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JANUARY/FEBRUARY 2026 | VOLUME 31 | ISSUE 1

ESCRS Research Explores BigPicture Issues New and ongoing projects address key clinical issues and future needs.

ALSO IN THIS ISSUE Expanding the Reach of International Registry Data New approaches aim to personalise treatment with help from AI and a treasure trove of data.

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GLP-1RAs: a Cause for Concern? Experts discuss the issues of retinopathy and NAION.

Lumps and Bumps New column explores challenging cases involving eyelids.

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LIGHT UP YOUR LEARNING IN

Think of Helsinki and you may think of the northern lights (also known as the aurora borealis).The 2026 ESCRS Winter Meeting in Helsinki will offer an excellent opportunity to view the northern lights—and to ‘light up’ your knowledge and skills! The Winter Meeting offers a unique opportunity for ophthalmologists, surgeons, specialists, researchers, and industry representatives to exchange ideas and insights while also serving as an ideal forum to network and forge new connections in a more intimate setting. HONE YOUR SURGICAL SKILLS

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Experience the ultimate in practical learning with our immersive Surgical Skills Labs. Designed to deepen your expertise across cataract, refractive, and intraocular lens surgery, these popular hands-on sessions cover a broad array of essential topics.

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You’ll master fundamentals like phacoemulsification basics, learn advanced techniques for IOL implantation and astigmatism correction, and acquire crucial training in complication management (such as small pupil or zonular weakness) and MIGS procedures. Expert faculty lead every lab, combining detailed surgical demonstrations with direct, practical skills coaching. It’s an ideal setting to refine techniques, ask direct questions, and elevate your confidence in crucial surgical decision-making.

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Contents January/February 2026 | Vol 31 Issue 1

Lids: Lumps to Watch For Clare Quigley MD

Corneal Haze Update Sharita Siregar MD

GLAUCOMA 28

The Future of Glaucoma Medication Gauti Jóhannesson MD, PhD

Is AI a Future Frenemy? Luis Abegão Pinto MD, PhD, FEBOS-G

A Challenging Case of Aqueous Misdirection Andrew Tatham MD, MBA

PAEDIATRIC OPHTHALMOLOGY

08 Cover

ESCRS Research Explores Clinical Issues Large and Small New and ongoing projects address key clinical issues and future needs. 04

Editorial: Guidelines and Grey Areas

ESCRS Update: LBI Video Explores Challenges of Managing an Ophthalmic Team; New Educational Resources Available Online; BoSS Podcast Explores Generational Diversity in Ophthalmology

THEME

RETINA

Surgery for IOL Luxation in Vitrectomised Eyes Silvia Bopp MD

Options for IOLs in Eyes with Retinal Disease Andrea Hassenstein MD, FEBO, MBA

Finding the Right IOL After Corneal Surgery Ruth Lapid-Gortzak MD, PhD

MCO-010 Optogenetic Therapy for Vision Restoration Jordi Monés MD, PhD

Debating RLE in Younger Adults Murtaza K Adam MD, FASR; Kamran M Riaz MD

OCULAR UPDATE

The Power of Registries Madeleine Zetterberg MD, PhD

Personalising Care with Data Insights Line Kessel MD, PhD, FEBO

Late Post-LASIK Enhancements Steven J Dell MD; Julie M Schallhorn MD, MS

Retinal Detachment After Cataract Surgery Martin S Zinkernagel MD, PhD

CATARACT & REFRACTIVE

Collaborative Registries Aim to Improve Care Anders Behndig MD, PhD Long-Term Data Key to Surgical Success Flora Lum MD

WSPOS Myopia Consensus Statement Provides Clear Answers Ken K Nischal MD, FAAP, FRCOphth; Dominique Brémond-Gignac MD, PhD, FEBO

CORNEA 24

Postoperative Corneal Complications José Luis Güell MD, PhD

GLP-1RAs: A Cause for Concern? Francesco Bandello MD, FEBO; Enrico Borrelli MD, PhD, FEBO; Lonny Stokholm MScPH, PhD

INDUSTRY INSIGHTS 38

Global Ophthalmology Trends Stephen McLeod MD; Ronald Yeoh MBBS, FRCOphth; Francis S Mah MD; Nicole Eter MD; Filomena Ribeiro MD, PhD, FEBO; Newton Andrade Jr MD; Béatrice Cochener-Lamard MD, PhD; Luis Abegão Pinto MD, PhD, FEBOS-G

EUROTIMES | JANUARY/FEBRUARY 2026

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15 Publisher Tom Ogilvie-Graham Executive Editor Stuart Hales Editor-In-Chief Sean Henahan Senior Content Editor Kelsey Ingram Creative Director Kelsy McCarthy Graphic Designer Emily Christenson Circulation Manager Lucy Matthews

Contributing Editors Cheryl Guttman Krader Howard Larkin Roibeárd O’hÉineacháin Contributors Laura Gaspari Soosan Jacob Timothy Norris Andrew Sweeney Colour and Print CitiPost Advertising Sales Roo Khan MCI UK Tel: +44 203 530 0100 | roo.khan@wearemci.com

ALSO IN THIS ISSUE 40

Leadership, Business, and Innovation Who’s the BoSS?

Industry News

JCRS Highlights

Citation Index

Upcoming Events

EuroTimes® is registered with the European Union Intellectual Property Office and the US Patent and Trademark Office. Published by the European Society of Cataract and Refractive Surgeons, Suite 7–9 The Hop Exchange, 24 Southwark Street, London, SE1 1TY, UK. No part of this publication may be reproduced without the permission of the executive editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

Learn more about EuroTimes or connect with ESCRS at ESCRS.org JANUARY/FEBRUARY 2026 | EUROTIMES

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EDITORIAL

Guidelines and Grey Areas

n this issue, we highlight the impressive array of ESCRS-sponsored clinical research programmes, past, present, and future. Earlier large-scale studies, such as the ESCRS Endophthalmitis Study and the PREMED (Prevention of cystoid macular oedema after cataract surgery) study, forever changed clinical ophthalmology practice in Europe and beyond. We also explore how large registries such as EUREQUO are used not only to refine overall practice but also to personalise patient care. These research projects have been designed to address the major questions facing ophthalmology. The ESCRS tackled one of the biggest of these questions—what is the best way to perform cataract surgery—when it undertook its development of evidence-based guidelines. This involved a painstaking methodological process of collecting existing data, evaluating and grading it, and issuing recommendations. The researchers made every effort to avoid bias and conflicts of interest. The final result is a nearly 400-page document, with an executive summary of nearly 50 pages. Both are available online at escrs.org. The clinical recommendations are crucial for promoting better patient care and transparency and reducing unwanted practice variation. Key recommendations of these guidelines include (according to levels of evidence) the support of intracameral antibiotics for endophthalmitis prophylaxis, the use of topical anaesthesia, and the efficacy of femtosecond laser-assisted cataract surgery (FLACS). But not all the findings were black and white. The process of creating the guidelines also revealed areas where evidence

was low or moderate. So, what should we be doing? This was the title of a main symposium session at the recent ESCRS Congress in Copenhagen discussing that very question. The guidelines mention ‘knowledge gaps’ that limit the span of recommendations in some areas. Many presenters referred to ‘grey areas’ when it comes to applying the guidelines, which will doubtless form the basis for further research projects. Yet the guidelines will continue to evolve, with updates planned for every five years. Ultimately, addressing the grey areas in cataract surgery underscores the evolutionary nature of clinical research. As the science advances, the cataract procedure is no longer simply about removing a cloudy lens; it is about tailoring vision to individual lifestyles and expectations. Part of our remit at EuroTimes is to present and discuss the implications of ESCRS research projects. Accordingly, we will include a series of articles in coming editions that take a deeper look at some of the issues and grey areas raised in the ESCRS Cataract Surgery Guidelines. We will also provide updates on the ESCRS guidelines for refractive surgery, which are now undergoing the same rigorous methodology as the cataract guidelines and are expected to be released later this year. To quote Albert Einstein, “The important thing is not to stop questioning. Curiosity has its own reason for existing.” Sean Henahan Editor-in-Chief

EDITORIAL BOARD

Thomas Kohnen

José Güell

Adi Abulafia (Israel) Bruce Allan (UK) Noel Alpins (Australia) Juan Alvarez de Toledo (Spain) Gerd Auffarth (Germany) Başak Bostanci (Türkiye) John Chang (Hong Kong SAR, China) Béatrice Cochener-Lamard (France) Burkhard Dick (Germany) Mor Dickman (The Netherlands)

Joaquín Fernández (Spain) Oliver Findl (Austria) Nicole Fram (US) Sri Ganesh (India) Farhad Hafezi (Switzerland) Nino Hirnschall (Austria) Soosan Jacob (India) Jack Kane (Australia) Yao Ke (China) Mika Kotimäki (Finland)

Paul Rosen

David Lockington (UK) Artemis Matsou (Greece) Cyres Mehta (India) Jod Mehta (Singapore) Sorcha Ní Dhubhghaill (Belgium) Rudy Nuijts (The Netherlands) Catarina Pedrosa (Portugal) Konrad Pesudovs (Australia) Nic Reus (The Netherlands) Filomena Ribeiro (Portugal)

Andreia Rosa (Portugal) Giacomo Savini (Italy) Julie Schallhorn (US) Sathish Srinivasan (UK) Paola Vinciguerra (Italy) Shin Yamane (Japan) Ron Yeoh (Singapore) Mihail Zemba (Romania)

EUROTIMES | JANUARY/FEBRUARY 2026

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FULL PAGE AD

Educational Resources Advanced FEBOS-CR Exam/Diploma (Cataract and Refractive Surgery) ESCRS iLearn • ESCRS Research Portals • Important Publications ESCRS EuroTimes Podcasts • ESCRS on Demand • JCRS Online Case Reports The Video Journal of Cataract, Refractive, and Glaucoma Surgery

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ESCRS UPDATE

ESCRS Update LBI Video Explores Challenges of Managing an Ophthalmic Team

The ESCRS Leadership, Business, and Innovation (LBI) programme hosted a webinar on 23 October that looked at the factors involved in managing a team within an ophthalmic practice. The 37-minute webinar featured a discussion among three speakers: Matt Jensen, senior vice president of client services at RightSourcing in the United States; Vincent Qin, an ophthalmic surgeon at the Catholic University of Louvain in Brussels, Belgium; and Başak Bostanci, medical director at the World Eye Hospital in Istanbul, Türkiye. Drs Qin and Bostanci are both members of the ESCRS LBI Committee. The webinar addressed several issues related to managing an ophthalmic team, including hiring and retaining staff, communicating to ensure smooth team functioning, keeping team members motivated, and helping team members feel they are playing an essential role in the patient journey. “A team and its management are, I believe, among the most important things in healthcare today,” Jensen said. “We have a minimal number of providers, and that number is—depending on which subspecialty you’re looking at—going down, as compared to the rising population. This means access is becoming a real challenge, and providers can only provide so much efficiency and so much technological advancement. So they have to rely on their non-practicing partners or business managers to succeed.”

To view the webinar, scan the QR code.

New Educational Resources Available Online

The ESCRS independent medical education (IME) programme has added several new resources for ophthalmic surgeons that are available on the Society’s website. A 12-page report (mailed with hard copies of the January–February 2026 issue of EuroTimes) examines key findings from the 2025 ESCRS Clinical Trends Survey and provides an in-depth analysis of how Society members approach glaucoma management, with a particular emphasis on minimally ESCRS Clinical Trends Series: invasive glaucoma surgery (MIGS). Glaucoma Another report, about refractive IOLs, will be available exclusively on the ESCRS website. Several recent IME video interviews are also available online. In a video that aired on 21 November, Drs Francesco Carones and Andrea Janeková explain why a healthy ocular surface is essential before cataract refractive surgery. Even mild dry eye can skew keratometry readings and IOL calculations, yet this condition is often overlooked. Left untreated, dry eye can cause refractive surprises and postoperative dissatisfaction. Drs Carones and Janeková stress a thorough ocular surface evaluation and show how treating dry eye beforehand ensures more accurate results, better outcomes, and happier patients. In another video interview, Drs Nic Reus and Ramza Diamanti discuss the critical role of modern diagnostic tools in achieving accurate IOL power calculations and selecting the optimal lens. They highlight key innovations that enhance precision, emphasise the importance of axial length measurement and corneal topography, and explore how advancements in calculation formulas have improved clinical decision-making and patient outcomes. Additional IME videos available on the ESCRS website include the following: • Optimizing Refractive Surgery Success: From Preoperative Planning to Patient-Centered Communication (Bruce Allan and Thomas Kohnen) • Modern Presbyopia Correction: Innovations in IOL Technology and Customized Patient Planning (Joaquín Fernández and Oliver Findl) ESCRS SURVEY REPORT | JANUARY/FEBRUARY 2026

To see all IME resources, scan the QR code.

EUROTIMES | JANUARY/FEBRUARY 2026

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A team and its management are, I believe, among the most important things in healthcare today. — Matt Jensen, Senior Vice President, RightSourcing

In a podcast that aired on 13 November, several guest speakers explored how generational perspectives influence values and attitudes toward work culture, collaboration, and sharing knowledge. Moderated by BoSS co-chairs Artemis Matsou and Diana Silva, the podcast featured speakers from Alcon, the University of Nottingham, Generation STORM, and the University of Bradford as well as ESCRS Trustee John Bateson. The podcast included conversations about the following: • How generational perspectives influence values and teamwork

• Balancing hierarchy with collaboration • Mentorship and knowledge transfer • Embracing new technologies • Fostering respect across diverse teams

To view the podcast, scan the QR code.

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JANUARY/FEBRUARY 2026 | EUROTIMES

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COVER ARTICLE

ESCRS Research Explores Clinical Issues Large and Small New and ongoing projects address key clinical issues and future needs. BY SEAN HENAHAN

n a few short years, the ESCRS has evolved from a regional organisation of cataract surgeons to a leading authority in international ophthalmology research, particularly projects involving the anterior segment. ESCRS has sponsored numerous landmark studies that have changed clinical practice worldwide. Indeed, keeping up with the number and reach of ESCRS research projects—past, present, and future—is becoming increasingly difficult. Let’s start the new year with a timely update. ESCRS research projects take many forms, such as ongoing long-term registry studies (such as the European Registry of Quality Outcomes for Cataract and Refractive Surgery, EUREQUO), large clinical studies, and collaborative working groups addressing specific clinical questions as well as support for new, smaller-scale proposals that encourage young ophthalmologists to pursue research ideas in areas such as AI and sustainability. “ESCRS supports high quality, evidence-based studies to drive innovation in ophthalmology. Our mission is to identify key challenges, foster global collaboration, and translate discoveries into real-world benefits for doctors and patients,” said Farhad Hafezi MD, PhD, incoming head of the ESCRS Research Committee. Larger-scale projects have included the landmark ESCRS Endophthalmitis Study, the PREvention of Macular oEDema after cataract surgery (PREMED) study, and, more recently, the Effectiveness of Periocular drug Injection in CATaract surgery (EPICAT) study and the

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COVER ARTICLE

MYOPRED study (Influence of posterior vitreous detachment on retinal detachment after lens surgery). Each of these studies provided evidence-based answers to some of the bigger questions in clinical ophthalmology and have helped transform practices worldwide—all with support from the ESCRS Clinical Research Award (CRA) programme. The CRA is for bigger projects, multicentre pharmacological and device trials, and surgical techniques as well as studies looking at bigger topics such as outcomes, where a lot of money is involved, explained incoming ESCRS president Burkhard Dick MD, PhD. The CRAs also aim to engage and encourage the networking potential of the ophthalmic clinical community across the European Union with the common aim of improving both patient care and clinical outcomes, he noted. ESCRS also supports research focused on existing published material. The Systematic Review Award (SRA) programme encourages the development of high-quality reviews of cataract and refractive surgery literature, following the methodology of the Cochrane Library reviews.

