies for ocular conditions like open-angle glaucoma will protect ganglion cells and the optic nerve and may even reverse long standing glaucomatous damage. This exciting prospect promotes gene therapy and genome editing into the forefront of ophthalmic research in the hope that it may in due course provide a real therapy instead of the current indirect therapeutic approach of IOP-lowering.”

A total of 28 instructional courses will be running throughout the day on Saturday. The majority of these are 90 minutes long and start at 08:30, 10:30, 14:00 and 16:00. Shorter one-hour courses begin at 14:30. Free Paper Sessions and Presented Poster sessions will also be taking place and the Exhibition Hall will be open from 09:00 to 18:00.

The Main Symposium, on “High Volume Cataract Surgery”, will take place at 11.00 on the Sunday. The JCRS Symposium will be held at 14:00 and a Video Symposium at 16:15 entitled “Surgical Complications: You Make the Call” is sure to draw curious ophthalmologists.Early evening sees the IIIC Symposium at 18:15 on “The Perfect Save: Challenging Cases Managed by International Experts”.

"I recommend this session for very personal reasons," Dr. Dick adds with a smile: "I had the great privilege to act as an editor of a fine new book at Springer, together with Jorge Alio and Bobby Osher, on how to overcome the challenges of complex and complicated cases in cataract surgery. It's so brand new, I even haven't received a copy of it myself! Hopefully I'll see it in 'Publishers Row' in the Exhibition Centre. This session deals with some of the situations that can be successfully treated with the techniques we describe in our book."

“The Main Symposium on ‘High volume cataract surgery’ may help us with how to cope with waiting lists, which have grown to more than a million eyes in some areas,” Dr Goes suggests.

Workshops on Visual Optics will be being held throughout the day, starting with “Visual Function – Visual Behaviour” at 08:30; “Ocular Biometrics/IOL Optics and Calculation” at 10:50 and finally “Imaging of the Human Eye” at 14:00.

Also at 14.00, a “Case Report” Session aims to delve into “Preoperatory Complications and Difficult Manoeuvres”. Meanwhile, there will be a Young Ophthalmologists Session at 16:30 on “Cataract and Corneal Issues”. A Practice Management Masterclass, on how ophthalmologists can optimise the patient experience, will also take place on the Sunday; the exact timings for this are yet to be confirmed.

A further 27 Instructional Courses will be held, starting at 08:30, 10:30, 14:00, 14:30 and 16:30. These cover a broad range of topics including “Corneal Regeneration Therapy and Surgery”, “Enhanced Monofocals and EDOF IOLs” and several aspects of cataract surgery.

Instructional Courses also continue with 33 taking place, again starting at 08:30, 10:30, 14:00 and 16:00. Topics covered include “The Art and Science of Personalizing Refractive Outcomes in Cataract Surgery and Beyond”; “When Cataract Meets Glaucoma”; “All You Need To Know About Contact Lenses as a Refractive Surgeon”; and “Phaco Nightmares and Worst Case Scenarios”.

Prof Konstas observes: “Of particular value in current practice would be the Course “When Cataract Meets Glaucoma”. While the chance of improving vision in glaucoma patients manifesting co-existent cataract has never been better, significant controversies still exist requiring further clarification. Emerging evidence however suggests that earlier cataract surgery in patients with glaucoma, especially those with exfoliative glaucoma, will benefit long-term outcomes.

The final day of the Congress starts at 08:00 with an Orbis Symposium on “Innovative Ophthalmology in Conflict Zones” and a concurrent Presbyopia Workshop titled “Is there a change in the paradigm of presbyopia correction?” The final Main Symposium of the ESCRS at 10:30 is on the eye-catching subject of “How Not to Be Surprised by Refractive Surprise”.

“Since refractive market is growing and cataract surgery is more and more turning into a refractive procedure, dealing with refractive surprises is becoming increasingly important. Further, patients demands are getting higher,” explained Prof. Dirisamer.

“Surprises following refractive surgery do happen and thus the best way to prepare for them, how to optimize their outcome and, of equal importance, how to deal with our patients when they occur is critical,” Prof. Konstas comments. “Unfortunately, many refractive patients have overly high expectations, which will not be met when a refractive surprise occurs. The Main Symposium will help us to optimize the outcome of these surprises.”

