The Australasian Society of Cataract and Refractive Surgeons (AUSCRS) took a “step into the unknown (with a) changing of the guard” for its ‘Whole New World’ conference. Alan Saks was there.
New co-presidents, Dr Jacqueline Beltz and Professor Gerard Sutton, didn’t let a wet start put a dampener on proceedings, kicking off the 26th AUSCRS, held in Port Douglas in July, with a super opening cocktail party and dinner.
First up in the plenary sessions was the inaugural Barrett/Wolfe Gold Medal Lecture.
Dr Damien Gatinel, of the Rothschild Foundation in Paris, delivered the award talk, ‘Unveiling the secrets of precise IOL power calculation through theoretical analysis and cutting-edge modelling’. He covered various refractive models and complex intraocular lens (IOL) power calculations. Additionally, he detailed the open-source, Artificial Intelligence (AI) based PEARL-DGS formula – which stands for Prediction Enhanced by ARtificial Intelligence and output Linearisation, with DGS acknowledging the formula developers, Debellemanière, Gatinel, and Saad.
He explained how specific IOL designs and geometry can affect outcomes: If the posterior of the IOL is steeper, it may create a hyperopic surprise while if most of the IOL power is anterior, a mild myopic surprise may result. In another talk Dr Gatinel was also very firm in his belief that the root cause of keratoconus (KC) is through eye rubbing, which he illustrated with convincing cases.
The traditional rapid-fire sponsor presentations drew great applause from the delegates, with Glaukos taking home the prize. There were a number of breakfast and evening seminars with leading speakers hosted by the platinum sponsors, Alcon, Bausch and Lomb, Device Technologies, and Johnson & Johnson Vision. The trade exhibition was a hive of activity.
In the first themed session, Complex Cases ‘The good, the bad and the ugly’, Associate Professor Karl Stonecipher from North Carolina, in the United States, presented ‘Please don’t send me this patient, well, you can if you’re really frustrated…’
He mentioned Dextenza, a dexamethasone containing ophthalmic punctal insert, which provides a 90-day steroid release. For a Sjögren’s patient with post IOL exaggeration of symptoms, cenegermin-based Oxervate was prescribed as an eye drop which contains a recombinant form of human nerve growth factor, with promising results.
Adjunct Professor Soon-Phaik Chee from Singapore shared cases of ‘Managing intraoperative zonulysis’ with excellent surgical videos illustrating capsular hooks, suture snares, capsular tension rings, and fixating IOLs, as did some of the other presenters. She elaborated on various tips and tricks, like cutting sutures with a slant to enable easier threading. She advised supine examination with an ophthalmoscope to find an errant lens, as well as ultrasound biomicroscopy.
Speakers and commentators highlighted the use of Lissamine Green to light up desiccated tissue. Professor Michael Lawless suggested prescribing a short course of strong initial steroids (like dexamethasone) for maximal effect to break the cycle of inflammation, then tapering with milder steroids.
This sort of interaction, from those on stage and delegates in the audience, is one of the highlights of AUSCRS. No-holds-barred discussions provide excellent learning opportunities and insights. Even a top gun like Professor Graham Barrett admitted to learning something new from Professor Mahipak Sachdev who, in his film festival case explained how a ‘simple’ suturing technique could retain a silicone-oil retinal detachment tamponade, while a full thickness corneal transplant was completed in an aphakic eye.
HOT TOPICS
Every AUCSRS has issues that crop up repeatedly. Extended depth of focus (EDOF) IOL options were on the agenda in a big way. Mini-monovision and blended vision were suggested to enhance reading / intermediate vision.
There was increased coverage of small aperture IOLs. Although often used in the non-dominant eye unilaterally in cases of irregular astigmatism / keratoconus etc., they’re also of benefit bilaterally, in regular eyes.
Whether cataract surgeons should perform vitrectomies and pars plana techniques was debated. Surgeons presented cases and surgical videos explaining when and why they use this approach. A collaborative approach with retinal colleagues is advised, as a retinal tear may arise during or post-surgery. Surgeons need training and preparation. Some surgeons suggested simply backing off, closing the eye, and getting a retinal surgeon to deal with issues like lost lenses.
Numerous presenters showed strong evidence – via their own and colleagues’ research – with plenty of statistics and studies covering a broad range of subjects. That said, there’s still room for unique approaches and emerging trends. This can lead to formal research and the demonstration of efficacy, and safety.
