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Saturday / November 2.
HomeminewsAUSCRS 2024: The I-Land, Creating Connections

AUSCRS 2024: The I-Land, Creating Connections

The Australasian Society of Cataract and Refractive Surgeons (AUSCRS) once again raised the bar with its annual conference. Alan Saks was among the delegates soaking up the winter sun on fabulous Hamilton Island.

Record attendance in all facets of the AUSCRS meeting, which took place in July, is evidence that the clinical focus and fun – the trademark of the annual AUSCRS conference – continues to attract.

Following the impressive welcome reception the night before, the plenary sessions kicked off with the second Barrett/Wolfe Gold Medal Lecture presented by AUSCRS fan Dr Florian Kretz (Germany). He’s published over 100 journal articles and runs not-for-profit ‘Augenärzte für die Welt’ (Ophthalmologists for the World), supporting the Khmer Sight Foundation in Cambodia.

In ‘Finding the pathway through the optic jungle of presbyopia correction’ he presented market statistics and systematically reviewed each presbyopic intraocular lens (IOL) modality, and why we should consider specific IOLs for individually optimised outcomes. Sinusoidal diffractive optics, extended depth of focus (EDOF), multifocal IOLs (MFIOLs), torics, blended vision, spectacles, and all options in between, were detailed. Spectacle freedom is the goal. He delivered optical explanations, simulations of glare, haloes, and dysphotopsia, emphasising demonstration of these issues, so patients don’t experience post-op surprises, and advising the audience to ‘under promise’.

Enlightening rapid-fire presentations from the sponsors followed. The ‘Rayner Bunch’ prevailed, with the ophthalmic company’s entertaining Brady Bunch-inspired singalong.

Carefully consider patient motivation regarding spectacle freedom. Aberrations are an additive issue that must be accounted for.

In Depth Sessions

In ‘Thank God You’re Here’ AUSCSR co-chairs Dr Jacqui Beltz and Professor Gerard Sutton (Australia), attempted ‘surgery’ in a surgical suite on stage, calling on doctors to rescue them from their ‘boo-boos’. It was a hit.

In ‘Help, my nucleus is dropping’ Associate Professor Ron Yeoh (Singapore) demonstrated the ‘pupil snap sign’; a hydro-rupture of the posterior capsule during phacoemulsification, where the pupil dilates with initial hydro-dissection, then suddenly constricts with a ‘snap’, the moment the fluid bolus bursts through the posterior capsule.

For ‘Uncovering the treasure: Strategies for nailing cataract surgical outcomes’ co-chairs Professor Graham Barrett and Dr Andrea Ang (Australia) introduced another AUSCRS convert, Dr Lena Beckers (Germany). She took a deep ‘see’ dive, suggesting implantable collamer lenses (ICLs) broaden the limits of laser vision correction (LVC). She said 98.5% of ICL patients obtained the same or better acuity. Dr Beckers noted excellent safety, when implanted properly. Consider an ICL for any Rx between +10D and -18D. Compared to LVC, ICLs have shorter recovery time, less dry eye, are reversible, with no influence on IOL calculations. As Dr Dean Corbet (Australia) showed, cataracts develop sooner than normal, around 14 years after ICL implantation.

Professor John Kanellopoulos (USA/Greece) suggested that what’s most important is a premium surgeon, not so-called premium IOLs. He stressed the importance of angle kappa, and trust.

Dr Ben La Hood (Australia) illustrated cases of younger patients with traumatic or steroid-induced cataracts. The positive spherical aberration in an enhanced monovision IOL provides increased range of vision.

Prof Barrett discussed the ‘Future of IOL calculations’ in his usual, measured, analytical style, and compared artificial intelligence (AI) driven IOL calculators to various conventional calculators. The Barrett Universal II v3.0 calculator compared very similarly to an AI calculator across a number of measures and targeted outcomes.

‘Tropical troubles: Navigating IOL exchange challenges in paradise’ was chaired by doctors Aanchal Gupta and Kenneth Ooi (Australia).

In ‘IOL exchanges: Surgical pearls, considerations, and management of intraoperative challenges’ Dr Elizabeth Yeu (USA) showed how surgeons can leave IOL haptics in the bag and explant the lens alone if the haptics are firmly stuck.

