The Meeting of Minds

How did your relationship with the ESCRS Congress begin?

Robert H. Osher: If my memory is correct, I have attended every annual meeting since the second gathering of the EIIC, the precursor of ESCRS. Emanuel Rosen and Paddy Conden initially invited me to present the Video Symposium, a new concept which I had introduced in the US. Every year thereafter, I enjoyed showing challenging cases and management of complications to enthusiastic audiences. Eventually, I teamed up with Graham Barrett from Australia to teach a popular recurring course, and I would always have an entry into the Video Competition. I am pretty sure that I have won two Grand Prizes at this fabulous event introduced by Michael Blumenthal, and subsequently championed by English surgeon Richard Packard.

Thirty-eight years ago, I started the Audiovisual Journal of Cataract and Implant Surgery, which eventually became the Video Journal of Cataract, Refractive, and Glaucoma Surgery. I would watch every single video in the perennial Video Competition and then select the best videos to show in the Video Journal, which became a free member benefit of the ESCRS. As a result, the spectacular work of many leading European surgeons has been featured and shared with thousands of surgeons worldwide. 

What are your impressions of this year’s event?  

Cummings: I attended this year’s ESCRS Congress virtually. I thought that it was very well organized. Attendance was lower than usual, but compared to other meetings, such as ASCRS, it was very well attended.

Spalton: This year’s ESCRS was excellent. It was well organized by the new management team, with an excellent exhibition and an enthusiastic face-to-face audience.

Hafezi: I attended the meeting in person. Due to the continuing COVID-19 situation, it was clearly a smaller physical meeting than in previous years, but the speakers were given information about the number of virtual attendees for each session, and these numbers were impressive. The quality of presentations remained high throughout – nobody “rested on their laurels” in 2021, and I was impressed with the standard of work being presented.

Malyugin: I was glad to attend this 2021 meeting in person. I think the quality was very good, in spite of the fact that the number of attendees was about half of the usual size. Surprisingly, the exhibit hall was also full. People were happy to meet each other after a long break.

Torres-Netto: I attended the congress in person this year. It was a resumption of activities, more introspective, with some occasionally full rooms. Although much smaller than before, I thought it was an excellent event: I was able to talk with colleagues who I had not talked to for a long time. Since the size and distance between rooms was smaller, it was easier to meet colleagues and discuss cases and ideas. It was an excellent meeting, very well organized, and it provided a new and more intense interaction between colleagues. I’m looking forward to ESCRS 2022. 

Which presentations caught your attention the most at the 2021 ESCRS Congress?

Spalton: The one that stood out for me Osama Ibrahim on hyperopic SMILE an operation of the future.

Torres-Netto: Elastography to evaluate corneal biomechanics met with great interest from colleagues.

Hafezi: Literally every single one. Everyone was so happy to see each other. And of course, all of those productive conversations that happen at the end of a session or symposia with fellow speakers and delegates got to happen again – that’s something that is far harder to have when a meeting is online.

Malyugin: I liked the main symposia and clinical research symposia. The content was up to date and interesting.

What did you present on?

Malyugin: I was co-chairing “You make the call” and the “Best of the best” sessions as well as the main symposium on MIGS. I was presenting a talk in the Glaucoma Workshop on Cataract surgery in PEX.

Spalton: I chaired an excellent free paper session on EDoF IOLs and the Hyperopia Workshop.

Torres-Netto: Elastography to evaluate corneal biomechanics including the role of Bowman’s layer, PACK-CXL for the treatment of infectious keratitis.

Osher: This year my opening Video Symposium was pre-recorded. The 90-minute session was divided into Preoperative Challenges, Intraoperative Complications, and Postoperative Problems. Two years ago, I was surprised when at the end of the Video Symposium, President Beatrice Cochener, presented me with the inaugural Teaching Award. I certainly did not expect this wonderful honor. I was also surprised this year when I received an email announcing that my video entitled The Capsular Bag: A New Site for Sustained Drug Delivery received the First Prize in the category of Innovation. 

Hafezi: I presented the latest on the sub400 protocol, which enables surgeons to safely cross-link ultra-thin corneas, as low as approximately 200 µm, by modifying the amount of UV irradiation based on the patient's thinnest corneal pachymetry readings, and our work on making simple, effective epi-on corneal cross-linking a reality, without having to use supplemental oxygen or iontophoresis as adjuncts.

I also presented the work performed in collaboration with Sabine Kling of the ETH Zurich on OCT elastography, which enables in vivo measurements of corneal biomechanical strength, using a technology we all have in our clinics: OCT.

Finally, one of our research team, Reyhaneh Abrishamchi, gave a presentation about our laboratory work on high-fluence accelerated cross-linking. Accelerating cross-linking protocols (by delivering the same total amount of UV energy over a shorter period by using a higher intensity) is attractive because it reduces the procedure time for the patient. However, acceleration reduces the strengthening effect, with the greater the acceleration, the lower the effect on corneal biomechanics. This is thanks to the fact that oxygen is an essential component of the UV-riboflavin reaction, and it diffused from the air at a constant rate, and this limits the speed of the reaction. 
However, we now know that you can deliver higher total UV doses – fluences – than was thought possible before and not compromise the corneal endothelium. 
Through a series of experiments, we determined an accelerated, high-fluence cross-linking protocol that delivered Dresden protocol-like levels of biomechanical stiffening, in a considerably shorter period.

