Regular attendees of the Australasian Society of Cataract and Refractive Surgeons (AUSCRS) conference agree: it’s never boring. This year, along with participating in a host of entertaining presentations, delegates acknowledged the efforts of founding co-presidents Professor Graham Barrett AM and Dr Rick Wolfe, and welcomed a new leadership team who will take the Society – and its annual conference – into the future.
AUSCRS 2022, at Peppers, Noosa in early August was the largest AUSCRS conference ever hosted, with a total of 491 registrations.
Stop. Think. Act! Making the right choice at the time, on the fly, is key
The opening event featured a fantastic recap of the past 25 years, with some hilarious video highlights, and a thanks to the sponsors and supporters, followed by an outdoor dinner where many friendships were rekindled.
Everyone shared how happy they were to be face-to-face, at last!
The educational component began with an advanced trainee program and a three-day support staff program, both of which were well supported. The support staff program included keynotes on how to stand out online, change management, branding, communication, dry eye, and cataract flow. Exhibitors interacted with both support staff and doctors, showcasing the fantastic technology available in ophthalmology today. There were even demonstrations of lasers and techniques on real eyes.
The essence of AUSCRS centres around themed doctors’ sessions, which this year, had an African, Lion King flavour. The AUSCRS 25th Gold Medal Lecture was delivered by Dr Kerry Solomon, from Carolina in the United States, who talked about the sci-fi evolution of smart software for cataract surgery. Dr Solomon made the point that while many surgeons still pick their intraocular lenses (IOLs) by ticking a box on a printed sheet, today it’s all about the software ecosystem. He talked about auto-detection of all parameters, including missing data. Software should automatically indicate when there’s an outlier in the data, so deeper investigations can be made. Is a patient wearing an undisclosed contact lens during biometry or have they forgotten to mention previous LASIK? Digital workflow must streamline processes, save time/money, reduce manual data entry, and eliminate mistakes, using data from multiple sources. It’s all about being connected and intelligent, while harnessing big data. Software can be tweaked for surgeon specific, or global data. The process starts for the patient before the operation, with explanatory videos, history, visual goals etc.
The ultimate goal is better patient outcomes.
The first themed session, Negotiating the gorge: challenging cases and complications, was hosted by Dr Tanya Trinh. True to the ‘gorge’ theme, cases centred around torn or ruptured capsules with a great variety of challenges. A video by Dr Audrey Rostov (Seattle, United States) featured a ‘dropped’ (pre-existing) endothelial graft that occurred during IOL surgery. She recovered fast, accessing and implanting a new endothelial graft, while her retinal colleagues retrieved the missing graft. The panel noted that ‘lost’ endothelial tissue is hard to find. Dr Milind Pande (East Yorkshire, England) mentioned the importance of logical thought and remaining as calm as possible during such challenges, reinforced by Dr Florian Kretz (Rheine, Germany) whose motto is Stop. Think. Act! Making the right choice at the time, on the fly, is key. Surgeons need to interpret the body reacting, not react to the adrenaline as such, and appreciate the privilege of the faith patients place in them.
Dr Trinh’s video ended the session, showcasing a highly vascularised cornea, pre-existing DMEK, silicone oil and fibrosis. She stressed that view is everything, and proper control is essential to prevent silicone oil prolapse.
The panellists, dressed in theme as hyenas, had to partake of the biltong that Prof Barrett handed out…
Session two, was themed Hakuna matata: don’t worry – no more readers for the rest of your life? and chaired by Dr Lewis Levitz, who expanded the African ‘no worries’ theme, managing ten meerkat panellists very well. Monofocal IOLs, extended depth of focus (EDOF) designs, and trifocals were discussed. Varying degrees of monovision and depth of focus were covered. EDOF lenses seem to be gaining popularity.
Spectacle independence was defined by Dr Pande as 6/9 (or better), at distance intermediate and near, in mesopic conditions. He discussed ‘nanovision’ where binocular summation is still possible in mild cases of ‘monovision’ with a need to keep two eyes within 1D of each other. Spectacle top-ups were recommended, when necessary.
Excellent functional vision relies on the correct IOL choice and accurate end point refractive targets being achieved.
There was robust debate surrounding monovision and binocular vision, with differing views… as there has been for decades.
Does Aberrometry Enhance Outcomes?
Dr Solomon reported that manual planning proved better than intraocular aberrometry – even in post-refractive surgery cases. Barrett formulas and anterior keratometry are currently equal to or better than aberrometry. Dr Levitz noted that it’s not the first time we have a solution looking for a problem.
Is a MFIOL for everybody?
Simply put, they work – as validated by many patients – but there are problem cases. There’s no perfect IOL. If you extend the range of focus, you compromise. Reduced stereopsis and contrast, dysphotopsia, and top up glasses are some of the compromises. Always discuss potential issues: if a patient doesn’t experience a symptom that’s great, but if they experience a symptom you never mentioned, they’re not happy. Be aware of eyes with irregular astigmatism. Avoid MFIOLs for pilots, night driving, obsessive patients, and specific occupations/hobbies. Initiate dry eye management before surgery for better biometry and outcomes. Be aware of habitual pupil size and lens centration.
