A panoply of presbyopic lens possibilities point to improved outcomes with fewer photic effects.
Investigative Fluid-Filled Accommodative IOL
Two-year follow-up with shapechanging lens shows stable functional vision.
Coming to Terms with Dry Eye Disease
Survey suggests vast untreated population suffering from DED.
MYOPRED Results
Long-term ESCRS study sheds light on retinal risks of cataract surgery.
We’re willing to bet most eye care professionals don’t realise just how prevalent Demodex blepharitis is.
In fact, ~54% of eye care patients in Europe may have Demodex blepharitis (DB).1*
*Data from an evaluation of 804 patients from 6 countries in Europe, including 15 clinicians each with ~50 consecutive patients
WHAT ABOUT YOUR PATIENTS?
LEARN HOW DB CAN FLY UNDER THE RADAR AT
JEANETTE, real DB patient.
WITH PARTICIPATION OF THE FINNISH SOCIETY OF OPHTHALMOLOGY
WWW.CONGRESS.ESCRS.ORG
EXPLORE. LEARN. CONNECT.
The ESCRS Winter Meeting is known for offering an intimate and focused forum for discussion and learning about advancements in cataract and refractive surgery. Join your colleagues for three days of collaborative sessions and immersive learning opportunities at the Messukeskus Helsinki Exhibition and Convention Centre, 06–08 March 2026.
The 2026 Winter Meeting will combine the intellectual vigour of ESCRS, Europe’s leading organisation devoted to the study and practice of anterior segment surgery, with the sophisticated urban culture of Helsinki, a vibrant city known for its relaxed lifestyle and coastal nature.
Join fellow ophthalmologists, researchers, and industry experts at this can’t-miss event. Registration details coming soon!
13 EDOF Lenses Show Promise for Irregular Astigmatism
Daniel Schartmüller MD
14 The Importance of Ocular Surface Assessment
Ramin Khoramnia MD, PhD, FEBO
16 Assessing RD Risk After Lens Surgery
Oliver Findl MD, MBA, FEBO and Marlies Ullrich MD
17 A Series of Groundbreaking Procedures in Ophthalmology
20 Cannula Dislodgement: The Russian Roulette of Harm
24 Need to Know: Who Should Receive PPP for Aberropia?
Soosan Jacob MS, FRCS, DNB
26 Coming to Terms with Dry Eye Disease
Piotr Wozniak MD, PhD
27 The Second Global Consensus on Keratoconus
Farhad Hafezi MD, PhD, FARVO; Renato Ambrósio Jr, MD, PhD; and José Álvaro
Pereira Gomes MD, PhD
28 Bioengineered Endothelial Implant Shows Promising in vivo Results
Michael Mimouni MD
RETINA
30 Treatment for Macular Oedema Secondary to Inflammation
Charles C Wykoff MD, PhD
31 Privosegtor Shows Promise for AON
Sophie Bonnin MD, PhD
32 Targeting the Intravitreal Treatment Burden
Arshad M Khanani MD, MA, FASRS
INDUSTRY INSIGHTS
Ali Nowrouzi MD, FEBOS-CR, FICO, FACS, FWCRS
Thomas
Steven
Ron Kurtz MD; Tibor Juhasz MD, PhD; H Burkhard Dick MD, PhD, FEBOS-CR; Zoltán Nagy MD, PhD; and Imola
Ratkay-Traub MD, PhD
18 The Short-Sighted World
Thomas Kohnen MD, PhD, FEBO
33 CE Mark for Ciliatech’s Novel Glaucoma Implant
Philippe Sourdille MD
Senior Content Editor
Graphic Designer
Circulation Manager
Contributing Editors
Cheryl Guttman Krader Roibeárd O’hÉineacháin
Tel: +44 203 530 0100 | roo.khan@wearemci.com 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
. ISSN 1393-8983
Learn more about EuroTimes or connect with ESCRS at ESCRS.org
A Community of Collaboration and Consensus
As I conclude my two-year term as ESCRS president, I feel an immense sense of gratitude and pride in all that we have achieved together. From the outset, my guiding principle has been to strengthen collaboration, inclusivity, and scientific excellence—and I believe we have truly advanced our Society on all these fronts.
We have reinforced ESCRS’s long-term vision and strategic identity. Through Building Our Sustainable Society (BoSS), we have embedded inclusion and sustainability into every aspect of our work, ensuring the Society’s growth remains both responsible and forward-looking. BoSS has become a symbol of cultural evolution within ESCRS, shaping how we design programmes, select faculty, and support diverse perspectives. Our strengthened international partnerships have further amplified this openness.
Our Annual Congress has become the largest ophthalmology meeting in the world—a reflection not only of the scientific calibre of our programmes but of the extraordinary sense of community and belonging ESCRS inspires.
This growth brings a greater responsibility to the community that has guided many of our key initiatives. We have intensified efforts to disseminate the ESCRS Guidelines, broadening the reach of evidence-based standards. One of our most significant scientific milestones has been the ESCRS Simultaneous Vision Classification. Endorsed by all major international societies, this initiative aligns science, communication, and patient care under a unified, transparent framework.
The Global Refractive Summit brought together refractive surgeons from around the world, offering a truly international perspective on current challenges and innovations. By sharing diverse geographic experiences and approaches, the Summit underscored how local realities enrich global understanding— reaffirming ESCRS’s role as a catalyst for worldwide dialogue.
EDITORIAL BOARD
Adi Abulafia (Israel)
Bruce Allan (UK)
Noel Alpins (Australia)
Juan Alvarez de Toledo (Spain)
Gerd Auffarth (Germany)
Başak Bostanci (Turkey)
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)
Our Congresses in Barcelona (2024) and Copenhagen (2025) were defining moments in this journey. In Barcelona, we honoured the 75th anniversary of the first IOL implantation. In Copenhagen, we marked the 30th anniversary of femtosecond laser technology, a reminder of how profoundly technological progress continues to shape our field.
Education, mentorship, and engagement remain at the heart of our meetings. The ESCRS Training Lab offered hundreds of delegates free, high-fidelity simulator training—fully booked on the first day for both congresses. Building on this success, we have developed the ESCRS Cataract Training Curriculum, a comprehensive framework designed to streamline cataract surgical education across Europe and to guide participants through a structured, competency-based learning pathway. We also introduced new interactive formats such as The Arena, where live debates and open forums encouraged active participation, networking, and mentorship. By integrating elements of each host country’s culture, these sessions created vibrant, locally inspired spaces that blended scientific dialogue with shared experience.
Additionally, participatory models such as the World Café, Exhibition Tours, and TOGA Sessions fostered meaningful discussion and collegial exchange.
But there is still work ahead to ensure equitable access to innovation, sustain diversity in leadership, and translate our consensus work into practical tools for clinical practice. Yet I leave this role confident and inspired. Our community is passionate, forward-thinking, and united by a shared purpose to advance ophthalmology.
It has been the greatest honour of my professional life to serve as ESCRS president.
Filomena Ribeiro, ESCRS President
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)
Thomas Kohnen José Güell Paul Rosen
Highlights of ESCRS
The Art of Cataract Surgery
Volume 41, Issue 3, 2025
PREOPERATIVE CHALLENGES
Nanophthalmos .................................................................... Drs. O. Avedi, H. Smaoui, A. Jallouli, O. Hbaieb, & A. Trigui, Tunisia
Intermittent Globe Compression .................................................................. Dr. Robert Osher, USA
Megalophthalmos ....................................................................................... Dr. Bassen Fayez, Egypt
Morgagnian ..........................Drs. J. S. Kasanardjo & Gelre Ziekenhuizen Apeldoorn, Netherlands
Subluxed ........................................................................................... Dr. Gabriel Figueiredo, Brazil
Traumatic Aniridia ................................... Drs. A. Abolhassani, K. Sheibani, & R. Pourmatin, Iran
Posterior Polar ................................................................................... Dr. Tushya Om Parkash, India
Escape Route ................................................................................................ Dr. Robert Osher, USA
Exchange with Capture .............................................................................. Dr. Kumar Doctor, India
Dangling IOL/Bag Complex ...................................................................... Dr. Ahmed Assaf, Egypt
ESCRS Update
ESCRS Endorses Position Paper on Multi-Use Phacoemulsification Supplies
ESCRS and three other multinational societies of cataract and refractive surgeons have jointly endorsed a position paper on the importance of multi-use phacoemulsification cassettes to safely reduce unnecessary surgical waste.