Young ophthalmologist opportunities

The Society offers a wealth of opportunities for researchers in the early stages of their careers. The Pioneer Research Award programme, for example, supports ophthalmologists younger than 45 who are just starting their independent clinical research. The Pioneer Research Award aims to support and encourage independent clinical research in the field of cataract and refractive surgery, providing up to €50,000 for a single project lasting up to two years. Young ophthalmologists are also eligible for several ESCRS-sponsored fellowships, including the Peter Barry Fellowship, which provides support for research abroad, as does the ESCRS/Alcon Fellowship. Additionally, ESCRS supports a fellowship in partnership with the European Society for Advanced Studies in Ophthalmology (ESASO).

Be SURE about sustainability

A new programme, the Sustainability Research (SURE) Award, aims to promote sustainable practices in all areas of eye care. Ophthalmologists, ophthalmic nurses, and clinical researchers, especially those in the early stages of their careers, can apply for grants to support efforts to reduce waste, improve workflows, and implement innovative new protocols. Ophthalmology is at the forefront of the current digital transformation of healthcare, as evidenced by another new ESCRS programme, the Digital Research Awards. These awards support research projects that use AI to improve diagnostics, personalise treatments, and enhance patient care. The ESCRS Digital Health Special Interest Group builds on this commitment by creating online resources to support digital research. Resources now include a searchable online database of links to existing open-access image data sets relevant to cataract, cornea, and refractive surgery. The ESCRS is playing an increasing role in establishing clinical standards and guidelines, with the last two years seeing several important studies emerge. This includes the publication of the ESCRS Cataract Surgery Guidelines, the ESCRS Functional Vision Working Group on Simultaneous Vision IOL Classification, and the successful collaboration between the ESCRS and ASCRS to better define the diagnosis and treatment of astigmatism.1–3 “Scientific progress does not happen in isolation. ESCRS brings together researchers, clinicians, and industry partners to drive innovation in ophthalmology,” Dr Hafezi said. “By encouraging early career researchers, we are investing in the future of ophthalmic research.” More information on all these ESCRS research projects can be found on the research portal, www.escrs.org/research. For citation notes, see page 44.

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THEME

The Power of Registries Swedish experience with cataract surgery registries serves as a successful model. HOWARD LARKIN REPORTS

ore than three decades of data from the Swedish National Cataract Registry suggest quality registries can provide important information on cataract surgery risk factors, especially for rare complications such as endophthalmitis, according to Madeleine Zetterberg MD, PhD.1 These registries can enable better surgical planning and patient selection, which may lead to safer surgery with fewer complications and better outcomes. “The general strategy [for boosting outcomes] is to get knowledge on how to choose the right patient at the right time point for surgery and the right procedure,” Professor Zetterberg said. “Choosing the right prophylaxis to control inflammation and prevent infection and the right intraocular lens are also critical, as is communicating with patients to establish realistic expectations, often leading to higher satisfaction.” Originally founded in 1992 to track waiting times, the Swedish registry is now considered the most comprehensive record of cataract surgery anywhere in the world. It includes data on nearly 3 million procedures, currently covering about 93% of cataract surgeries performed at more than 100 surgical units nationwide. Over time, it has added features, including preand intraoperative data, outcomes and patient-reported outcomes (PROMs), and individual surgeon identifiers. Data collected preoperatively includes keratometry, axial length, lens formula, and planned refraction. Postoperatively, keratometry is collected as well as best-corrected visual acuity (BCVA), refraction, type of IOL, type of surgery, and any need for further follow-up. PROMs are collected preoperatively and three months postoperatively. This makes the registry a valuable trove for driving and documenting quality improvement.

Steady progress

The registry shows consistent improvement in several outcomes over time, Prof Zetterberg noted. For example, the percentage of patients without comorbidities achieving postoperative BCVA of 0.8 decimal or better increased from about 70% in 1997 to close to 90% in 2020 and 2021, while the median BCVA increased from 0.8 to 1.0 in 2024. Similarly, biometry prediction errors declined, with only about 55% within 0.5 D from planned refraction in 1997 to about 75% in 2024. “The median biometry prediction error has been zero since 2006,” she said. PROMs have also improved, with both pre- and postoperative subjective visual function, as measured by the Catquest-9, gaining over time. When combined with other registry data, this has yielded valuable insights for selecting and counselling patients, Prof Zetterberg observed. Insights include: older patients benefit as much as younger patients; comorbidities are

Quality registries may lead to safer surgery with fewer complications, which is especially good for rare complications.

the most common cause of bad PROMs outcomes; surgery in both eyes gives better outcomes; age-related macular degeneration patients benefit significantly from cataract surgery; and subjective improvement lasts a long time after surgery. And, crucially, good preoperative BCVA decreases the risk of dissatisfaction.

Understanding complications Complications also have declined, thanks in part to insights from the

Postoperative Visual Acuity over time Q1, Median och Q3 per year

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THEME

registry. One analysis found risk factors for posterior capsule rupture (PCR) include dense cataracts/use of Vision Blue, miosis/mechanical dilation, zonular weakness, inexperienced surgeons, and previous ocular trauma.2 PCR rates have fallen from about 2.8% in 2002 to about 0.5% in 2024. Other registry studies suggest achieving a PCR rate of less than 1.0% requires surgeons to perform at least 400 procedures per year.3,4 However, higher-volume surgeons tend to have a slightly lower case severity mix, which Prof Zetterberg said may contribute to their lower PCR rates. Sweden has collected data on endophthalmitis in a separate registry since 1998, including patient identification and time point of diagnosis, culture results (including pathogen and susceptibility to antibiotics), and visual outcomes post-diagnosis. Findings helped spur the landmark ESCRS Endophthalmitis Study in 2007, which found intracameral antibiotics are effective in reducing incidence.5 Since records began, the rate of endophthalmitis in the registry has fallen from 0.10% to 0.01%. Of interest, the rate for immediate sequential bilateral cataract surgery has been lower than for unilateral surgery. In recent years, the registry has also documented a decline in cefuroxime use and an increase in moxifloxacin. The Swedish National Cataract Registry also tracks comorbidities and their impact on outcomes and complications after cataract surgery, Prof Zetterberg said. Visual outcomes, patient satisfaction, and the need for additional procedures are all worse for patients with comorbidities ranging from glaucoma and macular disorders to corneal guttata and previous vitrectomy or refractive surgery. For example, patients with corneal guttata have about 68 times the rate of corneal transplants after cataract surgery as patients without.6

information for decision making and quality control. At the national level, the data help develop evidence-based guidelines as well as plans for healthcare resources. Future study topics include regional differences in access and outcomes, determining the optimal time for surgery, outcomes for diabetic patients, retinal detachment and PROMs, gender perspectives among surgeons, and new antibiotic regimens for preventing endophthalmitis. “Quality registries may lead to safer surgery with fewer complications, which is especially good for rare com-

plications, and it may enhance outcomes,” Prof Zetterberg concluded. Prof Zetterberg spoke at the 2025 ESCRS Annual Congress in Copenhagen. For citation notes, see page 44.

Madeleine Zetterberg MD, PhD is Senior Consultant and Head of Department at the Department of Ophthalmology, Sahlgrenska University Hospital/ Mölndal and Professor at the Department of Clinical Neuroscience, University of Gothenburg, Sweden. madeleine.zetterberg@gu.se

Posterior capsule rupture — change over time

Intracameral antibiotics — change in regimen over time

Real-world uses

Outcome data from the registry help individual surgeons monitor procedure volume, case mix, and complication rates, Prof Zetterberg said. For individual departments, the data are valuable for monitoring volume, providing

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Personalising Care with Data Insights Cross-referencing databases and registries can help predict individual needs. HOWARD LARKIN REPORTS

he age of individualised care is dawning. Powerful computer platforms are beginning to cross-reference massive amounts of data stored in various medical record systems, registries, and other databases to help predict disease and treatment responses in individual patients. This should enable tailored screening, prevention, and earlier treatment that can improve health outcomes and optimise resource use. However, while healthcare budgets hover around 10% of gross national product throughout the developed world, many people still develop preventable diseases or suffer injury or death for lack of timely treatment, said Line Kessel MD, PhD. Personalised medicine can address this in part by using genomic, socioeconomic, and other ‘omic’ data to identify and avoid treatments unlikely to work in a specific patient in favour of treatments that will work. This is especially important for high-cost treatments, including anti-VEGF agents and highly specific cancer drugs, she added. “At some point we are all going to have a lifelong healthcare plan that is tailored to the specific individual, and it’s all going to be based on the enormous amount of healthcare data and other data out there,” Professor Kessel said. “It is like looking into the future to see what lies ahead for all of us.”

The role of registries

Registry data can play an important role in personalising care. For example, data from the Swedish National Cataract Registry show that approximately 10% of male patients who are younger than 60 years old with an axial length of more than 25.0 mm will have a retinal detachment within 5 years after cataract surgery—a rate much higher than in other groups.1 This enables patient counselling and post-surgery monitoring to address the risk. “That’s taking registry data to an individual level,” Prof Kessel said. Similarly, registry data showed that children with congenital cataract were diagnosed earlier more often in Sweden, where red reflex testing of newborn infants was routine, than in Denmark, where it was not.2 This is important because early surgery is required to avoid permanent visual impairment due to irreversible amblyopia, Prof Kessel noted. As a result, red reflex testing has been added to newborn screening in Denmark, as have genetic tests for several metabolic diseases with ocular manifestations. This early testing allows for diagnosis before it’s too late for effective treatment. Indeed, while childhood visual impairment prevalence has remained stable in recent years, fewer

children are blind due to retinal detachment from retinopathy of prematurity, Prof Kessel noted.3 Conversely, registry data can be used to reduce testing. For example, diabetes studies in Denmark led to recommendations for longer screening intervals for patients without diabetic retinopathy and fewer screenings for pregnant patients without retinopathy. Comprehensive health registry data can be combined with other information, such as education level and income, to guide prevention and treatment strategies. It may even be used across generations to identify risk factors in children based on their parents’ health profiles, Prof Kessel said. Several patients with retinal disease have been discovered through genetic and pedigree screening for the RPE65 gene, enabling gene therapy. Prof Kessel spoke at the 2025 ESCRS Annual Congress in Copenhagen. For citation notes, see page 44.

Line Kessel MD, PhD, FEBO is professor and senior consultant at Rigshospitalet and the University of Copenhagen, Denmark. line.kessel.01@regionh.dk

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THEME

Collaborative Registries Aim to Improve Care Post-market product surveillance remains a never-ending challenge. HOWARD LARKIN REPORTS

omplying with regulatory requirements is a big motivator for surgeons and clinics to participate in post-market surveillance of drugs and devices. But detecting adverse events in the real world, comparing new products or treatments with the standard of care, and updating clinical guidelines if some patient groups benefit more than others are more substantive reasons, reports Anders Behndig MD, PhD. Registries, such as those run by national societies and the ESCRS, are good vehicles for conducting such surveys. And more collaboration among clinicians, governments, and industry will help. “Unleashing collaboration sounds very good,” Professor Behndig said. He pointed out that the US FDA defines post-market surveillance as “the active, systematic, scientifically valid, collection, analysis, and interpretation of data or other information about a marketed device.” “The key words here are ‘scientifically valid,’” Prof Behndig said. “This is all about real-life data from real patients being operated in real procedures,” so consistency and accuracy of reporting are critical. Prof Behndig’s home nation of Sweden has had a cataract registry since 1992, and many other countries have added them in subsequent years. They can collect and analyse large volumes of data to answer questions about real-world device use, typical target populations, and product performance

across subgroups defined by age, gender, ethnicity, and geography. Such data have led to important advances in patient safety, including the use of intracameral antibiotics to prevent endophthalmitis, and continuous improvement of refractive outcomes. “We have questions like, ‘How does a particular IOL perform in very high hyperopes?’” Prof Behndig noted. “It is a very small group of patients, and an individual clinic or clinician can never answer such a question.” But gathering data on new products or procedures from existing registries is not always possible, simply because they may not be collecting the right information, Prof Behndig said. Creating a whole new registry is possible and widely practised for post-market surveillance, but it is expensive and time consuming. “Probably the best way to go about this is partnering and collaborating with an existing registry.” The ESCRS registries were initially funded by the EU and are now supported by the Society. The format of the EUREQUO and other ESCRS registries is now used for ESCRS clinical trials, Prof Behndig noted. “In time, we will gather good scientific data that can be useful in post-market surveillance.” The ESCRS registries have created an industry task force to explore collaboration with academic and industry leaders. Its primary goal is to co-create a sustainable operating model for the ESCRS registries rather than pursuing purely company-specific objectives. Other goals include standardising data sets, sharing data, conducting studies, and initiating dialogue among regulators, companies, patient advocates, and registry holders. Possible concerns include privacy and security, competition, generalisability and data quality, and cultural challenges among different organisation types. But these can be addressed, Prof Behndig said. “The goal is a new form of collaboration beyond the public-private partnership model,” he explained. “Together, we can exchange data and use the registries to create public value.” Prof Behndig spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Anders Behndig MD, PhD is the co-chair of EUREQUO, former Head of the Swedish National Cataract Register and Swedish Ophthalmological Society, and Professor at Umeå University Hospital, Sweden. anders.behndig@umu.se

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Long-Term Data Key to Surgical Success Registry studies shed light on post-cataract surgery outcomes and risks. HOWARD LARKIN REPORTS

ong-term data collected by eye care registries are important for monitoring the safety and effectiveness of, and patient satisfaction with, cataract surgery. The insights gained inform advances in surgical techniques and technologies and guide preoperative decision-making, patient selection, and patient counselling, said Flora Lum MD. In the US, the IRIS® Registry (Intelligent Research in Sight), run by the American Academy of Ophthalmology, tracks eye care across all types of ophthalmic practices. Launched in 2014, the registry now includes about 70% of US ophthalmologists and is integrated with practice electronic health record systems. It currently includes data on more than 800 million visits by nearly 86 million unique patients spanning as long as 12 years, Dr Lum said. The IRIS Registry uses a randomly generated, unique patient identifier number to enable tracking of individual patients across practices—yielding greater information on how cataract surgery affects other ocular conditions over time. For example, its data show that within 1 year of cataract surgery, retinal detachments occur in about 0.21% of cases and retinal tears in about 0.17%. Because the IRIS Registry is integrated with electronic health records from retina and cataract practices, it also has identified several risk factors. Lattice degeneration is the most significant, increasing risk about 10-fold. High myopia, hypermature cataracts, complex cataract surgery, and posterior vitreous detachment all add risk as well.1 Similarly, data from nearly 2 million cataract patients show that those with higher intraocular pressure (IOP) immediately after cataract surgery have about double the risk of developing primary open-angle glaucoma (POAG) compared with normal IOP patients, with a median time to glaucoma diagnosis of 682 days. And the higher the IOP, the greater the risk.2 “Elevated postoperative IOP is a risk factor associated with future POAG development that is independent of age,

The registry now includes about 70% of US ophthalmologists and is integrated with practice electronic health record systems. sex, race, and ethnicity,” Dr Lum said, advising surgeons to monitor patients who had high postoperative IOP spikes after cataract surgery for potential glaucoma development. IRIS Registry studies also show that children with aphakia and a history of trauma are at higher risk for retinal detachment after cataract surgery.3 Those with a history of trauma, uveitis, or retinopathy of prematurity have higher risk for visual axis opacification, and anterior vitrectomy reduces the risk somewhat.4 Such insights guide practice and follow-up, allowing surgeons to make better treatment decisions and counsel patients on what to expect. Long-term follow-up also improves understanding of patient experience over time, flags complications to watch for, and highlights opportunities to improve treatments and evaluate devices and pharmaceuticals. Ultimately, this improves long-term surgical outcomes and patient satisfaction, Dr Lum concluded. Dr Lum presented at the 2025 ESCRS Annual Congress in Copenhagen. For citation notes, see page 44.

