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Right IOL? What is the - SPECIAL FOCUS - EuroTimes
SPECIAL FOCUS
                                 CATARACT & REFRACTIVE LENS

February 2019 | Vol 24 Issue 2

                                      What is the
                                    Right IOL?

        CATARACT & REFRACTIVE | CORNEA | RETINA | GLAUCOMA
                      PAEDIATRIC OPHTHALMOLOGY
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
Treq-Blue
the purest of all
dyes tested
The Treq-Blue stain has been developed
to enable clear visualization of the
capsulorhexis rim. This added
clarity helps prevent
surgical complications.

                   Dye                     Impurities measured            Purity*
                                               at 530 nm
                   Treq-Blue                           2%                   98%        • Unmatched purity due to two-step
                   Competition                                                           purification process
 Competitor 1      Western Europe                      5%                   95%
 Competitor 2      Western Europe                     13%                   87%
                                                                                       • High quality, ultra purified,
                                                                                         safe surgical dye
 Competitor 3      Southern Europe                    20%                   80%
 Competitor 4      India                              18%                   82%        • Siliconized plunger and finger flanges
                                                                                         for smooth intraocular injection
 Conclusion
 Treq-Blue is the purest of all dyes tested!

Competitor 1 contained twice as much impurities (measured
at 530 nm) as Treq-Blue. All other dyes contain between six
and nine times as much impurities as Treq-Blue.

* Purity of the dyes was monitored by HPLC chromatography, carried out at Department
  of Life Sciences and Chemistry, Jacobs University Bremen, Bremen, Germany.

   Treq-Blue                                      Competition

Chromatography show the absence of foreign dyes in Treq-Blue                                                   vitreq.com   bvimedical.com
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
P.38

Publisher
Carol Fitzpatrick

Executive Editor
Colin Kerr

Editors
Sean Henahan
Paul McGinn

Managing Editor
Caroline Brick

Content Editor
Aidan Hanratty

Senior Designer
Lara Fitzgibbon

                                    CONTENTS
Designer
Ria Pollock

Circulation Manager
Angela Morrissey

Contributing Editors                A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY                                                                                                              www.eurotimes.org
Howard Larkin
Dermot McGrath
Roibeard Ó hÉineacháin

Contributors                      SPECIAL FOCUS                     RETINA
                                                                                                                                                                                                                                                                             P.31
Maryalicia Post
Leigh Spielberg
                                  CATARACT                          20 Advances in imaging
Gearóid Tuohy
                                                                        technology vital in the
Priscilla Lynch                   & REFRACTIVE LENS                     understanding and treatment
Soosan Jacob
                                                                        of neovascular AMD
Colour and Print
W&G Baird Printers                04 Choosing the right IOL
                                      for you and your patient      21 Treating highly myopic
Advertising Sales                                                       macular holes
Amy Bartlett                      06 New IOLS – a view from
ESCRS
                                      the industry                  22 Collaboration with
Tel: 353 1 209 1100                                                     rheumatologists can aid
email: amy.bartlett@escrs.org
                                  08 IOLs and the risk of retinal       treatment of uveitis
                                      detachment
Published by the European
                                                                    23 Opting for vitrectomy
Society of Cataract and                                                 earlier in cases of
                                                                        proliferative diabetic
Refractive Surgeons,
Temple House, Temple Road,
Blackrock, Co Dublin, Ireland.
                                  CATARACT
                                  & REFRACTIVE
                                                                        retinopathy                   REGULARS
No part of this publication                                                                           31                                               Hospital diary
may be reproduced without
the permission of the             12 Better understanding           GLAUCOMA                          33                                               Books
managing editor.                      of phaco fluidics
Letters to the editor and other
                                      improves the safety of the
                                                                                                      34                                               Travel
unsolicited contributions are                                       24 New methods of drug
assumed intended for this             procedure
                                                                        delivery should improve       35                                               Industry News
publication and are subject
to editorial review and           13 JCRS update                        compliance and reduce         36                                               Society News
acceptance.                                                             side-effects
ESCRS EuroTimes is not            14 New FLACS approach                                               37                                               ESCRS News
                                      can reduce operating time     26 Consensus not universal
responsible for statements
                                                                        on the net benefit of         38                                               Random thoughts
made by any contributor.
These contributions are           15 Using corneal refractive           minimally-invasive            39                                               Calendar
presented for review and              techniques to correct             glaucoma surgeries
comment and not as a                  high astigmatism
statement on the standard of
care. Although all advertising                                      28 Structural imaging is
material is expected to                                                 being used to complement
conform to ethical medical        CORNEA                                functional testing
                                                                                                      Supplement
                                                                                                      February 2019
                                                                                                                                                                                                      Supplement
                                                                                                                                                                                                      February 2019

standards, acceptance does                                                                            RayOne Trifocal &

not imply endorsement by                                                                              Sulcoflex Trifocal:
                                                                                                      Leading the Way to Offer

                                  16 Newer technologies
                                                                                                      More Patients a Trifocal Solution

ESCRS EuroTimes.
                                                                    PAEDIATRIC
                                                                                                      Michael Amon (Austria)
                                                                                                      Early results from the new Sulcoflex Trifocal

                                                                                                      Fernando Llovet-Osuna (Spain)
                                                                                                      RayOne Trifocal: Premium lens outcomes in 150 eyes at Multisite Refractive Clinica Baviera

ISSN 1393-8983
                                                                                                      Tiago Ferreira (Portugal)
                                                                                                      Prospective comparative study of bilaterally implanted RayOne Trifocal versus

                                      can improve results
                                                                                                      Finevison POD F in 60 eyes

                                                                                                      Alessandro Mularoni (Italy)
                                                                                                      RayOne Trifocal vs PanOptix: Visual Outcomes and IOL stability

                                                                                                      Martin Kacerovsky (Czech Republic)

                                                                    OPHTHALMOLOGY
                                                                                                      Comparing RayOne and PanOptix Trifocal outcomes

                                                                                                      Georges Cherfan (Lebanon)
                                                                                                      Contralateral implantation of the RayOne Trifocal IOL and FineVision Trifocal IOL

                                                                                                                                                                                                              Diagnosing and Treating Ocular

                                      in moderate-to-high                                                                                                                                                   Surface Disease in Surgical Patients
                                                                                                                                                                                                                      Supported by an unrestricted educational grant f rom

                                      myopia
                                                                    29 Updating the classification    Included with
                                  18 Rise in endothelial                                              this issue...
                                      keratoplasty may be               system for Coats’ disease
As certified by ABC,                  linked to increase in                                           Rayner Supplement
the EuroTimes average                                               30 Cross-linking in the
net circulation for the               fungal endophthalmitis            children with progressive     ESCRS/EuCornea Education
10 issues distributed
between 01 January                                                      keratoconus                   Forum Supplement
2017 and 31 December
2017 is 45,316.