The paper calls on industry to prioritize development of multi-use supply options for every phacoemulsification machine platform and for regulatory agencies to facilitate review and approval of these products.
This marks the first time that ESCRS, the American Society of Cataract and Refractive Surgery (ASCRS), the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS), and the Latin American Society of Cataract and Refractive Surgery (LATAMSCRS) have collaborated on a joint position paper. The paper was developed in conjunction with EyeSustain, a global coalition of ESCRS and more than 50 other ophthalmology societies.
The position paper is an evidence-based review of the global phacoemulsification cassette market, global survey data on surgeon practices and opinions, and published evidence supporting cassette reuse safety and the impact on unnecessary carbon emissions and non-recyclable plastic waste from this practice. The paper argues that, with 30 million cataract surgeries being performed each year worldwide, multi-use cassettes and other supplies should be offered as an option for every phacoemulsification machine.
The paper also encourages surgeons and their facilities to consider adopting waste- and cost-reducing multi-use phacoemulsification supply options when available. The resulting savings in manufacturing, packaging, and shipping
costs should reduce facility costs, improve operating room efficiency, and dramatically reduce unnecessary waste without compromising safety.
Available evidence has not demonstrated that single-use phacoemulsification cassettes are safer compared to reusable cassettes. Many facilities worldwide reuse single-use cassettes off-label, particularly in Asian and Pacific markets. Day cassettes reused for multiple consecutive patients without sterilization are available for a few machines in some markets but are not offered by the largest machine manufacturers accounting for the majority of global market share.
Journal Articles Look at Measuring and Reporting Astigmatism
The June 2025 issue of the Journal of Cataract & Refractive Surgery contains an editorial and two articles exploring how to better measure and report astigmatism, including surgically induced astigmatism.
In a short video accompanying the publication of the articles, the two lead authors—Douglas Koch MD and Thomas Kohnen MD, PhD, who serve as co-editors of the JCRS—recount the genesis for the articles as a project that began in 2001, when experts in astigmatism analysis were provided with an astigmatism data set and asked to show the many ways it could be analyzed.
“It got confusing, and we realized we needed something more scientific,” said Koch. “That’s when Thomas decided we needed a working group.”
“It took us more than three years to come to this conclusion, but it was worth it,” said Kohnen. “I have to say, when we did this project together with this group, we all learned ourselves.”
It took us more than three years to come to this conclusion, but it was worth it.
— Thomas Kohnen MD, PhD
The articles provide recommendations for two analytical approaches that take into account astigmatism data are not normally distributed. “If a researcher wants to figure out their outcome, [they have] a tool,” Kohnen said.
Webinar Explores Small-Aperture Optic Procedures
An ESCRS webinar on 8 October examined the role of small-aperture optic surgical procedures in modern ophthalmology, from intraocular lenses and corneal inlays to pupilloplasty. An expert panel of speakers explored the science behind these innovations and shared real-world
clinical insights, including indications, patient selection, visual outcomes, and known complications.
• Pablo Artal: The science and promise of small aperture optics
• Claudio Trindade: Intraocular and other surgical pinhole techniques
• Robert Edward Ang: Patient selection and visual outcomes in small aperture surgery
• Roger Zaldivar: Managing pitfalls and postoperative surprises
The webinar offered a valuable opportunity to expand knowledge and stay up to date with the latest advancements. To view the webinar, scan the QR code.
INDUSTRY PARTICIPATION
The Power of Clareon: Not all Presbyopia
Correcting IOLs are created equal
At ESCRS 2025 in Copenhagen, leading surgeons highlighted how Alcon’s Clareon® Collection continues to set the standard for optical clarity, visual performance, and personalized presbyopia correction.
The presbyopia-correcting IOL (PCIOL) landscape is advancing faster than ever, with new technologies promising improved visual outcomes and patient satisfaction. Amid this evolution, surgeons face a critical question: how to identify innovations that elevate care.
During a symposium session, Dr. Ahmed and a panel of leading ophthalmologists presented their clinical experience with Alcon’s portfolio of PCIOLs. The discussion emphasized evidence-based considerations for selecting the most suitable PCIOL to address individual patient needs and ensure consistent, predictable visual outcomes.
Presbyopia Surgery Is Evolving, Are Your IOLs Keeping Up?
Presented by Dr. Ike K. Ahmed, Canada
To kick off the conversation, Dr. Ahmed asked his fellow panelists, “What do you value the most when selecting an IOL platform,” to which many agreed “IOL Material and Optic Design” should rank the highest on list of considerations. But why is this so critical?
As the field grows more competitive, Alcon’s Clareon Collection of IOLs expands and continues to deliver more solutions for what matters most to surgeons and patients: excellent refractive predictability and high quality of vision that have made Alcon IOLs the most implanted IOLs worldwide.1-9
Dr. Ahmed emphasized that the remarkable global adoption of PanOptix® (over 4 million implants) and Vivity® (over 2 million implants) is a powerful testament to the trust surgeons place in these advanced IOL technologies.8,9 “These numbers speak for themselves—they’re not being implanted by chance,” he noted.
Alcon’s PCIOLs not only meet ANSI standards for EDOF lenses, as demonstrated by Clareon Vivity, but also fulfill ISO criteria, the only two accepted global standards—backed by robust clinical evidence. In addition, the Clareon IOL family aligns with the evidence-based classification framework proposed by the ESCRS Functional Vision Working Group. Specifically, Clareon Monofocal is categorized under Partial Range of Field – Enhance, Vivity under Partial Range of Field –Extend, and PanOptix under Full Range of Field –Continuous, reflecting their respective optical profiles and the range of vision they provide.
“At the end of the day, the only thing that remains in the eye is the material—and that’s where Clareon truly stands apart.”
— Dr. Ike K. Ahmed
The EDOF Designed for the Real World
Presented by Dr. Ramin Khoramnia, Germany
To further the conversation on PCIOLs and EDOFs, Dr. Khoramnia reflected on a time when only less than 10% of cataract patients had access to PCIOLs, but the landscape suddenly changed when Vivity was
introduced. As the first PCIOL to deliver a monofocal visual disturbance profile, Vivity transformed the surgical mindset around presbyopia correction.
According to the 2024 ESCRS Clinical Trends Survey, EDOF technology now accounts for nearly half of all PCIOLs used in qualified candidates, a dramatic rise that began with Vivity’s introduction.10
Dr. Khoramnia then presented results from an independent optical bench comparison conducted at The David J. Apple Center for Vision Research, University of Heidelberg, comparing Clareon Vivity and TECNIS‡ PureSee‡. The analysis found that Vivity demonstrated superior intermediate performance, with TECNIS‡ PureSee‡ showing approximately 42% lower image contrast (MTF) at 66 cm compared to Clareon Vivity.11
“Vivity remains the most implanted EDOF worldwide—it performs beautifully in the real world, not just in the lab.”
— Dr. Ramin Khoramnia
Dr. Khoramnia spoke about real-world multicenter registry data of nearly 900 patients implanted bilaterally with Vivity, confirming Vivity’s reliability across a broader patient population, including those with mild ocular comorbidities.12 “For patients with stable glaucoma or early retinal changes, Vivity delivers outcomes that would be unthinkable with diffractive designs.”
He concluded that with Vivity now available on the Clareon platform, it offers clinicians and patients even more options to consistently achieve proven visual outcomes.
The Benchmark in Trifocal IOLs
Presented by Dr. Dagny Zhu, United States
If Vivity redefined EDOF, then PanOptix set the benchmark for full-range vision. Presenting new global data, Dr. Zhu described PanOptix as “the only trifocal IOL backed by the breadth of evidence and real-world confidence we see today.”
A pooled analysis of 13 prospective studies involving
more than 500 patients across 14 countries demonstrated that over 90% achieved complete spectacle independence at all distances, with most maintaining 20/20 or better vision from distance to near.13†§^ Even at 33 cm where you might expect to see greater drop, the lens achieved 20/25 or better visual acuity—a remarkable range of focus for everyday tasks.13§
When determining how this range of vision translated into spectacle independence, Dr. Zhu reported that more than 90% of patients reported never needing glasses at all distances. She shared that this was the largest cumulative study conducted that reported complete spectacle independence noting that PanOptix is the only trifocal IOL with such robust spectacle independence data.13
Additionally, Dr. Zhu shared that 97% of patients reported no highly bothersome and 95% no severe visual disturbances. “That’s what gives us confidence to recommend PanOptix across a wide range of patients,” Dr. Zhu noted.13§*
She then went on to describe improvements with Clareon PanOptix, which builds on AcrySof® PanOptix but delivers measurable gains in contrast sensitivity and fewer photic phenomena.
