Crystal Clear AUSCRS 2019

The AUSCRS educational meeting opened with the traditional Gold Medal lecture on Thursday 18 July. Good lenses gone bad: How to do an IOL exchange when all else fails, was delivered by Dr Steven Safran, an American corneal specialist with a special interest in cataract surgery and premium intraocular lenses (IOLs). Adept in treating patients with complex conditions, he presented a number of interesting cases, and explained that despite our best efforts, patients having premium IOLs often have high expectations and are sometimes disappointed. Planning is critical… dislocated lenses, negative dysphotopsia, visual dissatisfaction and other issues can lead to a need for a lens replacement. Optic capture, reverse optic capture, and sulcus fixated lenses were discussed in managing dysphotopsia, as well as strategic planning, should a lens exchange become necessary at a later date.

Dr Safran discussed techniques and strategies to manage the processes for successful lens replacement. Freeing up the haptic from the bag can be simplified with proper planning and techniques. Having an ideal replacement IOL on hand, as well as backup options to cover any unwanted surprises, was suggested. If the existing IOL design and power are known, use the Barrett Rx formula, measure biometry and review pre-operative data if available. The more data we have the better. Having intimate knowledge of IOL designs is helpful in deciding which one will provide the optimum result in a given case. Dr Safran stressed that attention to every little detail can make all the difference in tricky cases. He shared a series of interesting explanatory videos to demonstrate some of the techniques used. All in all, it was an entertaining and educational talk, in keeping with the philosophy of AUSCRS meetings, and worthy of the Gold Medal, presented in the form of a traditional New Zealand art work.

THE AVALANCHE

The ‘avalanche’ session comprised a number of doctors who covered a range of complications, with excellent explanatory videos. Dr Bryan Lee showed how he recovered a ‘lost’ endothelium in a Descemet’s membrane endothelial keratoplasty (DMEK) procedure. He had to repeat the DMEK procedure a week later – due to damage to the membrane sustained during the ‘recovery’ – fortunately with an excellent outcome.

Dr Sathish Srinivasan told us about his longest day in theatre, involving a patient with an aphakic left eye, who had lost the ability to manage her contact lens due to arthritis. He inserted a scleral fixated IOL with an artificial iris implant. Unfortunately, the iris implant displaced posteriorly to the IOL into the vitreous chamber. With assistance from a vitreoretinal colleague, he eventually recovered the artificial iris and sutured it in place. However, the artificial iris again migrated posterior to the IOL. Eventually they left it, effectively with an anterior chamber IOL anterior to the sutured artificial iris, after over three hours of stressful surgery. Dr Srinivasan demonstrated a better way to go about the procedure, learned as a result of this case: to suture the iris to the IOL prior to inserting it into the eye.

Surgeons have to be brave to share their worst, sometimes embarrassing cases – they open themselves up to potential criticism by colleagues. However in doing so, they certainly help others avoid the worst should they have to deal with similar situations.

This year’s AUSCRS panel and Q&A sessions proved the value of discussion, with different opinions and solutions to given problems and complications shared and debated.

North, south, east, west: which destination is best? dealt with toric IOLs and covered optimising implantation, axis, and low power toric IOLs, comparing calculators, incision location, alignment, aberrometry, posterior astigmatism, femtosecond laser, and optimising outcomes in patients with a history of refractive surgery. Surgically induced astigmatism (SIA), and how to avoid and minimise it, was also discussed. Dr Gilles Lesieur explained the various methodologies, biometry, and calculations that guide choices. He also showed how corneal diameter (white to white) is an important consideration guiding lens choice and outcomes.

MOVING ON

The ‘Logfire Chat’ looked at hot topics in ophthalmology and what the future holds. Dr Safran believes cleaning epithelial cells off the posterior capsule is something surgeons should be doing more of – he is already meticulously cleaning the capsule during surgery. He believes complications will be lowered and visual outcomes may be better by doing so, but some debated that opinion. Other doctors opined that digitisation will lead to better, easier outcomes and analysis. Using telemedicine to manage chronic diseases through remote care will become more widespread.

