XXXV Annual Meeting 2011
Southport Convention Centre, Southport
Thursday 13th and Friday 14th October 2011
Southport 2011 Review
The annual UKISCRS Congress held in October 2011 in Southport was a very successful event, with good attendance, excellent presentations and lively debate
Priscilla Lynch, Eurotimes
The 35th UKISCRS Annual Congress took place on October 13th-14th with a packed programme covering a range of topical issues of interest to cataract and refractive surgeons.
Welcoming delegates to the Southport meeting, President of UKISCRS Milind Pande stated that the 2011 Annual Meeting had a “fantastic programme” with top notch presentations covering a very wide range of topics and he expressed his gratitude for the work of all the speakers with special thanks extended to the high profile speakers from abroad.
Mr. Pande said the Society strives to provide cutting edge presentations from leaders in the field from across the world for the meeting, greatly benefiting the members. “The Congress meeting is a great learning, teaching and social experience for those attending,” he noted.
Mr. Pande informed attendees that the Society has now adopted the new memorandum and articles, the final stage of “a long and rigorous process”, which included a formal review of the membership as well as a formal ballot, following the initiation of the modernisation process by former Society President Tayo Akingbehin.
An overwhelming 93.3% of the membership voted in favour of adopting the new memorandum and articles and the adoption was formally passed at the AGM.
Announcing the election results, Mr. Pande congratulated new President Elect David O’Brart, and new third Director Paul Rosen.
Meanwhile this year’s retirees from Council were Christopher Liu, Nabil Habib and Manijeh Wishart, who Mr. Pande thanked for their contributions to the Society.
Meanwhile, Charles Claoué, Secretary of the Society, reported that the current membership stands at 485 with five new members since May. He drew attention to the Society’s forthcoming meeting in Dublin in March 2012, adding that UKISCRS would like to see more Irish representatives at the main Society meetings and hopes the Dublin meeting will encourage that. The AGM also heard that the Society is in good financial health and continues to grow.
One of the highlights of the two day event was the Choyce Medal Lecture given this year by Russell Foster, Professor of Circadian Neuroscience at the Nuffield Laboratory of Ophthalmology, University of Oxford, whose research led to the discovery of a third class of ocular photoreceptor in the eye.
His presentation on the link between eyes, light and the regulation of body clocks was both enlightening and fascinating.
Prof. Foster discussed the importance of the 24-hour body clock and circadian rhythms and why they are so important to the healthy functioning of humans, how the existence and role of the third ocular photoreceptor was discovered, the disconnect between ocular photoreceptors and 24-hour body clocks and the consequences of sleep deprivation, as well as the role ophthalmologists have in the area.
The body’s physiology changes throughout the day with proven variances in pain intensity and stroke risk for example, delegates heard.
“I think there is an extraordinary role that biological clocks play in our physiological behaviour. We are very different creatures from midday to midnight,” Prof. Foster commented.
He said even accounting for fatigue, our ability to process information at 4am or 5am is as impaired as if one had consumed sufficient alcohol to make one legally drunk, and the eye and the retina play a vital role in regulating this system.
The discovery of a third photoreceptor system within the eye based on melanopsin pRGCs argues that the clinical diagnosis of ‘complete’ blindness should assess the state of both the rod/cone and pRGC photoreceptive systems, he emphasised.
Discussing the animal research on the role of the pRGC, Prof. Foster said the results provide strong evidence that pRGCs can, at some level, contribute to awareness of environmental light, suggesting a greater functional overlap of the pRGCs and rod/cone subsystems than was previously assumed.
As it is now well understood that eye loss places patients into a world that lacks both vision and a proper sense of time, clinical guidelines should incorporate this information, he contended
He told the audience that a ‘blind’ individual who shows a bright-light-dependent pupil constriction should be encouraged where possible to expose their eyes to sufficient daytime light or even use light boxes to maintain normal circadian entrainment and sleep–wake timing.
Furthermore, patients with diseases of the inner retina that result in RGC death such as glaucoma are at particular risk of body clock issues and sleep disruption and should receive targeted treatment including potentially melatonin to address this.
Pearce Medal Lecture
Clive Peckar, consultant in private practice in Cheshire, gave this year’s Pearce Medal Lecture, and his presentation outlined the role of video and wet labs in learning and teaching.
Mr. Peckar is renowned for his contributions to ophthalmic surgical teaching and training through utilising video and microsurgical simulation laboratories.
His passion in promoting the importance of wet labs was clearly evident from his detailed and informative presentation, which contained many useful and contextual video clips from the early days of wet labs up to the present. He said it was important to show the audience archive footage from the 1980s as many would not have seen it and realised the progress and potential of wet labs and the importance of discussion sessions, especially on the management of certain conditions. Mr. Peckar said a key role of UKISCRS is to stimulate discussion and that it must continue to do so, especially for young surgeons.