Flora Lum MD is vice president of quality and data science at the American Academy of Ophthalmology. flum@aao.org

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Surgery for IOL Luxation in Vitrectomised Eyes Decision making requires consideration of numerous factors. CHERYL GUTTMAN KRADER REPORTS

ultiple options exist for managing intraocular lens (IOL) luxation in a vitrectomised eye. With a surgical plan that considers the pros and cons of the various choices, the existing clinical situation, and surgeon expertise, a good and stable refractive outcome can be achieved in most cases, said Silvia Bopp MD. Speaking during a EURETINA/ESCRS joint symposium in Paris, Dr Bopp discussed considerations for choosing refixation versus IOL exchange. In addition, she reviewed IOL choices and fixation techniques with a focus on the advantages, limitations, and indications for using the iris-fixated Artisan Aphakia lens (model 205), scleral-fixated three-piece foldable hydrophobic acrylic IOLs with polyvinylidene fluoride (PVDF) haptics (e.g., Avansee, Kowa and CT Lucia 202, Zeiss), and the FIL-SSF (foldable intraocular lens – sutureless scleral fixation, Carlevale) IOL as secondary implants. Based on these issues, Dr Bopp said her preference is to perform an IOL exchange using the FIL-SSF IOL. “The FIL-SSF is the only IOL that has been specifically developed and approved for scleral fixation,” she explained. “It is a foldable lens with a large (6.5 mm) optic, and the implantation surgery, which is a sutureless technique, is a

reproducible procedure. In addition, because of its specific design that provides four-point support with two-point fixation, the FIL-SSF IOL maintains a stable position postoperatively. In fact, studies show the degree of postoperative tilt with the FIL-SSF IOL is comparable to that of IOLs implanted in an intact capsular bag.”

Pros and cons of refixation

Dr Bopp said the main advantage of reusing the primary IOL is that, compared to an exchange procedure, the surgery itself exposes the cornea to less iatrogenic stress. When considering refixation, however, surgeons need to think about the exact design of the primary IOL in terms of its shape, dimensions, and angulation. “My recommendations are that a three-piece hydrophobic IOL with filamentous (flexible) haptics are best suited for reimplantation and that they should be refixated with a sutureless technique,” Dr Bopp said. She advised against refixation of one-piece IOLs because these implants usually have sharp edges and no angulation. Therefore, their repositioning risks the development of reverse pupillary block and uveitis/glaucoma/hyphaema.

Options for secondary IOL implants include conventional posterior chamber IOLs, which can be used for scleral fixation, either by suture or sutureless. The Carlevale-type IOL has been designed as a secondary IOL for sutureless scleral fixation.

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Comparison between the three most appropriate IOL types for lens exchange in vitrectomised eyes show design (top), postoperative appearance (haptics indicated by arrows), and haptic position by UBM.

In addition, the suturing technique can be challenging, and with the two-point fixation, it can be difficult to achieve a truly tilt-free, symmetric position.

Options for IOL exchange

Discussing the Artisan Aphakia, threepiece foldable hydrophobic acrylic IOLs, and FIL-SSF IOL as options for exchange, Dr Bopp said the advantages of the Artisan IOL include its use with or without anterior or complete vitrectomy, its fast and easy implantation, and its ability to provide a good barrier if gas or silicone tamponade is needed. However, the Artisan IOL also has several drawbacks, including a relatively small optic (5.0 mm), its rigid PMMA material that mandates implantation through a 5.0 mm incision, and risks for inducing iridodonesis, pupil distortion, and uveitis. It also carries a 5% risk of chronic cystoid macular oedema and a 10% rate of haptic release. “The indication for using an Artisan IOL would be a healthy eye with a robust, pigmented iris and no uveitis, glaucoma, or retinal detachment,” Dr Bopp said, adding that outcomes for achieving a target refraction within 1.0 D and for maintaining positional stability are poorer for the Artisan IOL compared with the FIL-SSF and threepiece IOLs. The three-piece hydrophobic acrylic IOLs can be implanted with a sutureless scleral tunnel technique and

Late IOL luxations are becoming more frequent, probably due to longer life expectancy and increasing numbers of younger people undergoing phacorefractive surgery. are versatile and practically universally applicable. However, complete pars plana vitrectomy (PPV) is necessary when choosing one of these lenses, and there are postoperative risks of haptic externalisation as well as tilt and iris capture if the scleral tunnel is not perfectly symmetrical when created. Data on achieving target refraction and centration, tilt, and stability show outcomes with the three-piece IOLs are not as good as with the FIL-SSF, Dr Bopp said. Complete PPV is also necessary when using the FIL-SSF IOL, and it carries a risk of reverse pupillary block. Additionally, its hydrophobic material means calcification can occur if there is a later need for air or gas tamponade. “With the latter risk in mind, the FIL-SSF IOL should be used in patients with a stable retinal situation,” Dr Bopp said.

A looming epidemic

Dr Bopp observed that late IOL luxations are becoming more frequent, probably due to longer life expectancy and

increasing numbers of younger people undergoing phacorefractive surgery. “Considering that 50% of the population is 50 years and older and potential candidates for lens replacement, the cumulative incidence of IOL subluxation is 3% over 25 years,” she said. “As late IOL dislocation occurs at an average of 8 to 12 years, we can expect a wave for such problems.” The likelihood of needing to manage IOL subluxation in a vitrectomised eye is increased by the fact that previous vitrectomy is a leading risk factor for this complication. “In our clinic, about 60% of late IOL dislocations were in eyes with previous vitrectomy,” Dr Bopp said. Dr Bopp spoke during a joint ESCRS/ EURETINA symposium at EURETINA 2025 in Paris.

Silvia Bopp MD is a senior consultant specialising in retinal and vitreous surgery at Bergman Clinics, Bremen, Germany. silviabopp@icloud.com

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Finding the Right IOL After Corneal Surgery The criteria for achieving the best outcomes for cataract patients after corneal surgery are remarkably diverse. ANDREW SWEENEY REPORTS

urgeons will note a lack of research on performing cataract surgery after cornea surgery, especially regarding simultaneous vision intraocular lenses (SVL). According to Ruth Lapid-Gortzak MD, PhD, this research has contradictory results. “One paper showed that patients reported higher satisfaction with worse refractive outcomes. I wish they’d come to my clinic, because this doesn’t reflect my experience.” Dr Lapid-Gortzak drew on her own experience to provide some clarity, starting with an outline of the two strategies currently used for treating this highly specific group of patients. The first is to restore corneal asphericity before cataract surgery, followed by the procedure with an SVL. Dr LapidGortzak said this strategy has the benefit of providing more control to the clinician, but as with any extra procedure, there are associated costs and risks. The second strategy is to deal with these patients “within the limitations our daily practices allow.” This more cautious approach is easier to apply, and naturally has fewer costs and risks, but it is “not academic.” Both approaches, she said, also require more research. Conductive keratoplasty (CK) came under criticism too. Dr Lapid-Gortzak said she had treated several patients who had undergone CK, describing the results with SVLs as suboptimal due to corneal irregularity. She advised against using SVLs in patients post-radial keratotomy as well, describing its results as “suboptimal, with an unstable cornea, higher-order aberrations, and irregular topographies leading to very unpredictable outcomes.” The key to successfully treating cataract patients postcornea surgery is choosing the right IOL, Dr Lapid-Gortzak said. Simultaneous vision IOLs may appear as an “easy way out,” but she cautioned that some of these lenses are actually “plain bifocal diffractive lenses that do not give anything on reading distance.” Dr Lapid-Gortzak also added that refractive lenses tend to create more side effects due to their different refractive surfaces, which can have a considerable impact on patient outcomes, depending on the lens. “I’ve seen a lot of people who have had different types of laser surgery,” she said. “From my own experience, I learned that the moment they have had surgery for more than five dioptres of myopia, the cornea won’t always work with a trifocal or diffractive lens.” The key to selecting the right lens for those good outcomes, therefore, lies in screening patients, Dr Lapid-Gortzak said. Those with a K value between 40 D and 45 D, a good tear film,

etc., could be candidates for a diffractive premium IOL, while those with more negative indications could be candidates for a different SVL. Their personal circumstances should also be considered too. “If someone comes to you and they got divorced two months before, they may project their frustration on you, so be careful,” Dr Lapid-Gortzak advised. “I always discuss the possibility of dissatisfaction, but you should always take their behaviour into account.” Dr Lapid-Gortzak spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Ruth Lapid-Gortzak MD, PhD is a cataract, cornea, and refractive surgeon at the Amsterdam University Medical Centers, Netherlands. r.lapid@amsterdamumc.nl

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Debating RLE in Younger Adults Considering the risks against the alternatives to refractive lens exchange. CHERYL GUTTMAN KRADER REPORTS

n unacceptably high risk of retinal detachment (RD) that could result in blindness argues strongly against performing refractive lens exchange (RLE) for extreme refractive error in patients younger than 40 years, according to Murtaza K Adam MD, who took the con position in a point-counterpoint debate held during the annual conference of the American Academy of Ophthalmology. Assigned as the proponent for performing RLE, Kamran M Riaz MD prefaced his presentation with a “protest” that he had a very difficult position to argue. He acknowledged that RLE is not a “cookie-cutter option” for all such patients but said careful patient selection and extensive counselling could make it a reasonable, definitive, and durable option for certain individuals for whom corneal laser vision correction (LVC) or a phakic IOL are not safe, viable, or economical.

Careful patient selection and extensive counselling could make RLE a reasonable option. Why not RLE?

To emphasise the risk of RD, Dr Adam, a retina specialist, reported a case from his personal files involving a 40-year-

old female who presented with a macula on RD and vitreous haemorrhage in her left eye four months after undergoing bilateral RLE. The repair seemed to have gone well. Then, one month later, the patient returned needing surgery for a macula on RD in the right eye, which also seemed to go well. Over the next several months, however, the patient required additional surgeries in both eyes for new complications. At last follow-up, her vision was 20/20 in the right eye and “count fingers” in the left eye. “I ask you, are glasses and contacts really that bad?” Dr Adam said. Admitting that this case, which he encountered in his second year of practice, might have pushed him to be an alarmist, Dr Adam presented evidence on RD risk to strengthen his position against performing RLE. He cited a paper reporting a 17.1% incidence in eyes with an axial length greater than or equal to 27 mm, along with a Danish registry-based cohort study of patients who had unilateral cataract surgery, that found the risk of RD was significantly higher in pseudophakic than phakic eyes among younger individuals and males.1,2 “There are many other risk factors to consider, including hyaloid status, presence of lattice degeneration, family history of RD, and fellow eye history,” Dr Adam cautioned. “So, when you are feeling pretty good about a patient who wants RLE, do not ignore that feeling of unease that something might go wrong.”

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Possible scenarios for RLE

Asking his colleagues to keep their minds open to the possibility of performing RLE for extreme refractive error in young patients, Dr Riaz outlined features describing potential candidates. He said the easiest argument for performing RLE could be made for addressing anisometropia in patients with unilateral cataract or traumatic aphakia. Other possibilities included patients with contact lens intolerance who had a contraindication to LVC or phakic IOL surgery, patients at risk for angle closure, and those with a dysfunctional lens index measured by raytracing technology. He also proposed cost as a consideration, noting that compared with RLE, a phakic IOL or LVC may be more expensive and require a second surgery. “Why choose RLE? When we approach corneal limits or higher refractive limits for LVC or phakic IOLs, and there is excellent anatomy, RLE has a predictable refractive outcome, does not alter the cornea, avoids induction of higher-order aberrations and corneal compromise, and removes future cataract risk,” Dr Riaz said. “It is especially effective for hyperopes for whom there is not a phakic IOL option in the United States and who, according to literature reports, achieve high satisfaction using modern IOLs.” While addressing the risk of RD after RLE in high myopes, Dr Riaz cited literature suggesting that the incidence appears to have decreased over time. Nevertheless, with the RD risk in mind, he said he would advise against bilateral RLE to correct high myopia in young patients. Before performing RLE in young patients with extreme refractive error, Dr Riaz said surgeons should mitigate RD risk by taking a careful history, doing a thorough retinal evalu-

ation, and performing appropriate prophylactic treatment for existing pathology, such as lattice degeneration. Patients should also be counselled on RD symptoms, and surgeons should obtain additional informed consent. Dr Riaz closed his defence of performing RLE in select patients by presenting a personal example. This female patient was in her 30s, had +6.0 D hyperopia bilaterally, and had already undergone peripheral iridotomy. “The patient was counselled about the potential for residual hyperopia but said she would be happy if she could just get out of her thick glasses,” Dr Riaz stated. Six weeks after RLE with implantation of extended depth of focus IOLs, the patient’s binocular visual acuity was 20/20 at distance and 20/25 at both near and intermediate. It was stable at her last visit at one year postoperatively, and the patient was very happy. Both presenters spoke at AAO 2025, Orlando, Florida, US. For citation notes, see page 44.