                                                                                                                                                                                           EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
2      EDITORIAL

                                                                                       A WORD FROM OLIVER FINDL MD, MBA, FEBO

                         GUEST EDITORIAL
                                                                                 How do you know
                                                                                 which IOL to use?
                                                                                 Deciding on the choice of IOL can be
                                                                                 a difficult task, not only for the patient
                                  Oliver Findl                                   but also often for their surgeon

                                                                                 I
                                                                                         am very pleased to be invited to write this editorial for
                                                                                         EuroTimes, which has a special focus this month on IOLs.
                                                                                            As my colleague Soosan Jacob points out in this issue,
                                                                                         deciding on the choice of IOL to implant can sometimes
                         MEDICAL EDITORS                                                 be a difficult task, not only for the patient but also often
                                                                                 for the surgeon who counsels the patient. The numerous types of
                                                                                 available IOLs as well as relative advantages and disadvantages of
                                                                                 each can be challenging.
                                                                                   As a surgeon, my advice to younger colleagues is always to use
                                                                                 the lens that you are most comfortable with, but also the one that
                                                                                 you think is best suited to the individual patient.
                                                                                   As we are all aware, as more exciting technologies come on
                                                                                 the market our patients may have higher expectations of the
                                                                                 improvement in vision that can result after a lens is implanted.
           Emanuel Rosen                              José Güell                   In my opinion, when talking to our patients before we enter
         Chief Medical Editor                                                                                             the operating theatre, we
                                                                                 As a surgeon, my                         must always stress that
                                                                                                                          we can never guarantee
                                                                                 advice to younger                        perfect vision or a dramatic
                                                                                 colleagues is always                     improvement in vision
                                                                                 to use the lens                          after a lens is implanted.
                                                                                                                          We must always be honest
                                                                                 that you are most                        with our patients and advise
                                                                                 comfortable with                         them that while we will
                                                                                                                          always do our best for them,
                                                                                                                          there is no such thing as the
            Thomas Kohnen                            Paul Rosen                  perfect procedure. We should follow the motto “underpromise
                                                                                 and overdeliver”.
                                                                                   As ophthalmologists, we are always looking for the next big
                                                                                 innovation and with that in mind, I was also very interested to
                                                                                 read Howard Larkin’s report from the Ophthalmology Futures
                                                                                 Forum held in Vienna in September 2018.
                                                                                   At this forum, Julian Stevens said that designing successful
                                                                                 accommodating IOLs remains daunting and he noted that several
                                                                                 mechanical and flexible gel lens IOL designs have lost accommodative
                                                                                 range over time due to capsule fibrosis. He also pointed out that lens
                                                                                 mineralisation has developed as much as five years after implant. My
                                                                                 personal experience with the so-called accommodating IOLs has been
      INTERNATIONAL EDITORIAL BOARD                                              very disappointing, I do not use them at all. Even though electronic
      Noel Alpins (Australia), Bekir Aslan (Turkey),                             accommodating IOLs still appear futuristic, prolonged battery life
                                                                                 may make them realistic sooner than expected.
      Roberto Bellucci (Italy), Hiroko Bissen-Miyajima (Japan),                    This is a discussion that we will return to in the future, and as
      John Chang (China), Béatrice Cochener-Lamard (France),                     always part of the excitement of being an ophthalmologist is looking
      Oliver Findl (Austria), Nino Hirnschall (Austria), Soosan Jacob (India),   forward to what lies ahead and to see the benefits that years of
                                                                                 research can bring in real life situations in our daily surgeries.
      Vikentia Katsanevaki (Greece), Daniel Kook (Germany),
      Boris Malyugin (Russia), Marguerite McDonald (USA),
      Cyres Mehta (India), Sorcha Ní Dhubhghaill (Ireland)
      Rudy Nuijts (The Netherlands), Leigh Spielberg (The Netherlands),
      Sathish Srinivasan (UK), Robert Stegmann (South Africa),
      Ulf Stenevi (Sweden), Marie-José Tassignon (Belgium),
      Manfred Tetz (Germany), Carlo Enrico Traverso (Italy)
                                                                                 Oliver Findl is Secretary of the ESCRS and Chairperson of the
                                                                                 Young Ophthalmologists Committee

    EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
ADVERTISING FEATURE                3

                                                           THE MOST BALANCED
                                                           TRIFOCAL IOL

STRONG NEAR VISION                                                            DESIGN MATTERS
One of the main strengths of Liberty Trifocal IOL (Medicontur) in com-        Premium technology also demands premium design. The square edges
parison to other trifocal IOLs is the higher and extended range of            of the optic in Liberty (≤10 µ; 360°) are designed to prevent posterior
near vision. Patients achieve a higher depth of focus at near and this        capsule opacification (PCO), which is often one of the factors limiting
is the most important for us in a premium IOL implant that aims for           success of multifocal IOLs.
spectacle independence. You will always find surprises with multifocal        The large size of the IOL and its double loop haptic design are consid-
IOLs, but when you maintain a sufficient range of near vision focus           ered to be very important features for postoperative stability, particular-
these surprises tend to be less critical than those experienced with oth-     ly for toric MIOLs.
er trifocal IOLs from the past.
                                                                              After one year of experience with Liberty we have realised that not
EFFICIENCY THROUGH USING                                                      all hydrophilic IOLs produce the same rate of PCO. With Liberty, after
OCULAR PHYSIOLOGY                                                             12 months 83% of our patients remained in grade 0 and 17% in grade
We got used to incorrectly labelling IOLs as “pupil-dependent” or “pu-        1 for PCO classification, whereas the previous hydrophilic IOL we im-
pil-independent” while we forget that it is the patient who is “pupil-de-     planted achieved percentages of 44% in grade 0, 29% in grade 1 and
pendent”, not the IOL design. The function of the pupil plays an impor-       27% with higher degrees of PCO after the same follow-up time. In short,
tant role in the performance of trifocal IOLs, as it controls the intensity   with Liberty we reduced our PCO rates at 12 months.
of light going through the specific lens zones.                               CONTRAST SENSITIVITY, DYSPHOTOPSIA
Once you measure the pupils you discover that Liberty can maintain            AND LIGHT SCATTERING
near vision in low light conditions. We usually test our patients             There is always some level of compromise in contrast sensitivity with
in low photopic light conditions (90 lux) and in these conditions they        diffractive multifocal IOLs. Light scattering induced by IOLs is caused
achieve a mean of 20/25 for near and 20/32 for intermediate monoc-            by each single diffractive step and, depending on the manufacturing
ular vision, and one additional line of visual acuity in binocular vision.    quality, these light scatters can occur on multiple points on each step.
Liberty has an intermediate vision weakness in patients with pupils           Therefore not only the quality but also the quantity of the manufac-
larger than 3.5 mm in low photopic conditions. In these cases patients        tured steps can have a great impact on the amount of correctly utilized
should increase environmental light, which decreases pupil size lead-         light energy within the eye and influence contrast sensitivity. Liberty
ing to improved intermediate vision.                                          achieves trifocality with only 7 diffractive rings which is the lowest num-
                                                                              ber amongst the leading MIOLs today.
                                                                              We are truly convinced that the 7-ring technology is enough to
                                                                              maximize visual performance at multiple distances with the
                                                                              main advantage of avoiding additional light scattering produced by the
                                                                              narrow peripheral rings in night vision. Although dysphotopsia with
                                                                              MIOLs is a topic which needs more relevant scientific evidence, theoret-
                                                                              ical simulations confirmed our expectations of reduced glare and halos
                                                                              with Liberty.
                                                                              Nevertheless, in our experience dysphotopsia is a short-term phenome-
                                                                              non, decreasing in the long-term. Furthermore, while dysphotopsia and
                                                                              loss of contrast sensitivity are limiting factors for implantation of multi-
                                                                              focal IOLs today, it should not be forgotten that dysphotopsia and con-
                                                                              trast sensitivity reduction are also experienced by patients with cataract.
                                                                              One of our main worries was to determine the proper age and preoper-
                                                                              ative degree of cataract that can lead to the highest positive experience
                                                                              after surgery, increasing not only close and intermediate range visual
                                                                              performance but also producing a positive experience in dysphotopsia
                                                                              and contrast sensitivity. With Liberty 50% of patients at around 60 years
                                                                              of age or with a cataract degree of CN1 on the LOCS III scale will actually
                                                                              improve their contrast sensitivity and experience less dysphotopsia in
                                                                              comparison to their preoperative vision with best spectacle refraction.