GOOD VIBRATIONS
The importance of good biometry was stressed. Dr Warren Hill, from Arizona, US, has been at the forefront of IOL calculations for many years. He mentioned that dry eye (including undiagnosed dry eye) is a culprit in creating less than ideal refractive outcomes. We need to optimise the ocular surface before biometry.
Dr Hill performs all of his refractions and noted that an autorefractor tells you what a patient ‘needs’, while a subjective refraction tells us what they want.
The importance of obtaining multiple sources of K-readings was stressed. Some suggested auto keratometry and at least one or two different methods of manual keratometry, and to avoid the use of sim-Ks.
A whole session, ‘Here’s looking at you kid’, was dedicated to IOL formulae with some serious horsepower on stage. The presenters delved into complex calculations, and modelling. Session chair, Dr Ben La Hood jokingly stated from the podium that the only people who really understood some of the IOL formula presentations were the presenters on stage.
Dr Hill and Professor Filomena Ribeiro from Lisbon, Portugal, both mentioned the value of the recently released European Society of Cataract and Refractive Surgeons (ESCRS) IOL calculator, as it includes seven of the leading calculators, all in one place for easy comparison (iolcalculator.escrs.org).
Prof Ribeiro and others agreed that the Barrett True-K calculator was best for keratoconus.
We are reaching the limit of refractive end-point precision. We need to know more about individual IOL designs and geometry – ray tracing comes from that and will help refine outcomes. Manufacturing tolerances need to be refined too, as this can amount to 0.50D and up to a dioptre of combined error.
Get to know one or two formulae very well, stick with those and tweak to reduce error margins.
We need to know more about individual IOL designs and geometry – ray tracing comes from that and will help refine outcomes
IN OR OUT?
The benefits, safety, and value of implantable contact lenses (ICLs), as well as add-on (piggyback) sulcus IOLs, were discussed. Dr Lena Beckers from Hamburg, Germany, spoke on the evolution of ICLs. Her most common ICL choice corrects up to -18.00DS and 6.00DC. Their use is indicated when laser refractive surgery is contraindicated, for surgeons who don’t have access to refractive lasers, and for optimal outcomes in hyperopia. Piggyback options can be used to correct for a refractive surprise. Dr Patrick Versace stressed the importance of safety, through assessing the anterior chamber depth/angle, as it can narrow by as much as 35%, increasing risk of glaucoma /angle closure.
In a session titled ‘Heroism can be confined to brutal and ferocious valour’, surgeons presented enlightening cases and videos on why the EDOF presbyopic IOL they use is best.
In ‘Deep learning: loosen the knot and let me go’ a variety of surgeons shared their learnings and results with a variety of phaco machines or particular IOL designs, with interesting insights.
HAPPY PATIENTS
Associate Professor Abi Tenen discussed the important issue of ‘Peri-operative refractive stability amidst a myopia epidemic’. She noted that the significance of refractive instability is greater post-COVID with increased digital device driven myopia progression. We want to avoid dissatisfied refractive surgery patients coming back with myopia progression and instability. Surgeons often provide no-extra cost retreatments, but should retreatment periods be time-limited?
In his talk ‘Evaluation of extended depth of focus with the light adjustable lens’, Dr Mark Kontos from Spokane Valley, US, said that these lenses work well in LASIK patients and other cases with increased risk of refractive surprises, and for monovision too. The ability to adjust refractive endpoints for a period of time post-op adds another level of confidence.
Angle alpha, premium IOLs – in the form of multifocal IOLs, EDOF, enhanced monovision, and other considerations – were discussed in depth, in the presbyopia IOLs session ‘It’s not the past that matters but the future’.
In an entertaining game show style cooking competition, pairs of surgeons had to decorate cakes while commentating on each other’s surgical videos. They had to decide if their partner would be their surgeon of choice and what IOL preference they would have for themselves. Drs Lena Beckers and Georgia Cleary were the winners with their fine cake and cases.
In the Happy Patients ‘Always look on the bright side of life’ session, Professor Kendall Donaldson of Plantation, in the United States, looked at aspects of visual acuity versus visual quality – what matters most. You can have good or poor quality 6/6 vision. Patients can be incapacitated at night through flare, glare, and starburst, particularly with multifocal IOLs. During this talk, and throughout the conference, modulation transfer function (MTF) was referenced. MTF is an optical bench measurement that helps us evaluate potential performance and a way to describe contrast sensitivity. Reading speed is a measure of visual quality as is stereo acuity, which is compromised with multifocal IOLs and monovision. New instruments can determine critical measures and aspects of vision and quality. Prof Donaldson also presented some metrics of patient satisfaction, quality, and what they want/expect. Residual refractive error and dry eye were the main complaints. She reported that 55% of doctors have poor communication.
