All astigmatism patients require Contoura Vision

Come-and-See Ophthalmologist s Conference

Transcript

1 Come-and-See Ophthalmologist s Conference June 2018 in Bad Horn, Switzerland Petrus meant well with the anniversary event of the Come and See Meeting, which took place for the 10th time this year and in bright sunshine. But the interesting topics and opportunities for discussion ensured that the lecture room was full, despite the beautiful weather. Again it is the program committee with Prof. Dr. Arnd Gandorfer, Prof. Dr. Rupert Menapace and Prof. Dr. Bojan Pajic under the direction of Prof. Dr. Manfred Tetz succeeded in creating a diverse scientific program that motivated the participants to engage in lively discussions. The sponsors of the event, HOYA, Mediconsult and Oertli are pleased about the increasing interest in the event they are supporting and plan to continue it in the next few years. TrudiDesign - Fotolia.com

2 Come-and-See Ophthalmologist s Conference June 2018 in Bad Horn, Switzerland IVOM How well does it work under routine conditions? Prof. Dr. Arnd Gandorfer (Lindau) As always, the event started with the posterior segment of the eye and Prof. Dr. Arnd Gandorfer (Lindau) summarized the real-life data of the anti-VEGF treatment of retinal pathologies. To do this, he compared the data sets of the large-scale studies commissioned by the industry and, in keeping with the meeting at Lake Constance, started the Ocean Study. In this prospective and currently largest health care study, the efficacy of ranibizumab in everyday treatment was evaluated over a period of 24 months. 369 study centers from Germany took part in the study, and a total of 5641 patients were followed up. Of these, 64% had neovascularizing age-related macular degeneration (namd), 22% had diabetic macular edema (DME), 13% had retinal vein occlusions (RVO) and 1% had myopic choroidal neovascularization (mcnv). After the administration of three IVOMs (upload), the dependence of the time interval from the initial examination to the first IVOM and other effect sizes were examined as effectiveness parameters. The results of the study confirmed the gut feeling of many retinologists, according to Prof. Gandorfer, according to which a delayed start of treatment after the diagnosis has an unfavorable effect on the course of the disease. On average, treatment of patients in Germany begins with a 15-day delay after diagnosis, and for conservative ophthalmologists even with a 27-day delay. More than half of all patients have started therapy more than 14 days after diagnosis. This delay is also influenced by whether the IVOM is carried out in one's own practice or referred to a colleague. The diagnosis also seems to have an influence on the start of therapy; for example, the median therapy for DMO is only initiated 21 days after the diagnosis. If the visual acuity is plotted as the difference to the basic visual acuity, the later the treatment started after the diagnosis, the worse the visual acuity progression. The specialization of the specialist, the need for a referral for angiography and the type of underlying diagnosis can be recorded as influencing factors on the treatment. These factors suggest a capacity bottleneck in the care of these patients. The aim must be to enable all patients with the corresponding symptoms to have a prompt examination and, if necessary, a treatment appointment within 14 days. The patient should be fully informed to avoid delays on his part as well. Conclusion: Logistical problems seem to be the main cause for a delayed start of therapy in IVOM patients. This can be counteracted by having the specialist perform the IVOM and fluorescence angiography himself. It is also interesting to compare the different countries with the treatment regimens for patients with namd. The retrospective, non-interventional AURA study examined this aspect in eight countries with ten to 40 study centers and 444 patients per country. In Germany, a high dropout rate of 38% was observed within two years. The reasons for this lay in the stabilization of the disease (30.4%), treatment discontinuation due to fibrosis, atrophy or scarring (14.6%) or unsuccessful treatment (11.4%). The AURA study showed that patients in Germany had eight doctor visits in the first year and only three in the second year, which gives a significantly different picture than the approval studies with a four-week visit rhythm. The visual acuity of patients with fewer than seven injections over two years deteriorated significantly. With more than seven injections, the visual acuity improved by an average of 2.3 letters. The upload with the three initial doses is important for an initial gain in visual acuity, but then a gradual decrease in visual acuity is recorded again. In an international comparison, the same curve shape was found in all countries, but very different visual acuity levels. England performed best, followed by the Netherlands, all other countries were below the average. In England a profit of six lines was observed, in Germany only 1.1 lines. The total number of visits within two years in England was twice as high as in Germany, and OCTs were performed five times as often in England. In England it was injected nine times in the period, in Germany only 5.6 times. As can be seen in Figure 1, the difference in the change in visual acuity due to these differences is considerable. In the discussion, Prof. Gandorfer was asked to reduce the results to a simplified treatment scheme. If wet AMD is diagnosed, the patient should be informed immediately about this and about the importance of observing the examination frequency. The upload should be done with three injections. Then it makes sense to check whether the patient is reacting to the therapy at all and to continue the examinations every four weeks. If the AMD is still wet, therapy must be continued. 2

3 Fig. 1: Country comparison for IVOM treatment of namd (modified from Holz FG et al. Br J Ophthalmol 2015; 99 (2):). Conclusion: The patient must understand how important it is to keep the examination appointments. After uploading three IVOM injections, it should be checked whether the treatment is working and should be followed up every four weeks. Biostimulation of the macula with the nanolaser transport mechanisms between the choroid and retina. Dr. Hakan Kaymak (Düsseldorf) presented his experiences with the Nanolaser 2RT from Ellex. This laser uses 3 ns pulses with a spot size of 400 µm. The laser beam is inhomogeneous, i.e. not evenly distributed over the entire area. Effective peaks are applied to around 15% of the total area and thus less energy is introduced into the eye. The new laser technologies aim to preserve the tissue and improve the retinal structure and function. The restorative treatment with the nanolaser prevents the typical laser effects, but makes the drusen disappear. The smaller the pulses, the lower the expansion of the heat. One only wants to tickle the pigment epithelium with the nanolaser. The pigment cells diffuse into the surrounding areas, which increases the metabolism. The decisive factor here is improving the oxygen supply to the retina. Dr. Kaymak reported clinical results in the treatment of central serous chorioretinopathia (CCS) with the nanolaser. This disease is a neurosensory retinal detachment with or without RPE detachment with an incidence of 1: 50% of patients heal spontaneously, 50% develop relapses and 10% multiple relapses. CCS is divided into acute and chronic forms. The study looked at patients with chronic CCS, with and without good pigment epithelium. A CNV was ruled out. Every four weeks, the laser was used if the macula was not yet dry. With good pigment epithelium (PE), the macula was dry in 90% of the patients after 180 days, with poor PE only in 30%. The absorption of the subretinal fluid and the microperimetry were significantly better with good PE, the visual course was somewhat better (Fig. 2). In the case of pronounced RPE atrophy, nanolasertherapy can be started, but at the same time a cost estimate should be submitted to the health insurance company for a half-dose PDT. Dr. Hakan Kaymak (Düsseldorf) With the nanolaser a regeneration of the retinal pigment epithelial layer (RPE) and its function is possible without inducing damage to the overlying neurosensory retina. Photoreceptors and choroid are spared. When the laser pulse is emitted, micro-bubbles form around the melanosomes within the RPE cells, which damage the affected cells from within. Due to the controlled spot size, the energy output is limited to a few cells within the pulse diameter, the neighboring cells remain undamaged. The laser pulses activate intra- and extracellular signaling pathways and thus induce migration and division of RPE cells. The simultaneous increase in the permeability of Bruch's membrane improves Fig. 2: Resorption of the subretinal fluid after treatment with the nanolaser (n = 15 per group; blue: good PE; red: bad PE). 3

