The 40th annual congress of the European Society of Cataract and Refractive Surgeons (ESCRS) was back to full size this year and the venue was the MiCo, Milan Convention Centre, one of the largest in Europe (figure 1). This year’s ‘hybrid’ conference also gave the option for attendees to attend virtually.
As in previous years, the Congress offered (almost 9,000) delegates a breathtaking choice of scientific and clinical content with plenty of networking opportunities for those excited about meeting up in person again. Formats included clinical research symposia, challenging cases sessions, clinical courses, free paper presentations, poster sessions (figure 2), practice development programmes and over 100 wetlabs. The exhibition halls (figure 3) enabled attendees to interact with over 200 exhibitors throughout the meeting and 25 industry sponsored sessions provided a chance for suppliers to update delegates on their latest offerings.
New initiatives for the ESCRS included the development of a portal to provide information for patients, open access databases and the collection of healthcare data. The Congress also saw the launch of a free ESCRS online IOL calculator tool that aggregates seven different online IOL calculators at a single site. Users simply load the clinical data and choose the desired IOL and the site utilises the most recent information to help clinicians choosing the optimum IOL power.
The meeting began with speciality day events on cornea, glaucoma and paediatrics, as well as a new interactive iNovation event designed to connect clinicians and experts in business to focus on anterior segment eye healthcare and, importantly, to consider how technological innovations could address unmet clinical needs in the coming years. Topics included emerging technology for managing presbyopia, cataract and glaucoma as well as digital practice, big data, artificial intelligence and digital operating rooms.
Figure 3: Attendees at some of the over 200 exhibitor sites
Sustainability
A key theme for the meeting was how to make ophthalmology more sustainable and there were discussions about different ways to eliminate waste, emissions and pollution continuing throughout the meeting. The Society has committed to offsetting the ESCRS Congress carbon emissions and the sustainability wall installation as you entered the conference (pictured, below) was a striking reminder that we all need to play our part.
Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress. Dr David Chang advised this will cause a rise in trachoma infections, onchocerciasis infections, cataracts, skin cancers, corneal and conjunctival lesions, eye injuries, age-related macular degeneration, glaucoma and allergic eye diseases.
Alarmingly, Dr Chang relayed that healthcare sector waste in the US accounts for 10% of greenhouse gas emissions and, in the UK, Canada and Japan, it accounts for approximately 5%. Dr Chang also highlighted that a key factor to being more sustainable is wastage reduction. Reuse of surgical gowns, gloves, IA tubing, irrigation bottles, blades, sutures, topical and intraocular drugs is common practice at the Aravind System in India, and yet rates of endophthalmitis are not increased when compared to rates in the US where reuse of such items does not occur.
Strikingly, the carbon footprint of a single phaco surgery in the UK and US is 20 times higher than that in Aravind System India. This is equivalent to driving a car 500km, as compared to 25km with the Aravind model.
Dr Chang outlined the steps we can take to reduce our carbon footprint through the EyeSustain approach. The mission statement includes collaboration within the industry to reduce wastage, engage, network, and educate our global ophthalmic community about more sustainable practices, supporting advocacy and education about the public health impact of climate change were a few of the steps outlined.
Digital Revolution – Transforming Ophthalmic Practice
It has been shown that, in times of crisis, there is a speedy evolution of science and technology. The Covid-19 pandemic triggered an explosion of new technologies and innovations, particularly within the healthcare sector.
Professor Beatrice Cochener-Lamard delivered the Ridley medal lecture entitled ‘How the digital world is entering our practice’. The lecture highlighted the significant increase of the use of telemedicine post peak of Covid-19. The components of telemedicine were discussed: teleconsultation (remote diagnosis by healthcare practitioners); tele-expertise (expert opinion); remote monitoring of patients and tele-assistance and medical regulation.
New technologies were described, including the development of the Zeiss Visuconsult tele-refraction system enabling the possibility of the remote eye examination, as well as web applications for the assessment of ocular surface disease (OSD) for clinical research. Professor Cochener-Lamard outlined significant developments in the application of artificial intelligence (AI) in ophthalmology, including the role of deep learning to assist in automated screening for diseases such as diabetic retinopathy. She then discussed the limitations of AI applications and emphasised the need to collect quality data systematically, to define economic models for AI, and to guarantee the integrity and security of data.
The importance of quality of data was also emphasised in a dedicated digital medicine session. It was pointed out that cloud-based platforms already exist to allow clinicians to get involved and advance their own research by uploading images to train AI models. Dr Ranya Habash described the exciting metaverse, the virtual reality that we are currently using in everyday practice, perhaps without even realising. An example of this comes from the world of e-commerce, whereby patients can try on spectacles virtually. Dr Habash then outlined the benefits of virtual and connected care, describing an innovation in amblyopia therapy whereby the dominant eye of a child is fogged using a headset and visual attention is directed to a Disney movie.