Professor Michael Knorz of Mannheim, Germany, noted that monofocal IOL exchange is an option but should not be done before six months, as many patients will adapt. IOL exchange rates are low, at around 0.05%. In 99% of cases of dissatisfaction, patients are unhappy with distance vision. Do one eye first, then decide. Try YAG capsulotomy if the patient was initially happy, or an IOL exchange if they were unhappy from the start. Consider treating residual refractive error with options like laser refractive tweaks or add-on IOLs / ICLs, but this may not help with dysphotopsia.
In ‘Double trouble: double vision following cataract and refractive surgery’, Dr Lana Del Porto reported that anaesthetic infiltration into the inferior rectus can cause a hypertropic strabismus and diplopia. To avoid a fixation switch in patients with pre-existing strabismus / suppression, it is advised to do surgery on the dominant eye first. Other tips were not to mix and match IOL designs and keep anisometropia to less than 1.00D difference.
Dr Del Porto said she is seeing an increase in digital device related issues and myopic esotropia, with prolonged fixation on devices resulting in over-flexing of the medial recti. If prism was prescribed, get rid of the prism glasses and get the patient off devices for a few months. If there’s no resolution, strabismus surgery may be necessary.
THE HOME STRAIGHT
Saturday’s sessions kicked off with Technology Updates.
Dr Florian Kretz from Rheine, Germany, discussed how surgeons (and industry) can reduce their environmental impact. He suggested re-usable injectors and instruments that can be resterilised instead of using disposables. Use smaller sterilisers and wait for a full load of instruments. Manufacturers are reducing packaging and package inserts. The right handpiece can be used as many as 700 times. Surgeons can almost function autonomously, avoiding the need for nurses having to change their mask/gowns after each patient, if they are not needed in theatre. Do we need 25 instruments when seven might suffice?
Other speakers looked at virtual integration and AI.
Dr Cathleen McCabe of Sarasota, in the United States, discussed virtual meetings that dramatically reduce the carbon footprint, plus the convenience of watching recordings. She detailed benefits of virtual reality ‘hands-on’ training. But what’s missing is the great value of personal interaction, which AUCSRS offers by the spadeful. Virtual observation and 3D virtual surgery is amazing. Dr Beltz noted that in a world-leading initiative, all registrars in Australia and New Zealand must now comply with, and be proficient in virtual surgical techniques and training, before being allowed to operate on humans.
It was noted that AI software can create ‘hallucinations’ and give out false information, so caution is needed.
In the final AUSCRS lecture session, leading refractive surgeons presented their favoured approach and methods of patient selection. Femtosecond-laser small incision lenticule extraction refractive surgery is now favoured by many surgeons. Methods to achieve optimal results were detailed as were some new platforms from laser providers that offer smoother lenticule extraction, reduced swelling, and larger optics zones. There are still however, those who prefer LASIK and PRK.
Unaided intermediate vision is a priority for patients undergoing refractive and cataract surgery. For trifocals, the trade-off is dysphotopsia and reduced contrast.
Refractive surgery and IOLs in keratoconus were further addressed in this session, as was dry eye. Dr Pooja Khamar from Narayana, India, discussed how low vitamin D levels can be a cause of dry eye disease, and that in a significant number of cases ‘dry eye symptoms’ were in fact more likely asthenopia, as orthoptics and vision therapy alleviated subjective dry eye symptoms.
FILM FESTIVAL AND GALA DINNER
The traditional film festival was, as usual, a fitting close to the lecture sessions at AUSCRS 2023. After many film festival submissions over the years, Dr Ben La Hood was proud to finally take home the AUSCRS film festival trophy with his well-presented video and live voice-over, with a good mix of surprises, learnings, and humour.
The fancy dress gala dinner was another roaring success with the dance floor packed from go to whoa, followed by late night drinks in the pub where the die-hards enjoyed each other’s company until the wee hours.