4 Good results with the nanolaser can also be achieved with DMO, ideally in combination with anti-VEGF and cortisone and subsequent laser treatment. Conclusion: The double grid laser treatment with the 2RT nanolaser is an effective treatment for chronic CCS with moderate RPE atrophies. Multiple treatments are possible and necessary in the majority of chronic cases. After six months, no visual loss or defects in microperimetry can be observed. The recurrence rate cannot yet be definitively estimated. Cutting quality one of the most important requirements for vitrectomy cutters Prof. Dr. Armin Wolf (Munich) Fig. 4: Push-pull drive of the Oertli cutter. Push-pull drive Precise work with cutters in vitrectomy is, according to Prof. Dr. Armin Wolf (Munich) only possible if the following requirements are met: sufficient cutting force, good cutting quality, efficient aspiration, constant flow and continuous holding force for optimal control without pulling and tearing. These prerequisites are necessary for different work steps, such as the ablation of the central vitreous body and the vitreous body base, the dissection of diabetic membranes and the backward shaving. The retinal surgeon also has to cope with various challenges. This includes avoiding iatrogenic retinal holes, lifting the vitreous body boundary membrane, controlled and efficient vitreous body ablation with detached retina and with small gauge sizes and iridotomy with the cutter. The cutting effectiveness is defined by the design of the opening, the blade grind, the cutting force and the play against each other. If the cutter does not cut as intended, iatrogenic retinal holes may occur or the vitreous humor may not lift off completely. Unintentional retinectomies and damage to the iris are also the result of an inadequately working cutter. In general, movement of the vitreous should be avoided. It must be possible to control the vacuum from zero to high values ​​in order to lift off the glass body. Over the past two years, Oertli has worked closely together to pursue two approaches: improving the cutting force and improving the cutting quality. Basically, cutters are built according to the guillotine principle, i.e. the inner cutting tube moves back and forth in the outer tube. Since the outer tube is bent, the tubes touch at the opening and the necessary pre-tension is created. The sharp edges in the area of ​​the opening allow the cut. Cutters work with different drives: The Oertli Continuous Flow Cutters (Fig. 3) use the push-pull principle (Fig. 4), in which the cutting tube is driven in both directions by a two-chamber system via blasts of air. In contrast to the system with only one pressure chamber and one spring, the push-pull drive allows linear control of the movement over the entire cutting rate range. In the case of cutters with a spring, the pressure can only be released slowly, the reset period is longer. With the Oertli two-chamber system, therefore, high cutting rates are possible with a great deal of frictional engagement. Thanks to the special design Fig. 3: New Oertli 27G Continuous Flow Cutter. of the double-sided cutting inner tube, the cutter opening is never closed during the work process, which ensures a continuous flow and calm conditions. Sharp blades are an important prerequisite for efficient work with the cutter. The blades can become dull if they should strike the inside of a defective dome during the cutting process. A manufacturing process newly developed by Oertli is used both to reshape high-quality tips and to manufacture particularly sharp blades. If the cutting openings and edges are not precise and sharp-edged, it is not possible to cut precisely and jamming can occur. Furthermore, an optimized bending angle of the outer tube contributes to the cutting quality. Due to the bending angle, the pipes touch each other, creating a preload similar to a pair of scissors. Additional measures have been taken for the 27-G cutter: The longer cannulas are made of a more rigid material and have an optimized diameter for more flow. Conclusion: There have been significant changes in technology from 20 to 23 G or 27 G in recent years. The new developments in pumps, the cutter control module and the cutters themselves lead to excellent cutting quality. The Oertli technology allows precise cutting in all situations, complete vitreous removal and high efficiency in vitreous removal in all gauge sizes. 4th