                                                                              Joaquín Fernández, MD, PhD
                                                                              joaquinfernandezoft@qvision.es
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
4      SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

What is the Right IOL?
                           Choosing and using IOLs can be a daunting task.
                             Soosan Jacob MD sets out how to go about it

    D
                    eciding on the choice        various types of IOLs available, it is wise to   can help set the stage for a one-on-one
                    of IOL to implant can        try and find out what activities matter most     direct discussion with the patient.
                    sometimes be a difficult     to the patient, how they feel about wearing         Understanding the patient’s lifestyle
                    task, not only for the       glasses some/all of the time and to know         and visual preferences – whether there is a
                    patient but also often for   if they want/ expect complete spectacle          requirement for greater clarity at distance,
    the surgeon who counsels the patient. The    independence. This conversation helps in         intermediate or near vision is important. It
    numerous types of available IOLs as well     guiding patients towards the possible best       is also important to set realistic expectations
    as relative advantages and disadvantages     choice for them as well as helps in setting      regarding a reasonably but not completely
    of each can be daunting.                     realistic expectations preoperatively.           glasses-free life, and clear understanding
      At the outset, before explaining the          Questionnaires and informational videos       that some activities will need glasses.

    EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
SPECIAL FOCUS: CATARACT & REFRACTIVE LENS                                                   5

   It is generally advisable to focus on good
distance visual acuity in the dominant eye
and either have better intermediate or near
vision in the non-dominant eye depending
on the patient’s requirement.
   Taller patients have a slightly farther
requirement for their near point than
shorter patients and the body build should
also be considered.
   Possible need for postoperative laser
vision correction for any residual refractive
error should be kept in mind by the
surgeon and informed to the patient. There
should be preoperative clarity about the
financial considerations for this possible
enhancement.

STANDARD MONOFOCALS
I still use monofocal IOLs for many of
my patients who do not want premium
IOLs. Knowing their visual demands
helps to plan better. Patients opting for
monovision or micromonovision have the
dominant eye focused for distance and the
other for near/ intermediate by aiming for
slight myopia. These patients should be
given a monovision trial prior to surgery
to check suitability and to get a first-hand
preoperative experience of monovision.          Fig A: Toric IOL seen being implanted. Alignment marks on cornea are visible (yellow arrows); B: IOL implanted in-the-bag. Alignment
                                                marks on IOL are visible (black arrows); C: IOL is rotated to lie short of the corneal alignment marks following which viscoelastic is
                                                completely removed; D: IOL is rotated into its final position
PREMIUM IOLS
Before choosing a premium IOL, I always
try to make sure the patient is a good
candidate. A healthy ocular surface allows
accurate IOL power calculations and a
                                                (Alsanza) and Acriva Reviol (VSY                                      option. Standard toric IOLs are available
satisfied patient post-operatively. History,
                                                Biotech) – provide better intermediate                                in the range of 1.5D to 6.0D cylinder (to
variable measurements and irregular
                                                vision with fewer side-effects. Most also                             correct 0.75D to 4.75DC). Higher powers
patterns on topography and ocular staining
                                                have toric versions.                                                  are available when required. It is important
are important and any dry eye is treated
                                                                                                                      to assess posterior corneal astigmatism to
pre-operatively if present. A macular OCT       Extended Depth of Focus (EDOF) IOLs:                                  avoid errors in IOL calculation.
helps rule out early maculopathy. I also        I like EDOF IOLs because of the better
look for large-angle kappa and increased        intermediate vision they provide with
higher-order aberrations, which may             lesser side-effects of glare, halos or loss                            FUTURE
result in unhappiness with multifocal           of contrast as compared to multifocals.                               Preoperative decision making needs to
IOLs. Astigmatism on topography and             EDOFs would be preferred more than                                    become yet more refined in terms of
keratometry help determine the need for         multifocal IOLs in maculopathy or                                     extremely precise IOL power calculations
toric or multifocal toric IOLs.                 irregular corneas, though monofocals                                  in complex eyes as well as in having
                                                would still be the first choice in these cases.                       the ability to preoperatively simulate
Multifocals: These IOLs use diffractive                                                                               realistically to each patient the kind of
                                                   They have an elongated focal area, giving
optics and split light into far and near                                                                              vision they can expect postoperatively from
                                                an extended depth of focus, minimal effect
foci, thereby creating peaks at individual                                                                            a particular lens choice. This becomes
                                                on peak resolution and give reasonably
focal points that the patient can focus on.                                                                           especially important with presbyopic IOLs
                                                clear vision at all distances (especially far
However, blurry vision in between the                                                                                 as these patients form the most demanding
                                                and intermediate). However, near vision
two foci and glare and haloes from the                                                                                group and it would definitely help decrease
                                                with a higher add multifocal is better,
other images are disadvantages.                                                                                       chair time if they could be made precisely
                                                therefore, bilateral EDOF with -0.5 to
  I prefer implanting multifocals after                                                                               aware as to what to expect postoperatively.
                                                -0.75D micromonovision strategy or a
a detailed conversation with the patient                                                                                 Intraoperative and postoperative factors
                                                mix-and-match strategy with EDOF in the
about the expected benefits as well as                                                                                such as toric IOL alignment, postoperative
                                                dominant eye together with +3.25 near add
the visual symptoms that may occur,                                                                                   rotation etc are other factors which need
                                                multifocal in the non-dominant eye may be
especially during night driving.                                                                                      to be perfected yet more. Another problem
                                                used if the patient desires more near vision.
  A mix-and-match policy can help                                                                                     that also needs to be further refined is
                                                   I like both the Tecnis Symfony
expand the range of vision offered by                                                                                 postoperative IOL power adjustment
                                                IOL (AMO, California) and the AT
different multifocals. Newer rotationally                                                                             and the ability to have effective dropless
                                                LARA 829MP (Carl Zeiss Meditec).
asymmetric segmented bifocal IOLs with                                                                                surgery via canalicular or punctal sustained
                                                Postoperatively, patients can show over
sector-shaped near vision segment give far                                                                            release drug-delivery systems.
                                                minus values on both autorefractor and
and near (+3D add) focus zones for better
                                                manifest refraction. The highest plus
depth of focus and include the Mplus,                                                                                 Dr Soosan Jacob is Director and Chief
                                                possible should therefore be prescribed by
Mplus X (Oculentis) and SBL-3 (Lenstec).                                                                              of Dr Agarwal’s Refractive and Cornea
                                                using a fogging technique.
  Trifocals – AT LISA (Carl Zeiss                                                                                     Foundation at Dr Agarwal’s Eye
Meditec), FineVision (PhysIOL,                  Toric IOLs: When astigmatic correction                                Hospital, Chennai, India and can be
Belgium), PanOptix (Alcon), Alsafit             is also required, toric IOLs provide a good                           reached at dr_soosanj@hotmail.com

                                                                                                                                                     EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
6      SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

                                         NEW IOL
          TECHNOLOGIES
                                There may be many paths forward, though
                                      technical challenges remain.
                                          Howard Larkin reports