The Free Paper Sessions continue, as do a series of Wet Labs starting at 08:00 and 10:30.There will be a final twelve Instructional Courses starting at 08:30 and 10:30, including courses on “Tips and Tricks for Challenging Cataract Surgery” and “Ocular Trauma Assessment and Management”.

The Congress finishes with the ever-popular “Best of the Best” session starting at 12:45 which highlights the best parts of the meeting.

Articles

Members of the Ophthalmology Times Europe Editorial Advisory Board offer comments on the symposia they are most excited to attend at the 2022 ESCRS Congress in Milan, Italy.

Top ophthalmologists anticipate ESCRS sessions

Taking place from 16–20 September 2022, and following the success of last year’s congress, the 40th ESCRS will again be a face-to-face event but supported by a virtual conferencing platform that will allow the sessions to also be streamed.

At the time of going to press, the ESCRS had not released the full, in-depth programme, however, a range of symposia, programmes, video sessions and workshops will be on offer and are discussed in this brief preview article. There will also be a daily exhibition, enabling delegates to learn about the latest technological advancements in ophthalmology and providing networking opportunities.

New for 2022 is the ESCRS iNovation Day. The agenda for iNovation Day includes discussions on the most urgent clinical needs and the use of technology to address them, along with perspectives from the European investment, regulatory and research communities. In parallel to this, the World Society of Paediatric Ophthalmology will be holding their Subspecialty Day.

Also new this year are the “Cornea Day” and “Glaucoma Day” streams that are due to take place throughout the day. Cornea Day topics will include cataract surgery in patients with ocular comorbidities; ocular surface and anterior segment surgery; and developments in posterior lamellar keratoplasty, keratoconus and cross-linking, whilst Glaucoma Day will cover profiling glaucoma patients, hints for cataract surgeons who are considering MIGS, surgical complications and surgical controversies.

At 16:00 there will be an IME Symposium on Presbyopia IOLs and at 17:00 a Video Symposium on the topic of “Challenging Cases”.

A three-part Refractive Surgery Didactics Course will be ongoing on Saturday. The first session at 08:30 covers diagnostic techniques; the second session at 10:45 is entitled “Therapeutic Techniques: Intraocular Surgery”; and the final session at 14:00 covers “Therapeutic Techniques: Corneal Surgery”.

Monday morning has two Main Symposia, beginning with the Heritage Lecture at 10:30 and followed at 11:00 by a session entitled “Where Are We in Intracorneal Implantation?” An IME Symposium on the subject of “3D Cataract Microscope Visualisation” will be held at 13:00.

A Video Session on “Getting Into Trouble” should provide delegates with some useful tips on overcoming surgical challenges at 14.00. Throughout the day there will be the opportunity to attend Practice Management workshops and the Free Paper Sessions and Presented Poster Sessions continue to run.

At 16:15 the CSCRS Symposium will be held on the subject of “The Patient Journey in Cataract Surgery.” There will also be an ISRS Symposium at 18:15 to end the day.

Taking place from 16–20 September 2022, and following the success of last year’s congress, the 40th ESCRS will again be a face-to-face event but supported by a virtual conferencing platform that will allow the sessions to also be streamed. 

Congress of the ESCRS reaches milestone age

On the final day of this year’s European Society of Cataract and Refractive Surgeons (ESCRS) congress, Monday 12th October, the number of delegates at the RAI Centre in Amsterdam were starting to thin out and the Exhibition Hall was also closed that day, but the relatively smaller audience in the speaker halls by no means reflected any lessening of the quality of the talks, and I came away with some interesting insights.

One particular session I had looked forward to attending following a couple of recommendations by the 

® Editorial Advisory Board ahead of the meeting was the Orbis one in Hall 11. Orbis International is a non-profit organisation that since 1982 has delivered sight-saving treatments to developing countries through training programmes, public health education, local partnerships and advocacy. It is perhaps best known for its Flying Eye Hospital — a custom-designed aircraft complete with operating theatre that can deliver sight-saving eye care where it is needed most.