5 Same diagnosis, different treatment: two exciting cases Prof. Dr. Michael Georgopoulos (Vienna) An interesting case from the posterior segment was presented by Prof. Dr. Michael Georgopoulos (Vienna). A 27-year-old patient reported deterioration in her left eye for ten days. The slit lamp examinations showed no findings in either eye, the visual acuity in the left eye was 0.05. The fundoscopy revealed a retinoschisis in the right eye with several defects but an adjacent macula, while a schisis ablation with six defects and macular detachment was seen in the left eye. The preoperative OCT showed that there was also an ablation in the right eye with detachment of all retinal layers, which was observed with regular OCT examinations. First, the left eye was operated on: During the operation, the posterior vitreous boundary membrane was lifted off, and attention must always be paid to the development of smaller defects in the periphery. Retinal defects can be marked with endodiathermy so that the places can be easily found after the fluid-air exchange. After two months the results of the left eye were satisfactory, the right eye appeared unchanged, but the OCT showed an increase in the ablation. Therefore, the right eye was also operated on. Prof. Georgopoulos recommends triamcinolone staining to induce posterior vitreous detachment, which makes the procedure much more controlled. The operation went smoothly and the one-year check-up showed a tight retina in both eyes (Fig. 5) and good visual acuity (1.0 / 0.8). Prof. Dr. Matthias Bolz (Linz) also reported on a young 21-year-old patient in whom a schisis ablation was discovered by chance on both sides. The patient herself had not noticed anything. The team of doctors at the clinic and with the patient discussed whether a surgical procedure makes sense here. The likelihood that the patient will see worse after the operation was not small, she would probably not be able to see better. Therefore, it was observed closely at first. Over the course of the follow-up examinations after one week, two weeks and the first few months, the fluid decreased and had almost disappeared centrally. However, bleeding was found in the right eye at a follow-up visit. After a cerclage, the retina was well laid out and the subretinal fluid had disappeared. In the meantime, the findings of the left eye were Fig. 5: OCT images pre- and post-op: A and C: OD pre- and post-op; B and D: OS pre- and post-op. advanced and a cerclage was also performed. Developments in intraocular lenses (IOL) where are we headed? Dr. Isaak Fischinger (Berlin) The developments and trends in the IOL market were highlighted by Dr. Isaak Fischinger (Berlin). If one looks at the number of cararact operations worldwide, a correlation between the number of operations and the gross domestic product can be determined, whereby it should be noted that the figures come from 1994 and 2004, respectively. Only India does not matter, with a comparatively high number of cataract operations, which is probably due to the very low costs for the IOL, which are mostly produced in their own country. In Germany, Austria and Switzerland the cataract operation rate is largely comparable, with the proportion of ophthalmologists operating in Germany being higher than in the other two countries. With an average price of $ 29 per IOL, India is on the lower end of the price spectrum, while the IOL in Japan is at the top at $ 266. The median price worldwide is USD 109. In the global IOL market, premium IOLs still only make up just under 8%.A share of a good 12% is expected by 2022. Toric IOLs currently make up about half of all premium IOLs. Premium IOLs cost around 4.5 times as much as monofocal IOLs. In the USA, the very high proportion of accommodating IOLs compared to Western Europe is striking. The numbers for these lenses were reported 8.5 times higher for the U.S. in 2017. For the year 2022, it is forecast that the number of accommodating IOLs will have exceeded that of multifocal IOLs. In terms of materials, it can be observed that PMMA (polymethyl methacrylate) is almost only used in developing countries 5

6 will. Hydrophilic IOLs allow small incision surgery, but are associated with lens opacities and poor contrast vision. Hydrophobic IOLs are said to have good biocompatibility and a lower rate of re-gelling, but require larger incisions. The five largest IOL manufacturers have hydrophobic IOLs in their range. Globally, hydrophobic acrylates are used in over 50% of all cases, in Western Europe the proportion is two thirds. Microincision IOLs, defined as implantable by an incision size of 1.8 mm or less, have a market share of 22% and an increase is not currently expected. Whether blue filter lenses are useful is still controversial, but their share is 37%, in Japan even 90%. Almost 60% of the IOLs have a C-loop feel, 11% a plate feel. With modified C-loop haptics, forces occurring during capsular bag contractions are to be absorbed. New developments include XL lenses with particularly large optics, which should enable a large rhexis when there is a risk of capsular phimosis, provide a good peripheral fundus view and fewer dysphotopsias. Another new concept is the attachment of the IOL to the rhexis, as with the Femtis IOL from Oculentis. The rhexis is precisely created with a femto laser. This is to ensure optimal centering and rotational stability and better predictive accuracy of the IOL position. Refractive Index Shaping is a new approach to changing the refractive index of an acrylate lens with the femtosecond laser. With the change in the hydrophilicity of the material in the upper 50 µm layer, changes of up to 4 D should be achieved with a precision of ± 0.1 D. Conclusion: At the moment, the proportion of premium IOLs is quite low at just under 8%, of which toric IOLs make up about half. New developments could pave the way for further options for patients with high quality glasses-free vision. Intraocular lenses on the clinical test bench Dr. Christoph Kniestedt (Zurich) Dr. Christoph Kniestedt (Zurich). Although the PMMA IOL has lost its importance due to the large incision required, the heparin-coated version has proven itself in uveitis and is still used as a sulcus lens, anterior chamber lens or phakic IOL (iris claw lens). Foldable hydrophobic IOLs show high uveal and capsular bag biocompatibility, but tend to produce positive and negative dysphotopsias. In contrast, foldable hydrophilic IOLs are often associated with a higher PCO rate and adhesion of bacteria, epithelial and endothelial cells. Foldable silicone IOLs have a low rate of re-gelling, but require larger incisions due to the three-piece design. In clinical use, Dr. Kniestedt gained experience with several IOL models. With the hydrophobic IOL, he finds the Zeiss CT Lucia IOL and the KOWA Avansee IOL comfortable to implant, but the operation of the respective injector is quite tedious. With the Nidek SZ1, the haptics exit almost at right angles, which makes it difficult to rotate into the capsular bag. With the HOYA Vivinex (Fig. 6), Dr. Kniestedt gained experience in over 1000 implantations. He uses the blue filter model almost exclusively. The rotary injector is easy to use, the IOL can be implanted through a 2 mm incision. The lens unfolds quickly, but still in a controlled manner in the eye, the haptic anchors the IOL stably in the capsular bag. Due to the textured, rough haptics, they do not stick to the lens optics when folded. What he values ​​about the Vivinex IOL is the low tendency to glistenings and whitening and also found less capsular contracture, which is probably due to the special surface treatment. The lenses are treated with ozone by the manufacturer. As a result, adhesion molecules are produced, which are supposed to bring about an improved contact between the IOL and the lens capsule. The refractive predictability has so far been better than with other IOL models due to the stable axial position. The injector for the HOYA Vivinex IOL has a slot in the tip of the cartridge that reduces the resistance when the IOL is pushed through, so that the lens begins to unfold during the injection. However, this procedure is not suitable for docking with the incision. Alcon recently launched an interesting new injector concept for its Clareon IOL. With the automatic AutonoMe injector, the IOL is propelled using a CO 2 cartridge. On clinical experiences with the toric HOYA Vivinex IOL, which was only available with a blue light filter at the time of the event, Dr. Christina Leydolt (Vienna). As part of a study, the rotation of the IOL from the operating table was measured after four to six months. Dr. Christina Leydolt (Vienna) Using a case study, Dr. Leydolt describes the procedure at the Vienna General Hospital for the implantation of a toric IOL. First, a keratometry was carried out with the IOLMaster 700 and the result of the corneal astigmatism was validated with a topography or an OCT examination. The Casia-2 OCT also provides the astigmatism of the horn Fig. 6: HOYA Vivinex IOL. 6th