    M
                        ultiple intraocular lens
                        (IOL) technologies,
                        including multifocal,
                        EDOF,       adjustable,
                        and both mechanical
    and electronic accommodating lenses,
    will continue developing over the
    next few years as industry and ocular
    surgeons seek better treatments for
    presbyopia, according to presenters
    at the Ophthalmology Futures Forum
    Vienna 2018.
       However, designing IOLs that
    provide reliable and durable presbyopia
    correction remains daunting, said Julian
    Stevens MRCP, FRCS, FRCOphth, DO
    of Moorfields Eye Hospital. He noted
    that accommodating mechanical and
    flexible gel lens IOL designs that rely on
    ciliary contraction to physically move or
    reshape lenses often lose accommodative
    range as capsules contract and stiffen
    over time due to fibrosis.
       Similarly, lens implants can develop
    long-term unpredictable change with            MK Raheja PhD, Jan Willem de Cler and Julian Stevens MRCP, FRCS, FRCOphth, speaking at the Ophthalmology Futures Forum in Vienna
    shift in position, and recently for one
    manufacturer mineralisation developing
    as much as five years after surgery.            world what do we need for safety and                              optical trade-offs that may be more
    This      severely degrades multifocal          efficacy? How many years do you wait                              acceptable for some patients than others,
    performance and makes lens exchange             before you say ‘yes, that’s good enough’?”                        and this takes time to assess. “We need
    extremely difficult, particularly following     There should be a European database                               to better understand patient needs as well
    posterior capsulotomy, Dr Stevens               for long-term follow-up at 10, 15 and 20                          as physiology of their eye to increase the
    said. Attempts to induce multifocality          years and beyond, he believes.                                    probability of success with the presbyopia
    in adjustable lenses after implantation                                                                           solution that we provide”.
    can result in optical complexities and          MULTIPLE SOLUTIONS                                                  Laurent Attias, senior vice president
    optical irregularity, which is challenging      How much development time is needed                               for corporate development at Alcon, sees
    for patients and very difficult to correct,     depends on the technology, said MK                                merit in continuing development of light-
    he added.                                       Raheja PhD, head of ophthalmic implants                           splitting, accommodating and adjustable
       Detecting such problems lengthens            R&D for Johnson & Johnson Vision.                                 lenses. “Each has its own challenges,” he
    development time, but is necessary,             Mechanical accommodating designs rely                             said. Multifocals must balance a mix of
    Dr Stevens said. “Given that we are             on performance of the capsular bag and                            near, intermediate and far vision while
    implanting these lenses in younger and          ciliary muscles, which can deteriorate with                       minimising dysphotopsias, mechanical
    younger people for refractive reasons,          time and therefore require more time to                           accommodating lenses must preserve
    how long would you like to see outcomes         demonstrate efficacy. Multifocal, EDOF                            an acceptable range of movement and
    data? Forget the regulations, in the real       and adjustable lens technology involves                           the precision and long-term safety

    EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
SPECIAL FOCUS: CATARACT & REFRACTIVE LENS                               7

of adjustable lenses must be proven.                            not that far off… we’ve seen [lifespan]
“The good news is each are viable                               improvements from four years to 20 years.”
routes toward the same golden egg                                  Rapid progress is also being made on
called presbyopia.”                                             other issues that will make electronic
  Dr     Stevens     believes     electronic                    accommodating lenses usable. These
accommodating IOLs that adjust refractive                       include managing the speed and precision       We need to simplify
power by varying lens refractive index will
be an attractive solution. However, battery
                                                                of accommodation, which are critical to
                                                                patient acceptance, and developing foldable
                                                                                                               using [presbyopia-
technology must improve to provide a                            electronics that will enable insertion         correcting IOLs]
40-to-50-year lifespan with enough energy                       accommodating IOLs through monofocal-
density to be light enough to implant.                          size incisions of 2.5mm or so.                 and simplification
“Once that comes in it will be a total game-                       In fact, Attias sees electronic             will take time. We
changer,” he said. However, any electronic                      accommodating IOLs pulling ahead of
lens implant will not be compatible with                        contact lenses due to the challenges of        are counting on
MRI scanning, and this will likely be a
serious drawback.
                                                                keeping contacts comfortable. “Unless you
                                                                solve for comfort, nothing else matters.”
                                                                                                               the early adopters
  Alcon is making progress on electronic                           Raheja believes that future presbyopic      to demonstrate the
accommodating IOLs and contact lenses,                          IOL solutions may combine approaches.
Attias said. “The battery technology is                         Every technology has its advantages            concepts
                                                                and limits and all are at an early stage,      Julian Stevens, MRCP, FRCS, FRCOphth
                                                                he said. “We need to push forward on
                                                                every front.”

                                                                SIMPLIFYING SURGERY
                                                                According to Carl Zeiss Meditec, another       this becomes a barrier to use. “We need
                                                                critical factor in boosting acceptance of      to simplify using [presbyopia-correcting
     We need to better                                          presbyopia-correcting lenses is providing      IOLs] and simplification will take time.
   understand patient                                           diagnostics that support predictable           We are counting on the early adopters to
                                                                patient outcomes. The company reports          demonstrate the concepts.”
      needs as well as                                          that it is very important not to look at         Dr Stevens said lenses optimised to fit
    physiology of their                                         the IOL in isolation as it is also a process
                                                                of diagnostics, using information to
                                                                                                               into a precision-cut anterior capsulotomy
                                                                                                               are a step toward increasing success
    eye to increase the                                         perfect the technique so the end result is     because they allow centring the lens
                                                                what is expected.                              precisely and permanently on the visual
 probability of success                                           Failing to recognise this can lead to        axis. “You don’t have lateral movement
  with the presbyopia                                           the avoidance of prescribing presbyopia-       and you don’t have decentration.” He
                                                                correcting IOLs not because of any problem     believes that optimising lens design to
          solution that                                         with the lens itself, but a lack of knowing    take advantage of the potential precision
            we provide                                          how to implant it accurately.
                                                                  Attias agreed. Even today’s toric lenses
                                                                                                               offered by femtosecond laser technology
                                                                                                               will eventually increase use of presbyopia-
                                               MK Raheja, PHD   require extra time and skill to implant, and   correcting and other speciality lenses.

    The beginning
    of a new era.
                                                                                                                «A clever design is not only pleasing
                                                                                                                on the eye. A clever design integrates
                                                                                                                well into your workflow and seam-
                                                                                                                lessly becomes part of your system.
                                                                                                                Think about mobility, simplicity
                                                                                                                and safety significantly to enhance
                                            at
                                Visit us                                                                        efficiency.»
                                     019
                               APAO 2 8
                                              3
                                  Booth Z                                                                       Thomas Köppel
                                                                                                                CEO This AG

    Please note: Device is not yet approved. It has been
    submitted for EU-market (CE) approval but cannot
    be purchased until approval has been granted.                                                                                www.sophi.info

                                                                                                                                          EUROTIMES | FEBRUARY 2019
Right IOL? What is the - SPECIAL FOCUS - EuroTimes
8      SPECIAL FOCUS: CATARACT & REFRACTIVE LENS

                                                                       Refractive surgery
           Pentacam® AXL                                               for high myopia
           The All-in-One                                              Differences in risk something to
                                                                       consider when weighing alternatives.
           Unit!                                                       Cheryl Guttman Krader reports

                                                                       E
                                                                                     ach of the surgical options for correcting high
           Visit our booth at ESCRS                                                  myopia has a unique set of pros and cons, but
           Winter Meeting, Athens!                                                   only refractive lens exchange (RLE) appears
                                                                                     to be associated with an increased risk of
                                                                                     retinal detachment.
                                                                          Speaking at the 18th EURETINA Congress in Vienna,
                                                                       Austria, Andrzej Grzybowski MD, PhD, MBA, reviewed
                                                                       the literature on risk of retinal detachment in high
                                                                       myopes and with cornea and lens-based refractive surgery
                                                                       techniques. He concluded that RLE increases the risk
                                                                       significantly, while phakic IOL implantation does not.
                                                                       Although excimer laser keratorefractive surgery might be
                                                                       excluded from consideration for other reasons, there is no
                                                                       evidence that it increases the risk of retinal detachment,
                                                                       said Dr Grzybowski, Chair of Ophthalmology, University of
                                                                       Warmia and Mazury, Olsztyn, Poland.
                                                                          According to published reports, the risk of retinal
                                                                       detachment in non-operated myopic eyes ranges between
                                                                       0.71% and 3.2%. Compared with the general population, the
                                                                       risk of retinal detachment is estimated to be about 50-fold
                                                                       higher in the subgroup with myopia -15D.
                                                                          “In addition, the risk of retinal detachment in myopes
                                                                       is particularly high during the second, third and fourth
                                                                       decades of life, mainly owing to atrophic retinal holes,” Dr
                                                                       Grzybowski said.