Automating electronic medical records by coordinating and integrating instruments and data acquisition is also on the cards. Digital operating microscopes are developing, with potential advantages, and are likely to become more widely taken up in the near future. Electronic IOLs could be a game changer, as may lens capsule ‘filling’ and light adjustable IOLs. Such technologies, however, have been bandied about for many years and some believe they may remain technologies of the future.

As with AUSCRS 2018, there were plenty of discussions throughout the conference on sulcus fixated lenses, including one on preferred techniques, such as Yamane Intra Scleral Haptic Fixation (ISHF) and variations on the theme.

Opacified lenses, in certain designs and brands, may be a ticking time bomb and many will fail in ten years, leading to potential spikes in IOL replacement.

Optical coherence tomography has been a quiet revolution – it is now in widespread use and has become a technology we cannot live without. Bioengineered corneas could revolutionise anterior segment care. Genetic testing for refractive surgery patients e.g. screening and rapid tests that would predict ectasia or keratoconus risk, would be welcomed. It was also speculated that providing specific spectra of violet light exposure to patients may be a game changer in stopping the myopia epidemic, while neuroprotectives may prevent glaucoma damage.

BUT WAIT, THERE’S MORE…

AUSCRS meetings are not only about the doctors’ plenary sessions. A preconference advanced trainee program covered a number of useful topics including communication, slide production and video editing, as well as slit lamp photography.

Support staff were also catered to during parallel streams with a wide variety of interesting and entertaining topics.

A number of satellite meetings and dinners, hosted by the sponsors, were well attended. Several doctors provided sponsor specific and general lectures. At the Alcon TropSAT dinner meeting, Prof Graham Barrett, AUSCRS cofounder and current president, detailed which IOL calculators to use and when, with simulations and tips. Prof Barrett is widely regarded as having developed the most accurate IOL calculators, which are now used worldwide.

Meetings like this are impossible without the valued support of the fantastic sponsors and exhibitors. Each sponsor had an opportunity to present to the delegates, in rapid fire presentations lasting 60, 45 or 30 seconds. While they all did a great job getting their prime message across, the winner was AcuFocus.

IN CLOSING

Another long-standing tradition of AUSCRS is the film festival. Surgeons presented homemade videos and soundtracks with live voice overs, illustrating specialised surgical techniques, interesting procedures and challenging cases. Dr Colby Hart won with an excellent production titled Problematic Paediatric Phacoemulsification Paradigms, which dealt with persistent hyaloid vessels and leukocoria, detailing some superb surgical techniques that he used to avoid complications.

AUSCRS closed off with a ‘middle earth’ themed gala dinner, complete with an excellent band that had everyone up and dancing from the first note to the very last. Full credit to the organising committee and conference organisers, Corporate Communique, who have staged every one of these legendary meetings. Join us all at Noosa in 2020, and see what you’ve been missing out on. 

Frank, Respectful & Fun

Professor Gerard Sutton

AUSCRS is a unique conference around the world where all the key issues in cataract and refractive are raised and discussed. International guests can’t believe the frank discussions and respectful disagreement that is the hallmark of the meeting.

Over 23 years, Graham Barrett, Rick Wolfe and Jenny Boden have managed to create a culture of ‘a high level of psychological safety’ where people feel safe enough to be involved. Initially, I was a bit doubtful about the ‘themed’ dressing up required for each session but the feedback I have received is that it helps everyone feel comfortable asking questions and making comments.

Over the years the scientific content has improved significantly and is cutting edge. It is an intimate meeting that allows you direct interaction with the true international leaders in the field, something not possible in larger meetings.

I genuinely believe that any ophthalmologist who performs cataract and refractive surgery and does not attend AUSCRS is not able to provide the best level of care for their patients.

That’s not to say there isn’t room for improvement and the AUSCRS Board (on which I sit) is constantly looking for ways to improve and become more inclusive.

Professor Gerard Sutton is an internationally recognised ophthalmologist with expertise in cataract surgery, laser vision correction and corneal transplantation. He practises at Vision Eye Institute in Chatswood.