Murtaza K Adam MD, FASR is a Vitreoretinal Surgeon and Chair of Clinical Research, Colorado Retina Associates, Denver, Colorado, US, and Adjunct Clinical Associate Professor, Rocky Vista University, Parker, Colorado, US. murtaza.adam@gmail.com Kamran M Riaz MD is the Thelma Gaylord Endowed Chair in Ophthalmology and Vice Chair for Clinical Research at the Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, US. Kamran-Riaz@dmei.org

Leadership, Business and Innovation Podcasts Scan to Listen

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Late Post-LASIK Enhancements Epithelial thickness mapping provides valuable insight for treatment and patient counselling. CHERYL GUTTMAN KRADER REPORTS

pithelial remodelling after LASIK can lead to refractive changes due to the lensing effect of the epithelial layer, but the pattern of remodelling is highly unpredictable. Therefore, epithelial thickness mapping can help guide the best treatment option for patients who present with significant refractive error years after LASIK. Photorefractive keratotomy (PRK) is performed most often for refractive correction, but surgeons must also set proper patient expectations during preoperative counselling— knowing the rate and pattern of epithelial regrowth after PRK is variable. These were the take-home messages provided by Julie M Schallhorn MD and Steven J Dell MD, who discussed the role of epithelial mapping in guiding treatment when a patient presents with 3.0 D of myopia ten years after myopic LASIK. Emphasising the variability of epithelial remodelling after refractive surgery and its role in the surgical outcome, Dr Schallhorn discussed a study that analysed the impact of corneal epithelial thickness on refractive error in eyes that had LASIK for myopia or myopic astigmatism.1 The study included more than 200 eyes, and the researchers concluded that the difference in corneal epithelial thickness between the central and midperipheral zones may play a role in the final refractive error. Notably, the individual patient data showed huge variability in the magnitude of the difference between the central and midperipheral zones. Further underscoring the point that “epithelial remodelling is not created equally” and should be considered when planning a late enhancement, Dr Schallhorn presented two Epithelial Lensing Effect

Considerations for performing PRK

Drs Schallhorn and Dell agreed PRK would be the best option for late refractive correction in a post-LASIK patient. “We don’t want to relift old LASIK flaps because of the risk of epithelial ingrowth,” Dr Dell said. “We could make a new side cut, but that is technically difficult and not commonly done. Another approach would be to cut a larger, deeper flap encompassing the entire prior flap, but that is also not commonly done. In rare cases, an ICL may be an option.” Although PRK may be the best option for a late enhancement procedure in a post-LASIK eye, both surgeons emphasised that it is not perfect. “Late LVC enhancements are complicated,” Dr Dell said. “The epithelium hides a lot of LVC sins, but it also creates new issues for us.” Dr Schallhorn explained that the epithelium does regrow after PRK when it is performed over a LASIK flap, but the process is slow, and in a sizeable proportion of cases the epithelium does not always return to its pre-PRK configuration. Therefore, the outcome of PRK can be unpredictable.

Epithelial Epithelial EpiMaps Maps Epi LensingEffect Effect Lensing

PostHyperopic Hyperopic Post LVC LVC

Epithelium Epithelium

cases from her personal files. One case involved a 56-year-old female, seen ten years after myopic LASIK, whose corneal epithelium was thin centrally and thicker inferiorly. The second case involved a 58-year-old male who was eight years post-myopic LASIK and had a very thick central epithelium. “If you treat these patients with PRK based only on their residual refractive error, you will get a different outcome based on their post-treatment epithelial thickening,” she said.

35 35 microns microns

80 80 microns microns

PostMyopic Myopic Post LVC LVC

Epithelium Epithelium

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CATARACT & REFRACTIVE

“Regrowth of the epithelium is a finicky business. It depends on the magnitude of the preoperative treatment, but it is also impacted by other factors, such as postoperative topical drop use,” Dr Schallhorn said. “These patients have come for treatment of refractive error and might have become presbyopic. If they are being treated with PRK to treat myopia, they will probably be hyperopic until the epithelium regrows. However, post-PRK epithelial hyperplasia can be massive in some patients and very minimal in others, and it will take a long time to re-establish the same epithelial thickness that was present before the procedure. That is why we tell patients it will take a lot longer for visual recovery after the retreatment compared to initial procedure.” Illustrating the variability in regrowth after a PRK enhancement, Dr Dell presented a patient he treated for -3.0 D myopia bilaterally. Both eyes had a central epithelial thickness of about 75 microns. At four months after PRK, the epithelium had reverted to its preoperative pattern in the left eye, and the refractive outcome was perfect. The right eye, however, was hyperopic because the epithelium was thin and irregular. “This begs the question, what is the refractive surgeon to do?” Dr Dell said. “Do you wait and see if the epithelium eventually reverts to its original configuration? Or do you try to split the difference of the epithelial lensing effect in your preoperative planning?” He noted that the epithelial lensing effect is generally proportional to the magnitude of the original LVC correction. “If the primary correction was for -3.0 D of myopia, it will probably not be a problem, but it will be if the original

After hyperopic LASIK, almost any eye with refractive error is going to have a very irregular and somewhat unpredictable epithelial layer. correction was for more than -6.0 D. I find that after hyperopic LASIK, almost any eye with refractive error is going to have a very irregular and somewhat unpredictable epithelial layer,” Dr Dell said. Drs Dell and Schallhorn spoke on this topic at AAO 2025 in Orlando, Florida, US. For citation notes, see page 44.

Steven J Dell MD is Medical Director at Dell Laser Consultants, Austin, Texas, US. steven@dellmd.com Julie M Schallhorn MD, MS is Professor and Rose B Williams Chair for Research in Corneal Disease, Department of Ophthalmology, University of California–San Francisco School of Medicine, San Francisco, California, US. julie.schallhorn@ucsf.edu

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Retinal Detachment After Cataract Surgery Knowledge of risk factors directs patient management and informed consent. CHERYL GUTTMAN KRADER REPORTS

he incidence of rhegmatogenous retinal detachment (RRD) is increasing globally, and cataract/refractive lens surgery is a known risk factor for this event. Speaking during a EURETINA/ESCRS joint symposium in Paris, Martin S Zinkernagel MD, PhD discussed risk factors for RRD after cataract surgery and risk mitigation strategies as a guide to appropriate patient counselling, preoperative intervention, and postoperative follow-up.

Who is at risk?

Findings from multiple studies identify male sex, high myopia, history of RRD in the fellow eye, absence of complete posterior vitreous detachment (PVD), and lattice degeneration as risk factors for RRD in general and/or after cataract surgery.1–4 In addition, a cohort analysis showed that among cases of pseudophakic RRD, the highest risk of RRD was in the 40- to 55-year-old age group.1 “This information underscores a need to be particularly cautious about performing elective lens surgery in these young patients,” Dr Zinkernagel said. The association between younger age and pseudophakic RRD risk corresponds with data showing that PVD prevalence increases with age. But while preoperative PVD is associated with a decreased risk of RRD after cataract surgery, its development after cataract surgery is certainly a major driver causing postoperative RRD. “It is important to remember that 27% to 60% of eyes develop PVD within 1 year after cataract surgery.5 This rate of progression is much faster than in unoperated eyes,” Dr Zinkernagel said.

Risk mitigation

Determining vitreous and retina status preoperatively will help surgeons identify patients at risk for RRD after cataract surgery. Vitreous attachment is easily identified using optical coherence tomography (OCT), and Dr Zinkernagel mentioned that a project underway in his department aims to develop a deep learning-based screening system for automated detection of peripheral retinal breaks and detachments on fundus photography images.6 He advised that any existing retinal tears should be treated with laser before a patient undergoes cataract surgery, especially when there is no pigment or the lesion is a horseshoe tear rather than a round hole. The need to treat lattice degeneration is less clear. “Even though lattice degeneration has been identified as an RRD risk factor, there is conflicting information about whether there is benefit for its prophylactic treatment,” Dr Zinkernagel said. “Retinopexy is usually not recommended, but I [typically use] laser peripheral degenerations in eyes with significant risk factors for RRD, such as absence of PVD or a history of RRD in the fellow eye.”

Prompt recognition

The risk of RRD after cataract surgery is highest in the initial months and remains substantial during the first postoperative year but continues to be elevated for up to 10 years.1 Dr Zinkernagel recommended that patients at high risk for RRD after cataract surgery be monitored closely for several months postoperatively using multimodal imaging (OCT/widefield retina imaging) to identify development of PVD and retinal breaks. In addition, the informed consent for all patients undergoing cataract surgery should mention a reminder to watch for RRD warning signs (flashes, floaters, or shadows) and to seek care immediately if they occur. This information should be reinforced to highrisk patients. Dr Zinkernagel presented during a joint ESCRS/EURETINA symposium at EURETINA 2025 in Paris. For citation notes, see page 44.

OCT imaging shows vitreous attachment preoperatively (top) and development of PVD at 3 months after cataract surgery (bottom).

Martin S Zinkernagel MD, PhD is Professor and Head of the Department of Ophthalmology at the University of Bern, Switzerland. martin.zinkernagel@insel.ch

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Postoperative Corneal Complications Managing corneal complications of refractive surgery can present significant clinical challenges. ROIBEARD O’HÉINEACHÁIN REPORTS

evere corneal complications after refractive surgery are rare but are sometimes difficult to manage when they occur, notes José Luis Güell MD, PhD. “Although elective refractive surgery has a very high safety index and patient satisfaction rate—and serious complications are rare—the numbers are significant because the number of refractive procedures is extremely high,” he said. Significant residual opacities with or without surface irregularities account for most severe complications after corneal refractive surgery. The clinical assessment should begin with an evaluation of best-corrected vision with rigid permeable contact lenses and a meticulous examination of the cornea with slit lamp, topography, and anterior segment OCT. If the opacity is minor or not central, cases with various irregularities are often managed with rigid corneal or scleral lenses. Examples of cases Professor Güell has successfully treated in this manner include an eye with high irregular astigmatism as a long-term complication of radial keratotomy and a patient with significant visual loss due to corneal thinning and irregularity after a complicated PRK. Surgically repairing a LASIK flap may be necessary in some cases. In eyes featuring large folds, he recommended removing the epithelium from the flap before elevating it

and placing it back down on the stromal bed. No flap stretching is necessary during this manoeuvre, provided the epithelium is removed. Epithelial ingrowth treatment is more complex, sometimes requiring a peribulbar block to allow the surgeon to meticulously remove the epithelium from both sides of the flap. Sutures should be used to secure the flap and prevent regrowth. Superficial anterior lamellar keratoplasty should only be considered when opacity is the problem and there is no significant irregular astigmatism because the anterior lamellar cut will leave the irregularity intact. Topography-guided PRK, with or without cross-linking, can also be an option in such eyes, provided there is no significant irregularity, the cornea is sufficiently stable, and the ablation depth does not exceed 100 microns. However, in most cases where there is significant opacity, deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK) will be necessary to restore vision. If the endothelium is healthy, DALK is preferable to PK. Among his successful DALK cases, Prof Güell shared a contact lens-intolerant patient with significant corneal irregularity and stromal lysis after a complicated PRK and an eye with post-LASIK ectasia in which intracorneal ring segments had failed to resolve. He noted that PK may be indicated in eyes where the irregularity is more extreme, as in the case of the contact lens-intolerant patient who, in addition to developing severe irregular astigmatism after PRK, also had a cataract. Prof Güell removed the cataract and performed PK in one procedure, delaying intraocular lens implantation for a few months to allow more precise biometric calculations. He observed this approach is also useful for cataract patients undergoing DALK to correct refractive surgery complications. Prof Güell concluded his remarks by presenting several cases where endothelial keratoplasty was indicated due to intraocular refractive surgery damage to the endothelium. Prof Güell made his presentation at the 2025 ESCRS Annual Congress in Copenhagen.

José Luis Güell MD, PhD is Director of the Cornea and Refractive Surgery Unit, Instituto Microcirugia Ocular of Barcelona, Spain; Professor of the IMO Master Programme UAB; Lead Professor and Coordinator, Anterior Segment Diseases European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland. jose.guell@imo.es

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Lids: Lumps to Watch For “This cyst just keeps coming back!” BY CLARE QUIGLEY MD

“H

mm,” I say, noting a patch of redness on my patient’s lower eyelid margin. The irregularity is fairly subtle, with no well-defined swelling of a chalazion to be seen. “It’s been there for a year or two,” my patient says, “and it just keeps flaring up. I tried everything: heat, massage, ointment, antibiotics… I’m ready to have it out!” “Sure,” I say, noting the small gap in his lashes, “I’ll take a look.” On the slit lamp, a short length of the lower eyelid, measuring a couple of millimetres at most, looks eroded. The area is not big enough to show obvious rolled edges or pearly telangiectasia. What I can appreciate is a change in the lash growth—there are not as many lashes as there should be. In a busy clinic, spotting a lid lesion like this can make a difference. Treatment is less invasive when the basal cell carcinoma (BCC) is still at a paltry few millimetres, before the inexorable growth spreads further along the eyelid and leads to a technically challenging subsequent reconstruction. A ‘rodent ulcer’ is an apt term for these skin lesions, as they can nibble along the lid at the normal adnexal structures, most obviously causing madarosis on the lid margin. Basal cell carcinoma is the most common skin cancer, and about 20% of these appear on the eyelids. Clinical features vary, and classification is useful as different subtypes may be more or less aggressive in their clinical behaviour and risk recurrence, which is overall about 5%. Nodular BCC is the most common subtype and features classic rolled borders, often with a central eroded space. Superficial spreading BCC is flatter in comparison and can appear red and ulcerated. Both superficial spreading and nodular BCC have a more benign clinical course and have a lower risk of recurrence. In comparison, infiltrative BCC can be more difficult to recognise, resembling a scar, and the margins can be challenging to define clinically. Recurrence risk and risk of invasion to adjacent structures, including the orbit or paranasal sinuses, are higher. What did I do for my patient? In my clinic, I am fortunate to work with Michelle Walsh, an excellent oculoplastic nurse, who is happy incising and draining cysts and taking biopsies of more suspicious lid lumps. We usually use a 3- or 4-mm punch, under subcutaneous anaesthetic such as lidocaine with adrenaline. Patients go home with a double pad for a couple of hours, and we usually receive our histology result within a week or so. I would biopsy every case, even if the diagnosis seems clinically obvious, as surprises arise. Occasionally, I have seen a benign lid margin cyst associated with madarosis, or conversely, a BCC that looks little more than a patch of meibomian gland dysfunction.