AUSCRS committee member Associate Professor Abi Tenen summed up AUSCRS 2023 very well, “A conference is most successful if the discussions, debates, and exchanges of information are candid and innovative. AUSCRS has the unique ability to bring together world class speakers and the very best of industry in an environment that boosts learning simply because it is fun!
“A truly jampacked schedule consisting of the doctor’s program, advanced trainee and support staff programs, satellite sessions, a bustling trade hall and a host of social events, left everyone with almost too many choices! The indicator of success was that every time I looked around, all I could see were people smiling. They didn’t want to be anywhere else.
Cataract and refractive surgeons attending a breakfast at AUSCRS gained real-world and clinical trial insights into the technology behind premium intraocular lenses (IOLs) with a specific focus on two extended depth of focus (EDOF) products, the IC-8 IOL and LuxSmart (Bausch and Lomb).
Following a presentation by Dr Damien Gatinel from Rothschild Foundation Hospital in Paris, France, on the key mechanisms employed in EDOF IOLs today (with refraction and diffraction being the key players), attention turned to Dr Karl Stonecipher.
THE IC-8 IOL
A Clinical Professor of Ophthalmology at the University of North Carolina, and Clinical Adjunct Professor of Ophthalmology at Tulane University, Dr Stonecipher evaluated subjective and objective visual quality results achieved with the IC-8 IOL.
Describing this extended depth of focus lens design as “a brilliant lens… that really gives a true range of vision”, he explained that “the small aperture design filters out unfocussed and aberrated peripheral light that degrades image quality, allowing only central light rays to focus on the retina”.
Having been among the first in the United States to trial the lens, Dr Stonecipher is currently the number one implanter of the IC-8 in his country. He has used it on and off label, and every one of his IC-8 patients, except one, has had the lens implanted bilaterally.
Dr Stonecipher reported on a US clinical trial, which enrolled patients in one of two groups:
• The IC-8 group (n=343) received a monofocal or monofocal toric IOL in the fellow eye, targeted to plano and an IC-8 small aperture IOL in their study eye, targeted to -0.75.
• The control group (N=110) received bilateral monofocal or monofocal toric IOLs targeted to plano in both eyes.
The study reported outcomes at six months post-op on binocular photopic and mesopic contrast sensitivity and subjective patient visual symptoms.
It found that the IC-8 IOL group achieved monofocal-like binocular photopic and mesopic contrast sensitivity, with patients reporting very low-level visual symptoms post-operatively in both the IC-8 IOL and control groups.
At 12 months, of 331 patients, only 3.0%, 3.6% and 3.6% respectively, reported experiencing severe glare, halos and star bursts. There were no problems reported with moving from bright light and into dim light (or vice versa) when compared with the control group. He said uncorrected visual acuities in the fellow eye performed “a touch better” but not significantly so.
Despite being a monovision IOL he said this “modernised monovision” lens design provides useful vision for 85–90% of tasks.
“The IC-8 is such a win over the standard monofocal – I don’t even offer a standard monofocal anymore,” Dr Stonecipher said. He added that the benefits of a premium IOL far outweigh additional costs, in terms of quality of vision and lowering the risk of falls etc.
LUXSMART IOL
Dr Paul Athanasiov spoke about the LuxSmart IOL, describing it as an extended range of vision intraocular lens with some “really fancy optics” that achieved predictable outcomes. Based on a combination of 4th and 6th order Spherical Aberration of opposite signs, this hydrophobic one-piece preloaded IOL has four-point fixation and ultraviolet and violet light filters.
A proclaimed agnostic when it comes to choosing IOLs, Dr Athanasiov said he uses “pretty much any lens” he wants to use, depending on the patient.
As the first surgeon in Australia to use LuxSmart toric and non-toric IOLs, he said he started implanting them more than a year ago because of unmet need, putting them in all candidates for a distance or an EDOF lens, except those with severe dry eyes or myopia, or those who desired complete spectacle independence.
Dr Athanasiov noted that demand for functional intermediate and near vision has increased among seniors, particularly since COVID, because of their use of digital technology.
Specifically, the number of seniors with internet at home has grown from 68% to 93% and the number and type of digital devices that seniors use – for keeping in touch, shopping, entertainment, and managing personal affairs – has also increased.1
Speaking of 268 eyes he has implanted with LuxSmart (40% of them with toric IOLs) he said the majority have achieved 6/6 binocular uncorrected distance visual acuity (BUDVA) with excellent intermediate and functional nearby. Additionally, while this is not a near vision lens, a lot of patients were able to read unaided.