7 Rotation (degrees) Fig. 7: Rotation of the toric HOYA Vivinex IOL from the operating table up to four to six months. skin back surface for total keratometry (TC) and higher order aberrations. The lens refractive power was calculated using the HOYA calculator with and without Abulafia-Koch regression for TK. The sclera image from the IOLMaster 700 was imported into the operating microscope, which simplifies the alignment of the lens. The study with 103 patients resulted in a postoperative rotation with a median [range] of 1.1 [0; 5.0]. The postoperative rotation was 5 in all patients (Fig. 7). Conclusion: IOLs made of hydrophobic acrylate offer many advantages, such as a low post-solidification rate and a stable fit in the capsular bag. The HOYA Vivinex IOL has hardly any glistenings and offers good refractive predictability. The sophisticated injector facilitates implantation. Prof. Dr. Achim Langenbucher (Homburg / Saar) designed web-based platform IOLCon provides important information about intraocular lenses with just a few clicks and is manufacturer-independent and non-commercial. It is available to all IOL and biometer manufacturers and all ophthalmic surgeons. On the one hand, the database serves as an interactive reference work for technical data and delivery areas, but it also provides downloads for importing the IOL constants into the biometer and offers individual optimization of formula constants. Pooling lenses of the same design is also helpful for the surgeon, which saves a lot of time when searching for IOLs. The specifications and delivery areas are stored for all IOLs contained in the database. Constants optimized with IOLCon have a global optimization of all cases and biometers, as was already known from the ULIB database. In addition, the individually optimized data can also be differentiated according to the ethnicity of the patient, refraction status, shape factor, biometer / keratometer, operating theater center and surgeon. So far, SRK / T, HofferQ, Holladay1 and Haigis have been stored for IOL formulas. With the Haigis formula, with a number of up to 100 data records, only a0 is optimized. If there are more data records, then a1 and a2 are also optimized; 500 data records would be ideal for optimizing the variable triplet. IOL constants contain a variety of variables. A general optimization is sufficient for the parameters lens optics, haptics, angulation of the haptics, material, refractive index and center thickness. However, individual optimization includes other important factors such as the surgeon's handwriting, the surgical technique, environment and equipment, the characteristics of the biometer, keratometer, topograph and tomograph and the refraction technique for postoperative measurements. The user-friendly IOLCon platform enables you to search for different criteria such as manufacturer, type, material, appearance, size, haptic type and delivery area (Fig. 8). If you have made a preselection using the criteria, you can manually select the desired lens. Templates can be downloaded for individual optimization. Depending on the data record quality, one can assume for a 1-constant optimization that from around 100 data records a reasonable predictability of the constant is available. IOLCon can be used free of charge by doctors. Registration is required if you want to carry out an individual IOL optimization. At the end of June 2018, 254 IOL models from 19 manufacturers were stored and around 7000 surgical results were uploaded. Optimization has already been carried out for 50 IOL models. IOLCon user-friendly tool for IOL selection and biometry Prof. Dr. Achim Langenbucher (Homburg / Saar) Fig. 8: IOLCon search mask with criteria for the IOL search. 7th

8 Conclusion: The new web-based platform IOLCon offers an archive overview of currently available IOLs with all relevant technical, geometric and material-specific characteristics as well as an illustration of the IOL. With a selection and search function, IOL models can be selected according to different criteria. The download of the technical data and IOL constants and the upload of the data for constant optimization work via an open interface. IOLCon offers calculation tools for global and individual constant optimization. Emmetropia for every patient is that possible? especially after the implantation of multifocal IOLs. Is it possible to fine-tune the astigmatism intraoperatively and how close can you get to the 0.00 D postoperative residual astigmatism? Studies show that the cylinder has more influence on the image quality, for example on the point spread function, than the spherical aberration (Fig. 9). The total induced astigmatism (TIA), which is composed of the posterior corneal astigmatism, the decentering and tilting of the lens and the induced sectional astigmatism, is very important for a desired residual cylinder of 0.0 Dpt. Many toric calculators take into account surgically induced astigmatism (SIA, surgically induced astigmatism), but this is usually not constant even with the same surgeon (Fig. 10). The aim here should be to make incisions that have no effect, i.e. also do not have a torus-reducing effect. All other factors that contribute to the TIA can only be compensated for by implanting a toric IOL to eliminate any torus and measuring the remaining cylinder at the end of the operation. The TIA for a 2.5 mm incision at 90 also depends, for example, on the preoperative orientation of the cylinder: TIA with preoperative WTR astigmatism = 0.76 ± 0.43 D TIA with preoperative ATR astigmatism = 0.64 ± 0 , 26 D TIA for preoperative oblique astigmatism = 0.56 ± 0.36 D Oblique astigmatism is the least common and therefore has the lowest number. Manfred Tetz (Berlin) Prof. Dr. Manfred Tetz (Berlin) himself some time ago and now the audience. His answer, based on his clinical results, is: With the right combination of a smart calculator, carefully selected incision, toric IOL and intraoperative wavefront, it is possible. There is currently no discernible movement in the toric IOL market. Only 3% of the implanted IOLs are toric, although 70% of the patients have an astigmatism greater than 0.5 D. However, toric lenses usually only correct astigmatism from 1.5 D, which corresponds to 19% of the preoperative cataract population. The costs often reach EUR 1000 per eye, which means that the toric IOL is in a niche market. Refractive cataract surgery should be aimed at for everyone, i.e. at reduced costs. Correcting astigmatisms below 2.0 D would help 90% of all cataract patients. The question arises whether a residual astigmatism must or should be accepted, SE = -0.1 D Cyl -0.42 A117 SE = -0.1 D Cyl -1.1 A42 Fig. 9: Representation of a point spread Function with the same SE and different Cyl. Fig. 10: Induced astigmatism through the same 2.5 mm incision 90 post limbal. 8th