                                                                       REFRACTIVE SURGERY-RELATED RISK
                                                                       In an article reviewing published data on RLE, Dr
                                                                       Grzybowski and colleagues found that the reported rate
                                                                       of retinal detachment ranged from 0% in some studies to
                                                                       8.1% in one paper (Alió JL, Grzybowski A, Romaniuk D.
                                                                       Eye Vis (Lond). 2014 Dec 10;1:10.).
                                                                          “It is quite well known that phacoemulsification itself
                                                                       increases the risk of retinal detachment by 10-fold, and
                                                                       young age is one of the risk factors,” said Dr Grzybowski.
                                                                          The proposed mechanism involves induction of
            Optical biometry and inbuilt IOL                           posterior vitreous detachment, which might occur in
            formulas for any eye status                                close to 80% of highly myopic patients undergoing RLE,
                                                                       he explained.
            Use Total Corneal Refractive Power (TCRP) keratometry         Traumatic effects resulting from placement of the
            to account for individual total corneal astigmatism of     microkeratome suction ring combined with the shock-
            every patient and select suitable aspheric, toric and      wave and thermal effects of the excimer laser create
            multifocal IOL candidates more confidently. Perform        a mechanistic basis for an increased risk of retinal
            swift IOL calculations using the inbuilt IOL Calculator,   detachment after excimer laser keratorefractive surgery.
                                                                       However, the rate of retinal detachment after LASIK for up
            avoid manual transcription errors and optimize your
                                                                       to -10D myopia was very low in a study of almost 12,000
            personal constants.                                        eyes (Arevalo JF, Lasave AF, Torres F, Suarez E. Graefes
            Included: Barrett IOL formulas and customized              Arch Clin Exp Ophthalmol. 2012;250(7):963-970.).
                                                                          “Studies comparing PRK and LASIK found no difference
            formulas for post-corneal refractive patients
                                                                       between the procedures in the rate of retinal detachment,”
                                                                       Dr Grzybowski said.
                                                                          Only a few studies evaluated the rate of retinal
                                                                       detachment in myopic eyes that underwent phakic
        www.pentacam.com                                               IOL implantation, and they did not find an increased
                        Follow us!                                     risk, he added.

                                                                       Andrzej Grzybowski: ae.grzybowski@gmail.com

    EUROTIMES | FEBRUARY 2019
Seeing to succeed
in cataract surgery.
ZEISS OPMI LUMERA 700

 »We are able to give our
  patients a much more
  predictable outcome. That
  I think is key for today’s
  cataract surgeons, the
  ability to predict and deliver
  what we tell them we’re
  going to do.«
  Ronald Yeoh, MD
  Eye and Retina Surgeons
  Camden Medical Centre, Singapore

                           Passionate about his profession, Dr. Yeoh is committed to
                           providing cataract patients with the best possible outcome.
                           The superb imaging and markerless toric IOL alignment
                           capabilities of the OPMI LUMERA® 700 and CALLISTO® eye
                           from ZEISS enable him to deliver on patient expectations.
                           We share his commitment to his calling. What´s your calling?

                           www.zeiss.com/mycalling
10      ADVERTISING FEATURE

                                             HOYA Evening Symposium, Vienna 2018

                  Clinical Research and
                Product Innovation Update
           At a symposium held during the 36th ESCRS Congress in Vienna, a group of world experts on
         intraocular lens performance met to provide an update on HOYA’s research into IOL technology,
          with presentations on the new multiSert™ injector system and studies comparing the Vivinex™
                      lens to other lenses in terms of rotational stability, PCO and glistenings

     Performance of the new HOYA multiSert™ Preloaded
     Injector System for the Vivinex™ IOL
     Gerd U Auffarth MD FEBO
     International Vision Correction Research Centre (IVRC)
     The David Apple International Laboratory University Eye Clinic
     University Eye Clinic Heidelberg, Germany

     T
             he new multiSert ™ Injector System      very controlled and consistent delivery
             for the Vivinex™ IOL provides an        of the IOL into the capsular bag for both
             increased range of flexibility to       push and screw modes. The multiSert™
     the cataract surgeon, allowing injection        injector system adds further options with
     with either a single-handed push mode           an adjustable mechanism, the insert
     or a two-handed screw mode. Previous            shield, that serves as a depth-limiting
     preloaded injectors from the HOYA iSert®        device when choosing to perform a wound-     The glistening-free hydrophobic Vivinex IOL
     series like model PY-60AD or model 251          assisted IOL implantation. Moreover, the
     were designed for the two-handed screw          Vivinex™ lens comes preloaded with the
     mode only.                                      device, which requires only a very simple    surgery. Screwing two-handed or
        The multiSert™ injector’s tip has an         preparation prior to the injection.          pushing single-handed are both possible
     outer diameter of 1.7mm, allowing delivery         In summary, by combining the options      with or without use of the advanced
     of the IOL into the capsular bag through        of both a push and a screw mode for IOL      insert shield for insertion through the
     a sub-2.2mm incision. At The David Apple        injection, the 4-in-1 multiSert® provides    wound tunnel or direct implantation in
     International Laboratory, we observed a         the best of two worlds in cataract           the capsular bag.

     Defining and Assessing True Rotational                                                       degrees. Similarly, in eyes with the
     Stability of Toric IOLs                                                                      Johnson & Johnson Vision TECNIS®
                                                                                                  1-Piece IOL the mean rotation was only
     Rupert Menapace, MD                                                                          2.2 degrees but there were two outliers
     Professor of Ophthalmology & Optometry                                                       with around 40 degrees of rotation.
     University of Vienna Medical School, Vienna General Hospital, Vienna, Austria                Furthermore, in eyes with the Bausch +
                                                                                                  Lomb EnVista® lens there was a mean