A post op assessment and questionnaire completed by 56 patients he implanted between May 2022 and May 2023 assessed patient satisfaction with binocular uncorrected distance, intermediate, and near vision, finding:
• Binocular uncorrected distance vision: 92.9% achieved 6/7.5 or better; 100% achieved ≤ 6/12. • Binocular uncorrected intermediate vision (BUIVA): 98.0% achieved N6 or better, with 100% achieving N8 or better.
• Binocular uncorrected near vision (BUNVA): 88.2% achieved N8 or better with 98.0% achieving N10 or better.
• 100% of patients responded “Yes” to the questions: “Are you satisfied with the treatment result?”, “Would you recommend the treatment to a friend or relative?”, and “If given the choice, would you select the same treatment?”.
When rating their vision without glasses he reported that the average scores were: 9.3/10 for physical or leisure activities (such as walking, playing sports, cooking, or shopping); 9.2/10 for watching movies or sports, 8.4/10 for using a computer, and 7.4/10 for using a tablet or smartphone.
When discussing vision requirements with patients, Dr Athanasiov noted that rather than referring to near, intermediate, and distance vision, it is more useful to provide real life examples of what they might do with the different levels of vision that can be achieved with alternate lenses. This creates more realistic expectations.
the benefits of a premium IOL far outweigh additional costs, in terms of quality of vision and lowering the risk of falls etc.
The Launch of Elita SILK
At another breakfast seminar, Johnson and Johnson Vision took the opportunity to launch SILK, a new laser refractive procedure performed using Johnson and Johnson Vision’s Elita platform.
Dr Patrick Versace kicked off with a backgrounder, explaining the pros, cons, and differences between femtosecond, LASIK, and small incision lenticule extraction (SMILE) refractive surgery. He noted refractive outcomes were the same; that tear break-up time and the ocular surface disease index were better in SMILE; but uncorrected distance visual acuity was better with LASIK at one month and three months. He noted that SMILE could be further improved with features such as auto-centration, toric alignment, easier lenticule removal, the precision of energy delivery and an enhanced re-lenticule procedure – all of which were either on the wish list, being developed, or have landed.
Johnson and Johnson’s new offering – the Elita platform which facilitates smooth incision lenticular keratomileusis (SILK) technology – is one such promising evolution of laser refractive surgery technology. It was detailed by Professor Mahipal S. Sachdev from Delhi, India, who having worked with the platform since January 2020, has performed many SILK procedures. Prof Sachdev spoke about the safety profile of the Elita platform and provided an in-depth explanation of this next generation lenticule procedure. He described how the Elita platform delivers low energy treatment via ultrashort pulse duration, ultrafast pulse frequency, small focus spot size, and sub-micron precision. This results in the creation of fast and smooth cuts for easy lenticule access and removal, with minimal stromal tissue disruption. Research demonstrates excellent accuracy of Elita, and the platform achieves consistent flap thicknesses.
Target patients are 18-years or older, with stable refraction and in the range of <-6.00DS and up to -2.00DC. People with compliant, easy-going, positive personalities are the most suitable candidates. They need to discontinue contact lenses prior to the procedure, not be pregnant or nursing, have no other contraindications, and must be able to lie flat.
Dr Pooja Khamar from Narayana, India – the youngest person to achieve a PhD in ophthalmology – covered advancements in refractive surgery. She explored the versatility of Elita and other procedures and compared theoretical versus clinical results with pre- and post-op data. She noted that SILK shows less change in corneal asphericity and less induction of higher order aberrations compared to SMILE.
In a comparative study she was involved with, Status of residual refractive error, ocular aberrations and accommodation after myopic LASIK, SMILE, and TransPRK, she concluded that the refractive and aberrometric status of LASIK eyes was closest to normal eyes and that the SMILE procedure may benefit from slight overcorrection of the preoperative refractive cylinder. She also discussed depth of field results.
Some of the main take-home points were that with SILK, the lenticule was ‘free’, requiring very little dissection with minor or no tissue adhesions, cold spots or bridges, an excellent entry cut and fast visual recovery.
A panel session with audience participation resulted in delegates and the presenters discussing a variety of issues before the meeting closed and delegates headed off to the AUSCRS plenary sessions.
Reference
1. Australian Communications and Media Authority. Communications and media in Australia. The digital lives of older Australians, May 2021.