Professor Jod Mehta (Singapore) explained dysphotopsias, the most common complication of routine cataract surgery. He stressed patience before intervening. In the early post-op period, 67% of patients had positive dysphotopsias and 26% had negative dysphotopsias. Symptoms dwindled to around two to three per cent respectively at one year. By five years only 0.07% of patients have an indication for surgical intervention.

Dr Uday Bhatt (Australia) presented ‘Laser refractive correction to improve patient dissatisfaction with trifocal intraocular lenses’. In his study, 89.4% of patients were fully satisfied but 8.5% were highly dissatisfied. Distance vision issues generated twice as many complaints as  near vision. Some were resolved with glasses or yttrium aluminium garnett (YAG) laser capsulotomy for posterior capsule opacification (PCO). Around two thirds of the highly dissatisfied cases underwent a contact lens trial, proceeding to photorefractive keratectomy (PRK) / laser in situ keratomileusis (LASIK). Only 0.3% remained dissatisfied.

… this serious but entertaining session provided an overview of the pros and cons of immediately sequential bilateral cataract surgery

Let the Games Begin!

In the head-to-head ‘EDOF Showdown: Going for gold at the Olympics’, Dr Beltz and Prof Sutton invited doctors Lena Beckers, Luke Anderson, Josefina Botta, Dan Black, and Armand Borovik, to explain why the presbyopic IOL they use is best. Compelling arguments were presented. Avoid hydrophilic IOLs if the patient will need additional surgical procedures. Alignment, rotational stability, and optical considerations are important.

In ‘Laser Olympics: Going for gold in lamellar dilemmas’, Dr Patrick Versace and Associate Professor Michael Lawless (Australia) introduced speakers who highlighted various keratorefractive lenticule extraction (KLEx) techniques.

Dr Sheetal Brar (India) explained that the 2 MHz laser platform she now uses is 10 times faster than the original version. Faster lasers mean less error, movement, and misalignment. The procedure can be completed in eight to 10 seconds. Such speed helped an anxious patient see it through, Dr Brar recalled. An older system that took 40 seconds would likely have taken too long for cooperation. In ‘Spotlight on KLEx/LALEX: Energies, spots, and lenticule profiles’ Dr Pooja Khamar (India) demonstrated the importance of good lenticule dissection. Minimising tissue interface damage reduces the risk of suboptimal vision. Low energy is better for a good interface, as is speed, helping improve day one and long-term visual outcomes. Dr Aanchal Gupta (Australia) was impressed that Dr Brar could get good tissue separation with the low energy she detailed. Dr Versace took a deep dive into how femtosecond lasers create a refractive lenticule and how to scientifically optimise visual outcomes, elaborating on aforementioned issues.

Dr Kishore Pradhan (Australia) used machine learning/data analysis of many variables to determine the best predictors of visual acuity (VA) improvements. Three key components explained around 80% of the variance, namely system settings, gender, and age of patient at treatment. Lower pulse energy, larger spot, tighter track, higher spot to track distance ratio, lower dose, and less cross talk were linked to a higher chance of VA gain. Less swelling on day one leads to happier patients.

Younger patients do better due to softer corneas and better endothelial cell counts. High astigmatism and steeper corneas do worse, Dr Pradhan said.

The ‘Score big: Game-changing presbyopia correction strategies during cataract surgery’ session was chaired by Dr David Kent (New Zealand) and Dr Lana del Porto (Australia). Professor Michael Knorz (Germany) reported satisfactory results with ‘Implantation of trifocal IOLs after LASIK’. Carefully consider patient motivation regarding spectacle freedom. Aberrations are an additive issue that must be accounted for. Avoid MFIOLs if higher order aberrations are over 0.5 microns. Retreatment rates are higher for post-LASIK patients.

In ‘Comparing diffractive and refractive EDOF IOLs’ Dr Francesco Carones (Italy) noted that diffractive patients present with night vision issues from the diffraction gratings. Although most patients were happy, he reported variation between the four designs evaluated.