Two optometrists who wore monovision contact lenses (CLs) pre-cataracts, opted for EDOF IOLs. They’re happy, largely spectacle free, and shared the reasoning behind their IOL choice and experiences.
The Indaba Chat, chaired by legendary AUSCRS founders Dr Wolfe and Prof Barrett, included a variety of surgeons and industry personnel.
It was stressed that bilateral sequential cataract surgery is not the standard of care, but should it be? The consensus was no, not now anyway. Some surgeons are pro bilateral, sequential cataract surgery and perform it routinely, but others are strongly against. The main concern is endophthalmitis, and some surgeons want to review the first IOL before finalising the second IOL choice. Fair enough.
Innovations on the Horizon
Infinite refractive adjustment post-op is highly desirable. Light adjustable IOLs have been mooted for over a decade and are now making an entry. A femto-adjustable IOL technology might be able to tweak an Rx post-surgery.
Digital Versus Optical Microscopes
Digital microscopes have different ergonomics, and a surgeon can ‘swipe’ to overlay topography, or other scales and data. Some surgeons use 3D digital systems exclusively, others are resistant. 3D is one thing, but integrated technology is a top benefit. Once you switch you don’t go back, said the converts.
The Indaba continued with Sangoma Barrett, ‘throwing the bones’. An Indaba is a meeting (or conference) and Sangoma is a Zulu term for a highly respected healer who diagnoses, prescribes, and often performs rituals to heal a person physically, mentally, emotionally, or spiritually.
Doctors discussed how to aim for perfect outcomes, elaborating on their processes, techniques and IOL choices, with some result-driven comparisons to support their choices. Dr Liliana Werner (Utah, United States) predicted that true accommodating IOLs are in our future, and as they are monofocal designs, dysphotopsia should not be a problem.
Comparisons of biometers revealed variations, some clinically significant, others not. Instruments work on different principles and technology, but which is right? It’s probably the instrument you get to know…
Assoc/Prof Michael Goggin discussed posthyperopic LASIK IOLs as a challenging area, noting such patients are keen to quickly restore vision when developing cataracts. His take home tip was to get the sphere, cyl and axis correct, and the rest follows. Prof Barrett discussed post-refractive surgery ectasia, keratoconus, and predictions. Historically, IOL outcomes tended to result in hyperopia in these eyes. Formulas and biometry have evolved, and results can be improved with careful attention to detail. Via online Barrett calculators, he demonstrated working through the variables and how to get the ideal sphere and cyl, stressing the need to get the cyl on axis during surgery.
TUG OF WAR
Friday morning kicked off with a tug of war.
Dr Ben La Hood brought his usual humour to his presentation in a ‘no holds barred’ head-to-head session, aimed at convincing colleagues of why they should use his favourite IOL. He used superheroes to illustrate the powers and weaknesses of different options. In a similar vein, Dr Rostov used horror movies to critique various IOLs, in a variety of conditions.
Glistenings were mentioned, but they seem to be becoming a thing of the past. Another long-standing debate centred around whether an IOL should be blue light filtering or not. Globally, around half the IOLs prescribed are blue filtering.
Dr Kretz talked about haptics and loops, his preferred lens and why – which mostly centred around capsular shrinkage, keeping the lens in position and on axis. He won the battle, but it turns out he has Olympic standard training in tug of war! Great fun was had by all.
Two sessions, The forge: tools for cataract surgery, chaired by Dr Georgia Cleary, and The eye of the vulture, chaired by Professor Gerard Sutton, featured some exciting technologies, current and future, a variety of issues related to IOL types, and comparisons. Phaco methods, techniques and alternatives were showcased via great videos.
Low energy femtomatrix robotic cataract surgery, inflammation, and how you can fly with (or transport) a compact phaco machine were detailed.
Portable phaco machines were of particular interest to those operating in remote clinics in Australia and the Pacific Islands.
Dr Wolfe spoke enthusiastically about helping many patients to be spectacle-free, post-cataract surgery, for over thirty years. He mentioned having a laser refractive enhancement plan at the ready for tweaking outcomes.
Angle alpha/kappa, the visual axis, geometric centre, and centre from the limbus were discussed; while many felt these don’t make a huge difference, they agreed that extreme variations can be an issue. Patient selection and accurate refractive end points were again stressed. Recentring a lens post-op, in a further procedure, can be very successful to enhance satisfaction.
WHO AM I?
The session You don’t know me: or do you? featured four surgeons in disguise, with voice altering technology, showcasing their surgical skills via videos. The audience and panel did a great job of identifying them. This was an interesting session all round, as we got to know more about the surgeons’ personal lives, interests, hobbies, and philanthropy, and how they were steered toward ophthalmology.
Friday’s last session, chaired by Dr Alison Chiu, was themed Ask Zazu: avoiding problems after cataract surgery.
Professor Helen Danesh-Meyer reported that around 26 Australian ophthalmologists will see a patient with a brain tumour masquerading as a cataract. She noted that colour vision anomalies, brightness sensitivity differences, retinal nerve fibre layer and macula ganglion cell layer abnormalities on optical coherence tomography were all indicative of such lurking brain tumours.
