Each year Sydney cataract and refractive surgeon DR PETER SUMICH blocks out his calendar to attend the American Society of Cataract and Refractive Surgery’s annual conference. He provides an update on the latest innovations from ASCRS 2023 and their relevance to Australia.
ASCRS 2023 saw the world’s leading cataract and refractive surgeons descend on the vibrant melting pot of San Diego, California. Several concurrences contributed to a festival city atmosphere, with 5th Street closed to traffic and outdoor diners lining the streets. The Padres baseball team were playing the Dodgers at Petco Stadium; the streets were closed for Cinco de Mayo (5 May, to celebrate the Mexican victory in battle against the US) and the ASCRS circus was in town.
I have been going to the American Society of Cataract and Refractive Surgery’s annual conference for 25 years and something felt oddly different this year. It wasn’t just that corporate sponsorship and promotional excess had lessened. I realised that the wrinkle in time caused by three years of COVID has seen a changing of the guard at ASCRS and some cultural changes.
There were far more female representatives on senior panels than in previous years. They were impressive, eloquent and advanced. There were younger main speakers, formerly the sidekicks of the headliners; young presenters who had served their time in the minor sessions. The former headliners seemed to have receded into roles as father-figure convenors, rather than unabashed industry spruikers and opinion makers. What hasn’t changed is the excellent standard of presentations and the performative nature of the speakers. Nobody does a conference like the Americans.
IOL update and AI
A key theme was the trend away from multifocal IOLs and the increasing adoption of EDOF lenses. These lenses provide a reasonable degree of spectacle independence without the well documented downsides of diffractive multifocal optics. Multifocal IOLs are exquisitely sensitive to any residual refractive error and tear film imperfections.
Dr Warren Hill noted that the wavefront displacement of an EDOF creates an altered path length without spherical aberration and excessive loss of contrast. He noted that whilst the most demanding of presbyopes will continue to want full multifocal IOL spectacle freedom, the safety margins of EDOF technology can be pushed to a point where most would be satisfied.
Occasionally it needs to be emphasised that the most crucial refractive interface remains a stable tear film. Around 50% of the population are affected by dry eye. Many new devices were demonstrated in Trades Hall which heat, massage, squeeze or otherwise modify meibomian gland disease. Special guest comedian Ken Jeong, famous for his role in The Hangover movies, humorously presented his personal story of dry eye and how it affected his life. A massive immediate unmet need for dry eye management exists. An obvious commercial opportunity awaits optometrists to provide dry eye clinical services outside of Medicare.
Artificial intelligence (AI) was trending. In biometry it has become a genuine option. Several large, big data groups are beginning the collection of post-surgical refractive data to derive new biometry relationships beyond the current optical theorems. Working backwards from refractive results, the AI looks to define new relationships within the data sets. This might include gender, race, age, eye pressure, disease states or other relationships. It is an entirely agnostic process, devoid of preconception.
AI does not start with a predetermined notion but with a new frame of reference where only data relationships matter. For example, AI can predict gender in 97% of people by looking at a retina. It can see a relationship which is beyond the unassisted human mind to correlate. Disturbingly, we cannot interrogate the AI to ask how it knows because it has not been programmed to explain it to us.
Those things being said, we are near the biologic floor of biometry prediction now. The cornea, zonules, IOL tilt and capsule are the largest unknowns in any given patient. Interestingly, the post operative refraction, which can vary in a patient from day-to-day and between refractionists, is a significant error source in refractive results analysis.
What biometry fails, post operative manipulations can refine. The LAL, or light adjustable lens, had another outing at ASCRS this year. The lens is a photopolymer which can shape change upon UV exposure. It is a rather clumsy procedure in which a patient with post cataract refractive error is given a treating dose of UV which photopolymerises the IOL and creates a shape change. Then the patient must wear sunglasses for a few months to avoid any environmental UV exposure and then requires a fixing dose of UV to ‘lock in’ the changes.
The LAL is unlikely to be widely adopted in Australia. Here we can make post operative refinements with sulcus based piggyback lenses (US does not have them) and excimer corneal laser enhancements (PRK or LASIK). Enhancements are not easily available in the US under managed care, because it constitutes extra billing which is disallowed under most contracts. Therefore, to assure a refractive outcome a patient must self-insure, receive a premium lens or pathway, and lose insurance coverage. Yet again we are witnessing the perverse incentives that US managed care creates.
ASCRS wouldn’t be complete without the latest iteration of an accommodating lens implant.
The Jellisee accommodating IOL was presented and looks as good as any of the accommodating lens technologies to date. It is modelled on a fluid filled paediatric crystalline lens which has a stronger elastic anterior capsule, such that it is permanently accommodated. Dis-accommodation is necessary for distance viewing and is achieved by residual ciliary muscle activity. The curvature changes take place on the anterior capsule, thus making the posterior capsule irrelevant. Early human implants have demonstrated some success in pilot stages with accommodation up to 7D.
Sometimes everyday items can be reimagined. A new phaco handpiece was demonstrated by Dr Elizabeth Yeu. The ZEISS Micor 700 contains all the flow pumps in a small handpiece with no phaco machine needed. It requires only irrigating fluid plugged into the handpiece and takes a fraction of the time to set up. It is not traditional phacoemulsification. It seems to rely on mechanical energy with no ultrasound. Whether it is applicable to cataracts of all densities was uncertain to me.
The latest in glaucoma
The Innovators session is always stimulating. A new femtosecond laser procedure forming a trabeculotomy was demonstrated. Using a patient interface which includes a gonioscope, the laser is aimed at the trabecular meshwork creating a slit trabeculotomy which was patent up to several months. With the current Glaukos iStent, the trabecular Glaukos iDose slow-release implant and then this new femto laser, we may see glaucoma evolve into a purely surgical disease. It might be time to consider selling your shares in topical glaucoma medication companies!
It is truly remarkable to see the continued innovations that are occurring in ophthalmology. Most originate with small companies and enthusiastic researchers based on a clever clinical idea, a cross fertilisation with science industry, and commercialisation by a major player. So, if you have an innovative idea, it might be worth making a start on it today.
The wellness session
What is happiness? During the wellness session, Dr Daniel Lerner excerpted parts of his book Goodness, Greatness and Grit. The brief takeaway is that happiness is not just raw success or money. Positive emotions in life can be self-reinforcing. Keep a gratitude journal about the things you are grateful for. Take a three-minute breathing break from work twice a day to sit, breathe quietly and relax. Engage with others using your character strengths at work and enjoy what they have to offer to you. Keep your key home relationships healthy by reaching out to your loved ones every day, ask for help when you need it and offer help when it’s requested. Find activities that give you true meaning to your life by helping other people or making the world a better place.
Aussies matching it on world stage
When I attend conferences, I am looking to learn new ideas but also to self-check that I am thinking in the right ways. I think we all do this. What is profoundly obvious is that Australian ophthalmology is at or above the standards overseas. This is due to our mostly reasonable regulatory system allowing devices to be used here, our clinical independence from insurers and our excellent AUSCRS conference which parses and debates new technology and techniques.
Professor Graham Barrett deserves great credit for setting up AUSCRS and has created the local milieu for cataract and refractive surgeons to adopt early and develop expertise rapidly. AUSCRS will be held in Port Douglas on 26-29 July and the new co-presidents Professor Gerard Sutton and Dr Jacqui Beltz will no doubt continue the tradition of academic debate, lighthearted repartee and social generosity. If you missed ASCRS, then get to Port Douglas in July.