“PanOptix gives patients functionally complete vision—from reading to night driving—without compromising clarity or confidence.”
— Dr. Dagny Zhu
Dr. Zhu noted that in real-life, clinical data from a recently published paper shows that 36% of TECNIS‡ Odyssey‡ patients needed glasses for near vision and that almost half of patients experienced moderate to severe halo.14
“In my experience, PanOptix delivers a predictable, full-range result,” she said. “It continues to be my go-to choice in trifocals.”
Clareon Custom Match: The Smart Personalization for Demanding Patients?
Presented by Dr. Dominique Monnet, France
Bridging range and quality, Dr. Dominique Monnet introduced the Clareon Custom Match concept as a modern evolution of the classic binocular strategy, offering surgeons a flexible and tailored solution for some of their patients.
“I would say that Custom Match seems to get the best of the two worlds in terms of benefits.”
— Dr. Dominique Monnet
His approach places Clareon Vivity in the dominant eye and Clareon PanOptix in the non-dominant eye, creating what he called “a smart balance between range, contrast, and neuroadaptation.”
This method extends presbyopia correction to patients who may not tolerate bilateral trifocals or are suboptimal for a single-lens strategy.
Compared with bilateral EDOF implantation, Custom Match provides:
•Broader patient eligibility
•Extended range of vision
• Fewer visual disturbances than bilateral trifocal solutions
Dr. Monnet emphasized that the Custom Match strategy can broaden the population eligible for presbyopia correction, particularly for patients with high visual demands who seek a balance between range and visual comfort.
Clarity, Consistency, Customization
Closing the session, Dr. Ahmed emphasized that with the Clareon Collection, surgeons now have a complete ecosystem built on a unified material platform—from monofocal to EDOF to trifocal.
The message from Copenhagen was clear: the combination of Clareon technology with both clinical and real-world performance sets Alcon PCIOLs apart.
† Pooled mean binocular defocus curve at 3-6 months postoperatively from 6 prospective trials on AcrySof ® IQ PanOptix® in cataract patients; n=542.
§ Based on data for AcrySof® IQ PanOptix® Trifocal IOL. AcrySof® IQ PanOptix® is optically equivalent to Clareon® PanOptix®
^ Snellen VA was converted from logMAR VA. A Snellen notation of 20/20-2 or better indicates a logMAR VA of 0.04 or better, which means 3 or more of the 5 Early
* Patient reported visual disturbances per QUVID questionnaire at 6 months.
‡ Trademarks are the property of their respective owners.
** AUC: Area under the curve.
# MTF is measured in green light at 550 nm, 3.0 mm Aperture, 50 lp/mm
References: 1. Lane S, et al. J Cataract Refract Surg. 2019;45(4):501–506. 2. Werner L, et al. J Cataract Refract Surg. 2019;45:1490–1497. 3. Oshika T, et al. J Cataract Refract Surg. 2020;46(5):682–687. 4. Maxwell A, Suryakumar R. Clin Ophthalmol. 2018;12:2031–2037. 5. Lehmann R, et al. Clin Ophthalmol. 2021;15:1647–1657. 6. Berdahl P, et al. Visual Performance of a Novel Wavefront Shaping EDOF IOL. J Cataract Refract Surg doi:10.1097/j.jcrs.0000000000001742. 7. Zhu D, et al. Ophthalmol Ther. 2023;12(2):1157–1171. 8. Alcon data on file, 2023. REF-22137. 9. Market Scope 2025 IOL Market Report – REF-27211 10. ESCRS Clinical Trends Survey 204 Results, EUROTIMES, Supl. Sept/Oct 2025 11. Niknahad, A., Wu, Z., Son, H.-S., Auffarth, G. U., Khoramnia, R., & Łabuz, G. (2025). Evaluation of Clareon Vivity and PureSeeintraocular lenses: optical quality, depth of focus and misalignment effects.Scientific Reports, 15, 26943.https://doi.org/10.1038/s41598-025-07970-y 12. Howes F, Rementeria-Capelo LA, Poyales F, Borovik A, Khoramnia R, Perez-Vives C, Nuijts RMMA. Visual Performance and Patient Satisfaction of Bilaterally Implanted Extended Depth of Focus Intraocular Lens: Outcomes of a Multicenter Registry. J Refract Surg. 2025 Feb;41(2):e131-e143. 13. Zhu D, Ren S, Mills K, Hull J, Dhariwal M. Rate of Complete Spectacle Independence with a Trifocal Intraocular Lens: A Systematic Literature Review and Meta-Analysis. Ophthalmol Ther. 2023;12(2):1157-1171 14. Alcon Data on File 2024. REF-25452
Alcon medical device(s) comply with the current legislation for the medical devices. Please refer to relevant products instructions for use for complete list of indications, contraindications and warnings.
PanOptix shows superior image quality (MTF) on the optical bench14
Small Pupils and EDOF
Continuous transitional focus more forgiving than central HOA designs?
HOWARD LARKIN REPORTS
Intraocular lenses (IOLs) providing extended depth of focus (EDOF) using a continuous transitional focus multifocal refractive design may be better tolerated by patients with small pupils than IOLs using a central higher-order aberration (HOA) segment to extend focus depth, according to a study by Ali Nowrouzi MD.
Retrospective case series
The study evaluated 250 patients for photopic pupil size using a Pentacam (Oculus). One hundred fifty had received EDOF IOLs using central HOA designs (either Alcon Vivity or Bausch + Lomb LuxSmart), and 100 received EDOF IOLs using a continuous transitional focus design (Ophtec Precizon Presbyopic). For patients with photopic pupil size of less than 2.5 mm, visual function and patient satisfaction were assessed using a VF-14 questionnaire modified to evaluate tasks without spectacles, Dr Nowrouzi said.
Overall, 7 (2.8%) patients receiving central HOA IOLs had photopic pupils measuring less than 2.5 mm. Mean myopic refractive error was -0.50±0.25 D. Six of these patients underwent laser treatment due to dissatisfaction with uncorrected distance vision.
A total of 1-0 (4.0%) patients receiving the continuous transitional focus lenses had photopic pupils measuring less than 2.5 mm. Mean myopic refractive error was -0.25±0.25 D. None of these patients require laser treatment.
The difference in intervention rates was significant (p < 0.001), Dr Nowrouzi reported. In addition, the continuous transitional focus group scored significantly better on the VF-14.
Pupil size impact
The difference in outcomes can be explained by how small pupils interact with the various EDOF IOL designs, Dr Nowrouzi said. Small pupils affect IOLs using central HOAs more because, at 2.5 mm, about 80% of the light enters the central zone, which primarily enhances intermediate vision. The result is an increased myopic shift for distance vision.
By contrast, IOLs using continuous transitional focus have a steady, nonlinear power distribution in the central zone. Because there is no segmentation for specific near or intermediate focus, lens power is blended, offering smoother vision transitions across all distances. As a result, they are less affected by small pupil size, Dr Nowrouzi explained.
In conclusion, Dr Nowrouzi noted that in patients with photopic pupil size of less than 2.5 mm, continuous transitional focus IOLs produce less myopic shift and patient dissatisfaction than IOLs with a central HOA segment.
“It’s important to evaluate pupil size before surgery, mainly with EDOF lenses with the central segment, to prevent problems,” he advised.
Dr Nowrouzi spoke at the 2025 ASCRS annual meeting in Los Angeles.
Ali Nowrouzi MD, FEBOS-CR, FICO, FACS, FWCRS is an ophthalmologist in private practice at Hospital Quironsalud, Marbella, Spain. dralinoroozi2020@gmail.com
New hydrophobic acrylic lenses offer good visual performance at all distances.
HOWARD LARKIN REPORTS
Amultifocal presbyopia-correcting intraocular lens (IOL) made of a new, glistening-free hydrophobic acrylic material and available in both aspheric and toric aspheric versions provided good visual acuity at all distances in recent studies. It also delivered high patient satisfaction and spectacle independence and good contrast sensitivity, according to Thomas Kohnen MD, PhD.
Moreover, though nearly three-quarters of patients reported experiencing optical phenomena such as glare and halos, they were not troubling, he added.