Although the focus of the Orbis Symposium was advancements in technology and training, and how artificial intelligence (AI) and simulation are changing global ophthalmology, Dr Albanderi Alhamzah of the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia, presented her research team’s findings on the dangers of laser eyebrow removal at the podium in a sort of ‘warm-up act’ to the main event.

She described the case of a lady who had undergone this procedure without being offered eye protection and gone on to suffer from, thankfully short-lived, uveitis. It was thought the laser had caused damage to the iris but not to the retina. Her presentation was gratefully received: this was clearly an issue that a few of the ophthalmologists in attendance (both in person and virtually) had not come across before; indeed, one or two appeared not to have heard of laser eyebrow removal as a beauty treatment at all, so it sparked plenty of discussion.

After a short break, Mr John Ferris, a consultant ophthalmologist based at Gloucestershire Eye Unit in the UK kicked off the Orbis session itself with his presentation on use of simulation to teach ocular surgery in the developing world. Mr Ferris described today’s pressures on surgical training, including the shorter duration of training programmes, reduced surgical opportunities, the costs incurred and the drive for greater theatre efficiency.

Despite these challenges, it is important for surgeons to engage in “sustained deliberate practice” throughout their careers, Mr Ferris said. Famous musicians spend hours per week practising their instruments, he argued — it should be no different for surgeons.

“Simulation does not have to be high-tech or expensive,” he assured. Indeed, ophthalmologists starting out have a lot of cheap and freely available tools at their disposal when practising surgical techniques. Take the humble apple. It turns out it’s not just for eating; glaucoma patients due to undergo a trabeculectomy might be reassured to know that the more junior ophthalmologists will have spent hours honing their flap cutting techniques on this fruit before doing their first procedure on a human eye.

Foam, too, can provide trainees with a handy way of simulating releasable sutures on flaps, Mr Ferris explained, pointing to photos of bright yellow foam ‘eyeballs’ being carefully operated on. And for those who need further convincing, the statistics speak for themselves: surgical complication rates were reduced by 72%, Mr Ferris pointed out, when simulation cataract surgery training was employed, and ophthalmologists’ scores of confidence in their glaucoma surgical skills doubled after they took a simulation course.

Meanwhile, supervision of students does not have to take place in person. A remotely supervised corneal suturing practice, demonstrated in a short video depicting Mr Ferris mentoring his students over live video feed from his home, was another interesting learning point during the presentation.

Equitable access to artificial intelligence in eyecare was the topic of the next talk by Dr Nicolas Jaccard, principal AI architect at Orbis. In this engaging talk, Dr Jaccard introduced Orbis’ Cybersight AI-enabled platform, whereby more than 20 machine learning algorithms detect sight-threatening conditions. Results can be available in fewer than 10 seconds and the service is free in low-and middle-income countries.

Bath-based consultant ophthalmologist Mr Rob Walters, who was chairing the session, posed the question that is no doubt an issue at the forefront of many people’s minds when they consider the use of AI in diagnostics: how do you deal with the problem of false negatives? Dr Jaccard provided the reassurance that they try to get the rate by which patients are incorrectly screened out of the healthcare system below the 3–5% mark. However, he admitted that the occurrence of false negatives is a “fundamental problem” in AI systems and one they are working on.

But does any rate of false negatives in an AI system justify its use at all? This is a question that no doubt many listeners were pondering, and it remains to be seen whether modern algorithms such as these will ultimately be able to overcome such limitations in the future.

The final Symposium at this year’s ESCRS, the ‘Best of the Best’ was surprisingly busy, given that no doubt at this late stage in the Congress many delegates were already on their way home, but it was clear why as the series of videos shown during this session—some with upbeat music soundtracks—stimulated lively discussion and debate amongst a panel of ophthalmologists sat in a row of comfortable-looking armchairs across the stage.

The footage was mostly quite topical as well. For example, one video featured new protocols that had been put in place at one European hospital as a result of the COVID-19 pandemic. This led to the panel discussing the safeguards they put in place at their own clinics, which varied from country to country. It was interesting to hear, first-hand, how the differing levels of severity of the pandemic in the first few months in different countries (Italy, for example, was particularly badly hit) affected the ophthalmologists and their clinics.