Once BCC is confirmed, treatment can be planned. Usually, this involves complete surgical excision. Issues arise in equity of access to some of the most useful, effective ways of managing periocular BCC. Particularly for invasive BCC that has entered the orbit, there can be limited access to Mohs surgery and to the small-molecule inhibitor vismodegib. Risk of BCC recurrence is lowest—and the excised tissue can be limited to the tumour as much as possible—when a margin-controlled excision can be completed. Margin control is a process through which the edges of the excised tissue can be examined before lid reconstruction. In my hospital, we are fortunate to have access to a Mohs micrographic surgery service. Mohs surgeons, typically dermatologists who have undergone subspecialty fellowship training, excise the BCC. They evaluate all margins of the excised tumour for any signs of remaining neoplastic cells. There are alternatives, including frozen-section margin control or fast paraffin-embedded sections, though Mohs is generally considered the gold standard. Once a BCC invades the orbit, it is not amenable to simple excision and reconstruction, and clearance would require orbital exenteration—a disfiguring procedure that can be used as a last measure to reduce intracranial extension risk. Ideally, treatment with vismodegib can shrink BCC and obviate the need for exenteration. This is the first in a series of columns discussing eyelid conditions.

Clare Quigley MD is a Consultant Eye Surgeon in private practice in Progressive Vision and in public practice in the Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin, Ireland.

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CORNEA

Corneal Haze Update Tips on haze after surface ablations: how to avoid and how to treat. ROIBEARD O’HÉINEACHÁIN REPORTS

aze after surface ablations such as PRK can usually be prevented by limiting treatment to mild-to-moderate refractive errors and carefully using mitomycin-C (MMC). If haze does occur, most cases respond to topical steroids, though surgery may occasionally be necessary, according to Sharita Siregar MD. “To avoid corneal haze, don’t perform PRK for high myopia or astigmatism more than 3.0 D or hyperopia more than 6.0 D,” she noted. “But if you must, you can still do it—but do not forget to use MMC intraoperatively.” She explained that following PRK, epithelial injury from the laser releases inflammatory mediators and activates epithelial hyperplasia and keratocyte apoptosis. TGF-β then activates nearby keratocytes, turning them into myofibroblasts. Normally, these myofibroblasts undergo apoptosis after 24 days. However, if they persist, corneal haze can develop. Risk factors for corneal haze following surface ablation procedures include high myopia or hyperopia exceeding +6.0 D, astigmatism greater than 3.0 D, stromal irregularities, persistent epithelial defects (such as anterior or epithelial basement membrane dystrophy), severe dry eye, exposure to ultraviolet light, and the omission of MMC during the procedure. Haze can be graded based on the appearance of the cornea when viewed under the slit lamp using the scale (proposed by Fantes, et al.), Dr Siregar said. In the five-stage system, stage 0 indicates no haze, and stage 0.5 identifies trace haze that becomes visible under oblique slit lamp illumination. In stage 1.0, the haze does not interfere with the visibility of fine iris details. Stage 2.0 describes mild obscuration of iris features, while stage 4.0 signifies complete obscuration of the iris. There are two types of haze following PRK, Dr Siregar noted. There is early-onset haze, which is the most common form and typically appears within three months, generally resolving within one year. There is also late-onset haze, which arises after three months and can persist for up to three years. Late-onset haze may significantly compromise vision and lead to corneal scarring, resulting in visual disturbances. Dr Siregar is conducting an ongoing study involving 173 eyes from 139 patients who received myopic PRK. The results indicate that both early and late haze rates were greater in eyes with corrections exceeding -6.0 D compared to those with lower corrections. The study also found no significant difference in haze incidence based on whether MMC was applied for 20–60 seconds or 60–120 seconds. For early haze, Dr Siregar recommends 1% prednisolone administered every 4 hours. Patients should be evaluated at the 2-week mark to assess treatment efficacy and complete a 12-week steroid regimen. For late haze, patients should

receive 1% prednisolone every 2 to 3 hours as part of a 4-week course, with follow-up appointments scheduled at 2 and 4 weeks. If haze persists, treatment depends on its depth. Superficial haze (less than 15 microns) can be managed with mechanical debridement, MMC, and 1% prednisolone every 4 hours. For deeper haze (more than 15 microns), PTK or PRK with 0.02% MMC is recommended. After PRK, patients should apply a bandage contact lens, topical NSAIDs, and preservative-free artificial tears and complete a 12-week course of topical steroids. Dr Siregar also advises patients to wear sunglasses and take vitamin C and D supplements. Dr Siregar made her presentation during the 2025 ESCRS Annual Congress in Copenhagen.

Sharita Siregar MD is a cornea and refractive surgeon at Jakarta Eye Clinic (JEC) Eye Hospital and Clinics, Jakarta, Indonesia. sharita@jec.co.id

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Need a quick introduction or refresher about a surgical procedure? Have a tip to share about a technique or approach you use that makes surgery easier? The ESCRS 100 is the place to go. It’s a library of short (roughly 100 seconds), high-quality instructional videos about all ﬁelds of cataract and refractive surgery. More than 50 videos have already been created, and additional videos are being uploaded each month. Current videos include the following topics: • Phaco chop • CTR implantation • Phacoemulsiﬁcation, IOL implantation and DSO on a central guttae Fuchs patient

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GLAUCOMA

The Future of Glaucoma Medication Towards a clearer, more efficient way to address outflow. TIMOTHY NORRIS REPORTS

n glaucoma treatment, the sheer number of different compounds, variations, and brands on the market can become a little bit confusing. However, the future of glaucoma medication promises to be brighter, with safer and more effective treatments already on the horizon. “Don’t despair. I am sure that meds are going to make glaucoma great again,” Gauti Jóhannesson MD, PhD commented in a recent presentation. Dr Jóhannesson noted the only proven treatments for glaucoma are the IOP-lowering compounds, aiming at three main targets: the trabecular meshwork, uveoscleral outflow, and aqueous production. Their primary outcome is to correct the physiological defect involving the aqueous outflow. One class of new compounds already on the market is the rho-kinase inhibitors, particularly netarsudil, usually in combination with prostaglandins. Another interesting actor is nitric oxide-donating drugs. Nitric oxide (NO) is a strong vasodilator and regulator of vascular tone, which can increase outflow facility and reduce IOP by reducing trabecular meshwork cell volume, as well as relaxing the Schlemm’s canal. However, nitric oxide alone is a gaseous transmitter with an extremely short half-life, so it needs a donating drug to be released at the level of the target tissue. The first NO-donating drug approved by the FDA is latanoprostene bunod, which delivers nitric oxide to the trabecular meshwork while also providing the benefit of being a prostaglandin analogue. “Normally, the prostaglandin analogues target the prostaglandin F (FP) receptors, but what if you also target the prostaglandin E (EP) receptors?” Dr Jóhannesson asked. The EP receptors are found in the trabecular meshwork and ciliary muscle. Targeting both FP and EP receptors causes muscle relaxation and dilatation, affecting uveoscleral as well as trabecular outflow. A novel compound with dual agonistic activity acting on both receptors is in an early stage of development, but the initial data is promising, he added. Another long-sought option for glaucoma treatment is neuroprotection. First, citicoline, a nerve-protecting molecule studied in neurodegenerative diseases such as Alzheimer’s and Parkinson’s, has a multifactorial mechanism of action including homeostasis, mitochondrial dynamics, and neurotransmission. Several studies investigating citicoline have shown inconclusive results, urging further investigation into the compound. Hopefully, in the coming years, an upcoming large trial will shed light on the efficacy of citicoline, he said. Glucagon-like peptide-1 (GLP-1) receptor agonists are also an interesting option. Already used in many different degen-

erative and metabolic diseases, GLP-1s are now being considered as a potential medication for glaucoma, with semaglutide tablets emerging as the most promising candidate, he said. Another agent, nicotinamide, has shown a strong neuroprotective effect in animal models. The preclinical findings are robust, and two pilot studies on humans have indicated positive effects on visual function in glaucoma patients. Ongoing large randomised controlled trials will provide further evidence of nicotinamide’s efficacy as a neuroprotective drug for glaucoma. The most exciting future possibility, Dr Jóhannesson said, is advanced therapy medicinal products (ATMPs). This umbrella term includes approaches such as gene therapy and tissue engineering. “This is the true game changer for the future of glaucoma, a subject that is already exponentially increasing in interest year after year,” he said. Dr Jóhannesson spoke at the 2025 ESCRS Annual Congress in Copenhagen.

Gauti Jóhannesson MD, PhD is Chief Physician at St Erik Eye Hospital in Stockholm and Associate Professor at the Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden. gauti.johannesson@umu.se

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Is AI a Future Frenemy? The technology presents challenges and benefits for ophthalmologists. TIMOTHY NORRIS REPORTS

rtificial intelligence is becoming increasingly precise, offering ophthalmologists powerful tools for diagnosis and imaging. However, to maintain the best quality of care, some boundaries need to be established. According to Luis Abegão Pinto MD, PhD, some learning machines already outperform the physician’s eye—for example, pattern recognition in glaucoma, influencing diagnosis. “Something that took you 10 or 15 years to train yourself to look at in the optic disc can compress to a couple of hours in an AI with the proper algorithm. This is the game changer,” he admitted. “We spent a lot of time and effort going to medical school, studying ophthalmology and so on, and then suddenly we must deal with this. It is challenging.” One of the primary reasons for defining the relationship between the doctor and AI is the patient. As Dr Pinto underlined, research shows patients are primarily concerned with proper diagnosis. Missing a diagnosis is a shared concern among doctors and patients, Dr Pinto observed, as AI is already good at prediction and extrapolation—and getting better. But AI is not always right, since it still guesses, he said. It is a trash in, trash out scenario, meaning if taught the wrong algorithm, the program will continue to make the same mistake. For example, if the algorithm is trained on the wrong data sets or searches for something it was not meant to recognise, it will derail and fail—a type of daily occurrence today, he said. This balance between benefit and concern often leaves ophthalmologists and diagnosticians feeling uneasy because AI is presented as a tool capable of doing such tasks without their supervision. However, AI continues to improve at an amazing speed. In just 35 years, mobile phones have transformed from massive

telephones into portable devices with more computing power than the machines that put humans on the moon in 1969, he observed. It is nearly impossible to predict life in 25 years, yet some informed guesses can be made, he added. Dr Pinto suggested an affordable, easily accessible AI could fill the gap of undiagnosed patients with support from policymakers to build the infrastructure for easier screenings—not only for glaucoma, but for a variety of conditions that can be diagnosed in a single test, such as glaucoma and diabetic retinopathy. Fundus pictures, for example, are already used to diagnose Alzheimer’s disease and cardiovascular conditions, he explained. If properly trained, these future algorithms could likely use the baseline exam to make an excellent risk profile assessment, allowing the physician to focus on the cases likely to progress while reassuring those expected to remain stable. “We will have identified the most effective treatment—faster, with [fewer] exams and more tailored [than] ever—rather than through trial and error,” he concluded. “But don’t worry. In the words of American cardiologist Eric Topol: ‘AI won’t replace doctors, but doctors who don’t use AI will be replaced by those who do.’” Dr Pinto presented at the 2025 ESCRS Annual Congress in Copenhagen.

Luis Abegão Pinto MD, PhD, FEBOS-G is Head of the Glaucoma Clinic of the Department of Ophthalmology at the Centro Hospitalar Lisboa Norte, Portugal. abegao.pinto@ulssm.min-saude.pt

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GLAUCOMA

A Challenging Case of Aqueous Misdirection An unusual solution to an unusual problem. TIMOTHY NORRIS REPORTS

“I

n glaucoma surgery, we don’t really like postoperative surprises,” said Andrew Tatham MD, as he presented a challenging case of aqueous misdirection in a patient implanted with the PreserFlo MicroShunt (Glaukos) at the 2025 ESCRS Annual Congress in Copenhagen. The patient, 80 years old and pseudophakic, with a twoyear prior glaucoma diagnosis, was also under treatment with clopidogrel due to a previous transient ischaemic attack. The patient’s intraocular pressure was 25 mmHg on maximal medical therapy, and there was evidence of progressive visual field loss. Given the severity of the glaucoma, the patient underwent a PreserFlo procedure, which Dr Tatham observed. The operation seemed to go well, with Dr Tatham noting a reasonable flow through the device at time of implantation. However, the patient exhibited a shallow anterior chamber, 28 mmHg pressure, and slightly reduced vision the following day. Although a shallow anterior chamber can be due to over-drainage, this was clearly not the cause, given the high IOP. Dilated fundus examination and B-scan ultrasound showed a flat retina and no choroidal effusions or suprachoroidal haemorrhage, both potential causes of anterior chamber shallowing in the early postoperative period. Suprachoroidal haemorrhage also frequently causes pain and typically more severe vision loss. The diagnosis was aqueous misdirection, also referred to as malignant glaucoma, which Dr Tatham explained as a condition resulting from a build-up of pressure in the back of the eye, leading to compression of the vitreous and reduced conduction of fluid through the vitreous from posterior to anterior, creating a vicious cycle. The pressure differential between the back and the front of the eye causes a posterior pushing force and secondary angle closure. Unlike primary angle closure, which is caused by pupil block, posterior pushing mechanisms of angle closure should not be treated with miotics like pilocarpine. He explained the management of aqueous misdirection should follow a stepwise approach. Step one is suppressing inflammation and uveal swelling with topical steroids, attempting to deepen the anterior chamber using atropine and lowering intraocular pressure with aqueous suppressants, including oral acetazolamide. Step two involves creating a peripheral iridotomy or iridectomy to encourage fluid flow from the posterior to anterior segment, ideally with an attempt to laser the anterior hyaloid through the iridotomy. Dr Tatham recommended limited cyclodiode laser as a good option for step three, but ultimately, some patients require a more inva-

Although the definitive treatment for aqueous misdirection is a complete pars plana vitrectomy, it is essential to also remove the anterior hyaloid. sive surgical treatment to establish a ‘one-chamber’ eye and break the cycle. This particular patient presented deterioration despite atropine and acetazolamide, with a worsening vision and gradually increasing intraocular pressure, prompting Dr Tatham to opt for a cyclodiode laser treatment followed by a zonular-hyaloido-vitrectomy. He added this procedure can be performed through an anterior approach, following the technique pioneered by Naomi Lois (et al). Although an anterior approach zonular-hyaloidovitrectomy may feel like a “crazy move”, Dr Tatham said it can be very effective and avoid the need for a retinal surgeon. There is a method in this madness: passing the anterior vitrector through the iris into anterior vitreous. Although the definitive treatment for aqueous misdirection is a complete pars plana vitrectomy, it is essential to also remove the anterior hyaloid. Sometimes retinal surgeons perform only a core vitrectomy, but this is likely insufficient. Studies have suggested similar outcomes with the anterior zonularhyaloido-vitrectomy compared to pars plana vitrectomy. According to Dr Tatham, this is a rare condition, but not unheard of in a patient implanted with PreserFlo. “Think about case selection,” he said. “This kind of problem is more common in small eyes, so look at the axial length. If it is shorter than 20 mm, you should seriously consider what you want. To quote Radiohead, we want ‘no alarms and no surprises.’” Dr Tatham presented at the 2025 ESCRS Annual Congress in Copenhagen.