     S
                                                                                                  rotation of 3.2 degrees but there were
            ignificant secondary rotation of an       position directly after implantation and    outliers of up to 44.9 degrees.
            implanted toric lens once it has          then at one hour, one day, one week,          Most of the rotation with all lens types
            been implanted is uncommon in             one month and six months afterwards,        occurred in the first hour after surgery
     most of the leading IOL models on the            using haptic junctions and fixed            and almost none occurred after the first
     market, but some of the lenses have              landmarks on globe as reference points.     postoperative week. That is because
     outliers that can be enough to annihilate           We found that in eyes with the HOYA      by one week the capsule is closed and
     the anti-stigmatic effect of the lens.           Vivinex™ IOL, the mean rotation at to-six   by one month the capsular leaves have
     Therefore, it is important to determine          months was only 1.5 degrees, and in no      fused. Therefore, what counts is not
     the true rotational stability of a lens.         eyes was there rotation greater than        the deviation from the intended axis but
        We have compared the amount of                five degrees. By comparison, although       the positional change starting from the
     postoperative rotation for each of four          the mean rotation in eyes with the Alcon    end of surgery, and not from one hour,
     different single-piece hydrophobic IOL           AcrySof® IQ lens was only 1.7 degrees       one day or even later. What also count
     models. The patients all underwent               at six months postoperative, in a few       are the outliers, not the mean values or
     examination of their implanted lens              outliers the lens rotated by up to 15.8     standard deviations.
ADVERTISING FEATURE                   11

Comparative PCO Performance Analysis of the HOYA                                             mimic post-surgical inflammatory
                                                                                             events, and allows for the observation
Vivinex™ IOL and a Leading Competitor                                                        and definitive measurement of different
Michael Wormstone FARVO                                                                      phases of PCO formation following IOL
                                                                                             implantation in an in-vitro setting.
Professor of Ophthalmology, School of Biological Sciences,
                                                                                                This improved graded culture system
University of East Anglia, Norwich, UK
                                                                                             has been used to compare the PCO-

T
                                                                                             performance of the Vivinex™ lens with
        he human capsular bag model              contributions from Prof David Spalton’s     that of a leading competitor in a series
        is one of the premier in vitro           group in St Thomas’ Hospital in London.     of match-paired human capsular bag
        systems to understand the                  Based on the findings of studies          experiments. The team found cell growth
biological regulation of PCO and how             using flare measurements of protein         on the posterior capsule to be slower
implanted IOLs can influence this                concentrations in the anterior chamber      on the HOYA Vivinex™ when compared
common condition. This model was                 following cataract surgery, the team at     to the leading competitor. Cell growth
first pioneered by a team of scientists          UEA have developed a graded culture         on the posterior capsule was retarded,
and clinicians at the University of East         system whereby the delivery of human        light-scatter in the central visual axis
Anglia (UEA) in the 1990s and has                serum and transforming growth factor-β      was found to be lower and growth on the
developed in to several iterations since,        levels is carefully controlled over time.   IOL surface was markedly reduced with
through continued work at UEA and                This approach is designed to closely        Vivinex™ versus the leading competitor.

Comparison of Two Hydrophobic Intraocular Lenses: A Prospective Study
Dominique Monnet MD PhD
Université Paris Descartes, l’hôpital Cochin, Paris, France

T
       he two-year interim results of              At two years’ follow-up in 34 eyes,       out so far was in an eye implanted
       a prospective, ongoing three-             we found that both lenses performed         with the AcrySof® lens. The Vivinex™
       year multi-centre study we are            almost identically in terms of refractive   lens also developed significantly less
carrying out indicates that new Vivinex™         predictability and stability. The mean      “glistenings”, which by two years were
IOL is highly resistant to PCO and is less       BCDVA of both lenses was equivalent         absent or of low-grade density in eyes
prone to glistening than the AcrySof®            with 0.0±0.1 logMAR at two years.           with the Vivinex™ lens but were present
lens. The trial involves an intent-to-           The two lenses also had identical and       and of a high-grade density in most
treat population of 85 patients with a           very low, quantitative PCO scores.          eyes with the AcrySof® eyes.
mean age of 73.6 years. All underwent            However, there was a trend towards
randomised implantation of the Vivinex™          less PCO in the Vivinex™ group, and
IOL in one eye and the implantation of           the only YAG-laser capsulotomy carried
the AcrySof® lens in their fellow eyes.
The two IOLs investigated are similar in
being single-piece lenses composed of a
hydrophobic material and having a
sharp optic edge. In the Vivinex™
lens, the optic’s posterior surface
has additionally undergone an “active
oxygen” surface treatment.
                                                                                             The 4-in-1 multiSert™ preloaded delivery system

How to Optimise Monovision Outcomes?
Peter Hoffmann MD                                                                            myopised. However, with a 1.0D add,
                                                                                             myopisation of the non-dominant
Castrop-Rauxel, Germany
                                                                                             eye resulted in a slightly lower

W
                                                                                             intermediate visual acuity than when
            e tested the visual acuity           “...63% of participants                     the dominant eye was myopised. In
            and subjective reports of                                                        addition, 63% of participants reported
            46 bilaterally pseudophakic
                                                 reported a worse sensation                  a worse sensation of binocularity with
patients under simulated monovision              of binocularity with a                      a myopisation of 1.0D compared to
conditions. We measured their                    myopisation of 1.0D compared                emmetropia, compared to only 2%
emmetropised monocular and binocular                                                         when myopised by 0.5D. Moreover,
visual acuity at 6m, 80cm and 40cm,              to emmetropia...”                           in a study of fusional amplitude in
first with 0.5D add in the dominant eye                                                      12 bilateral pseudophakic patients,
and then with the same add in the non-             We found that with a binocular acuity     we found that good binocularity
dominant eye. We also performed the              with a 0.5D add was identical whether       would be achieved in most eyes if
same sequence of testing with a 1.0D add.        the dominant or non-dominant eye was        anisometropia was limited to 0.75D.
12      CATARACT & REFRACTIVE

      Cataract and glaucoma
        Optimised fluidics key to safe and uncomplicated surgery in glaucomatous eyes.
                                  Roibeard Ó hÉineacháin reports

     T
                   he fluidics of the phacoemulsification
                   system in cataract patients with
                   glaucoma should be optimised to
                   ensure a stable, low-pressure anterior
                   chamber during surgery and prevent
     damage to the optic nerve, Roberto Bellucci MD,
     Verona, Italy, told the 36th Congress of the ESCRS
     in Vienna.
       “Better understanding of phaco fluidics
     improves the safety of cataract surgery especially in
     glaucomatous eyes,” he emphasised.
       Microincision cataract surgery (MICS) is the
     best option in glaucomatous eyes because it has
     gentler fluidics than standard incision surgery,
     whether using a Venturi or peristaltic pump settings.
     Femtosecond laser-assisted cataract surgery is
     indicated in glaucoma eyes with shallow anterior
     chambers, pseudoexfoliation and low endothelial
     cell counts, he said.