I was pleased to hear that long-term sustainability touched on (the pandemic resulted in a greater use and disposal of plastic in hospitals), and the discussion was rounded up on a positive note, with the panel members acknowledging the state of preparedness clinics and hospitals now find themselves in post-pandemic: the healthcare sector is now armed and ready to tackle any future surges in infections.

Moving to specific treatments in the cataract and refractive space next, one video showcased the benefits of the dexamethasone intraocular suspension 9% (Dexycu, Eyepoint Pharmaceuticals) for the treatment of postoperative inflammation following cataract surgery. The panel had a lot to say about this.

Dr Rudy Nuijts was the first to give his input, remarking that it is too expensive to use in the Netherlands despite the concept being ‘very attractive.’ Avoiding drops post-surgery is the future direction cataract surgery is taking, he added.

Other videos during the Best of the Best Symposium demonstrated scleral fixation of IOLs, which provoked the panel into debating scleral flap techniques, and topography-guided PRK and CXL for keratoconus, which prompted a discussion on the merits of topography guided methods.

All in all, the final session I attended at this year’s ESCRS was fascinating and topical and rounded up the event nicely. As I continue to digest the wealth of information I came away from the conference with, it only remains to be said that I look forward to the 40th Congress that will take place in the beautiful city of Milan (Italy) next year. See you there!

Ophthalmologists gather to discuss artificial intelligence and the issue of false negatives, practice for surgeons and Best of the Best at the European Society of Cataract and Refractive Surgeons congress.

Simulated operation practice, artificial intelligence diagnostics dominate discussion on final day of ESCRS 2021

This year’s Congress of the European Society of Cataract and Refractive Surgeons that took place on 8th to 12th October at the RAI Centre in Amsterdam offered Sessions across such a wide range of subspecialities within ophthalmology that it was something of a challenge deciding which ones to attend. Thankfully, with the congress being on a smaller geographical scale this year, owing to its ‘hybrid’ (part virtual) format, the halls that hosted the talks were very close to one another, making manoeuvring between them a doddle.

Symposia in review: IOLs, MIGS and surgical innovation

The Main Symposium on the Saturday morning, entitled Selecting Advanced IOLs, certainly deserves a mention, attracting as it did an impressively large number of attendees, the largest, I noticed, of all Sessions throughout the conference. The popularity of these presentations demonstrates just how fast-moving advancements within the IOLs field are: everyone wanted in on the action.

Chaired by Drs Nic Reus of the Netherlands and Filomena Ribeiro, from Italy, the focus of the talks squared largely on the patient: the ultimate challenge in selecting premium IOLs, as Dr Reus pointed out, is “how to communicate … as to which lens is best”. This was echoed by several of the speakers, who also discussed the importance of informed consent and, above all, the demand for clear IOL terminology that is simple enough for all patients to understand.

“We should know our patient, listen and provide solutions where appropriate,” Dr Roberto Bellucci, in private practice in Saló, Italy, highlighted in his presentation on Management of the Unhappy Patient. He added that it is important to really understand patients’ personalities; the neurotic patient is likely going to be unhappy whatever lens they get.

There was clearly agreement that time is of the upmost importance, too. Time to help patients choose the right lens requires more than a quick 20-minute chat in the clinic, pointed out Dr Arthur Cummings, an ophthalmologist based in Dublin, Ireland, via video link.

He feels that observing patients in their home environment for, say, 36 hours, is ideal, something that is becoming showed feasibility during a clinical trial at the Wellington Eye Clinic in Dublin whereby patients considering multifocal IOLs wore a visual behaviour monitor that attached to their own spectacles. The device, worn over 3 days, could track a patient’s working distances, heat movements and even lighting conditions, before relaying data on their specific refractive requirements back to the clinic.

However, even with such comprehensive efforts at patient personalisation, with any IOL there will be some compromise involved when it comes to the visual acuity improvements achieved at given distances. The fact that choosing a lens is always going to be a compromise was a sentiment that cropped up a few times during the Symposium.

Dr Boris Malyugin, of the S. Fyodorov Eye Microsurgery Institution in Moscow, Russia, and pioneer of the Malyugin Ring pupil expansion device, chaired the MIGS Main symposium on the Saturday afternoon. Topics up for discussion included the opportunity of combining cataract surgery with glaucoma surgery and the need for more studies in this area; suprachoroidal shunts; and trabeculectomy.