Andrew Tatham MD, MBA is a consultant ophthalmic surgeon at Princess Alexandra Eye Pavilion, Edinburgh, UK. He is president of the UK and Éire Glaucoma Society. andrew.tatham@nhs.scot

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PAEDIATRIC OPHTHALMOLOGY

WSPOS Myopia Consensus Statement Provides Clear Answers Controlling myopia progression is the new strategy. LAURA GASPARI REPORTS

he 2025 Myopia Consensus Statement from the World Society of Paediatric Ophthalmology & Strabismus (WSPOS) helped fulfil the need for clear guidance on what works and what doesn’t work when attempting to slow the progression of myopia. The statement summarises the current consensus on the essentials of myopia management and treatment. Myopia has become more of a public health concern, with a rise in the prevalence of nearsightedness globally. Experts are talking about a myopia pandemic, and by 2050, half of the global population may be myopic, with more than 740 million children and adolescents affected. The need to control myopia progression stems from the risks associated with high myopia, which can increase the chances of retinal detachment, glaucoma, cataracts, and other eye conditions. “The longer your eyeball, the more nearsighted you are, and as the eyeball becomes longer, it starts to affect the function and the outcomes of eye health,” Ken K Nischal MD, founder of WSPOS, explained. “When the eyeball gets beyond 26 millimetres, the retina does not function properly.” Several solutions with at least two years of follow-up and solid scientific evidence are now available to control myopia progression, including defocus lenses and contact lenses, lowdose atropine eye drops, orthokeratology, low-level red light therapy, and combination treatments. The WSPOS Consensus Statement presents all these options in an accessible and easy-to-understand format, while also explaining their mechanisms of action and potential side effects. “The consensus statement provides new data for practitioners, and it is very important to update it regularly, because it is essential to keep children away from high myopia,” Dominique Brémond-Gignac MD, PhD noted. “Every dioptre increases the risk of maculopathy, so every dioptre counts.” However, as the statement highlights, prevention and behavioural interventions remain key in the fight against myopia progression. Daily exposure to natural light, for example, has strong scientific support in protecting children from myopia. Good habits—such as managing screen time and near work, taking breaks every 30 minutes, and avoiding reading in dim light—are also essential. In this context, the role of parents is pivotal, especially in ensuring children adhere to the prescribed treatment to support progress and prevent worsening. It is also important to consider customised solutions according to what the child and family need, especially financial ones, which must be thoroughly discussed, according to Professor Brémond-Gignac.

Collaboration with public health institutions and schools should also be effective in educating the public about the risks of myopia, as Prof Nischal wrote in an editorial published in Eye. Some countries, such as France, dedicate an entire week each year to national myopia campaigns, featuring free screening programmes and advertisements on social media, TV, and newspapers. The myopia epidemic was discussed during a myopia innovation session at the WSPOS specialty day conference at the 2025 ESCRS Annual Congress in Copenhagen. Other topics included paediatric cataract, ocular surface disease, uveitis, and retinitis of prematurity. The WSPOS Consensus Statement is available online at https://wspos.org/myopia-consensus-statement-2025.

Ken K Nischal MD, FAAP, FRCOphth is division chief, Pediatric Ophthalmology, Strabismus, and Adult Motility, University of Pittsburgh School of Medicine, Pennsylvania, US, and founder of WSPOS. Dominique Brémond-Gignac MD, PhD, FEBO is professor and head of the ophthalmology department at University Hospital Necker-Enfants-malades and Paris University, France.

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RETINA

Options for IOLs in Eyes with Retinal Disease Choosing the best implant requires attention to multiple matters. CHERYL GUTTMAN KRADER REPORTS

here are special considerations for intraocular lens (IOL) power calculations and selection in patients with retinal disease. Andrea Hassenstein MD, who specialises in anterior segment surgery, discussed these issues while speaking to an audience of retina specialists at a recent conference. “If you have any questions about special cases, do not hesitate to ask your friendly cataract surgeon colleague.”

Pearls for power determination

Optical biometry is the preferred method for obtaining measurements for IOL power calculation. However, if media opacity precludes its use, ultrasound will be needed. “Although the axial length measurement is slightly shorter using ultrasound, this difference does not have to be considered for the IOL power calculation,” Dr Hassenstein said. In cases where a patient has a macula-off retinal detachment (RD) and requires combined cataract surgery and vitrectomy, ultrasound biometry has a high prediction error for IOL power calculation; optical biometry is often not possible due to lack of patient fixation. To determine axial length in these situations, Dr Hassenstein suggested checking the patient’s glasses to see if the refractive error is the same in both eyes. If so, one can measure and use the axial length of the fellow eye. “In rare cases where there is much uncertainty about axial length in the eye with the RD, it may be best to postpone the

cataract surgery,” she said. “If postponement is not possible, I recommend estimating the IOL power with the option of implanting an add-on IOL later to correct anisometropia.” For IOL power calculation, Dr Hassenstein recommended using the Haigis or Barrett Universal formulas that are accurate regardless of axial length. However, she cautioned surgeons about the need for special formulas in eyes with a history of keratorefractive surgery. Usually, the IOL will be placed in the capsular bag or with optic capture, targeting emmetropia (0.0 to -0.5 D). The power should be adjusted if sulcus placement is planned by subtracting 1.0 D for IOLs between 18.0 and 25.0 D or by 1.5 D for higher power IOLs. Power adjustment is also necessary in eyes with a silicone oil endotamponade that causes a hyperopic shift of 5.0 to 6.0 D. Although cystoid macular oedema theoretically causes a slight myopic shift (approximately -0.5 D), no adjustment is needed in this situation, and hopefully the oedema will resolve after the retinal treatment, Dr Hassenstein said.

Thoughts on IOL type

Hydrophobic acrylic is the preferred material for IOLs in eyes with retinal disease. Dr Hassenstein recommended against choosing silicone, hydrophilic acrylic, or copolymer IOLs (hydrophobic with a surface coating) because they may opacify if exposed to gas endotamponade in the posterior or anterior segment.

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“This is not a very common situation, but it can occur,” she said. A blue light-filtering IOL can be used according to surgeon preference, recognising there is no evidence proving they protect macular health or have any downsides. Regarding IOL optic size, 6.0 mm is generally preferred. A 7.0 mm optic offers improved visualisation of the fundus periphery and is available, for example, with one particular IOL (Aspira-aXA, HumanOptics), although this implant is made of hydrophilic acrylic. Dr Hassenstein suggested that when patients need to undergo cataract and retinal surgery, interest in using a toric IOL to correct astigmatism or a simultaneous vision IOL (SVL) to fulfil the individual’s desire for reduced spectacle dependence should be addressed later using an add-on IOL—assuming the retinal surgery is successful and the patient has a good visual prognosis. “It used to be said that a multifocal IOL is a ‘no go’ in a patient with retinal disease because it would prevent vitrectomy for RD from being performed as usual, but in fact that is not an issue,” Dr Hassenstein said. Using an add-on IOL (spheric, toric, SVL) may upgrade outcomes for the patient if the visual prognosis is good. If placing an SVL in just one eye, Dr Hassenstein advised choosing the non-dominant eye so the brain will suppress potential halos. When using an add-on SVL in both eyes, she advised implanting the IOL with the higher add power in the non-dominant eye for the same halo suppression. A spherical add-on IOL can be used to correct refractive error, and one with an add power of 5.0 to 6.0 D could be considered in eyes that need permanent silicone oil tamponade and have good vision, which are rare cases, noted Dr Hassenstein. In cases where a patient is aphakic after complicated cataract surgery or has a luxated IOL, options for vision rehabilitation include placement of a posterior chamber Carlevale IOL, use of an iris-fixated IOL (Artisan, Ophtec), or scleral IOL fixation using a sutured (Z-suture) or sutureless technique (Yamane). “Many roads lead to Rome,” Dr Hassenstein said. “The choice of an IOL in these situations depends on the individual surgeon’s comfort level and experience, as well as the anaesthesia.” The Scharioth Macula Lens, which is a +10.0 D add-on magnifying IOL, is something to consider for patients with severe macular disease. A big advantage of this lens is that there is the opportunity to simulate its effect on vision preoperatively by having the patient look through a +9.0 D magnifying glass.

Do Your Patients Know What to Expect? Helping your patients understand

what to expect from their cataract or refractive surgery is critical to

maximizing their satisfaction. ESCRS has developed a Patient Portal to educate

patients about their conditions relating to upcoming or recent cataract or refractive surgery.

The Patient Portal is split into two

sections: Cataract and Refractive. Each

section provides an easy-to-understand summary and clear diagrams of the

different types of conditions, including the benefits, risks, procedures, and aftercare of common conditions.

Posters are available to download, and we encourage you to print them and place in your clinic waiting rooms or

present them on screens as appropriate. Poster languages:

English / French / Italian

Dr Hassenstein MD spoke at EURETINA 2025 in Paris.

Andrea Hassenstein MD, FEBO, MBA is associate professor and managing senior physician in the department of ophthalmology at the University of Hamburg, Germany. hassenstein@uke.de

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RETINA

MCO-010 Optogenetic Therapy for Vision Restoration Long-term study documents durable safety and efficacy profiles in advanced retinitis pigmentosa. CHERYL GUTTMAN KRADER REPORTS

single intravitreal injection of MCO-010 optogenetic therapy continues to demonstrate safety and is providing durable, clinically meaningful vision improvement in patients suffering severe and permanent vision loss from advanced retinitis pigmentosa (RP), new clinical results suggest. “MCO-010 is currently undergoing the Biologics License Application process at the US Food and Drug Administration and hopefully will be approved soon,” said Jordi Monés MD, PhD. Nanoscope Therapeutics is developing MCO-010, a transgene for a high-performing opsin that sensitises bipolar cells to light stimuli. It is delivered by a proprietary adenoassociated virus and uses the mGluR6 promoter-enhancer to ensure the opsin gene is expressed specifically in retinal bipolar cells. “MCO-010 solves crucial issues that limited the success of other optogenetic therapies for retinal degenerative diseases,” Dr Monés explained. “Thanks to the mGluR6 promoter, it transduces bipolar cells that are ten times more numerous than ganglion cells and lead to higher resolution. In addition, MCO-010 is sensi-

tive to all wavelengths of visible light, responds to ambient light levels, and has rapid kinetics for no image blur.” The 152-week results were collected from patients participating in REMAIN, a long-term follow-up study of RESTORE, a phase 2b/3, multicentre, double-masked study that randomised 27 patients 1:1:1 to receive low-dose MCO-010 (0.9E11 gc/eye), high-dose MCO-010 (1.2E11 gc/eye), or sham injection. Patients enrolled in RESTORE had a clinical diagnosis of advanced RP with BCVA in the study eye worse than 1.9 logMAR (Snellen equivalent 20/1600) and no better than 1.6 logMAR (20/800) in the fellow eye. RESTORE met its primary endpoint, showing that at week 52, patients treated with both the low and high doses of MCO010 achieved significantly greater BCVA improvement from baseline compared to the sham group. At week 52, the mean change from baseline in both MCO-010 groups corresponded to about 3 ETDRS lines, and 40% of patients gained at least 3 ETDRS lines. The study also met key secondary endpoints, analysing the change in BCVA from baseline to week 76, with additional improvements observed in shape discrimination and mobility testing, and with tolerable ocular and systemic safety.

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Eight patients treated with the high dose of MCO-010 and seven patients treated with the low dose were evaluated at week 152 in REMAIN, and their BCVA results showed the optogenetic therapy’s benefit for improving visual function remained stable. Mean improvement in BCVA from baseline to week 152 was 0.243 logMAR in the high dose group and 0.454 logMAR in the low dose group; 40% of patients still maintained a gain of 3 ETDRS lines. Its safety is consistent, and there have been no serious adverse events nor cases of retinitis, choroiditis, vasculitis, ischemic neuropathy, hypopyon, or hypotony. Presence of anterior chamber cells was the most frequent adverse event in the MCO-010 groups (low dose 66.7%, high dose 33.3%, sham 22.2%), followed by ocular hypertension (low dose 44.4%, high dose 44.4%, sham 11.1%). These adverse events were mild or moderate in severity and controlled with short-term topical therapy. Only a single patient treated with MCO-010 developed vitritis requiring ongoing management with a topical corticosteroid.

Only a single patient treated with MCO-010 developed vitritis requiring ongoing management with a topical corticosteroid.

Dr Monés spoke at the 25th EURETINA Congress in Paris.

Jordi Monés MD, PhD is Director of the Institute de la Macula, Barcelona, Spain. jmones@institutmacula.com

Durable Improvements in Visual Acuity Through 152 Weeks MCO-010 Had 5x Higher BCVA-AUC vs Sham AUC Profiles RESTORE

70 BCVA Change From Baseline AUC (LogMAR*Weeks)

65 60

MCO-010 High-dose (n=9)

MCO-010 Low-dose (n=9)

REMAIN Sham (n=9)

55 50 45 40

†

35 30 25

†

MCO-010 High-dose (n=8)

†

MCO-010 Low-dose (n=7) Sham (n=6) Not followed after unmasking

†

20 15 10 5 0

100 Week

126

152

†P < .05 AUC, area under the curve; BCVA: Best–Corrected Visual Acuity (Freiburg Visual Acuity). Nanoscope. Unpublished data on file.

BCVA-AUC demonstrates durable improvements in visual acuity through 152 weeks after MCO-010 dosing. Comparison of BCVA-AUC profiles demonstrates 5-times greater vision gains in both MCO-010 dose groups and statistically significant improvements compared to sham control.