Dr Gerd Auffarth (Heidelberg, Germany) showcased a novel artificial endothelial layer for managing chronic corneal oedema. Although impermeable and unable to control deturgescence like a real endothelium, it can help reduce oedema. Future developments may lead to the kind of permeability required.
Saturday morning opened with Smoke and mirrors: trends in refractive surgery, chaired by Dr Andrea Ang.
Mirror-clad presenters covered SMILE, femtosecond lasers, inflammation, managing/avoiding complications, hyperopic LASIK and presbyopic blended vision laser refractive techniques, among other topics. Dr Pavel Stodulka (Prague, Czech Republic) enthusiastically presented a promising new collagen biosynthetic corneal micro-lens inlay for presbyopia, which has shown promising results.
With her usual enthusiastic style, incoming AUSCRS co-president, Dr Jacqui Beltz, chaired the session Heads above the clouds: current and future trends in corneal surgery.
Participants dealt with the complex and challenging issues of cataract surgery in keratoconus, presbyopic IOLs in aberrated corneas, small aperture IOLs, cross linking techniques/results/complications and allogenic intrastromal corneal ring segments. Dr Beltz stressed that visualisation and wound integrity are important, as are IOL selection and calculations. Such patients often have irregular, oblique, high astigmatism, and high order aberrations. Results can be unpredictable. If a patient will still need a rigid contact lens post-surgery, avoid toric IOLs. Only use them if good vision is possible. A variety of endothelial and lamellar graft techniques were also detailed. Such cases remain a significant challenge to even the experts. Very thorough measurement, planning, and counselling are necessary for good results.
Saturday’s final plenary session was Follow the stars: astigmatism correction with toric IOLs, chaired by Dr La Hood. Australia continues to lead the world, with many surgeons implanting 80% toric IOLs. They’ve drilled down to extremely tight refractive targets, with even 0.3D of astigmatism regarded as significant – light years ahead of where we were just a few years ago.
At least three instruments should be used to verify astigmatism, improve accuracy, and lens selection. Topographers only output simulated-K rather than actually measuring K, so optical keratometers should be the standard. A topographer is useful in providing a comparison to the other instruments and for detecting irregularity.
AUSCRS FILM FESTIVAL
Prof Graham Lee was the well-deserved winner of the AUSCRS Film Festival. His surgical movie and live voice-over of Terror of the poppy eye was certainly eye-popping. The standard was high. As was the case throughout AUSCRS. Full credit to surgeons for showing us some of their ‘worst’ cases. It takes guts to stand up in front of your peers and present cases you’d rather not share, all in the interest of improved patient care.
Having founded and led AUSRCS for over 25 years, Prof Barrett and Dr Wolfe announced they would be stepping down, and introduced AUSCRS’ new co-presidents, Dr Beltz and Prof Sutton who will run AUSCRS in 2023, and beyond.
Prof Sutton is internationally renowned, and Dr Beltz brings a fresh approach to AUSCRS – they share plenty of passion and experience as AUSCRS presenters and committee members. Dr Beltz, who won the film festival as an advanced trainee at her first AUSCRS in 2008, said, “I’ve been lucky to be included in AUSCRS and have spoken on the program just about every year since then”. She’s passionate about contributing to the advanced trainee program and encourages registrars and colleagues to take part in the film festival.
Acknowledging their respect for what AUSCRS has achieved, Dr Beltz and Prof Sutton said they want to keep the essence of AUSCRS, while at the same time applying a fresh approach. They’re excited to take on this challenge.
“Graham and Rick started AUSCRS from nothing and built it to be this amazing community of practice within ophthalmology,” Dr Beltz said. “We love and respect everything they’ve done and are happy they’re not going anywhere. They’ll be a part of the committee and hopefully involved for a long time yet… There’s no way Gerard and I can fill their shoes. We don’t plan to and don’t think we have to. Together, Gerard, the AUSCRS community and I, just need to keep this going. There will be change, but it’s not our priority. Everything changes with time. The goal to improve surgical results and innovations for our patients remains a cornerstone of AUSCRS!”
Prof Sutton added, “Our goal is to maintain the unique culture of AUSCRS, with the great mix of scientific content, discussion and fun it’s renowned for”.
In recognition of Prof Barrett and Dr Wolfe’s amazing contribution to AUSCRS, a major announcement was made at the famous AUSCRS gala dinner. Henceforth, the AUSCRS Gold Medal lecture will become the Barrett/Wolfe Gold Medal Lecture, a well-deserved recognition of these legendary stalwarts.
Congratulations to Prof Barrett and Dr Wolfe as well as to Jenny Boden for shooting for the stars and setting in motion an orbiting comet that shines brightly. Under the guidance of Prof Sutton, Dr Beltz and the AUSCRS family, there’s no doubt that it will continue to return cyclically.
In 2023 AUSCRS will return, this time at the Sheraton Mirage, Port Douglas, from 26–29 July.