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!

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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.

Patient-centric healthcare, combined surgeries and cost-effectiveness considered at ESCRS 

Swinging open its doors to ophthalmologists and industry, the RAI Convention Centre in Amsterdam greeted those who chose to attend the 39th Congress of the European Society of Cataract and Refractive Surgeons in person on 8th to 12th October and the, albeit somewhat scaled down, event did not disappoint. I felt privileged to be amongst those able to attend the hotly anticipated schedule of Symposia, Courses, Papers and Programmes in person; the 38th ESCRS had originally been slated for Amsterdam last year too, before being replaced with a fully virtual format when the coronavirus pandemic continued to cling on.

After two long years of conferences being confined to computer screens, it was a somewhat reassuring experience to witness delegates once again take to podiums, exhibition booths and coffee tables, sit together in the halls and discuss the latest advancements in ophthalmology face to face. And exciting too: the buzz of finally being able to conduct business interactions and share research findings in real life seemed to be putting a spring in everyone’s steps.

Despite attendees being provided with complimentary ESCRS-branded face masks when registering and collecting their name badges, fewer people chose to sport them in the congress centre than I had anticipated, even when networking within the confines of a fairly small (and much smaller than in previous years — perhaps to the relief of those with a less-than-perfect sense of direction) Exhibition Hall. Social distancing was also clearly now a thing of the past, and hands were shaken despite the occasional sign asking people to refrain (the elbow bump greeting must have JUST been a fleeting idea during lockdown).

Perhaps the setting had something to do with the relatively relaxed attitudes: I noticed fairly few anti-Covid-19 measures in place in Amsterdam in general whilst there, which is no doubt testament to the fact the Dutch, like many countries, are seeing the positive effects vaccination has had on society. I had a real taste of the changing times at a packed concert at the Het Concertgebouw which I attended on the Friday evening: hundreds of people gathered inside the famous venue to enjoy Berlioz’ Symphonie fantastique and Stravinsky’s Firebird and there wasn’t a covered nose-and-mouth in sight.

That’s not to say the conference organisers at RAI did not take precautions to ensure those entering were deemed a low risk: I had to show my double-vaccination status and ID every time I wanted to enter the building. I also noticed that some exhibition booths had signs requesting that people sanitise their hands before entering.

One thing I had pondered as I collected my badge at on Day 1 was how the ‘hybrid’ nature of it, i.e., part-in-person, part-virtual, would work in practice. This was my first time physically attending such a unique format of conference since the pandemic began, so I was intrigued. According to figures released by the ESCRS, of the 7,122 registrations for the event, a whopping 3,000 of these had opted to participate virtually.

And I was impressed by how seamlessly the two formats were combined during the Symposia; when it was the turn of an off-site ophthalmologist to speak, a video of their talk appeared on the huge screens at the front of the Hall. Some of these had been pre-recorded (this did not ruin my enjoyment of them, as it was still effectively the first time they were being shown).

Other doctors were speaking live from their home country and thus were also able to participate in the Q&A sessions following their talks. I even attended a Session in which the Chair himself was sitting comfortably in his home study back in the UK, introducing the speakers from there, his well-stocked bookcase and criss-cross floral patterned wallpaper providing a visually appealing change of scenery to the usual off-white background you see in congress centres.

Video conferencing formats rarely come without some element of danger, but the technical difficulties were few and only minor; needless to say, they still sparked some sniggering in the crowds: speakers appearing to silently mime their talks (we’ve all heard the line “You’re on mute” enough times to last a lifetime, but there’s no sign those three little words are going away any time soon) or disappearing from view entirely (in one comical moment, an attendee eagerly awaited an answer to his question from the microphone he stood before at the front of the hall only for the presenter to go offline immediately — a mishap that prompted the Chair to suggest, in jest, of course, that the question had not gone down well!)

Overall, the blending of videos with in-person talks added another interesting dimension to the Symposia and by no means lessened the quality or accessibility of the information being disseminated. It’s a format that I suspect may be here to stay even in the post-Covid world, since there will always be reasons that people wishing to attend and/or present at congresses cannot participate in person: it seems better that they can do so in some sort of capacity than not at all, after all.

In the next part of my review of this year’s ESCRS, published next week, I’ll cover a few of the Symposia I had the pleasure of attending over the four days. Stay tuned to find out more!

ESCRS

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

Patient-centric healthcare, combined surgeries and cost-effectiveness considered at ESCRS

A melting pot of curious minds congregate in-person and virtually at this year’s ESCRS