Cataract day - Endophthalmitis, the most dreaded complication
The opening scientific session of the meeting was a comprehensive examination of the dreaded endophthalmitis, its causes, presentation, prevention and treatment. Surgeon Peter Barry from Dublin told the audience that a review of the international research had revealed that a surprising risk factor was the use of silicone IOLs which led to a three times greater risk of developing endophthalmitis as opposed to other IOLs, such as acrylic based ones. In addition, there was a five times greater risk if there were surgical complications like tears, vitreous loss, iris prolapse, wound breakdown etc. However, overall, the greatest risk factor remains the failure to use peri-operative antibiotics, Mr. Barry reported.
American speaker Terrence O’Brien discussed the pathogenesis of pseudophakic endophthalmitis and confirmed that there is concern in the US over the inappropriate use of topical antibiotics, which is “perhaps selecting out resistant strains which are more virulent than conventional strains of bacteria”.
Prof. O’Brien summarised that successful treatment is dependent on the rapid and aggressive recognition of the bacteria and referral for diagnosis and treatment, but treatment and outcomes will improve in the future if a more detailed understanding of the interactions between the pathogen and the host is achieved.
The audience was reminded, however, by Christopher Liu, Brighton, that prevention is always better than cure and that are many ways that surgeons can optimise their endophthalmitis prevention precautions. He strongly emphasised the importance of absolute cleanliness from the surgeon himself, to the theatre, to the instruments, and the patient, and that the highest standards of hygiene must be applied at all times pre, during and post op. Summarising his prevention strategies, Mr. Liu said surgeons should keep their operations short and free from complications as far as possible, use subconjunctival or intracameral cefuroxime while some patients may benefit from pre-op antibiotics, pay close attention to wound architecture and wound protection and place a suture if in doubt, and use an eye shield for temporal wounds and for patients you do not trust.
Discussing the presentation of endophthalmitis, Malhar Soni, London, said it is really important to remember that the current evidence of symptoms is not highly specific in predicting the nature of endophthalmitis and that any delay in diagnosis and treatment can result in a poor prognosis and outcome of what is arguably the worst potential complication of cataract surgery.
The treatment options for acute post operative endophthalmitis were discussed by Edward Hughes, Sussex, who said that in his opinion surgeons should perform an immediate (under one hour) vitreous tap and also start intravitreal antibiotics +/- dexamethasone.
Mr. Hughes said he believed an early vitrectomy, i.e. within 48 hours, is justifiable for severe cases, even if visual acuity is better than light perception but cautioned not to delay initial treatment to arrange a vitrectomy. If there is no improvement or the signs are worse after 48 hours Mr. Hughes advised re-injecting antibiotics and considering a vitrectomy.
The successful management of patient and indeed surgeon expectations was a key topic during the meeting’s plenary symposium. Delegates were told that patient expectations are always growing and have to be realistically managed with an emphasis on fully informed consent, while surgeons need to realise that their never ending quest for absolute perfection often means they don’t realise patients are often perfectly happy with their particular improvement in vision.
Advising how to manage disadvantaged patients with presbyopia IOLs, Terrence O’Brien, Director of refractive eye surgery and ocular infectious diseases, Miami Miller School of Medicine, cautioned delegates not to oversell ‘premium’ IOLs to patients, to fully disclose all risks beforehand and carefully assess the patient’s expectations before surgery.
Milind Pande, UK, during his presentation on assessing functional vision in these patients, said careful assessment and closely managed patient expectation is vital as “essentially until we get to the stage where we have a perfect lens we are always going to have to choose and select”.
Discussing the new Avedro microwave based system and cross linking, John Marshall, London, voiced his concern about the risks of invasive refractive surgery and promoted the benefits of significantly strengthening the cornea and treating keratoconus through cross linking in a two step procedure using Avedro’s system, as opposed to weakening the cornea through LASIK.
Because Avedro’s non-invasive, incision less, Keraflex procedure thermally remodels the cornea without the removal of any tissue, the procedure induces refractive change without weakening the cornea’s biomechanical integrity, as happens with LASIK and other refractive correction procedures, he explained.
The meeting also heard about the commercial reality of laser eye surgery from Ultralase Chief Executive Tony Veverka. Despite the recession
Mr. Veverka was optimistic about the future of elective LASIK surgery, contending that the public overplayed the risks of laser eye surgery. Strong satisfaction ratings and a growing acceptance of the procedure coupled with the cyclical nature of the market means that laser eye surgery is here to stay and will see market expansion again in the coming years, he contended.
A great debate
The ‘great debates in refractive surgery’ session was a lively and robust affair with head to head presentations on the best options for thin corneas, moderate to high myopia, and phakic IOLs. Advocating surface ablation as the best choice for thin corneas, David O’Brart, London, stated surface laser ablation with modern laser systems and management has really good refractive outcomes and less risks than LASIK.