The trifocal aspheric Clareon PanOptix and toric aspheric Clareon PanOptix IOLs (Alcon) build on the legacy of the PanOptix multifocal lens—first implanted by Professor Kohnen in July 2015 in Frankfurt, Germany. The new Clareon material is free of glistenings, enhancing lens clarity by reducing light scatter and surface haze. Clareon lenses also feature a proprietary edge design to reduce optical phenomena.
Visual acuity results
In a prospective, single-site study of 27 patients implanted bilaterally with aspheric or toric aspheric Clareon PanOptix IOLs, visual acuity results were good, Prof Kohnen reported. At the 12-month follow-up, mean monocular visual acuity at distance measured 0.01±0.12 logMAR uncorrected and -0.03±0.10 corrected. Intermediate at 80 cm measured 0.02±0.10 uncorrected and 0.03±0.09 distance corrected, and at
72%
72% perceive optic phenomena but are not disturbed by them.
60 cm 0.00±0.10 uncorrected and 0.00±0.09 distance corrected. Near vision at 40 cm came in at 0.08±0.11 uncorrected and 0.07±0.09 distance corrected.
About one-third of eyes reached a visual acuity of -0.10 or better at distance and at 40 cm intermediate, uncorrected. Defocus curves for the new material lenses were similar to those observed for the previous, non-Clareon PanOptix lenses, peaking at about -0.02 for distance at 0.00 D defocus compared with -0.05 for the earlier lens, and again around 0.05 at an intermediate defocus of -1.50 D compared with -0.01 for the earlier lens.1
Contrast sensitivity of the new lenses proved slightly better than the previous material PanOptix lenses and slightly worse than an Alcon standard SN60WF monofocal lens, Prof Kohnen observed.1– 2
Patient-reported outcomes
More than 90% of patients reported spectacle independence, with 2 patients reporting a need for glasses at intermediate distance. Halos were observed by 67%, glare by 33%, starbursts by 7%, and distorted vision by 4%. No patients reported ghosting or double vision.
“We still have halos; it is a trifocal design,” Prof Kohnen said. However, halos, as seen by a visual simulation of mean results, diminished between 3 months and 6 months after surgery, suggesting visual habituation to the phenomena over time.
So, in addition to good vision, patient satisfaction, and contrast sensitivity, “72% perceive optic phenomena but are not disturbed by them,” Prof Kohnen concluded.
Prof Kohnen spoke at the 2025 ASCRS annual meeting in Los Angeles.
For citation notes, see page 40.
Thomas Kohnen MD, PhD, FEBO is professor and chair, Department of Ophthalmology, Goethe University, Frankfurt, Germany. He is also past ESCRS treasurer and co-editor of the Journal of Cataract & Refractive Surgery kohnen@em.uni-frankfurt.de
Modular Shape-Changing IOLs
Lens position, refraction, and accommodative range stable at 24 months.
HOWARD LARKIN REPORTS
An investigative intraocular lens (IOL) that uses a fluid-filled module to change shape and refractive power remained stable in the eye and demonstrated a wide accommodative range 24 months after implantation, according to Steven J Dell MD.
The OmniVu (Atia Vision) is a dual-optic accommodating IOL consisting of a fluid-filled base that simulates natural accommodation by changing shape in response to ciliary muscle contractions. It is joined with a fixed-power front optic that aims to achieve emmetropia. The combination delivers excellent visual quality throughout the functional visual range, from far through intermediate and near vision at 40 cm, Dr Dell said.
Because the lens is bulkier than a conventional single-optic IOL, it better fills the capsular bag, Dr Dell added. “The goal here is to preserve a more physiological orientation of the anterior segment.”
This orientation may help keep the IOL position and anterior vitreous face stable and minimise posterior capsule opacification, Dr Dell said. It may even increase safety by preventing the vitreous from moving forward, possibly reducing the risk of retinal damage.
Two-year results
A stable, effective lens position is key to long-term refractive stability, and the OmniVu delivers, Dr Dell said. In a prospective, open-label, first-in-human study involving 29 eyes in 19 patients, mean effective lens position as measured by anterior chamber depth varied by approximately 0.1 mm from 1 month through 24 months after surgery.
Similarly, mean manifest refraction spherical equivalent was both accurate and stable, running between 0.0 and 0.3 D and varying less than ±0.5 D throughout the 24-month follow-up period.
“These are some of the best results I have seen for refractive predictability for any IOL, accommodating or otherwise,” Dr Dell said, adding refractive cylinder was also quite stable.
Mean visual acuity was also excellent, with corrected and uncorrected values nearly identical, Dr Dell reported. Monocularly, mean VA was 20/20 for distance and intermediate and 20/25 or J1 for near vision. Binocularly, that improved to 20/16 for distance and intermediate and 20/25 for near vision.
Defocus curves were also broad, spanning 4.7 D above 20/32 binocularly at 24 months. Contrast sensitivity with and without glare was similar to published monofocal IOL data.
Visual disturbances were also minimal, with only mild glare and halos in 1 patient each out of 16 and 2 patients with mild and 1 with severe starbursts, Dr Dell reported. “This is also very consistent with a monofocal visual quality.”
Future progress
Currently, the OmniVu requires a 3.5 mm incision. “I’m not thrilled about that,” Dr Dell said. “I’d like to see that at sub3.” It also requires a carefully created 5.5 mm capsulotomy, and size and centration are important, he added. The current study and design development are ongoing.
Dr Dell summed up by noting the OmniVu maintained a more physiological anterior segment, remained stable in refraction and astigmatism, provided excellent uncorrected and corrected vision, and delivered continuous focus throughout the functional vision range. “We continue to chip away at this problem of presbyopia with different creative optical solutions, but we all know that ultimately the solution is going to be an accommodating IOL.”
Dr Dell spoke at the 2025 ASCRS annual meeting in Los Angeles.
Steven J Dell MD is an ophthalmologist in Austin, Texas, US. steven@dellmd.com
EDOF Lenses Show Promise for Irregular Astigmatism
Low to moderate irregular astigmatism is not an exclusion criterion for binocular implantation of EDOF IOLs.
LAURA GASPARI REPORTS
Low to moderate irregular asymmetric astigmatism does not affect the visual performance of an extended depth of focus (EDOF) IOL, according to a study presented by Daniel Schartmüller MD.
“Modern IOLs aim for the best possible visual acuity and presbyopia correction, and the current opinion is that presbyopic IOLs depend on the regularity of the cornea,” Dr Schartmüller said. For this study, AcrySof Vivity IOL (Alcon) was considered to determine how well it performs in eyes with low to moderate anterior surface irregularities or asymmetries. The overall diameter of the Vivity IOL is 13 mm, and the optic diameter is 6 mm.
The study involved 28 patients with bilateral age-related cataract and irregular astigmatism exhibiting an anterior root mean square (RMS/a) greater than or equal to 0.3 µm/mm2 in the central 3 mm zone measured at the OCT. Eyes with astigmatism more than 75.0 D received a toric IOL. As Dr Schartmüller reminded the audience, both eyes were implanted with the Vivity EDOF lens, as advised by the manufacturer.
At the six-month postoperative follow-up, the researchers performed binocular best-corrected distance visual acuity (BCDVA), binocular distance-corrected intermediate visual acuity at 66 cm, and monocular defocus curves, as well as IOL tilt and decentration. Preoperative mean RMS/a was 0.0037. Dr Schartmüller reported that the defocus curve resembled those seen in the Vivity IOL. The
monocular defocus curves of the Vivity IOL showed an enhanced depth of focus of 0.16 logMAR at -1.5 D defocus in eyes with corneal irregularities.
Binocular distance visual acuity showed very good results with a mean of -0.08 logMAR. Only minimal deviations of decentration and tilt compared to preoperative values were observed at the anterior segment OCT measurement.
The study revealed that low to moderate irregular astigmatism is not an exclusion criterion for binocular implantation of EDOF IOLs. “We wanted to prove that—even though you have an irregular eye—you could have binocular, functional, good vision and a mean below zero, meaning we had a very good distance visual acuity, and the distance corrected intermediate visual acuity for both eyes was below 0.1,” Dr Schartmüller concluded.
The Clareon Vivity IOL has received CE approval and is commercially available in Europe. Other Clareon IOLs include the monofocal, toric, and PanOptix versions.
Dr Schartmüller presented the results of this study at the 2025 ESCRS Annual Congress in Copenhagen.
