Best of the best 2020

Experts discuss the best ESCRS papers and posters

Dermot McGrath

Posted: Monday, March 1, 2021

A comprehensive study of rebubbling after Descemet’s Membrane Endothelial Keratoplasy (DMEK), the long-term outcomes in paediatric patients using an innovative bag-in-the-lens technique and a new fluid-filled, modular accommodating IOL for presbyopia were among some of the topics discussed in a special ESCRS online review session of the best free papers and poster prize winners from the 38th Congress of the ESCRS.

Co-chaired by Oliver Findl MD and Boris Malyugin MD, the review session brought together a panel of international experts – Béatrice Cochener-Lamard MD, PhD, from France, Rudy Nuijts MD, PhD, from the Netherlands and Marie José-Tassignon MD, PhD, from Belgium – to discuss the issues raised in the winning papers and posters and their significance on current and future clinical practice.

The session commenced with the best free paper for cornea from Sebastian Siebelmann et al entitled “The Cologne Rebubbling Study – an analysis of 624 rebubblings after Descemet’s Membrane Endothelial Keratoplasy (DMEK)”. Based on the study, the authors recommended performing rebubbling less than 10 days after surgery if the detachments were more than one-third of the graft area, and later than 10 days for similar size detachments depending on the clinical course and in cases of strong curling tendency of the transplant.

Dr Nuijts said he was a little surprised by the outcomes given that the Cologne centre performed a lot of DMEKs and the surgeons are experienced in this type of surgery. “The rate of one-third of patients having a detachment is pretty high I think.” He noted that data from the Dutch corneal transplant registry indicated a detachment rate of about 25%. Despite a lot of studies, he said it was still something of a mystery why detachments occurred so often, even in the hands of such very experienced surgeons as our German colleagues.

“We can do a perfect surgery and it still occurs. Is it something correlated to the storage medium that we use, with or without dextrane, or perhaps the positioning of the patient at home after surgery and whether they respect the instructions to remain in the supine position? There are still a lot of unanswered questions,” he said.

The panel next turned its attention to a poster study by Hélène Bailleul MD et al from France that looked at the rate of reintervention in paediatric cataract surgery with bag-in-the-lens (BIL) fixation over a 10-year period. The authors found that BIL fixation was feasible in over 90% of patients and a clear visual axis was maintained in 95% of children with a low rate of complications. Commenting on the poster, Marie-José Tassignon, the creator of the BIL fixation technique, said that the results were very much in line with her own experience with the lens and the learning curve involved. “We have published our own results in the JCRS and the complication rate was very low. It is why we have been able to push the indications for this lens and we can now operate on children as young as two months with very good results,” she said.

The next study under review was a free paper by Liliana Werner MD, PhD, et al on the long-term capsular bag clarity of a new fluid-filled, modular accommodating IOL. The Juvene IOL (LensGen Inc.) integrates a base lens supported by capsule-filling circumferential haptics and a fluid-optic, curvature-changing lens that allows for continuous range of vision.

The panel expressed reservations about the long-term capacity of the lens to resist fibrosis, pointing out that the study was in a rabbit model with just six months’ follow-up. Dr Nuijts added that the 3.0mm incision required for implantation would probably also impede uptake of the lens for many surgeons. Prof Cochener-Lamard said the lens followed in a long line of presbyopia-correcting IOLs over the past decade, none of which had really satisfied all the criteria required for widespread adoption. “It always returns to the same question – the predictability of the lens and the duration of the effect and its ability to remain transparent over time. I am also not sure that the ophthalmological community will accept a larger incision and to put these heavy materials into the capsular bag,” she said.

In the refractive poster category, the review panel discussed a study by Emilio Torres-Netto MD that looked at a photoactivated chromophore for infectious keratitis cross-linking (PACK-CXL) and concluded that 89% of eyes treated with this approach healed without the use of antimicrobial therapy.

Prof Cochener-Lamard said she would have ethical concerns about using this approach for treating serious infections when tried-and-trusted antimicrobial treatments are already available. “I think we need to be very cautious and not be seen to promote the idea that riboflavin cross-linking treatment might be sufficient on its own for treating infections,” she said. Dr Nuijts agreed and said that while the outcomes were interesting, he believed that such a study would probably not obtain approval in the Netherlands given the potentially serious consequences of infectious ulcers not being properly treated.