The advantages of the metaverse for the advancement of research include decentralised clinical trials by novel virtual platforms like Huma. This platform collates patient data remotely, sometime from the participants’ homes. Advantages from this that were highlighted include a better diversity of participants, real-time recruitment and real-life data collection.
Gene Therapy
Gene therapy is the introduction of genetic material (nucleic acid) into target cells to cure, slow down or prevent disease. There are three billion ‘letters’ of DNA and 350 inherited eye diseases caused by mutations in over 500 genes.
Professor Tara Moore, whose current work focuses on gene silencing for corneal dystrophies, described the main challenge of gene therapy as ‘finding the needle in the haystack that causes disease and fixing it.’ Prof Moore highlighted how the cornea is an ideal structure for gene therapy; it is easily accessed and disease status and treatment success are easily observed. Also, importantly, the prevalence of corneal dystrophies in the population are sufficient for clinical trials. Early clinical trials have shown how topical non-invasive siRNA delivery induces effective gene silencing in the corneal epithelium for patients with transforming growth factor β-induced (TGFBI) corneal dystrophies.
Dr Thomas Corydon discussed his current research using experimental anti-angiogenic gene therapy for age-related macular degeneration. Key benefits include reducing the number of intravitreal injections a patient requires and improved efficacy. Early laboratory clinical trials have conveyed safe suppression of choroidal neovascularisation by anti-angiogenic gene therapy.
Professor Isabella Audo described the ground-breaking, successful treatment of patients with Leber’s congenital amaurosis (LCA) using the gene therapy drug voretigene neparvovec. Patients were treated with a single subretinal injection six days apart between both eyes. From the first month after surgery, patients demonstrated improved visual function and mobility with a rapid and sustainable improvement in visual function at low levels of light intensity.
Gene therapy research for ocular disease is rapidly progressing, clinical trials coming to fruition with life-changing treatments for ocular diseases that reduce quality of life and in the most severe cases as with LCA cause genetic blindness.
Heritage Lecture
This year’s heritage lecture was delivered by Lucio Buratto who described the history and evolution of pseudophakia IOLs. He outlined the limitations of the early treatment of aphakia with spectacles (distortion and reduced field of view) before the advent of intraocular lens surgery.
Buratto acknowledged key influencers in the research and development in IOLs including Sir Harold Ridley, Peter Choyce, Cornelius Binkhorst and Edward Epstein. The struggles of Sir Harold Ridley, who implanted the first IOLs in the 1950s, were outlined. These included surgical issues, such as lens dislocation, and opposition to his work by colleagues. Pictured below, the Sim Vis Gekko Visual Simulator was used by a delegate to compare the optical effects of different multifocal IOLs.
Evolution of surgery then progressed to anterior chamber IOLs. To avoid posterior chamber IOL dislocation into the vitreous, surgeons Strampelli, Barraquer, Dannheim and Choyce (and others) used intracapsular techniques; where the IOL haptics were supported by the anterior chamber angle. Postoperative complications, including glaucoma, Descemet’s membrane damage and subsequent bullous keratopathy, were caused by this generation of lens design.
Buratto described how, by using their knowledge of the shortcomings of the previous lens designs, Epstein, Binkhorst and Fyodorov decided to move away from the anterior chamber angle and the first iris-fixed IOLs were invented. Despite their advantages due to the weight and mobility of these lenses, postoperative complications including severe and persistent cystoid macular oedema occurred with this lens design.
In 1977, Steven Shearing changed the lives of millions of people with the introduction of the modern lens design that we still use today.
Burrato described how milestones in the ophthalmological world were being achieved in all areas of the surgical process including phaco machinery, microscopes and lasers. By the late 1980s to early 1990s processes continued to evolve including the introduction of bifocal IOLS (1986), UVA IOL protection (1988) and toric lenses (1992).
Today, IOLs are continuing to evolve with the advent of enhanced monofocal lenses (to give functional intermediate vision), extended depth of focus (EDOF) and multifocal lens designs. We look forward to the future of this evolution where, perhaps, effective accommodative lens designs maybe on the horizon.
Exhibitors shared details of new and enhanced IOL designs in all the categories described above. There were also new technologies for laser vision correction; for example, there are new lasers for delivering small incision lenticule extraction that can now be used to treat hyperopia. An innovation of interest to those using multifocal lens technologies was a visual simulator that can be used to allow patients to experience the real world through multifocal correction, whether by IOL implantations or contact lens fitting.
Welcome Return
In summary, this congress delivered and then some. As it is impossible to attend every session, a welcome feature of the ESCRS meetings for the most dedicated is that, most sessions, free papers, posters and case reports are available on demand for ESCRS members and delegates so they can be reviewed after the event.
- Dr Nabila Jones is the Eye Sciences Research Associate at Optegra Eye Health Care, and Dr Clare O’Donnell is Head of Eye Sciences & Optometry at Optegra Eye Health Care.