Daniel Schartmüller MD is an ophthalmologist and researcher at the Medical University of Vienna, Austria. daniel.schartmueller@meduniwien.ac.at
The Importance of Ocular Surface Assessment
Careful screening for ocular surface disease is key to ensuring good surgical outcomes.
At least 25% of cataract patients present to the operating theatre with clear signs of ocular surface disease, according to the 2024 ESCRS Clinical Trends Survey.
“We have to keep in mind that there are many more patients suffering from this disease,” said Ramin Khoramnia MD, PhD. “In fact, about 60% of routine cataract patients are asymptomatic dry eye patients, and finding those patients is the duty we must fulfil.”
Reviewing the Clinical Trends Survey, Dr Khoramnia observed how 66% of respondent ophthalmologists are very likely to postpone surgery in a patient with moderate dry eye—meaning that even though the biometry is not giving accurate data, 34% of surgeons do not postpone. This can lead
to worse outcomes, he added, suggesting it may be important to prioritise patient assessment over surgery.
However, only 55% of cataract surgeons systematically check the ocular surface during preoperative examination. This can lead to a lot of missed diagnoses, which prompted Dr Khoramnia to urge his colleagues to carefully consider the importance of screening patients for ocular surface disease.
A slit lamp examination is the first step; evaluating film stability and tear breakup time (TBUT) and osmolarity testing are also necessary. Inflammatory marker testing, meibography, and Schirmer tests are all valuable options to assess cases of dry eye. Dr Khoramnia also underlined the importance of the Dry Eye Questionnaire.
TIMOTHY NORRIS REPORTS
Red flags
The ESCRS Clinical Trends Survey also revealed that 75% of respondents believe mild to moderate dry eye significantly affects keratometry and IOL calculations. Even the best surgeon implanting the best lens will never get good outcomes if the data taken prior to surgery is not compiled in an orderly fashion, Dr Khoramnia said.
Taking good and consistent preoperative measurements through multiple readings is therefore paramount, including confirming the stability of the ocular surface. If it is not the surgeon who conducts the exams directly, Dr Khoramnia said, their staff must be trained to take multiple readings and verify reproducibility.
Since data validation is important, Dr Khoramnia outlined red flags for consideration: more than one dioptre of difference between the eyes in average K should lead to further examination, as well as average K greater or less than 47.0 D, cylinder more than 2.5 D, ACD higher than 4.2 mm or lower than 2.0 mm, and axial length higher than 30.0 mm and lower than 22.0 mm.
Careful patient selection for the right kind of lens is another essential factor, Dr Khoramnia noted. Alcon’s Vivity lens is one of his IOLs of choice, thanks to the wavefront-shaping technology that leads to greater spectacle independence with lower photic phenomena.
It’s very important that we screen the ocular surface in every patient—even if the patients are asymptomatic— and optimise the ocular surface.
“It’s very important that we screen the ocular surface in every patient—even if the patients are asymptomatic—and optimise the ocular surface,” Dr Khoramnia said. “We need to confirm a very stable and repeatable keratometry and look for the right lens choice. We really must optimise the surface to ensure an accurate power calculation and to achieve better vision quality. If we do all that, then the patient’s satisfaction can be as high as possible.”
Dr Khoramnia spoke at the 2025 ESCRS Congress in Copenhagen.
See the Unseen Experience Cornea Layer Segmentation
Detailed Sub-Layer Assessment
Combining the proven power of Scheimpflug imaging with the precision of ultra high-resolution OCT enables the detection of previously unseen corneal pathologies with unprecedented clarity.
Diagnose earlier. Treat smarter. Care deeper.
Ramin Khoramnia MD, PhD, FEBO is Director of Ophthalmology at the Carl Gustav Carus University Clinic of Dresden, Germany.
Assessing RD Risk After Lens Surgery
Prospective MYOPRED study documents impact of preoperative PVD status in myopic eyes.
CHERYL GUTTMAN KRADER REPORTS
The five-year results from the ESCRS MYOPRED study confirmed its working hypothesis that among myopic eyes undergoing cataract or refractive lens exchange (RLE) surgery, those with a complete posterior vitreous detachment (PVD) preoperatively have a lower postoperative risk of retinal detachment (RD) compared to eyes with no or an incomplete PVD.
The research, presented by Marlies Ullrich MD at the 2025 ESCRS Congress in Copenhagen, showed RD rates increased during follow-up in both the complete PVD and no/incomplete PVD groups. At 5 years, the RD rate was 0.7% in the group with complete PVD versus 5.4% in the no/incomplete PVD group. In addition, the risk of postoperative RD was significantly higher (approximately 8-fold) among males compared to females. Young age was also associated with higher RD risk.
Dr Ullrich noted that the findings have important implications for patient care.
“The MYOPRED study shows that preoperative PVD status is a useful additional parameter in estimating RD risk in myopic eyes after lens surgery and should be assessed preoperatively—ideally with optical coherence tomography (OCT) and particularly in groups with high-risk features. This information
can impact selection of candidates for RLE, and it helps us inform patients more individually about their RD risk.”
“This is the first large prospective trial in only myopic eyes assessing the effect of PVD status before lens surgery on longterm RD,” project leader Oliver Findl MD told EuroTimes
“For me, the outcome of the MYOPRED trial calls for performing OCT with a long scan through the macula and optic disc to identify PVD in myopic patients planned for lens surgery. This is relevant for the informed consent before surgery in cataract patients and for deciding whether to plan RLE or a phakic lens in myopes [hoping] to get rid of their glasses,” he said. “Sometimes we also encounter high myopes with unilateral cataract—for example, after RD surgery in one eye—and the question arises [as to] what we should do with the other eye. If the eye already has a PVD, I would proceed with RLE. Otherwise, I would suggest a phakic lens.”
MYOPRED is a prospective observational multicentre study conducted at 10 sites in 5 European countries. The ESCRSsponsored trial included eyes with an axial length of 25 mm or greater undergoing cataract surgery or RLE. Eyes undergoing a planned combined procedure and with a previous history of RD, intraocular surgery, uveitis, or trauma, were excluded.
PVD status was mainly assessed with OCT and graded by a reading centre. The number of follow-up visits in the first postoperative year depended on PVD status, ending earlier for eyes with complete PVD preoperatively. Follow-up after the first year was conducted through a telephone interview that queried patients about whether they had an RD, intraocular surgery, or laser treatment. Reported events were verified by in-office examination or review of surgical records.
The study included 600 study eyes and 368 fellow eyes that fulfilled the inclusion criteria. Males and females were almost equally represented in the study cohort. Patients had a mean age of 65 years, with a wide range of 23 to 92 years. Median axial length was 26 mm in both study and eligible fellow eyes and ranged up to 35 mm. A majority of eyes had a complete PVD at baseline, and the rate of complete PVD was significantly higher in females versus males across all age strata.
Marlies Ullrich MD is a medical investigator at the Vienna Institute for Research in Ocular Surgery (VIROS),
Oliver Findl MD, MBA, FEBO is Chief of VIROS, Professor and Chair of the Department of Ophthalmology, Hanusch Hospital, Vienna, Austria. oliver@findl.at
Hanusch Hospital, Vienna, Austria.
A Series of Groundbreaking Procedures in Ophthalmology
Femtosecond laser playing an ever-expanding role in ophthalmic surgery.
SEAN HENAHAN REPORTS
The 2025 ESCRS Annual Congress in Copenhagen celebrated the 30th anniversary of femtosecond laser eye surgery with an interactive exhibition detailing the remarkable evolution of this essential tool.
A reception at the Congress included a live interview with some of the pioneering ophthalmic surgeons who developed these remarkable applications. Guests included Ron Kurtz MD; Tibor Juhasz MD, PhD; and Burkhard Dick MD, PhD.
European surgeons who played an important part in the development of femtosecond eye surgery were also present, including Zoltán Nagy MD, PhD, who performed the first femtosecond laser cataract procedure, and Imola Ratkay-Traub MD, PhD, who performed the first femtosecond laser LASIK procedure in a sighted eye.
“When Tibor and Ron began to explore femtosecond laser applications, some people said ‘you will never use a laser for cataract or glaucoma surgery’. Some of those people are now pretending they always knew it would work,” Professor Dick joked.