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OCULAR UPDATE

GLP-1RAs: A Cause for Concern? Risk and benefits of revolutionary semaglutide and tirzepatide treatments from an ophthalmological point of view. TIMOTHY NORRIS REPORTS

irst introduced in 2017 and 2022, respectively, semaglutide and tirzepatide are considered two revolutionary first-line treatments for people living with type 2 diabetes and obesity. Overall, use of both glucagon-like peptide-1 receptor agonists (GLP-1RAs) suggests a very positive risk–benefit profile, providing clear cardiometabolic benefits and showing an association with lower rates of stroke and dementia. Ophthalmologists, however, have recently raised concerns regarding the effect of GLP-1RAs on the retina that, despite their many beneficial effects, need serious consideration. “Initially, these drugs were associated with an acute worsening of diabetic retinopathy in treated patients,” Francesco Bandello MD said. “This was considered a primary adverse effect of GLP-1RAs, but further investigations pointed out a negative association

As glycaemia rapidly improves in diabetic patients, so does the risk of onset of diabetic retinopathy, mostly in the first six months from the start of treatment.

between this effect and a rapid glucometabolic improvement. This is a phenomenon that was already observed in patients undergoing more intense insulin-based treatments.” Investigations such as the Diabetes Control and Complications Trial (DCCT) and the Steno 1 study showed a rapid metabolic improvement could have a long-term beneficial effect on a patient with an active retinopathy, Professor Bandello underlined.1,2 “Paradoxically, in the short run, a sharp glucometabolic improvement was strongly

associated with an increase in retinal complications, and this is something we all experience in our clinical practice as retina specialists.” “As glycaemia rapidly improves in diabetic patients, so does the risk of onset of diabetic retinopathy, mostly in the first six months from the start of treatment,” added Enrico Borrelli MD, PhD. “Moreover, the same drugs have recently been associated with an increased risk of ischaemic optic neuropathy, especially in patients more than 60 years of age.” Such an increase might well be associated with the vascular response provoked by the rapid decline in blood glucose levels induced by the GLP-1RAs, suggested Lonny Stokholm MScPH, PhD: “This leads to a transient ischaemia, potentially contributing to a higher incidence of non-arteritic anterior ischaemic optic neuropathy (NAION).” A national registry-based prospective cohort investigated the association between semaglutide and NAION.3,4 As part of the research team, Dr Stokholm pointed out that while there is still no confirmed mechanism explaining this association, several plausible hypotheses exist. One leading explanation involves rapid glycaemic control and the same early worsening phenomenon that can affect retinopathy in diabetic patients. Semaglutide can cause a rapid reduction in haemoglobin 1Ac, Dr Stokholm said, while emphasising that type 2 diabetes, hypertension, dyslipidaemia, and obesity can all be strong predisposi-

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Francesco Bandello MD, FEBO

Enrico Borrelli MD, PhD, FEBO

tion factors to NAION rather than a direct drug effect. On the other hand, as tirzepatide was only approved in Denmark in October 2024, the current follow-up time and patient numbers are still insufficient to evaluate any potential association with this drug, she observed. Despite the concerns, there is no scenario where a specialist could suggest an abrupt interruption of the treatment. Semaglutide and tirzepatide are revolutionary drugs, particularly for their ability to reduce the risk of hypoglycaemia—a wellknown, potentially life-threatening complication for patients treated with insulin. Thanks to their ability to stimulate the secretion of insulin only when blood glucose levels are high, there is no risk of putting the patient at risk, Prof Borrelli said. Certainly, both semaglutide and tirzepatide represent one of the most important resources not only for a diabetic patient, but also for patients suffering from obesity and related cardiovascular comorbidities. According to Prof Bandello, many obese patients struggle throughout their lives to achieve a normal body weight, seldom obtaining consistent results despite diets and exercise. This frustrating lack of results can be incredibly discouraging, he said. It is no surprise that the introduction of these drugs brought hope, offering patients not only a chance to lose weight but also improvement in their mental health. Despite the groundbreaking efficacy, patients taking GLP1RAs require careful monitoring throughout treatment from their endocrinologist and diabetologist. These drugs can be harmful if self-administered, Prof Bandello said. The risk, especially for diabetic patients, is never zero. Although NAION remains a very rare event—occurring in less than one in ten thousand patients under semaglutide treatment—it is a severe side effect that needs to be taken seriously, Dr Stokholm said. Both NAION and diabetic retinopathy have a fundamental and grave impact on the visual function, Prof Borrelli added, suggesting the need for a strict collaboration between specialists when managing a patient under GLP-1RA treatment. “A tight communication between the diabetologist and the ophthalmologist has always been essential, and it is even more essential now,” he said.

Lonny Stokholm MScPH, PhD

As ophthalmologists, we need to protect the patient and their visual acuity, especially through the first critical phase of glucometabolic treatment. “It is necessary to assess the patient’s condition, check if the retina presents major lesions, and recommend frequent checkups,” Prof Bandello said. “As ophthalmologists, we need to protect the patient and their visual acuity, especially through the first critical phase of glucometabolic improvement.” The risk–benefit ratio is undoubtedly favourable but can be further improved with a little care from the clinicians and further research. “It is important to remember that, even if the rare side effects need to be carefully considered, GLP-1RAs are amongst the most effective modern treatments for patients with type 2 diabetes, offering patients substantial improvement in diabetic control,” Dr Stokholm concluded. “Our findings highlight the need for continued observations and further studies to clarify whether these associations represent a drug-related effect or reflect [the patients’] underlying risk factors.” For citation notes, see page 44.

Francesco Bandello MD, FEBO is Professor and Chairman of the Department of Ophthalmology, University Vita-Salute, Ospedale San Raffaele, Milan, Italy. Enrico Borrelli MD, PhD, FEBO is Associate Professor of Ophthalmology and Senior Consultant at the University of Turin, Italy. Lonny Stokholm MScPH, PhD is Associate Professor and Head of the Research Unit of Ophthalmology at the University of Southern Denmark, Denmark.

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INDUSTRY INSIGHTS

Global Ophthalmology Trends Progress depends on ethical collaboration and taking on challenges. HOWARD LARKIN REPORTS

nnovation drives better patient outcomes in ophthalmology. Ensuring ethical collaboration with industry, addressing regional, demographic, and environmental barriers, and developing guidelines for integrating new technologies are among the challenges ophthalmologists must address for continued progress, according to global ophthalmology society leaders.

We think much more [about] how to develop new devices than how to make access to them.

Collaborating with industry

industry, but also research and how societies can link doctors, researchers, and patients” to develop and implement new care solutions. Specialty societies should push for industry participation in public registries rather than keep technology research and outcomes data collection in-house, added Béatrice Cochener-Lamard MD, PhD. She also emphasised collaborating with patients in new product and technique development.

Reconciling ophthalmic specialty societies’ varied interests, including education and practice guideline development, with industry activities requires transparency, said Stephen McLeod MD. “Even though there is a tremendous overlap in our interests and activities, we want to make sure that is appropriately communicated and coordinated with industry, and that our role in it is independent. [So,] where there is overlap in our interactions, it is very transparent.” The Council of Medical Specialty Societies has established a code for interaction with companies1 that the American Academy of Ophthalmology follows, he noted. Nicole Eter MD agreed. “Disclosure is the key, not only in terms of what you can do with technology provided by

Regional barriers

As in other fields, globalisation is a major force in ophthalmology. However, regional barriers, including access disparities, workforce shortages, regulatory issues, and infrastructure gaps, interfere. Ophthalmic societies can help ensure consistent standards of care and innovation adoption across diverse areas, said Filomena Ribeiro MD, PhD. “Societies have a real role in [gathering] all the research in different areas to share knowledge [and] provide the same standard of care and access.” Over the past 20 years, there have been improvements, particularly in education, said Francis S Mah MD. “Obviously, there are areas that we still need to grow. The biggest challenge now is access.” Access to providers, technology, and new medications are all major concerns, even in higher income countries, he noted. However, developments such as border conflicts and tightening visa requirements are affecting knowledge sharing by making it harder to attend international conferences, said Ronald Yeoh MBBS. “I don’t know how we address these geopolitical issues.” Promoting the capacity of organisations such as ESCRS to enrol international participants can help, Dr Ribeiro said.

Sustainability

Efforts to reduce waste—such as making appropriate use of disposable instruments and promoting local manufacturing—could go a long way toward making ophthalmic surgery more environmentally friendly, but require regulators to get involved, Dr Cochener-Lamard said. Making better use of AI and remote monitoring could also reduce follow-up visits that waste not only physical resources, but also patients’ and caregivers’ time, noted Luis Abegão Pinto MD, PhD.

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Demographics

Perhaps the greatest challenges facing ophthalmic innovation are demographic changes. Boosting efficiency, efficacy, and productivity will be required to keep up with populations that are increasingly ageing, chronically ill, and diverse. “It’s a numbers game,” Dr McLeod said. “What it comes down to is [whether] our healthcare systems and the technologies we use [are] up to the challenge.” But people tend to think of this challenge as a technology question when it is actually more a matter of efficiency, effectiveness, and cost. Getting care to patients where they are comfortable with it and can get to it is just as crucial; That means reaching out to primary care, pharmacies, and other partners. Lack of information about eye diseases and treatment options is another major challenge, said Newton Andrade Jr MD. “The biggest problem of blindness is not glaucoma, it is not cataracts, it is ignorance.” A change of mindset is needed, Dr Andrade added. “We think much more [about] how to develop new devices than how to make access to them. We think of how to make more precise surgeries—like 0.25 mm incisions—when there are people who are blind from cataracts.” More must be done to inform and serve the public, Dr Andrade said, which includes working with politicians to make eye care a bigger public issue and raise awareness. AI and other technologies (e.g., telemedicine) have a critical role to play, but innovation must be directed at finding and meeting patient needs. “AI won’t replace what we have to do.”

All comments were made at iNovation Day during the 2025 ESCRS Annual Congress in Copenhagen. For citation notes, see page 44.

Stephen McLeod MD is CEO of the American Academy of Ophthalmology (AAO). Ronald Yeoh MBBS, FRCOphth is past president and current board member of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS). Francis S Mah MD is president of the American Society of Cataract and Refractive Surgery (ASCRS). Nicole Eter MD is president of the European Society of Retina Specialists (EURETINA). Filomena Ribeiro MD, PhD, FEBO is immediate past president of the European Society of Cataract and Refractive Surgeons (ESCRS). Newton Andrade Jr MD is president of the Brazilian Association of Cataract and Refractive Surgery (BRASCRS). Béatrice Cochener-Lamard MD, PhD is past president of the European Society of Cornea and Ocular Disease Specialists (EUCORNEA) and the ESCRS. Luis Abegão Pinto MD, PhD, FEBOS-G is vice president of the European Glaucoma Society (EGS).

iLEARN ESCRS iLearn is an online learning platform, free for ESCRS members. Visit elearning.escrs.org to access over 30 hours of interactive, assessed, and accredited e-learning content, including surgical videos, diagrams, animations, quizzes, and forums.

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LEADERSHIP, BUSINESS, AND INNOVATION

Who’s the BoSS? Bridging the gap between medical expertise and leadership. ROIBEARD O’HÉINEACHÁIN REPORTS

n a Building Our Sustainable Society (BoSS) podcast, Diana Silva MD and Artemis Matsou MD hosted a discussion on the leadership lessons that ophthalmologists can learn from others in the industry. Sharing their expertise were Jeanette Bankes, President and General Manager for Global Surgical at Alcon; Ana Neves, Global Head of Strategic Marketing at Zeiss Ophthalmology; and Magda Michna PhD, Chief Clinical, Regulatory, and Medical Affairs Officer at Staar Surgical Company. Dr Matsou noted that unlike professionals in the corporate world, clinicians typically lack formal leadership training and learn on the job with little guidance. She asked what industry strategies physicians can adopt to become more effective and confident leaders. Ms Bankes emphasised the importance of structured leadership training, tailored to distinct career paths, whether in academia or private practice, and highlighted the pivotal role of people leadership. “What I’d love to see is a more deeply rooted foundation in physician training early on to navigate both a complex reimbursement structure and also how to effectively run a business in terms of both finances and people management,” she said, adding that a crucial aspect of leadership is the

ability to inspire and guide a team towards shared goals while addressing their individual aspirations. “Successful companies have demonstrated time and time again that investment in people leadership results in higher outcomes, so I’d put people first,” Ms Bankes said. “That would be my request of you—learn people leadership.” Ms Neves noted that leadership encompasses various competencies, and it may therefore be more effective to take a staggered approach rather than addressing all of them simultaneously. “Some people have some innate leadership skills already, but I think some sort of structured approach on the basics of managing people would be a good step,” she said. “On the business side, [a good step would be] financial management basics and knowing the profit and loss margin.” Dr Michna noted that when she transitioned from academia to industry, she noticed companies often struggled with leadership due to a lack of understanding of their goals. “You might have physicians that are very skilled technically, but on the people skills side, they may have some work to do,” she said. “But perhaps it’s not even important for them to be necessarily leaders of people. You have to ask yourself, do you want to lead an organisation, or do you want to be a

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technical leader, based on your technical skills? There are different types of leadership.”

Different types of leadership

Dr Matsou asked the panel if they thought women are better represented today in leadership positions both in ophthalmology and the industry. “I think we are progressing, but we are far away from parity,” said Ms Neves. “It is not because there are not enough women who are capable leaders, but I think the decision makers simply have an aversion to risk and they will look for the same type of people they have always appointed to such positions.” She added that closing the gender gap in leadership may require women to step outside their comfort zone and be more assertive in expressing their views. The conversation then turned to whether female leaders must adopt some traditionally male traits to become successful leaders, or whether a perfectly feminine and traditional female can achieve that as well. “I don’t think women should try to be like men at all. I actually think the opposite,” said Dr Michna. “I think there are skills that women have that men do not have, just innately. I think, as women, we succeed when we leverage strong collaboration skills, emotional intelligence, inclusivity, focus, and a more holistic approach to work-life balance. Trying to define success in a male version of success [probably] isn’t going to be the way to make yourself happy. But what you can do is leverage the strengths you do have as a female.” Ms Bankes concurred, saying, “Let’s praise the differences. We tend to be high communicators, high energy, or emotional in nature. Instead of emulating your male counterpart, try to figure out what is the most effective way to deliver your own communication style.” Dr Matsou closed the discussion by asking if the panel saw any conscious or unconscious biases in how industry selects the key opinion leaders who bridge the gap between innovation and clinical adoption. Noting she has never encountered bias in the major ophthalmology companies she has worked for, Dr Michna said that what companies seek in key opinion leaders are intellectually curious surgeons and clinicians who are eager to answer fundamental questions and advance medical knowledge in the industry, regardless of the product. “If I was talking to a young ophthalmologist, I would say do good work, be a good surgeon. Don’t worry about being a key opinion leader—that will come. Most of the key opinion leaders have been at this for 20-odd years, so be patient but do good work. Just be a good surgeon and do good research. And it will come.” She also encouraged participation in organisations such as Ophthalmic World Leaders and in networks where they can find inspirational leaders to emulate. “Mentorship and sponsorship are important. Seek out the people that you admire and aspire to be like to help you in your career journey,” Dr Michna said. BoSS is an ESCRS initiative, inspired by 2024–2025 President Filomena Ribeiro, that focuses on fostering an inclusive culture among members, staff, and industry partners in ophthalmology. The podcast may be viewed at https://www.escrs.org/channels/boss/boss-podcast-episode-5-leaders-in-ophthalmology/.

Artemis Matsou MD, MRCP(UK), FEBOS-CR, FEBO, PgDip CRS is Consultant Ophthalmologist and Cataract Lead at Queen Victoria Hospital, East Grinstead, UK. art.matsou@gmail.com Diana Silva MD, FEBO is based at Hospital da Luz, Lisbon, Portugal.