Professor Paul Ursell (United Kingdom) provided an informative talk on ‘Dementia and cataract surgery, a growing problem for us all’. Perform IOL surgery in dementia patients early, when you see them. If not, they don’t come back, suffering worse quality of life and outcomes. Improved vision reduces dementia and improves mobility, Prof Ursell explained. Monofocals are best. Dementia patients lose the ability to cope with MFIOL vision as higher cortical function declines.

Dr Brian Harrisberg (Australia) detailed five diffractive MFIOLs that ranged from seven to 29 diffractive steps. He noted exclusion criteria including corneal disease, scarring, irregular astigmatism, abnormal pupils, strabismus, and retinal/macular disease. Use a lens with the least dysphotopsia.

In ‘Survivor: Outwit, outplay, outlast cataract surgery challenges’, Dr Beltz and Prof Sutton ran a session themed on the Survivor TV show. The tribal council was brutal. Despite valiant attempts and convincing presentations from Drs Florian Kretz, Audrey Rostov, Josefina Bott, Abi Tenen, and Prof Paul Ursell, there was only one survivor! Dr Andrea Ang included a useful tip for finding toric IOL axis markings in small pupils, using lateral saccades, flicking from left to right pupil margins, and just seeing axis markings. Aligning the axis marks with a narrow optic section determines axis. Prof Sutton was impressed – this was a new tip he’d take on board. She cunningly used her get out of jail card at the end, taking the win.

In ‘Finding your true north: Shifting from surviving to thriving in ophthalmology’, Dr Beltz and Dr Jo Mitchell, a psychologist from The Mind Room in Melbourne, prompted very personal accounts from surgeons including Drs Stephanie Tiew, Helen Riad, Tanya Trinh, Ben Au, Associate Prof Lawless, and Professor Barrett. They shared moving experiences of shifting from surviving to thriving, including setbacks and failures.

Experiences included losing out on a plan to launch an IOL, death by suicide of a patient some years after LASIK, bullying/abuse by toxic bosses and potential mentors, burnout due to 100-hour weeks, lack of support when training and being blocked from registration after migrating to Australia. The surgeons prevailed, but not without major issues, some lasting years, with difficult decisions having to be made.

Cruising to the Finish

The final day delved into ‘Technological icebergs: Navigating updates in surgery’. Doctors Ben La Hood and Dan Black (Australia) chaired the session.

Dr Luke Anderson (United Kingdom) delved into minimally invasive glaucoma surgery (MIGS) in ‘When corneal surgeons operate in the angle’.

MIGS, as a microincision ab interno trabeculectomy procedure, is minimally traumatic with at least modest efficacy, favourable safety profile, and rapid recovery. A competent cataract surgeon is able to manage complications, which might include postop increased lOP > 10 mmHg (48% of cases). Lower risk issues (1–4% range) include cystoid macular oedema, hyphema, iritis, iris atrophy, and corneal oedema. Dr Anderson suggested practising viewing the angle and provided numerous tips. Collaborate with a local glaucoma surgeon in case the need for further surgical procedures, stent occlusion or replacement arises.

In ‘Early experience with normal IOP cataract surgery’, Associate Professor Smita Agarwal (Australia), explained a developing trend to performing reduced IOP cataract surgery – from 60 mmHg down to 20 mmHg – via an active monitoring system. Insights from early experience include greater stability, less surge, potentially reduced endothelial damage/corneal oedema with less ultrasonic phaco power needed, improved VA, and less potential retinal/ optic nerve head damage in compromised eyes.

In the ‘Shark Tank: Diving deep into corneal challenges’, chairs doctors Abi Tenen and Tanya Trinh (Australia) introduced Dr Josefina Botta’s talk on ‘Refractive treatment for keratoconus’. There are many choices, including corneal cross linking (CXL) to obtain stability to allow other refractive procedures. She mentioned intracorneal ring segments (ICRS) that these days would likely best be replaced with corneal allogenic intrastromal ring segments (CAIRS), detailed by Dr David Gunn (Australia), who elaborated in his presentation, ‘Six-month results of femto-CAIRS for keratoconus and post-LASIK ectasia’. Dr Botta presented cases using ICRS plus CXL plus a phakic IOL, as well as pinhole IOLs, noting that calculations (with various formulae) and repeat measurements are critical.