A serendipitous event at the University of Michigan, US, in 1993 eventually led to the development of the new tool for ocular surgery. During an experiment at the College of Engineering, a graduate student’s eye was accidentally exposed to a series of stray femtosecond laser pulses. The resulting retinal burns were noted to be highly localised, eventually sparking interest in the laser’s potential for medical applications. Collaboration with the university’s Center for Ultrafast Optical Science (CUOS) ultimately included Gérard Mourou (Nobel Prize in Physics, 2018), Dr Kurtz, Prof Juhasz, and others, with an initial focus on potential applications for corneal surgery.
“When Ron and I met, we realised we had a lot in common,” Prof Juhasz recalled. “Rather than competing, we decided it would be better to join forces, so I moved to Michigan and we started to work together. In about three years, we had a product that was stable enough, small enough, and reliable enough.”
By 1995, this team was able to demonstrate that femtosecond lasers could be used to perform lamellar resections of the cornea with minimal damage to the surrounding tissue. In subsequent reports, the team demonstrated flap creation (for LASIK), keratomileusis (for lenticule extraction), and other potential surgical procedures as alternatives to procedures that used the mechanical microkeratome.
Between 1997 and 2001, a team at IntraLase led by Drs Kurtz, Juhasz, Christopher Horvath, and others developed the first commercial femtosecond laser platform to enhance the safety, accuracy, and precision of LASIK procedures. The
femtosecond laser was shown to create a more precise and predictable flap that was thinner and more uniform.
“We did the first (femto) capsulotomy, and it really succeeded,” Prof Nagy said. “Then we proceeded to do the lens fragmentation, the corneal incision, and the astigmatic correction on the cornea. Gradually, within a couple of years, it became what I think is a perfect procedure.”
Today, the role of the femtosecond laser continues to expand to FLACS, SMILE, CAIRS, LIRIC, and glaucoma procedures, demonstrating how a lot of dedicated research can lead to transformative advancements in patient care.
“When we first started, we had the idea that we would start in the cornea and go all the way back to the retina. I still believe this will be the case,” predicted Dr Kurtz.
A video of the Copenhagen interview will appear in the Heritage Archive section of the ESCRS website.
Ron Kurtz MD is co-founder of IntraLase and current president and CEO of RxSight, maker of the light-adjustable lens.
Tibor Juhasz MD, PhD is co-founder of IntraLase, current CEO of ViaLase, and professor of biomedical engineering at the University of California, Irvine, US.
H Burkhard Dick MD, PhD, FEBOS-CR is professor of ophthalmology and chairman at Ruhr University Eye Hospital Bochum, Germany, and incoming president of ESCRS.
Zoltán Nagy MD, PhD is director of the department of ophthalmology, Semmelweis University, Budapest, Hungary.
Imola Ratkay-Traub MD, PhD is medical director of the Danube Bend Medical Center, Szentendre, Hungary.
The Short-Sighted World
Binkhorst Medal Lecture highlights need for further research on myopia.
LAURA GASPARI REPORTS
Today’s ophthalmologists have a considerable number of ways to correct myopia, but this year’s presenter of the prestigious Binkhorst Medal Lecture says we need further research and treatments.
“Be aware that in 2050 we will have 4 billion people myopic in the world,” Thomas Kohnen MD, PhD said. “That’s maybe half of the population. Correction is not the treatment. It’s a growing problem worldwide and without a cure, but we can do some things.”
Professor Kohnen noted there are risk factors that are well known by the ophthalmological community, such as not spending enough time outside, a lot of near work (especially with digital devices and more pressure in educational systems), staying in dim light, and, ultimately, genetics. He explained that the development of lens power over time shows a decline across all age groups, with a steeper drop indicating the onset of myopia. This suggests the compensation is insufficient to counteract axial length growth, meaning there is no effective mechanism to compensate for myopia.
Ophthalmologists have some weapons to counteract myopia: first, by raising awareness among patients of the impact of lifestyle changes such as (especially for children) spending more time outside, as outdoor recess has been demonstrated to reduce myopia onset by 50%; also by using atropine 0.1%, which has been demonstrated to be effective in slowing myopia progression with minimal side effects; and recommending myopic defocus lenses, which have been shown to be effective in reducing myopia progression and axial elongation by more than 50% in two years. Prof Kohnen warned about the rebound process if treatment is stopped, showing that the lowest rates of it are among those who wear glasses.
Refractive surgery—such as PRK/transPRK, LASIK, femtoLASIK, and KLEx—is another important option that has seen significant evolution over the past decades. Prof Kohnen presented meta-analysis data showing high safety and effectiveness rates for PRK, LASIK, and KLEx, with no superiority of
any single procedure. There are now many studies underway on the use of femtosecond and excimer lasers. Phakic IOLs (angle-supported, iris-fixated, and posterior chamber lenses), of which Prof Kohnen is a big fan, have expanded the possibilities for myopia correction, outperforming excimer lasers in safety and satisfaction in moderate/high myopia cases.
One big issue facing the ophthalmological community is high myopia and the possible complications these patients can face even after refractive surgery and phakic IOL implantation, including cataract formation, ectasia, and retinal detachment. Prof Kohnen emphasised the importance of creating guidelines for refractive surgery and the need for continuous research and improvement, efforts in which ESCRS is heavily invested through new studies, an IOL classification project, and guidelines for presbyopia as well as myopia. He recommended that ophthalmologists take a comprehensive approach when dealing with myopia. “Remember to treat the whole eye, not just a refractive error,” he said.
Prof Kohnen concluded with a call for reflection, quoting a 1934 article titled “Nationalism Against Science” that spoke of political shortsightedness as a threat to research and science and referenced the cultural milieu that preceded the rise of fascism in Europe.1
“Last week, Richard Parrish sent me this [article], and he wanted to republish it to remind us of the near-sighted world we have,” he said.
Prof Kohnen gave this lecture at the 2025 ESCRS Annual Congress in Copenhagen.
Complications of myopia
For citation notes, see page 40.
Thomas Kohnen MD, PhD, FEBO is a professor and chair of the Department of Ophthalmology at Goethe University in Frankfurt, Germany.
Kohnen
• Spectacles, CL
• Corneal refractive surgery (up to -10 D)
• Phakic IOL
• High myopia
• Contraindication for corneal surgery
• Refractive lens exchange
• Ectasia
• Maculopathy
• Glaucoma
• Retinal detachment
Cannula Dislodgement: The Russian Roulette of Harm
New survey reviews current experiences.
BY DR AMAR ALWITRY
The use of Luer lock syringes is standard practice in cataract surgery, with the specific purpose of avoiding cannula dislodgement. Despite their widespread adoption, ocular harm is still occurring—often due to the cannula shooting off the end of the syringe into the eye, damaging ocular structures and causing visual loss or even blindness in what should be a routine procedure.
An anonymous survey sent to members of the United Kingdom and Ireland Society of Cataract and Refractive Surgeons (UKISCRS), the ESCRS, and the readership of Eye News was designed to ascertain whether surgeons had experienced dislocation of a cannula during cataract surgery and whether any ocular damage was sustained.1
Eighty-four per cent (84.00%) of respondents had experienced dislocation of the cannula during an intraocular procedure. Seventy-eight per cent (78.04%) of respondents observed episodes of harm due to this complication, while 50.37% of respondents indicated ocular damage occurred the last time a cannula dislocated. Another 16.08% indicated they never experienced a cannula dislocation. Some 22.95% indicated that a cannula dislocation occurred on average once per year; 38.43% reported it happened twice per year; 15.66% reported three times per year; and 6.92% stated it happened four times or more annually.
Most correspondents, 86.90%, felt that a better cannula design or a safety device was required to prevent further occurrences. The next significant group, 45.76%, suggested checking to ensure the cannula was tight each time, while 25.46% and 23.80%, respectively, suggested better scrub practitioner training and surgical practice.
The problem has been reported extensively in the literature and has been the subject of two recent safety alerts by the Royal College of Ophthalmologists (England) and a UKISCRS alert.2–10
Cannula detachment is a well-recognised, unaddressed safety issue that can result in blindness or even loss of the eye.2–10 Estimates of incidence vary between 0.009% and 0.07%.2–3 The consequences can be blinding, and it is completely avoidable and indefensible.