9 Fig. 11: Intraoperative control of the cylinder thickness with I.O.W.A. desired result in 75% of cases without turning. With these results, the previous gold standard of only treating patients with an astigmatism of 1.5 D with a toric IOL should be reconsidered. Patients with a smaller cylinder should also receive a toric IOL. An RA below 0.5 D must be accepted, but not above. Intraoperative fine-tuning of the astigmatism was required in Prof. Tetz in 25% of the cases. With this method, an RA of less than 0.5 D can be achieved in over 90% of patients. Then the aspherical corneal-correcting IOL also makes sense, because then this aberration can also be corrected. It is important to use topical or intracameral anesthesia and to be able to restrain the patient. Fig. 12: Measurement and control procedure for intraoperative wavefront measurement with I.O.W.A. Conclusion: With an intelligent management of the surgically induced astigmatism and a toric IOL of approximately 1.25 D correction, very good postoperative results can be achieved in practically all astigmatism patients, even those with small cylinders. With intraoperative aberrometry in real time, the remaining cylinder can be brought to below 0.5 D in more than 90% of patients, compared with the best subjective refraction after about eight to twelve weeks. Influence, so the incision should be chosen at an angle. With current methods of toric lens implantation, a postoperative astigmatism of 0.5 D is achieved in% of patients. A mean residual astigmatism (RA) of 0.43 ± 0.33 D does not make patients happy. The aim would be an RA below 0.5 D in 100% of the patients and an RA of <0.75 D in 100% of the patients would be acceptable. With his methodology and intraoperative wavefront measurement, Prof. Tetz currently brings 91% of patients into a postoperative range of <0.5 D RA. The IOLMaster 700 has addressed the problem of the TIA and stored new formulas for calculation, which should lead to an RA <0.5 dpt in 70% of the cases. The I.O.W.A. device for intraoperative wavefront measurement imports the biometric data from the IOL master and recommends the IOL strength, the incision axis and the IOL axis with just a few clicks. The device takes the personalized IOL constants into account and thus reduces the preparation time. The I.O.W.A. device is used: 1. To check the incision and toric lens position calculated with the Smart Calculator. 2. For intraoperative readjustment if necessary (approx% required) (Fig. 11). In the microscope view the I.O.W.A. the target refraction, the spherical equivalent, the steep meridian, the axis and the cylinder. The IOL is now rotated in the direction of the steep axis until the astigmatism decreases. Prof. Tetz is currently reaching the An appointment for the cataract operation, both eyes operated with the Femto laser, does that make sense? Prof. Dr. Rupert Menapace (Vienna) According to Prof. Dr. Rupert Menapace (Vienna) makes sense especially in older patients. Postoperative rehabilitation is usually quicker and less stress is placed on the patient 9

10 and beyond, this procedure leads to cost savings. The lower costs result from the shorter period of use of the operating theater and socio-economic factors such as lost work by the patient and their companions, transport costs and other costs that arise from caring for the patient. According to published calculations, the socio-economic cost saving per patient is at least 740 EUR. For the 2,700 patients operated on by himself in this way, this results in a cost saving for society of around 2 million euros. The operation of both eyes in one session saved so much time that the day-clinic operation could be used for other purposes for 1.5 months. With this time and cost saving, one could at least partially compensate for the additional cost and time expenditure for modern technologies, such as a femtosecond laser. However, this only makes sense if the operation with the Femto laser offers greater precision and at least the same level of safety as conventional technology, and also offers additional benefits. In terms of precision, the capsulotomy can be dimensioned and centered more precisely with the Femto laser. With appropriate centering by automatic apexcentre, a more even overlap with the IOL optics is achieved. As far as the safety of the laser capsulotomy is concerned, the mechanical strength of the capsulotomy edge has recently improved significantly. Astigmatism management through arcuate incisions and post-cataract prophylaxis through a posterior capsulotomy are further potential additional benefits of femtolaser-assisted cataract surgery. The first results are positive, but technical refinements and clinical studies will have to be awaited. However, it is important for the ISBCS that the Femtolaser is mobile, which is why Prof.Menapace decided in favor of Ziemer's Z8 device. At 250 kg, the Z8 laser weighs significantly less than other femto lasers, is rollable and can be used quickly. With this mobility and the swing-out cardanic laser arm, the laser comes to the eye and not the other way around. The laser optics are integrated in the handpiece and can therefore be equipped with a high aperture. Short focal length and high aperture allow a narrowly defined effect with high energy density. With the low-energy technology, the Z8 sets small effects at small intervals, which results in improved cutting quality during capsulotomy and incisions and reduced tissue trauma. With conventional high-energy lasers, widening the aperture would require a massive, technically impossible increase in the diameter of the laser optics. In addition, the Z8 Femtolaser can be used in many ways, including corneal surgery, both for transplants and for refractive surgery. The suitability of the laser for temporal access is also important in order to allow astigmatism-neutral access. However, in the case of a temporal approach, the incision stability must be optimized, since the patient can easily reach the site and inadvertently press the incision open with the fingertip. With the Femto laser, the shape of the incision can be set exactly and reproducibly, and thus the incision stability can be optimized in every case by means of the appropriate geometry. How can a surgeon optimize his workflow for a bilateral operation? The surgeon should sit temporally next to the eye to be operated on so that he can operate on both eyes with the same movements. This optimizes safety, since no surgeon is completely ambidextrous. The location of the device for the right and left eye should be as identical as possible in order to ensure short, standardized paths. The process of the ISBCS with the mobile Z8 is shown in Figure 13. The femtosecond laser can help to provide the rapidly growing number of patients with standardized quality: partial steps can be automated and also outsourced. A delegation to technical staff is thus possible. Fig. 13: ISBCS workflow. Conclusion: Cataract surgery on both eyes in one session with the femtosecond laser makes sense if the laser is mobile and the surgical technology and workflow are adapted accordingly. 10