     FLUIDICS OPTIMISATION
     But what is most important is the optimisation
     of fluidics to avoid IOP elevation and anterior                                                                         Roberto Bellucci MD
     chamber oscillation, which can further damage
     the already compromised optic nerve, Dr Bellucci
     stressed.
        Using a high bottle height is a poor solution. Raising the         the anterior chamber. Furthermore, leakage provides a
     bottle height one metre above the eye will increase the pressure      reservoir of fluid, which helps in avoiding chamber collapse
     within the anterior chamber to 70 mmHg. If the bottle is raised       when aspiration increases abruptly. It also maintains some
     to 1.3m the pressure will rise to 100 mmHg. Raising the bottle        fluid stream within the anterior chamber during occlusion
     in this way will not only increase the patient’s pain but will also   or clogging.
     increase the oscillation of the anterior chamber depth. That,
     in turn increases the difficulty of the surgery and raises the        PRESSURE SENSORS
     risk of complications and damage to the optic nerve head. The         The latest evolution in phaco fluidics control are irrigation
     potential complications include posterior capsule rupture and         systems that use feedback from sensors that detect the anterior
     cystoid macular oedema.                                               chamber pressure. The result is better and more delicate fluidics
        Fluidics optimisation can instead be achieved by reducing          control. The increase of vacuum that the system allows and the
     the aspiration ports and system hysteresis, separate control of       small tip improve fragment hold-ability, and the reduced flow
     aspiration and ultrasound, avoiding occlusion, allowing some          improves fragment follow-ability.
     leakage and varying infusion pressure according to the pressure         “What is nice is that you can select the IOP you want; I use
     in the anterior chamber, Dr Bellucci summarised.                      25mmHg, which corresponds to a bottle height of 40mmHg.
        In MICS procedures, rigid low hysteresis tubing must be            Nobody was using such low bottle heights before these machines
     used, together with low hysteresis pumps possessing small             came along,” Dr Bellucci said.
     ports and pressure sensors and double venting systems.                  The choice of IOL also requires special consideration in cataract
        Separate control of aspiration and ultrasound allows the           patients with glaucoma. For example, “soft” hydrophilic IOLs with
     activation of ultrasound power at any vacuum level and                weak haptics are contraindicated in eyes with weak zonules, as in
     also avoids excessive pressure within the anterior chamber            eyes with pseudoexfoliative glaucoma, because they will not resist
     and resulting hydration of the vitreous. Venturi pumps and            capsular bag contraction.
     peristaltic pumps perform equally well in separately controlled         IOLs that decrease contrast sensitivity like multifocal IOLs
     aspiration and ultrasound systems, provided that they are             are also contraindicated in patients with glaucoma. On the
     properly adjusted.                                                    other hand, aspheric IOLs that enhance contrast sensitivity are
        The use of micro-pulse ultrasound delivery and small phaco         beneficial in such cases.
     tips will generate very small fragments, thereby avoiding               At the conclusion of surgery, thorough viscoelastic
     occlusion of the aspiration line. Phaco tips with transverse/         removal is essential to avoid post-op IOP spikes. IOP should
     rotational needle movement appear to work very effectively            be brought under control the same day, with attention
     when used with a peristaltic pump, Dr Bellucci said.                  to possible aqueous misdirection syndrome, he advised.
        He added that some incision leakage during surgery can
     be helpful. It avoids excessive pressure and deepening of             Roberto Bellucci: robbell@tin.it

     EUROTIMES | FEBRUARY 2019
CATARACT & REFRACTIVE                  13

                                                                                        CONGRATULATIONS!
                                                                   THOMAS KOHNEN         2017 OBSTBAUM AWARD FOR
                                                              European editor of JCRS      BEST ORIGINAL ARTICLE

  JCRS HIGHLIGHTS                                                                            Functional magnetic
                                                                                         resonance imaging to assess
VOL: 44 ISSUE: 12 MONTH: DECEMBER 2018
                                                                                         neuroadaptation to multifocal
PREDICTING POSTERIOR CAPSULE RUPTURE                                                          intraocular lenses
Anterior segment OCT (AS-OCT) can successfully predict the risk for
posterior capsule rupture during phacoemulsification in eyes with
                                                                                             Andreia M. Rosa, Ângela C. Miranda,
posterior polar cataract, a recent study suggests. The prospective                           Miguel M. Patrício, Colm McAlinden,
observational study included 64 eyes of 62 patients with posterior                          Fátima L. Silva, Miguel Castelo-Branco,
polar cataract who had phaco. All underwent preoperative                                            and Joaquim N. Murta
AS-OCT to assess the integrity of the posterior capsule. Phaco
was performed by the same surgeon, who was masked from the
                                                                                            J Cataract Refract Surg 2017; 43:1287–1296
AS-OCT findings, and who evaluated the integrity of the posterior
capsule intraoperatively. Preoperative AS-OCT showed eight eyes
(12.5%) to have probable posterior capsule dehiscence and 56                                2017 ROSEN AWARD FOR
eyes (87.5%) to have intact posterior capsules. Intraoperatively, the
surgeon noted posterior capsule dehiscence in five eyes (7.8%) and                         BEST TECHNICAL ARTICLE
an intact posterior capsule in 59 eyes (92.2%). The sensitivity and
specificity of AS-OCT for detecting posterior capsule dehiscence
was 100% and 94.92%, respectively. The negative predictive value
                                                                                             Artificial iris implantation
of AS-OCT was 100%. GP Kumaret al., JCRS, “Can preoperative
anterior segment optical coherence tomography predict posterior
                                                                                            in various iris defects and
capsule rupture during phacoemulsification in patients with posterior                              lens conditions
polar cataract?”, Vol. 44, Issue 12, 1441-4.
                                                                                              Christian Mayer, Tamer Tandogan,
                                                                                          Andrea E. Hoffmann, and Ramin Khoramnia
HOAs AND HIGH MYOPIA
A new study looking at corneal aberrations in high myopes                                    J Cataract Refract Surg 2017; 43:724–731
provides support for using aspheric IOLs in those cataract
patients. The study of 287 high myopia patients found no
negative primary spherical aberrations of the total or anterior                         The JCRS as we know it today was born out
corneal surface. The study did note differences between the                             of the amalgamation of two peer-reviewed
myope group and control group in terms of central corneal
                                                                                        journals, the Journal of Cataract & Refractive
thickness, astigmatism, primary spherical aberration, vertical
coma and oblique trefoil. However, these differences were not                           Surgery from the ASCRS and the European
consistent between different age subgroups. Higher-order                                Journal of Implant and Refractive Surgery from
aberrations were correlated with age. Posterior corneal vertical                        ESCRS. The merged journal, which marked
coma was correlated with axial length. M Zhang et al, JCRS,
                                                                                        its 20th year in 2016, is the direct outcome
“Analysis of corneal higher-order aberrations in cataract patients
with high myopia”, Vol. 44, Issue 12, 1482-90.                                          of the spirit of friendship and cooperation
                                                                                        that developed between the two societies, in
                                                                                        particular between the editors at the time of
CXL – ON OR OFF?
                                                                                        the merger, Stephen A. Obstbaum, MD, in the
Epi-off corneal collagen cross-linking might be better than
the transepithelial technique for the treatment of progressive                          United States and Emanuel S. Rosen, MD,
corneal ectasia in terms of steepest keratometry, a new meta-                                         FRCSEd, in Europe.
analysis concludes. The meta-analysis included seven randomised
clinical trials involving 505 eyes that met eligibility criteria for                    In honor of their passion and foresight, the editors
the review. The epi-off CXL group showed significantly better                           are pleased to announce the creation of two
outcomes in post-op changes in maximum keratometry during                               annual awards for articles published in the JCRS,
one-year observation periods. Transepithelial CXL resulted in
significantly greater post-treatment central corneal thickness and
                                                                                        the Obstbaum Award for Best Original Article
best spectacle-corrected visual acuity. The presence of a post-op                       and the Rosen Award for Best Technique Article.
demarcation line was significantly more frequent after epi-off
CXL than that after transepithelial CXL. H Kobashi et al., JCRS,
“Transepithelial versus epithelium-off corneal crosslinking for
corneal ectasia”, Vol. 44, Issue 12, 1507-16.

 Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

                                                                                                                             EUROTIMES | FEBRUARY 2019
14      CATARACT & REFRACTIVE

                                                       FLACS and
                                                       dense cataract
                                                       Randomised, controlled study finds
                                                       grid pattern reduces phaco time
                                                       and endothelial cell loss.
                                                       Howard Larkin reports

                                                       F
                                                                    ragmenting very dense cataract nuclei with a
                                                                    femtosecond laser using a grid pattern before

             European Union                                         phacoemusification significantly reduced effective
                                                                    phaco time (EPT) and endothelial cell count loss
                                                                    (ECC) compared with manual phacoemulsification
             Web-Based Registry                        or femtosecond laser-assisted cataract surgery (FLACS) using
                                                       a 16-segment fragmentation approach, Soon-Phaik Chee MD
                                                       told the 36th Congress of the ESCRS in Vienna.
                                                          In a prospective, randomised, controlled study, Dr Chee
             The aim of the project is to build a
                                                       and colleagues at the Singapore National Eye Centre assigned
             common assessment methodology             94 patients with nuclear cataracts of LOCS III NO grade 5, 6
             and establish an EU web-based registry    or more to receive manual phacoemulsification, FLACS using
             and network for academics, health         a 600-micron grid fragmentation pattern (FLACS grid) or
                                                       FLACS using a 16-segment pattern (FLACS 16) followed by
             professionals and authorities to assess
                                                       phacoemulsification in a 2:1:1 ratio.
             and verify the safety quality and            All FLACS patients were treated with a Victus
             efficacy of corneal transplantation.      femtosecond laser (Bausch + Lomb, Munich, Germany), and
                                                       all patients received phacoemulsification using a Stellaris
                                                       system (Bausch + Lomb, Rochester, New York, USA). All
                                                       procedures were done by Dr Chee using a direct phaco

             Join
                                                       chop technique. The study examined corneal safety using
                                                       the three approaches, examining effective phaco time and
                                                       endothelial cell loss one month after surgery.

                                                       EPT RESULTS
                                                       The study found nuclear density and treatment method both
             the ECCTR Registry                        affected effective effective phaco time, Dr Chee reported.
                                                       Perhaps not surprisingly, the 49 cases with NO5-6 required
                                                       significantly less mean phaco time than the 44 of higher than

             Track
                                                       grade 6 (p6 group.
                                                          These results vary from two non-randomised studies in
                                                       the literature, which found reduced effective phaco time and
                                                       endothelial cell with FLACS, Dr Chee noted. However, these
                                                       studies examined softer cataracts, and used 300-micron grid
                                                       patterns and a stop-and-chop phaco approach, which may
             ECCTR is co-funded by                     have influenced the outcomes (Hatch KM et al. J Cataract
                                                       Refract Surg. 2015;41:1833-1838. Chen X et al. J Cataract
                                                       Refract Surg. 2017;42(4):486-491.).
                             Co-funded by                 “FLACS grid but not FLACS 16 segment significantly
                             the Health Programme
                             of the European Union     reduced mean effective phaco time and lowered mean
                                                       endothelial cell loss at one month compared with manual
                                                       phacoemulsification in dense cataracts,” Dr Chee concluded.

                                                       Soon-Phaik Chee: chee.soon.phaik@snec.com.sg

     EUROTIMES | FEBRUARY 2019
CATARACT & REFRACTIVE                    15

                Corneal
          astigmatism options
                  Correction of high astigmatism is now feasible with a variety of
                   corneal refractive techniques. Roibeard Ó hÉineacháin reports

S
           urgeons have a number of corneal refractive procedures      PRK VS LASIK VS SMILE
           to choose from that can produce good results in eyes        Photoablative techniques like PRK and LASIK can correct
           with regular and irregular high astigmatism, Jesper         higher amounts of astigmatism and with greater accuracy than
           Hjortdal MD told the 36th Congress of the ESCRS in          incisional techniques and their results appear to be roughly
           Vienna, Austria.                                            comparable, he noted. In a study comparing the two techniques
  The general aim in correcting regular astigmatism is to flatten      in eyes with more than 3.0D of astigmatism, there was no
the steep axis of the cornea or compensate for the astigmatism         statistically significant difference between the efficacy and the
intraocularly with a toric IOL, said Dr Hjortdal, Aarhus University    two techniques had similar predictability. That is, in the PRK and
Hospital, Denmark.                                                     LASIK groups, 39% and 54%, respectively, had less than 0.5D of
  Whichever technique is used, accurate determination of the           astigmatism postoperatively, and 88% and 94% had less than
correct axis pre- and                                                                                        1.0D (Katz et al, J Refract
intraoperatively          is                                                                                 Surg. 2013;29(12):824-831).
necessary to bring about                                                                                        The results with SMILE®
the desired effect. If the                                                                                   appear to be comparable to
actual alignment axis is                                                                                     LASIK in eyes with high
off the target alignment                                                                                     myopic astigmatism. In a
axis by 30 degrees, the                                                                                      recent retrospective study,
procedure will have no                                                                                       Dr Chan and his associates
anti-stigmatic effect at all,                                                                                found     no      significant
he pointed out.                                                                                              between-group difference
  Indications           for                                                                                  in uncorrected distance
surgery in eyes with high                                                                                    visual acuity and manifest
astigmatism include poor                                                                                     spherical equivalent in
vision with spectacles,                                                                                      patients undergoing the
intolerance or discomfort                                                                                    procedures for myopic
with contact lenses and                                                                                      astigmatism. At three
concomitant cataract.                                                                                        months, 90% and 95.4%
The corneal surgical                                                                                         of eyes in the SMILE and
techniques         include                                                                                    LASIK groups, respectively,
incisional and photo-            Jesper Hjortdal MD
                                                                                                              were within ±0.5D of the
ablative varieties, and                                                                                       attempted        cylindrical
most recently stromal lenticule excision, he said.                     correction (p=0.423) (Chan et al, J Cataract Refract Surg. 2018
                                                                       Jul;44(7):802-810).
LIMITED EFFECT OF ARCUATE KERATOTOMY
                                                                          Topography-supported customised laser PRK is another
The oldest of the techniques currently in use is paired arcuate        technique that has been used in eyes with irregular astigmatism
keratotomy. The approach involves the creation of almost fully         due to PK or keratoconus. However, early results in a study
penetrating incisions in the peripheral steep axis of the cornea. It   involving penetrating keratoplasty patients showed significant
can achieve very good reductions in high astigmatism, although         haze following the procedure.
it can leave considerable amount of residual astigmatism in               More recently Dan Reinstein MD, PhD, UK, has introduced
highly astigmatic eyes and there can be considerable scatter in the    transepithelial phototherapeutic keratectomy (TE-PTK).
technique’s predictability.                                            The ablation is based on population epithelial thickness
   As an illustration, he cited a study he and his associates          measurements determined using very high-frequency digital
conducted 20 years ago involving highly astigmatic post-PK eyes.       ultrasound. Results to date with the technique suggest that
It showed that arcuate keratotomy reduced mean keratometric            TE-PTK can be a safe and effective method of reducing
cylinder by 50%, from 7.0D to 3.25D. However, the procedure was        stromal surface irregularities by taking advantage of the natural
safe and he noted that the greater the magnitude of preoperative       masking effect of the epithelium.
astigmatism, the greater was the anti-astigmatic effect (Hjortdal et      Last but not least are intracorneal ring segments (ICRS) for
al, Acta Ophthalmol. Scand. 1998: 76: 138-141).                        the treatment of keratoconus. Several studies confirm safety and
   In a more recent study arcuate keratotomy incisions produced        efficacy of ICRS. However, predictability remains a key challenge
with a femtosecond laser produced a similar reduction in corneal       and current nomograms are insufficient to cover all cases.
astigmatism, from 9.45D to 4.64D, and despite the precision of the
technique there remained some scatter in the results (Loriaut et al,   Jesper Hjortdal: jesper.hjortdal@clin.au.dk
Cornea 2015:34:1063-1066).

                                                                                                                  EUROTIMES | FEBRUARY 2019
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