What did you particularly enjoy about this year’s ESCRS meeting?

Malyugin: First of all, I was glad to meet all my friends and colleagues after such a long break! It was also great to witness the process of coming back to normality.

Torres-Netto: The strength of ESCRS 2021 was that it made it so much easier to meet colleagues from around the world that I had not seen for some time. The personal interaction provided by personal conferences in this sense is irreplaceable.

Do you think in-person meetings are important? 

Cummings: I do think that they are very important, especially when you are working with other sites on studies or projects, wanting to acquire new technology for your practice, or you simply want to socialize with colleagues and friends. If you are attending for academic reasons only, like learning a new procedure, reviewing the literature on a topic, listening to a panel discussion, then attending virtually is just as good. Most attendees that attend regularly and hardly miss a meeting would tell you that they learn most at the meeting when bumping into a colleague and having an informal chat.

Spalton: Yes, they’re very important! It’s great to see everyone in person and interact with colleagues face-to-face.

Hafezi: In-person events are important, but I believe hybrid meetings are the future. Virtual attendance means that the speakers can reach a far greater audience, and it gives the audience value, too – they can rewind and rewatch presentations at their leisure. These features have long been part of the large international congresses, but I think only over the last 18 months have we truly seen the value that hybrid congresses bring.

Malyugin: They absolutely are important; I have no doubts about that.

Torres-Netto: I think in-person events are essential!

What do you see for the future of the cataract and refractive surgery field?

Osher: With respect to the future, I believe we will continue to see exciting days for ophthalmology. As shown in my video, we have already made excellent progress in sustained drug delivery following cataract surgery. For years, I have predicted that there will come a day when every young patient with a refractive error will have a clear lensectomy followed by the implantation of an intraocular lens, which will not only correct hyperopia, myopia, astigmatism, and presbyopia, but will also be empowered to do even more. The intraocular pressure will be measured by the IOL as well as the blood glucose and other important chemistries. Artificial intelligence will keep the lens in perfect focus at all distances and we will see the end of glasses, eye drops, and all of the nuisances that we live with today. Even though I am in my seventies, I look forward to helping develop these innovations and to continue contributing to the amazing education which ESCRS provides.

Cummings: Data driven decisions. New IOLs that provide more complete ranges of vision without increasing dysphotopsia. New refractive lasers. New drug delivery systems. Technological advances in diagnostics. Myopia control with behavior modification, drugs, glasses, and contact lenses. This field simply doesn’t stop innovating!

Cataract surgery will become refractive surgery: performance based rather pathology based. For many refractive surgeons, cataract surgery has been regarded as refractive surgery for at least the past 10 years. In the past if the cataract was replaced with a clear monofocal IOL, the patient could get new glasses and see better than before, that was classified as success. Today, most patients in developed countries do not see that as success; they’re expecting an outcome where they are free from glasses. So, it is almost a given that there will not be complications of any sort and that the refractive target will be met and the correct IOL design selected (monofocal with blended vision, monofocal plus IOLs, EDoF, and trifocal IOLs). The surgical success is almost accepted as a given and the success determined by the refractive outcome and independence from spectacles. Both groups are going to grow: cataracts are increasing in number with the increasingly ageing world population, and refractive surgery is set to grow with the growing awareness of its safety and efficacy and peoples’ newfound change in their priorities: people are tending to spend money on themselves, often within the healthcare and lifestyle sectors. 

Spalton: For me, the future is EDoF/monofocal extended IOLs, with a greater emphasis post-COVID-19 on whether treatment advances are cost effective. I expect money to be in short supply as national debt is being paid off.

Malyugin: New multifocal IOL designs and the new tools to assess patients preoperatively to select what lens will work best for each individual case. New technologies in refractive surgery such as cornea refractive index shaping. In cornea – endothelial cells injection technology. In OR – new modalities of visualization with 3D virtual reality.

Better safety profile, better comfort for the patients with various new devices allowing for drop-free medication delivery, more precision in refractive results. New training and teaching techniques for cataract surgery.

Hafezi: We are now at a point where AI/“Big Data” is really beginning to make a difference. What was once termed “nomograms” is now something far bigger and more powerful, and we can see the effects that AI-assisted learning has delivered. In my field, we are already seeing more accurate and sensitive screening of the cornea for ectasias like keratoconus, but we see that AI is transforming the screening and monitoring of diseases throughout the eye. All of this dovetails nicely with the increasing performance and decreasing costs of imaging devices, such as smartphone camera technology. These advancements are making it easier to bring medical technology to more people at a lower cost – for example, we are currently developing a smartphone-based keratograph for keratoconus screening, and we view it as “democratizing access” as lower costs and wider availability brings this medical technology to more people who need it. Taken together, clinical practice might look very different in a decade thanks to what AI will reveal between now and then, and how these diseases are screened and treated.
In the longer perspective, additive therapy – where corneal tissue is added to patients’ corneas – looks like it is maturing well. This has the potential to help treat not only keratoconus corneas, but also other refractive errors, too, and may help improve patients’ vision without having to ablate or remove corneal tissue with a laser. This approach may not be applicable to every eye with keratoconus or a refractive error, but it certainly looks like it might become a valuable addition to our surgical offerings.