11 Corneal Presbyopia Treatment What's New? Prof. Dr. Bojan Pajic (Reinach) Presbyopia treatment is becoming increasingly important not only at the lens level, but also on the cornea. In addition to the loss of accommodation of the lens, the spherical aberration that increases with age also plays a role and must be taken into account. Prof. Dr. Bojan Pajic (Reinach). One approach to presbyopia treatment is monovision. Mostly the dominant eye is optimized for the distance, but there are also cases where the patient prefers to see better with the dominant eye close up. Therefore, a simulation with contact lenses is generally recommended. Neuroadaptation can be expected more quickly for the patient with low anisometry. The ideal age for monovision is usually given as 45 to 55 years, but the principle should also work for older patients. Anisometries between 1.5 and 2.0 D are usually well tolerated. Advantages of this procedure are the unchanged contrast vision and the reversibility, a disadvantage is the lower spatial vision. Presbytery with Supracor and Presbymax is suitable for patients over 50 years of age, including pseudophakic patients. The target refraction for the dominant eye for the distance is 0 D, for the non-dominant eye it is -0.5 D. Here too, preoperative simulation should be carried out with contact lenses. As with the multifocal lenses, two focal points are to be created on the retina with the Presbylasik procedure (Fig. 14). However, other refraction errors can be corrected at the same time during the procedure. Prof. Pajic conducted a study on 36 myopic presbyopic patients with a six-month follow-up. The aim was to examine the eyesight after bilateral femto-presbyopia with a multifocal wavefront-guided ablation profile. The patients achieved a visual acuity between 0.1 and 0.0 logmar in all distance ranges, intermediate range and near. On average, the patients did not need glasses 95% of the time. The spherical aberration was reduced by 0.2 to 0.3 µm due to the ablation profile. (Pajic B, Pajic-Eggspuehler B, Mueller J, et al. A Novel Laser Refractive Surgical Treatment for Presbyopia: Optics-Based Customization for Improved Clinical Outcome. Sensors (Basel) 2017 Jun 13; 17 (6). Pii: E1367. doi: / s). In 28 eyes of pseudophakic patients, Prof. Pajic investigated how well the Presbylasik procedure is suitable for refractive touch-up. This treatment should take place no earlier than nine months after the cataract operation so that the refraction has stabilized. Even with pseudophakic patients, very good visual acuity results between 0.9 and 1.0 were achieved in all distance ranges. It should be noted here that the optimal distance vision is only achieved after about six months. Corneal inlays are another option for corneal presbyopia treatment. Centering can be problematic here, and chronic inflammation has also been observed in individual patients. Where is corneal presbyopia correction going? Another step could be corneal inlays made from corneal tissue. The first approaches work with tissue slices with a diameter of 3–8 mm, which are then processed individually for the patient and implanted intracorneally. However, centering is challenging. Prof. Pajic also gave the audience an important tip on the way: In the case of monovision treatments, the patient must be informed that he must wear glasses to drive a car. Conclusion: The new algorithm of the central PresbyLasik profile creates a multifocal cornea without transition zones by raising the central 3 mm zone. This modification provides the additional power required for near vision, but at the expense of an increase in spherical aberration. The aberrations are corrected by the individualized wavefront-guided excimer laser method. Aspherical treatment in the zone between 3 and 6 mm corrects the residual refractive errors and improves visual acuity. This multifocality central 3 mm zone for near vision and the 3 to 6 mm zone for far vision can also be seen as an increase in the depth of field. The Linz DMEK learning curve Prof. Dr. Matthias Bolz (Linz) Fig. 14. Generation of two focal points with the PresbyLasik method. The most important indications for Descemet Membrane Endothelial Keratoplasty (DMEK) for the Kepler University Hospital in Linz include Fuchs' endothelial dystrophy, a corneal decompensation after intraocular surgery

12 Fig. 15: Medium used and reubbling rate. play with anterior chamber lenses or after complicated cataract surgery, and pressure-related endothelial decompensation, as in aphakic glaucoma or Posner-Schlossmann syndrome. From the point of view of Prof. Bolz, DMEK offers many advantages: From the patient's point of view, DMEK is similar to cataract surgery, with an operation duration of only about 20 to 30 minutes. Basically all types of anesthesia are possible. The visual acuity rehabilitation takes place quickly with a stability of refraction and visual acuity already after six weeks. The mechanical stability is also approximately normal, since in principle there is only one clear corneal incision and therefore practically no astigmatism is induced. Tissue rejection is less than 1%, as is primary graft failure. Re-DMEK is only required in 3% of cases; the insufficiency was mostly related to the pretreatment. Follow-up care after DMEK is easy, patients only have to come for a few follow-up checks. Nevertheless, some questions arise: Can the previous process be expanded or improved? Which rhexis size should you choose? Do you need an anterior chamber maintainer with additional access? Should the rhexis be performed under BSS, viscoelastic or air? Should an iridotomy be done before or after DMEK and at 6 or 12 a.m.? When should you start bubbling? Should the graft be marked? The Linz clinic has set up a DMEK register since 2012 so that questions of this kind can be answered. The register contains a total of 358 patients, 84 of them from the year The mean age of the patients was 71 years (27 91 years), the length of stay in hospital was 5.3 days (1 18 days). The hospital stay depends on the quality of the transplant and the patient's previous illnesses. Of the 358 eyes, 64.8% did not need to rebubble, 21.5% needed one reubble and 13.7% needed two or more rebubblings. Air was used as the medium in Descemetorhexis in 85.5% of the eyes, Healon in 7.8% and Healon GV in 6.7%. If one looks at the reubbling rates of the three surgeons, differences become apparent, but these have less to do with the surgeon's experience than with the criteria chosen for reubbling. In general, when using Healon, reubbling is indicated more often, which is due to the remaining residues of the viscoelastic. Rebubbling rates using Healon GV and air were comparable (Fig. 15). Conclusion: Rebubbling in DMEK is not a complication, but part of the operation. Air and Healon GV are equally suitable as media. There is still no consensus as to when one should decide to rebubble. Healon GV is particularly suitable for complicated initial situations such as vitrectomized eyes, deep-set eyes and large iris defects. Postoperatively, the patients at the Linz clinic are placed in their supine position for 24 to 72 hours. A tensio control is carried out to rule out an inverse pupillary block. A postoperative iridotomy at 6 and 12 o'clock avoids a pupillary block, whereas in Linz only an iridectomy is performed at 12 o'clock. A clearing of the cornea can be observed a few hours after the DMEK from central to peripheral. Ring-shaped epithelial edema can persist for up to two weeks after the operation. The postoperative diagnosis includes OCT images of the anterior segment and the macula, provided the pupil is free, and a Pentacam image with pachymetry. Macular OCT is mainly performed to rule out Irvin-Gass syndrome. Postoperative aftercare in Linz includes a topical antibiotic for one week (e.g. Floxal EDO) four times a day, a topical steroid for five years (e.g. PredniFluid or Inflanefran forte), initially six times a day. Subsequently, the dose is reduced by one drop per day per month up to a maintenance dose of one eye drop per day for five years, although the duration may still be adjusted due to a lack of long-term data. An unpreserved tear substitute is also prescribed if necessary. In the case of central dehiscence, reubbling should be carried out immediately. Conclusion: The transplant rejection risk is reduced by a factor of 10 with DMEK compared to pkp. All forms of anesthesia are possible with DMEK. Healon GV is recommended as a safe medium in difficult situations. Rapid visual rehabilitation can be expected within four weeks. Depending on the indication, an increase in visual acuity of five lines can be expected, and the majority of patients achieve reading ability. A further slow improvement in visual acuity can often be observed up to six months after the operation. If the increase in visual acuity is insufficient, Irvine-Gass should be considered. Correct manipulation of the transplant is decisive for the success of the operation; a learning curve was found here in Linz. Steroid eye drops should be given postoperatively for five years. 12th