Meanwhile, Dr Alex Huang travelled all the way from the United States (the David Geffen School of Medicine, UCLA, Los Angeles, California) to present his ground-breaking work on aqueous angiography, which is designed to optimise the efficacy of MIGS devices as well as improve understanding of aqueous outflow. This was a fascinating discussion on an imaging technique that is a relatively newer addition to the arsenal of imaging technologies within ophthalmology.

Has cost effectiveness and value-based healthcare entered ophthalmology? This was the subject of one of the Clinical Research Symposia I had earmarked as a must-attend on the Sunday, so I was pleased to find the presentations, chaired by none other than

 Editorial Advisory Board members Dr Rudy Nuijts and Prof. Jorge L. Alio, were both informative and varied.

Prof. Gregory Katz of the University of Paris School of Medicine was one of the first presenters to stand at the podium: he spoke of how transparency and the reporting of patient outcome data acts to incentivise and encourage practitioners. Pointing to a series of graphs during his presentation, he explained that when clinicians can see their hospital or department is outperforming, their performance starts to pick up (and the line on the graph starts to creep up). Conversely, without this knowledge, they tend not to make the needed improvement. Fundamentally, this makes a lot of sense: if you don’t know what is broken, you can’t fix it.

Rather worryingly, there is a lot of variation in patient outcomes not just country to country but within different regions of the same country. Focusing on cataracts specifically, Prof. Katz said that in 2018 in Sweden, for example, there was a staggering 3,100% variation in capsular complications after cataract surgery. The problem, he emphasised, is that health systems don’t measure the outcomes of the healthcare they pay for.

He concluded his talk by stating the importance of standardising questionnaires on patient quality-of-life through scientific calibration, digitising outcomes data and comparing results through case-mix adjustments to prevent adverse selection of patients. The integrity of outcome data needs to be audited, he added, and outcomes should be shared with patients, practitioners, payers and industry.

Up next was Mr Alexander Day, cataract and laser vision correction surgeon, who posed the question during live video feed from Moorfields Eye Hospital NHS Foundation Trust: what can we learn from European randomised clinical trials about cost effectiveness outcomes? Mr Day stated that for any technique to be cost-effective it needs to be cheaper and/or increase productivity (to offset higher prices) and have better short and long-term outcomes.

Take the femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsification debate, for example. A thorough assessment of the costs and benefits profiles of these two technologies leads one to the conclusion that FLACS is not cost-effective overall, Mr Day pointed out.

Also weighing up the cost-effectiveness of two techniques was Dr Rob Simons, who discussed the expense associated with delayed versus immediate sequential bilateral cataract surgery, drawing on findings from the BICAT-NL study that took place in the Netherlands. This study found that ISBCS is cost-saving since it results in shorter times in operating rooms; one day of admission less; fewer post-operative visits; less homecare; and lower travel costs. The two procedures result in similar refractive outcomes, Dr Simons pointed out, with no increased bilateral complications and no bilateral endophthalmitis seen with ISBCS.

Dr Marie Joan Therese Balgos of Spain took to the podium next, to discuss findings comparing the cost-effectiveness of PRK, SMILE and FS-LASIK. “Cost is a significant consideration for patients who are contemplating laser vision correction,” she stated, arguing that laser refractive procedures are more cost-effective than a lifetime use of spectacles or contact lenses. “SMILE, PRK and FS-LASIK are all cost-effective from the payer’s perspective when done between the ages of 20 to 60 years,” Dr Balgos concluded, convincing the audience that the earlier a corneal refractive procedure is performed, the lower the incremental cost-effectiveness ratio.

The take-away message, I considered as this Symposium winded up, was that this is not a topic that will die out any time soon: cost versus benefit considerations have indeed entered the field of ophthalmology and will no doubt continue to drive debate in years to come, as well as likely feature on the agenda of future ESCRS congresses.

Talk of lens selection and patient satisfaction dominated discussion during the Advanced IOLs Symposium; cost vs. benefit analysis emerges as a theme throughout the congress.

ESCRS