Data from the European Union of Medical Specialists (UEMS) show that there are more than 40,000 ophthalmologists in Europe.12 If 22.95% of these surgeons experience a cannula dislocation once per year, then it occurs 9,180 times annually. When including the numbers for those experiencing it even more frequently, the occurrence increases to an estimated 69,788 times per year. Accepting that in 50% of cases harm is seen, then avoidable ocular harm is occurring in al-
most 35,000 cases per year across Europe. For the majority, the harm will be minimal and potentially not even documented in the clinical record. For example, a small iris or angle bleed may settle rapidly and not cause any morbidity. However, the harm can be severe, and a Russian roulette of avoidable harm clearly unfolds daily in our work.
A paper published in Eye suggested “[s]imple statements that Luer locks never fail will not avoid future harm if human performance shortfalls cannot be eliminated from every possible step. The safest way to do this is at the manufacturing stage by moulding one-piece cannula-syringe devices, where syringe and cannula hub are moulded together—eliminating the possibility of detachment by force or inadequate tightening.”7
This recommendation is not financially feasible, as it would be costly and require accommodating every syringe size.
The issue has been highlighted by a paper as far back as 2012 in the Canadian Journal of Ophthalmology. 8 They found “[d]espite the use of Luer locks, 60 cases of cannula detachment were reported; 196 respondents experienced this complication, and the most common cause of cannula detachment was stromal hydration (50%). Hydrodissection and viscoelastic were experienced by 18% and 17%, respectively. No severe damage resulted in most cases (76 cases), but some serious complications were reported: retinal damage (9%) and vitreous loss (17%).”
For 13 years, there has been no solution available, and from a medicolegal perspective, it is indefensible. I still have one case every two months or so that results in visual loss, which is heartbreaking; a solution needs to be enacted. As shown in the Canadian Journal of Ophthalmology, this most commonly occurs during stromal hydration—which is likely at the end of an otherwise uncomplicated procedure—taking a patient from a perfect outcome to potential blindness in an instant.
Some viscoelastic suppliers have adopted a screw cap that goes over the cannula and screws to the body of the syringe. While this is a welcome acknowledgement of the issue, it is not feasible for all the other cannulas used during the procedure. As shown above, the viscoelastic is not the main culprit but rather stromal hydration from a Luer lock syringe of volume ranging between 2 mL and 5 mL.
Furthermore, the screw cap solution potentially has inherent safety issues. It is well established that surgeons should not re-sheath a needle or a cannula, and that is what the screw cap encourages.
The Aseptic Non-Touch Technique (ANTT) is a widely used international healthcare method that prevents infection
during clinical procedures by ensuring key aseptic sites and parts are protected. It clearly states that these parts, which include the tip of the cannula introduced into the eye, should not be touched—even with a gloved hand. Touch carries the risk of a ‘cannula-stick’ injury but also the risk of endophthalmitis and Toxic Anterior Segment Syndrome (TASS). As Figure 1 demonstrates, passing the cap over the cannula brings the cannula tip into proximity of the user’s fingers.
I still have one case every two months or so that results in visual loss, which is heartbreaking; a solution needs to be enacted.
The use of the screw cap is a step forwards, and in the absence of other safety methods, its use is encouraged. However, there must be a better solution that can be applied to all the syringes in use, particularly for the stromal hydration step, in which the viscoelastic is not involved.
As surgeons, we currently use syringes and cannulas with a known risk, and we need a solution that is cheap, fast, easy to apply to all syringes, and effective. We and our hospitals have a duty of care to minimise that risk.
In the interim, it is vital that surgeons are aware of this complication and do everything they can to minimise the risk, including checking that the cannula is tight each time.
An article featuring this research is expected to appear in the JCRS in November 2025.
For citation notes, see page 40.
Amar Alwitry BMedSci, BM, BS, MRCS, MRCSEd, MRCOphth, FRCOphth, MMedLaw PgD is a Consultant Ophthalmologist at Nuffield Health, England, UK.
Financial Declaration: The author is actively working with production partners to try to develop a safety device that will resolve the issue of cannula dislocation.
Figure 1
Patients Worth Fighting For
One clinician emphasises the value of treating cases involving some of the most catastrophic damage ever seen.
ANDREW SWEENEY REPORTS
When Patient K took his first hit of cocaine, it likely didn’t cross his mind that his body would suffer serious damage. However, nobody—not even the most stringent of physicians—would have predicted it would cost him both of his eyes.
Patient K hails from the United Kingdom, a country in the midst of a cocaine epidemic, with lifetime use among adults rising from 5.1% in 2001 to 10.3% in 2023.1 Drug poisoning
deaths are at an all-time high, but the popularity of the drug shows no sign of abating.
Most cocaine users will not likely be able to match Patient K’s record of drug abuse. He was a consistent user for more than 20 years, but over the last 5, he took a minimum of 2 grams per day—amounting to 730 grams per year—combined with daily tobacco usage of 20–30 cigarettes.
By the time he met Magdalena Niestrata MBChB, PhD, he already had a deviated septum, his left orbital wall had collapsed, and he had lost his right eye due to endogenous endophthalmitis—and this wasn’t even the most shocking damage she found.
Something that I’ve learned at this job, and with Patient K as well, is that the most hopeless eyes are the ones most worth fighting for.
“Patient K effectively had no interior wall. So, when you looked through where his other eye used to be, you could see up to the other side of the skull,” said Dr Niestrata.
“The left eye had developed severe, chronic corneal melt with five perforations. The patient had visual acuity of 2/60, IOP was 5 mmHg, and inferior corneal melt equalled more than two-thirds stromal loss with iris-plugged perforation.”
When it rains, it pours
Unfortunately for Patient K, the damage to his body, so severe that he currently requires a prosthesis to talk and eat, wasn’t solely due to cocaine use. Not only had he developed vasculitis, but he’d been unlucky enough to develop a specific type of the autoimmune disease characterised by the presence of anti-neutrophil cytoplasmic antibodies (ANCAs).
In essence, the body was already attacking itself while also experiencing the effects of decades of cocaine abuse. According to Dr Niestrata, Patient K’s case was among the worst she’s ever seen.
“The damage was so severe. When we were putting lenses in the remaining eye, he kept losing the lenses, and it took us a while to figure out why,” she said. “We discovered that they were falling into his skull, as there was no soft tissue to support them.”
The extremity of Patient K’s case also extended to the surgeries Dr Niestrata had to perform. Over the course of nine months, she carried out the following procedures:
Three multilamellar amniotic-membrane overlays; two halo corneal grafts, one intrastromal inlay, one tectonic patch; two tectonic penetrating keratoplasties with multiple corneal gluing; one tectonic Descemet stripping with automated endothelial keratoplasty; two collagen cross-linking procedures; four staged tarsorrhaphies involving a Gundersen flap and tenon translocation; cataract surgery; vitrectomy; and multiple intravitreal injections for endophthalmitis.
All these procedures had to be performed with local anaesthetic only, as the damage to Patient K’s throat was severe enough to compromise his breathing. Multiple complications arose, too, including several corneal perforations, superimposed bacterial and fungal keratitis, and bacterial and fungal endophthalmitis.
A patient worth fighting for
Despite the remarkable challenges at play, these procedures initially worked. Patient K’s globe was successfully preserved, with sight restored to the degree that he could see hand movement and perceive light.
Dr Niestrata reported her case study highlighted that early aggressive immunosuppression, rapid surgical escalation, and persistent follow-up can rescue even a severely compromised,
single-seeing eye. Unfortunately, there has since been unwelcome news.
“During treatment for a second round of endophthalmitis, he received between four and five intravitreal injections. He developed a funnel retinal detachment, and the cornea began to melt completely,” Dr Niestrata said.
“He’s now completely blind; he is also experiencing symptoms of heart failure and some hallucinations as well. It’s obviously very disappointing as the cornea just kept melting. We really fought for it, but at least we were able to give him some sight for nearly another year.”
Even with this difficult-to-accept result, both Dr Niestrata and her patient maintain a positive attitude about the attempt to save his sight. Since undergoing his treatment, Patient K has become focused on being an advocate for greater awareness about cocaine toxicity and vasculitis, and Dr Niestrata believes this case study can provide valuable lessons to fellow clinicians.
“Something that I’ve learned at this job, and with Patient K as well, is that the most hopeless eyes are the ones most worth fighting for. He was fighting for light perception in just one eye; it really puts things into perspective,” Dr Niestrata said.
“We knew it was going to be difficult, and other clinics Patient K went to said the cornea would melt anyway, so they basically turned him away. We knew he was worth fighting for.”
For citation notes, see page 40.