13 Can corneal interventions be simulated and thus optimized? Dr. Harald Studer (Reinach) If you ask yourself where the high variability of the results after corneal surgery comes from despite the high-tech equipment that is now available, the answer could be the inadequate planning of the surgery. Dr. Harald Studer (Reinach) reported on new developments in patient-specific planning for eye surgery. In principle, the simulation is based on the calculation of a virtual clone of a patient's cornea and the subsequent calculation of the treatment parameters. These parameters can be used to carry out an optimization run and change individual parameters until the optimum result is achieved in the simulation. Such simulations based on a customizable mathematical model of corneal biomechanics are conceivable for different indications: Effect of the phaco tunnel on surgically induced astigmatism Presbyopia correction with corneal inlays PRK Influence of ring segments in keratoconus LASIK with and without flap Arkuate incisions to correct astigmatism Crosslinking . A validation for the Arkuate Keratotomy was performed. For this purpose, preoperative data was recorded and the results of the simulation were then compared with the actual results of the surgery. The prediction error here was 0.23 ± 0.19 dpt. The additional simulation does not burden the workflow in the clinic, as the time required is less than three minutes. Fig. 16: Integration of the patient-specific OR simulation into the clinical process. It is already possible today to predict, plan and optimize the astigmatic incisions in a personalized way. In the future, it should also be possible to plan intrastromal, asymmetrical and multiple incisions. Conclusion: Biomechanical simulations have great potential in the planning and development of interventions on the eye. One area of ​​the future of personalized ophthalmic medicine lies in individualized planning. Transcleral glaucoma treatment isn't that destructive either? PD Dr. Marc Toeteberg-Harms (Zurich) The production site of the aqueous humor, the ciliary body, is easily accessible transsclerally and therefore a suitable place for therapy, even if the treatment is not physiological, explains PD Dr. Töteberg-Harms (Zurich). Cyclocryocoagulation as the first therapeutic approach to the ciliary body was described by Bietti as early as 1950, but it had many side effects. In 1984 Patresi then presented the obliteration of the ciliary body by means of transscleral cyclophotocoagulation (CPC) with the diode laser. With the Gaasterland-G probe, ten to 20 laser foci are placed 1.2 mm behind the limbus over 360, but not at 3 and 9 o'clock, so that the long ciliary nerves are not injured and pupillary disorders are avoided. By default, 2000 mw was treated over 2500 msec. Slow CPC with mw over msec leads to less coagulation damage. These procedures achieve a% reduction in intraocular pressure (IOP), but 25% of the time a second treatment, and occasionally a third treatment, is required. If the success of the treatment is plotted against the induced energy, the result is a fairly linear curve. The limited use of CPC is due to the not inconsiderable side effects, which include bleeding, pain, changes in the lens and accommodation disorders. The Iridex Cyclo G6 Glaucoma Laser System has three probes, a normal G-probe and an illuminate G-probe probe, for diaphanoscopic localization of the ciliary body. In addition to the continuous wave, the device also works with micropulses (MP): With the same exposure time, the laser is only active for 31% of the application time, which means that the tissue is less heated and less coagulated. In contrast to 13

14 to the G-Probe placed parallel to the visual axis, the MP3 probe is used to swing the probe. The MP-CPC can also be carried out outside the OP. For follow-up treatment, Dr. At the end of the procedure, Töteberg-Harms put a 0.5% atropine eye drop and an eye dressing with a fixed combination of dexamethasone and tobramycin once at the end of the procedure. Töteberg-Harms in 16 patients treated with the G-Probe and 16 with MP3 showed a comparable reduction in pressure with both methods (Fig. 17). However, the increase in glaucoma medication required shows that treatment must be repeated after two to three months. It is also noticeable that the MP3 method reduces the IOP significantly faster than the G-sample drug - which is not controlled by the drug and in which the patients refuse an operation. Furthermore, patients who are expected to have poor compliance in the follow-up care of a trabeculectomy and patients with drug intolerance are suitable for the procedure. Neovascular glaucomas or those for which other surgical procedures have not been successful are also suitable for CPC and MP3. Even patients who have already been treated with the G-Probe can be treated with MP3, as the mechanisms of action are different. A CPC or MP3 treatment can also be considered as an alternative to or combination therapy with other minimally invasive glaucoma surgery. Fig. 17: Comparison of the IOP course (upper curves) and the medication requirement (lower curves) after transscleral CPC (blue) and MP3-CPC (red) in 16 patients each. 0.1% drops of dexamethasone per day for five days and two to three drops of 0.3% ofloxacin per day for three days. After a G-Probe treatment, patients often report pain and need pain relievers, cells and flare can also be seen. Less heat generation, fewer inflammatory reactions and less pain can be observed with MP3. Peer-reviewed publications over a follow-up period of 30 days to 18 months show a% decrease in IOP with reduced medication and limited occurrence of unexpected events.A long-term study with a follow-up of 78 months found an IOP reduction of 43% with less need for medication. The patients received an average of 3.6 treatments over the 6.5 years. Treatment. Further analyzes with longer follow-up and higher case numbers are planned, and a worldwide RCT study (PRISM; Prospective Randomized Study on MicroPulse Laser) will investigate the micropulse method. The exact mechanism of action of the MP3 process is not yet known. While the G-probe is placed directly over the ciliary body, the MP3 probe is aimed more at the tissue in the pars plana region. A very important difference between the two methods is that MP3 is not cyclodestructive as long as the probe is swiveled. It is believed that MP3 increases uveoscleral and possibly trabecular outflow, while G-Probe use decreases aqueous humor. The indications for transscleral CPC and MP3 include all forms of glaucoma. Conclusion: MP3 treatment with the Iridex Cyclo-G6 glaucoma laser system lowers the IOP and reduces the need for medication. Compared to the G-Probe method, MP3 causes less pain and inflammation. The MP3 procedure is not cyclodestructive and appears to increase uveoscleral outflow and possibly trabecular outflow. The MP3 treatment is repeatable, but must be repeated more often for a sustained lowering of IOP. Minimally Invasive Glaucoma Surgery the New Standard? Prof. Dr. Kaweh Mansouri (Lausanne) If one looks at the number of trabeculectomies performed in Medicare patients in the USA, there was an initial decrease of 52% from 2003 onwards due to the availability of prostaglandin analogues, followed by a further decrease of 52 in 2012 % observed due to new surgical procedures. The technique of trabeculectomy 14