Dr Gunn further detailed 10-year outcomes of progressive keratoconus management with the Athens protocol (topography-guided partial-refraction PRK combined with CXL), which stabilises keratoconus (KC) and improves visual outcomes. The Athens protocol was developed by Professor Kanellopoulos at his clinic in Greece. The technique consists of transepithelial, topography guided PRK and immediately sequential CXL, with a stromal ablation depth < 50 microns. Restricting optical zones to 5.0 or 5.5 mm significantly reduces tissue consumption.

Dr Audrey Rostov (USA) explained her use of small aperture IOLs in complex corneas like radial keratotomy, keratoconus, LASIK problems, and off axis corneal scarring. Good results are possible. Tomography, macular OCT, and other diagnostics are essential. Carefully manage patient expectations. Pre-existing pathology ultimately limits visual acuity. The goal is to improve, not perfect.

… the chance to learn about new ray tracing technologies that may shape the way we approach refractive surgery was rewarding

Grand Finale

The Grand Finale sessions featured a debate, ‘Life of Pi: Navigating the bilateral simultaneous cataract controversy’. Chaired by Prof Knorz and Dr Rostov, this serious but entertaining session provided an overview of the pros and cons of immediately sequential bilateral cataract surgery (ISBCS). Despite good arguments in support of ISBCS from Dr Borovik and Dr Anton van Heerden (Australia), it seems that overall, Australasian cataract surgeons currently remain more conservative and risk averse (in the interest of patient safety). This is despite the very low risk of serious complications, like postoperative endophthalmitis of around 0.01%, and bilateral simultaneous postoperative endophthalmitis (BSPOE) in the region of 0.007% to 0.059%. Debate winners, Dr Georgia Cleary (Australia) and Professor Barrett were opposed to the widespread implementation of ISBCS, for now.

In the traditional closing of the educational component of the conference, the AUSCRS Film Festival ‘Walking the red carpet’ was co-chaired by legendary AUSCRS founders Professor Barrett and Dr Rick Wolfe (Australia). It was closely contested with loud applause from the audience for a variety of video presentations.

The winner was Dr Sean Every (New Zealand), with his noteworthy, hilarious pirate themed and Kiwi-accented pirate narration ‘Passing like ships in the night’. He demonstrated remarkable skill in simultaneously explanting a complex opaque IOL – in a case of aniridia – and then implanting a new one. It required complex suturing techniques for explantation, implantation, and securing the new artificial-iris IOL, in place. The narration had the audience in stitches. The Australian hosts were devastated that the trophy again went to a Kiwi, even more so that it was taken by a vitreoretinal surgeon, among a group of proud cataract and refractive surgeons. Like all things at AUSCRS, it was in the spirit of the event, with no hard feelings and congratulations all round.

Saturday night saw the usual event-ending gala dinner, with a record 285 people in super costumes. Dr Alison Chiu again took out the overall best costume award. The dance floor was full, from start to finish, with delegates jiving to the great sounds of SUPERBAND. Groups queued all night long to have their turn on the mivision spincam.

Dr Trinh summed things up. “I have always loved AUSCRS. In all my travels to conferences around the world, there is simply no place like home, and no organisation that does it like we do.

“Learning highlights included the energy and passion that Amanda and Francesco Carones provided, from both a clinical expertise and practice support and branding perspective. The ability to see one of my junior staff members take flight in their first public presentation, and the chance to learn about new ray tracing technologies that may shape the way we approach refractive surgery was rewarding. Personal highlights included the chance to reconnect with dear friends from around the world and to celebrate our staff and their learning. A small reprieve from the day-to-day craziness that is our lives.

“Huge thanks to Jenny Boden and her team, conference co-chairs Jaqueline Beltz and Gerard Sutton, and the AUSCRS executive for their tireless efforts at making the ordinary, extraordinary,” Dr Trinh said.

Kudos and grateful thanks to all the sponsors who seemed happy with the turnout and interaction. They put on a great exhibition with a record 44 booths, and a variety of excellent breakfast and dinner events.

AUSCRS 2025 will be held on 16–19 July in Darwin.

Alan Saks is a retired optometrist. He is the Chief Executive Officer of the Cornea and Contact Lens Society of Australia, and a regular contributor to mivision.

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