Jan Venter, London on the other hand maintained that thin flap LASIK has equally good results and safety as surface ablation with less side effects and discomfort plus quick visual recovery, concluding that it should be the preferred treatment in his opinion, even for patients with a cornea thickness of less than 500 microns as “they do great when we do a thin flap LASIK on them”.
Also presenting on the best option for phakic IOLs in support of iris/angle supported PIOLs, Prof. Venter said large-scale studies have shown that these PIOLs have a far lower incidence of cataracts compared to posterior chamber PIOLs. He also said there was very little difference in endothelial cell loss in follow up review studies and he preferred using an iris/angle fixated lens as it has the longest history (dating back to 1986), ‘one size fits all’, is so simple, is easy to reposition, is reversible, and has excellent centration.
In opposition, arguing in favour of posterior chamber PIOLs as the best choice, Bruce Allen, Moorfields Eye Hospital, focusing on patient quality of life said the debate wasn’t clear cut and a major trial is needed, but argued there is great refractive results and good safety to date in this lens.
Meanwhile, advocating LASIK as the best option for moderate to high myopia, Dan Reinstein, London, pointed out the risks and invasiveness of refractive lens exchange (RLE), and said there is a lot of confusion in the profession about the current capabilities of corneal surgery in high myopia because people think all technologies are the same. “What I am doing is forefront technology but it is a window into what is possible on the cornea and it is not going to be long before the better excimer lasers are doing that and before all excimer lasers will be copying it as well,” he stated.
Rajesh Aggarwal, Essex, on the other hand in supporting RLE as the best option for moderate to high myopia, reminded delegates of the problems of glare and night vision in some LASIK patients and the difficulties associated with thin corneas for carrying out LASIK, plus “it doesn’t address the problem of presbyopia” nor the potential for cataracts.
As technology improves so does the ability to provide some accommodation for patients, he elaborated. The advantages of RLE are obvious Mr. Aggarwal contended; it is a very familiar procedure, it is very rapid, predictable and gives a very stable outcome. The optics now are excellent and cornea thickness is not an issue, not to mention that it addresses presbyopia and there is no regression due to ageing lenticular change, so a second procedure is not needed. Acknowledging that LASIK can be a better option for younger patients, he believed RLE remained the better option for older patients and those with higher myopia, and as IOLs improve, more younger patients will likely opt for RLE.
Femtosecond laser in cataract surgery
The ongoing discourse in the profession over the revolutionary properties of femtosecond laser versus its costs and the potential unknown risks involved were the focus of a strong session during the second day of the meeting.
Delegates heard that while it is very expensive now, the price will come down eventually though there were warnings that it should always remain in the hands of ophthalmologists as opposed to lower grade clinicians. It was also argued that femtosecond laser will probably never completely replace traditional phaco surgery.
Jorge Alio of Spain in his presentation on femtosecond microincision cataract surgery, spoke about his pioneering work using the new technology which he reported has exciting results for better precision and results in this type of surgery, though he acknowledged the costs were an extra €750 per eye currently.
The importance of anterior segment imaging in femtocataract surgery was stressed by Ioannis Pallikaris, Crete, who said that it is obvious there is a long way to go with this technology and we are likely to see much more advanced and automatic systems in the future.
Anterior segment imaging and diagnostics
In a session examining the use of anterior segment imaging, Nabil Habib, Plymouth, noted that while there are number of modalities for anterior segment analysis, it is important to look at software development when choosing equipment and to remember that integrated technology is time saving.
Saj Khan, East Grinstead, in explaining how he screens his laser vision correction (LVC) patients, said he takes the approach that no patients are suitable for LVC unless proven otherwise. Mr Khan stressed that documented, thorough screening, especially for ectasia risk factors despite still being difficult to identify, is a must to ensure the best clinical outcome and protect the surgeon from unnecessary medico-legal risks.
The meeting also heard that accurate manifest refraction is the most important variable when calculating a phakic IOL procedure from Jan Venter, London, in his presentation on his screening and examination methods for phakic IOL patients.
There were 24 high quality poster paper presentations covering a variety of topical cataract and refractive surgery issues displayed at this year’s meeting.
The best poster prize went to Michael Tsatsos for his poster entitled ‘Visual outcomes in DEK is not related to aberrometry’, while Allon Barsam won the runner up prize for the best poster for his poster entitled ‘Visual outcomes in eyes with previous refractive surgery undergoing IOL implantation guided by an intraoperative wavefront aberrometer’.
Meanwhile in the best paper competition, Hamed Anwar won the best refractive paper prize for his paper entitled ‘Topography guided customized ablation to treat irregular corneas after keratorefractive surgery’. The best cataract surgery paper prize went to Anthony Spiteri for his paper entitled ‘A proficiency-based training curriculum on a visual reality cataract simulator’.
The top prize for the best overall paper at the meeting was won by David Lockington for his presentation entitled ‘Floppy iris, intracameral air and DSEK-the mechanics and modelling of iris buckling’.