15 has hardly been improved over the 50 years of its existence, according to Prof. Dr. Kaweh Mansouri (Lausanne) is the least predictable surgical procedure in modern ophthalmology and is associated with numerous early and late complications. We are therefore looking for the ideal glaucoma operation that follows the rule: an operation that takes 10 minutes and ensures an IOP of 10 mmHg over ten years. Prof. Mansouri reported on minimally invasive glaucoma surgical procedures (MIGS), which gradually supplement and partly replace traditional techniques such as trabeculectomies, drainage implants and cyclocryocoagulation. According to the definition of Dr. Ike Ahmed under MIGS is a minimally traumatic ab interno intervention with an at least moderate lasting effectiveness and an extremely high safety profile, in which the patients recover quickly and experience only minimal loss of quality of life. The XEN implant represents a MIGS approach to increase subconjunctival filtration. The 6 mm long hydrophilic stent made of glutaraldehyde-stabilized gelatin is implanted through a clear corneal incision with one end into the subconjunctival space, the other end protruding into the anterior chamber . The drainage should be improved with a filter pad. A study with 149 eyes was carried out at the Montchoisi Clinic. After twelve months, the pressure reduction was 31%, regardless of whether the stent was implanted alone or a combined glaucoma-cataract operation was performed. Fig. 18: Effectiveness, costs and handling of MIGS processes. 1. Mansouri et al. JOG 2018; 2. Minckler et al. Am J Ophthalmol 2014; 3. Seibold et al. AJO 2017; 4. Craven et al. J Cat Ref Surg 2012; 5. Pfeiffer et al. Ophthalmology 2015; 6. Vold et al. Ophthalmology medication decreased from 1.9 to 0.5 medication on average over the twelve months. Adverse events occurred in 15% of the patients, 37% of the patients had to be needling after an average of 136 days. Needling was required in 45% of the stand-alone operations and in 34% of the combined operations. According to Prof. Mansouri, experience shows that needling should be carried out as soon as the IOP rises in the first four weeks. Another goal of MIGS interventions is to bypass the trabecular meshwork directly. The trabectome is used to selectively remove part of the trabecular meshwork and the inner wall of Schlemm's canal, but this method has meanwhile faded somewhat. High-Frequency Deep Sclerectomy (HFDS) pursues the same goal. Starting internally, this method uses diathermy to create six deep pockets in Schlemm's canal and in the sclera. In contrast to ab externo interventions, the episcleral and conjunctival tissue is not stimulated. The rapid procedure can also be combined with cataract surgery. If you already have an Oertli phaco device, you only need an additional kit for the HFDS. With the additional intervention, the cataract operation is only extended by about two minutes. A prospective clinical study by Prof. Pajic in 53 patients with primary open-angle glaucoma and five patients with juvenile glaucoma showed a stable IOP decrease over 72 months after HFDS treatment. In a multicenter study, 54 eyes with combined cataract HFDS and 44 eyes with cataract surgery alone were examined. The reduction in IOP did not differ significantly between the groups during the three-year follow-up period, but the patients in the cataract HFDS group required significantly less glaucoma medication than the patients who only had cataract surgery. The success parameter IOP 16 mmhg without medication was achieved by eleven of 17 eyes in the cataract HFDS group and only one of 14 eyes in the cataract surgery group. The difference was statistically significant. With all methods of widening Schlemm's canal, it should be noted that dilation of Schlemm's canal alone is not sufficient; the collecting canals must also be activated. Figure 18 shows an overview of the effectiveness, costs and handling of different MIGS processes (Prof. Mansouri). Conclusion: The MIGS processes are very promising. Most interventions can be performed quickly and relatively easily. The safety profile is high and patients recover quickly from the surgery. In some cases, low IOP values ​​are achieved, but the rate of treatment failure is not yet known. Long-term data are required for all procedures. The relatively high cost is problematic. 15th

16 The scientific program was rounded off by interesting cases from ophthalmic surgery, presented by Dr. Stefanie Dr. Stefanie Schmickler (Ahaus) Schmickler (Ahaus) and Dr. Jerome Bovet (Wallisellen) and sparked lively discussions. Dr. Jerome Bovet (Wallisellen) The 10th Come-and-See event was also judged very positively by the participants. You rarely come across events where the discussion takes at least as much time as the lectures. The most important topics of ophthalmic surgery were carefully selected by the faculty and presented at a high level by the excellent speakers. The participants were able to take home a lot of suggestions and information for their work in the clinic and practice. Please note 11th Come and See Meeting June 2019 Hotel Bad Horn Ophthalmologische Nachrichten Biermann Verlag GmbH Otto-Hahn-Str. 7, Cologne, Germany Tel .: special supplement ON 12/2018 ophta special supplement ophta 6 / Come and See Meeting, June 2018 in Bad Horn, Switzerland With the kind support of HOYA Surgical Optics GmbH, Mediconsult AG and Oertli Instrumente AG Information: Oertli Instrumente AG Hafnerwisenstrasse Berneck, Switzerland Author: Dr. Monika Fuchs Layout & graphics: Biermann Verlag GmbH Printing: Griebsch & Rochol Druck GmbH, Hamm, Germany Photo credits: Dr. André Delley 16