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INDUSTRY NEWS

FDA Approval for Rayner’s RayOne EMV Toric IOL

Rayner announced the US Food and Drug Administration (FDA) has approved its RayOne EMV Toric intraocular lens (IOL) following the successful completion of a pivotal trial. Developed in collaboration with Professor Graham Barrett, the lens is engineered for exceptional rotational stability and refractive precision. In addition to correcting astigmatism, the new toric lens uses a non-diffractive optic and controlled positive spherical aberration to extend patients’ range of vision with monofocal levels of contrast sensitivity. rayner.com

Ryjunea myopia drops approved in UK

Sydnexis announced Santen has received UK Medicines and Healthcare products Regulatory Agency (MHRA) approval for Ryjunea (low-dose atropine 0.1 mg/mL), the first approved UK treatment to slow myopia in children aged 3–14 with a progression rate of 0.50 D or more per year and severity between -0.50 D and -6.00 D. This approval follows European Commission authorisation and an earlier launch in Germany. Sydnexis’ SYD-101, licensed to Santen as Ryjunea, will be commercialised in Europe, the Middle East, and Africa. sydneixis.com santen.com

LambdaVision gains funding for space age artificial retinas

LambdaVision has raised $7 million in seed funding to advance preclinical development and scale up production of its investigational therapy aimed at restoring sight in patients with retinal degenerative diseases such as retinitis pigmentosa and AMD. LambdaVision’s artificial retina uses photoactive proteins to mimic the light-absorbing function of natural photoreceptor cells, stimulating existing retinal neurons in patients who have lost photoreceptor function. The company’s proprietary process uses the microgravity environment of the ISS to produce ultra-uniform, 200-layer protein films. lambdavision.com

Haag-Streit imaging competition

Haag-Streit announced the results of its annual “Slit Lamp Imaging Competition 2025”. Dr Kasi Sandhanam, from the Singapore National Eye Centre, Singapore, won first place with an entry captured on a Haag-Streit BX 900. The composite winning image shows a persistent pupillary membrane. The overall winner of the video category was Augusto Paranhos Jr, Forno e Paranhos Oftalmologia, São Paulo, Brazil. haag-streit.com/en/Campaigns/slic/download

Prefilled ranibizumab biosimilar syringes launched in Europe

Formycon, Bioeq AG, and Teva Pharmaceutical have announced the European launch of FYB201/Ranivisio, the first Lucentis biosimilar in an EMA-approved prefilled syringe (PFS). The roll-out began in France in October 2025 with additional European markets, including Germany, to follow. Teva, Bioeq’s commercialisation partner for the vial formulation since 2022, will now also market the PFS version. formycon.com

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JCRS HIGHLIGHTS ACTION NEEDED TO STEM THE RISING TIDE OF MYOPIA The world is facing a pandemic of myopia, said Professor Thomas Kohnen. He noted that in 2010, more than a quarter of the global population was affected by myopia. Projections indicate that within the next two decades, cases of high myopia (≥-6.00 D) will double, while instances of moderate myopia (-3.00 D to -5.99 D) will triple. Research indicates that apart from genetic factors, adequate exposure to natural daylight during childhood is crucial in eye development. For schoolage children who already have myopia, using low-dose atropine drops has been shown to be effective in slowing its progression. Additionally, there are specially designed contact lenses and glasses that both improve vision and help slow myopia advancement. Surgical options like corneal refractive procedures and phakic IOLs correct the symptoms but do not address the underlying causes. Ophthalmology should not only provide symptomatic relief but identify and address the root causes of the imminent pandemic, Prof Kohnen said. T Kohnen. “Myopia: Still a widespread deviation from the norm or already a pandemic?,” 51(11): 939–940.

VARIATION IN PRESCRIPTION PATTERNS FOR DMEK A survey of corneal surgeons has revealed considerable variation in perioperative medication for DMEK. Out of 136 respondents across 16 national societies, most relied on departmental protocols (54%) or personal experience (48%), with only 22% following national guidelines. Infection prevention primarily involved intra- (72%) and postoperative (92%) antibiotics; preoperative use was less common (18%). Steroids were mainly used postoperatively (100%), intraoperatively (59%), and infrequently preoperatively (13%), with dexamethasone preferred. Steroid tapering once daily after 6 months was practiced by 46% and at varying times by 65%. High-risk cases often received additional topical (30%) or systemic (24%) immunosuppressants. For graft rejection, most respondents increased topical steroids (85%) or administered (peri)bulbar injections (42%). Mydriatics were used intraoperatively for pupil block prophylaxis (34%), while pressure-lowering agents were rarely used (0.7–2.2%). Steroid-induced ocular hypertension was managed by switching to weaker steroids (40%) or reducing frequency (43%). Y Ye. “Prescription patterns in DMEK: European survey,” 51(11): 941–947.

NEW LAL BRINGS INCREASED DEPTH OF FOCUS A multicentre registry study found that the new version of the light-adjustable lens (LAL+) offers a broader depth of focus than the standard LAL without compromising corrected distance visual acuity. Of the 150 patients—50 with LAL and 100 with LAL+ implants—the study showed that after refractive adjustment, 91.1% of LAL and 93.5% of LAL+ eyes were within 0.50 D of target. Additionally, 92.0% of LAL and 89.0% of LAL+ patients achieved binocular uncorrected distance vision of 20/20 or better. Mean uncorrected intermediate vision was -0.032 logMAR (LAL) and -0.046 (LAL+), while mean near vision was 0.140 (LAL) and 0.069 (LAL+) logMAR. Best-corrected distance vision was only slightly reduced for LAL+, with both lenses achieving high levels overall.

JOIN the leading community and trusted source for SCIENCE, EDUCATION & PROFESSIONAL DEVELOPMENT in the fields of cataract and refractive surgery. learn more about membership at escrs.org

J Doane, et al. “Clinical data registry comparing outcomes of two light adjustable lenses,” 51(11): 948–954.

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CITATION INDEX

Cited in this Issue ESCRS Research Explores Clinical Issues Large and Small Page 08

1. ESCRS Cataract Surgery Guidelines, https://www.escrs. org/escrs-guideline-for-cataract-surgery/ 2. Ribeiro F, et al. J Cataract Refract Surg, 2024 Aug; 50(8): 794–798. 3. Kohnen T, et al. J Cataract Refract Surg, 2025 Jun 1; 51(6): 440–446.

The Power of Registries Page 11

1. Zetterberg M. “Boosting outcomes with surgical registries: Insights from the Swedish National Cataract Registry,” presented at the European Society of Cataract and Refractive Surgeons Annual Congress, Copenhagen, Denmark, 13 September 2025. 2. Lundstrom M, et al. J Cataract Refract Surg, 2009 Oct; 35(10): 1679–1687. 3. Zetterberg M, et al. Ophthalmology, 2020 Mar; 127(3): 305–314. 4. Zetterberg M, et al. Ophthalmology, 2021 Mar; 128(3): 364–371. 5. ESCRS Endophthalmitis Study Group. J Cataract Refract Surg, 2007 Jun; 33(6): 978–988. 6. Viberg A, et al. J Cataract Refract Surg, 2020 Jul; 46(7): 961–966.

Personalising Care with Data Insights Page 13

Late Post-LASIK Enhancements Page 21

1. Cho Y, et al. Am J Ophthalmol, 2019; 207: 326–332.

Retinal Detachment After Cataract Surgery Page 23

1. Bjerrum SS, et al. Ophthalmology, 2013 Dec; 120(12): 2573–2579. 2. Hajari JN, et al. Retina, 2014 Aug; 34(8): 1658–1665. 3. Ludwig CA, et al. Sci Rep, 2023 Jun 9; 13(1): 9430. 4. Wallsh JO, et al. Ophthalmology, 2023 Jun; 130(6): 624–630. 5. Hayashi S, et al. Eye (Lond), 2022 Oct; 36(10): 1872–1877. 6. Christ M, et al. Transl Vis Sci Technol, 2024 Apr 2; 13(4): 1.

GLP-1RAs: A Cause for Concern? Page 36

1. DCCT Research Group. Diabetes Care, 1987 Jan–Feb; 10(1): 1–19, doi: 10.2337/diacare.10.1.1. 2. Stougaard EB, et al. Diabetes Obes Metab, 2025 Oct; 27(10): 5432–5443, doi:10.1111/dom.16606. 3. Grauslund, et al. Int J Retina Vitreous, 2024 Dec 18; 10(1): 97. 4. Wang L, et al. JAMA Netw Open, 2025 Aug 1; 8(8): e2526327.

Global Ophthalmology Trends Page 38

1. Council of Medical Specialty Societies Code for Interaction with Companies, https://cmss.org/standards/ cmss-code-for-interactions-with-companies/

1. Thylefors J, et al. Acta Ophthalmol, 2022 Dec; 100(8): e1595– e1599. 2. Haargaard B, et al. Acta Ophthalmol, 2015 Jan; 93: 24–26. 3. Kessel L, et al. Acta Ophthalmol, 2024 Nov; 102(7): 790–796.

Long-Term Data Key to Surgical Success Page 15

1. Morano MJ, Khan MA, Zhang Q, et al. Ophthalmol Science, 2023; 4: 100314. 2. Gim N, Jian Y, Bagdasarova Y, et al. Ophthalmol Science, 2025; 5: 100851. 3. Altamirano F, Jeon JH, Lee J-Y, et al. Ophthalmology, 2025; 132: 888–894. 4. Lee J-Y, Jeon JH, Altamirano F, et al. Ophthalmology, 2025 Jun 27: S0161-6420(25)00392-6. Online ahead of print.

Debating RLE in Younger Adults Page 19

1. Laube T, et al. PLoS One, 2017 Aug 31; 12(8): e0184187. 2. Bjerrum SS, et al. Ophthalmology, 2013; 120(12): 2573–2579.

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Upcoming Events March 6–8

March 6

ESCRS Winter Meeting 2026 Helsinki, Finland April 10–13

ASCRS Washington, DC, US

May 4–8

ARVO Salt Lake City, Utah, US

May 9–11

French Society of Ophthalmology (SFO) Paris, France

May 22–24

EuCornea Porto, Portugal

April 10

May 4

June 26–29

World Ophthalmology Congress Prague, Czech Republic

September 11–15

ESCRS Annual Congress London, UK

November 12–14

UKISCRS Annual Conference London, UK

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OVERALL SAFETY PROFILE SIMILAR TO CATARACT SURGERY ALONE1 Pivotal data and real world studies show that intraoperative and postoperative complications are rarely observed1-3

FAVOURABLE SAFETY PROFILE4 iStent inject® W was demonstrated to have a favourable safety profile when compared to other MIGS procedures4

THE TRUSTED AND PROVEN

SAFE TECHNOLOGY FOR GLAUCOMA

PROVEN TO BE SAFE AND TRULY TISSUE-SPARING6 iStent inject® has demonstrated the lowest reported rates of significant ECL in any MIGS pivotal trial at 5 years follow-up6

1- Samuelson, Thomas W., et al. “Prospective, randomized, controlled pivotal trial of an ab interno implanted trabecular micro-bypass in primary open-angle glaucoma and cataract: two-year results.” Ophthalmology 126.6 (2019): 811-821. 2- 7-Year Efficacy and Safety of iStent inject® Trabecular Micro-Bypass in Combined and Standalone Usage. Fritz H. Hengerer . Gerd U. Auffarth . Ina Conrad-Hengerer. 3- Neuhann, Tobias H., Raphael T. Neuhann, and Dana M. Hornbeak. “Ten-year effectiveness and safety of trabecular micro-bypass stent implantation with cataract surgery in patients with glaucoma or ocular hypertension.” Ophthalmology and Therapy 13.8 (2024): 2243-2254. 4- Data on file. Manuscript currently submitted by Kevin Gillmann and Athena Lallouette. 5- Data on file. 6- Ahmed, Iqbal Ike K., et al. “Corneal Endothelial Safety Profile in Minimally Invasive Glaucoma Surgery.” Journal of Cataract & Refractive Surgery (2024): 10-1097. iStent inject® IMPORTANT SAFETY INFORMATION INDICATIONS FOR USE: The iStent inject® is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject® can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject® System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascularglaucoma, because the device would not be expected to work in such situations • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the devices if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject® is MR-Conditional.• Physician training is required prior to use of the iStent inject® System. • Do not re-use the stent(s) or inserter, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events. • There are no known compatibility issues with the iStent inject® and other intraoperative devices (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminatedproducts must be disposed of as medical waste. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. iStent inject® W IMPORTANT SAFETY INFORMATION INDICATIONS FOR USE: The iStent inject® W, is intended to reduce intraocular pressure safely and effectively in patients diagnosed with primary open-angle glaucoma, pseudo-exfoliative glaucoma or pigmentary glaucoma. The iStent inject® W, can deliver two (2) stents on a single pass, through a single incision. The implant is designed to stent open a passage through the trabecular meshwork to allow for an increase in the facility of outflow and a subsequent reduction in intraocular pressure. The device is safe and effective when implanted in combination with cataract surgery in those subjects who require intraocular pressure reduction and/or would benefit from glaucoma medication reduction. The device may also be implanted in patients who continue to have elevated intraocular pressure despite prior treatment with glaucoma medications and conventional glaucoma surgery. CONTRAINDICATIONS: The iStent inject® W System is contraindicated under the following circumstances or conditions: • In eyes with primary angle closure glaucoma, or secondary angle-closure glaucoma, including neovascular glaucoma, because the device would not be expected to work in such situations. • In patients with retrobulbar tumor, thyroid eye disease, Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS/PRECAUTIONS: • For prescription use only. • This device has not been studied in patients with uveitic glaucoma. • Do not use the device if the Tyvek® lid has been opened or the packaging appears damaged. In such cases, the sterility of the device may be compromised. • Due to the sharpness of certain injector components (i.e. the insertion sleeve and trocar), care should be exercised to grasp the injector body. Dispose of device in a sharps container. • iStent inject® W is MR-Conditional. • Physician training is required prior to use of the iStent inject® W System. • Do not re-use the stent(s) or injector, as this may result in infection and/or intraocular inflammation, as well as occurrence of potential postoperative adverse events. • There are no known compatibility issues with the iStent inject® W and other intraoperative devices. (e.g., viscoelastics) or glaucoma medications. • Unused product & packaging may be disposed of in accordance with facility procedures. Implanted medical devices and contaminated products must be disposed of as medical waste. • The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. If intraocular pressure is not adequately maintained after surgery, the surgeon should consider an appropriate treatment regimen to reduce intraocular pressure. • Patients should be informed that placement of the stents, without concomitant cataract surgery in phakic patients, can enhance the formation or progression of cataract. ADVERSE EVENTS: Please refer to Directions For Use for additional adverse event information. CAUTION: Please reference the Directions For Use labelling for a complete list of contraindications, warnings and adverse events. ©2025 Glaukos Corporation. Glaukos, TMB®, iStent®, iStent inject® and iStent inject® W are registered trademarks of Glaukos Corporation. PM-EU-0390

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