Magdalena Niestrata PhD(Dist), MSc(Dist), MBChB(Hons), BSc(Hons), PGDip(Dist), FRCOphth, FEBO, FICO is a Corneal Fellow at the East Suffolk and North Essex Hospital Trust, Colchester, UK. magdalena.niestrata@doctors.org.uk
Need to Know: Who Should Receive PPP for Aberropia?
Part six of this in-depth series explains how to perform PPP for aberropia.
SOOSAN JACOB MS, FRCS, DNB
The last article in this series discussed pinhole pupilloplasty (PPP) as a technique of using pinhole optics to correct higher-order aberrations (HOAs) by acting as a wavefront filter. It also discussed the advantages of PPP as compared to other devices, such as pinhole IOLs or pinhole corneal inlays. This article will discuss how to evaluate a patient for PPP and the technique to perform it.
Preoperative evaluation
Preoperatively, the first step is a good refraction and slit-lamp examination. Next, study the corneal tomography and total, lenticular, and corneal ocular aberrations. Then conduct a rigid gas permeable contact lens trial and test pinhole visual acuity with over-refraction.
Patients older than 40 years of age—when accommodative loss has already begun—may be considered for PPP, since the technique also necessitates lens extraction and IOL implantation. Once a PPP is decided, the Holladay pinhole device is used to check for the ideal pupil size that provides the best possible vision. The Holladay pinhole device is a metal occluder plate with multiple precut apertures ranging from 0.5 to 4.0 mm. The patient looks at the visual acuity chart 4.0 m away (or further) through different apertures to determine which gives best clarity of vision. Generally, for patients with a preoperative root mean square HOA less than 5 microns for a 6.0 mm pupil, a 1.5 mm pupil size is suitable. When the HOA is more than 5 microns, a 1.0 mm pupil size is preferred. The smallest size set for the pupil in PPP is 1.0 mm, as sizes below this will create diffraction effects. With the subject fixated, the coaxially sighted corneal light reflex is marked preoperatively with the patient sitting at the slit lamp.
The pinhole pupilloplasty technique
A pinhole pupilloplasty is then performed by making multiple single-pass, four-throw pupilloplasties, preferably under viscoelastic. Vertical bites are usually preferred over horizontal, as hand movement is easier. A 10-0 prolene suture on a long, thin, curved needle is passed from the inferior limbus to take a bite of the iris about 1.0 mm from the margin. A 30-gauge needle is then passed through a paracentesis (ensuring the needle does not get caught in the incisional stroma by moving it gently side to side) and passed through the pupil on the other side, 1.0 mm from the limbus. The first needle is docked into the 30-gauge needle and railroaded out through the incision, followed by a suture loop brought out through the incision using a Kuglen hook. The cut end of the suture is then passed through the loop four times and the sutures on either
side pulled outwards to internalise and tighten the knot. The sutures are cut close to the knot using a microscissor.
While passing the needles, care should be taken to be gentle and to avoid tearing the iris. Thin needles should be used, and excessive tug on the prolene suture avoided. A microforceps, passed through a side-port incision to hold the iris firmly, helps facilitate an atraumatic process. Additional passes are made on either side of the pupil as required (typically three on either side). Once the pupil is small, the final positioning and sizing of the PPP is done carefully with a vitrector using a low cut rate. Centration should ideally align with the preoperative mark made on the cornea. It is important to position the patient’s head without any tilt to avoid parallax error. An endodiathermy may also help in adjusting centration and sizing.
Corneal magnification of the pupil size should be considered. For the average corneal radius of curvature and the average pupil distance from the corneal apex, the pupil image is bigger than that of the real pupil by about 8.6%.
AS-OCT studies have shown that with the Zeiss Lumera microscope, if the pupil touches P1 all around, the size of the pupil is roughly 1.0 mm, and if the size is just larger than P1, pupil size is approximately 1.5 mm. However, the steepness of the cornea will affect the size of P1, making these only rough estimates. The Holladay device is autoclavable and can also be used in the OR to estimate pupil size.
For deep-set eyes, the surgeon can sit (temporally) and perform sequential horizontal SFTs to make access easy. In case of monocameral, vitrectomised eyes, a trocar anterior chamber maintainer may be used instead of viscoelastic to form the anterior chamber. This keeps the AC well-formed and allows better centration and sizing. Despite HOA persistence, visual quality improves postoperatively due to the achieved wavefront filtration.
A simple experiment can demonstrate the effect of a pinhole: A high cylinder is placed in front of the eye, and then vision is checked. Next, the Holladay pinhole device is used to determine the ideal pinhole size. The test can be repeated with higher cylinders, and improved clarity observed with the appropriately sized pinhole. The same test can also be done with spheres of increasing amounts, yielding similar outcomes. Varying combinations of sphere and cylinder are tested, and at even higher combinations, a smaller pinhole aperture improves vision.
Disadvantages of pinhole pupilloplasty
A PPP can limit the examination of the retina, leading to
a recommendation of avoiding it in eyes with a history of retinal disease or if the patient is predisposed to retinal disease. Macular pathology will result in the PPP not working as expected and therefore should be avoided in such patients. This also applies to patients with multiple peripheral retinal degenerations or those who might need argon laser photocoagulation.
In all other patients, a thorough retinal examination is conducted preoperatively. Postoperatively, newer wide-angle fundus photography systems allow fundus examination to be done even through the PPP. Since the dilator muscles of the iris are still intact, mild retinal dilatation is still possible between the pupilloplasty knots on the two sides.
For cases requiring future retinal surgery, it is a simple procedure to open the PPP surgically to the desired diameter. If the retinal surgery requires silicone oil, retaining some of the SFT knots also helps decrease the incidence of silicone oil-associated glaucoma in these eyes.
A smaller pupil size may decrease retinal illuminance, affecting vision in dim light situations. However, this may be overcome by neuroadaptation. In addition, these patients are highly aberrated with very low vision that worsens further with pupillary dilatation, resulting in unmasking of more HOA in dim light. The PPP generally thus serves to improve their vision even in dim light situations. If any patient still
complains of dim retinal illuminance, the pupil can be enlarged slightly with the YAG laser.
Dr Agarwal’s Eye Hospital has performed visual field testing and found it to be satisfactory in patients with PPP. They are able to function normally, and the hospital team hasn’t seen patients complaining of difficulty navigating or seeing objects in the peripheral field.
For all the above situations, if the patient is still experiencing difficulty, the size of the pupil can be enlarged either using an argon laser or a YAG laser. PPP does have a learning curve, which is possible to overcome with practice.
Despite the learning curve, PPP is a surgical procedure that can be useful in certain scenarios to provide good quality vision to patients with aberrated corneas. This is a surgery that the anterior segment surgeon is well advised to keep in their surgical armamentarium.
This is the sixth in a multipart tutorial on higher-order aberrations. Previous articles in the series can be found at escrs.org/eurotimes.
Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com.
FIGURE: A) Single-pass, four-throw pupilloplasty bite is taken on one side of the pupil using 10-0 prolene suture on a long, thin needle. A 30-gauge needle is passed through a paracentesis and taken through the pupil on the other side. The first needle is railroaded into the 30-gauge needle to bring it out of the paracentesis; B) A loop is brought out and the leading end of the suture is cut and passed four times through the loop followed by pulling both ends apart to close the knot; C) A similar knot is taken on the other side; D) Multiple knots are taken until the pupil is small and centred on the patient-fixated, coaxially sighted corneal light reflex. A vitrector is used on a low cut rate and low vacuum to cut the pupil to adjust final size, shape, and centration.
Coming to Terms with Dry Eye Disease
NESTS survey highlights quality of life issues.
SEAN HENAHAN REPORTS
Dry eye is an issue in every area of eye care, especially the cataract, refractive, corneal, and glaucoma specialties. Attendees at the 2025 ESCRS Annual Congress had many opportunities to learn what’s new in the diagnosis and management of dry eye disease (DED), with 1 Masterclass, 3 entire sessions, 43 abstracts, and 85 presentations devoted to the topic.
Research presented in a poster session found that more than half of the general population in the US and Europe experience DED, yet only 20% of European patients and 17% of US patients were diagnosed, and they can wait years for professional help.
“Results from our studies reveal a substantial group of patients suffering without help,” Piotr Wozniak MD, PhD said. “The European questionnaire explored why people don’t seek treatment. Many see dry eye as a normal part of ageing and something to endure. As a medical doctor, I find this particularly concerning because a simple eye drop could offer significant relief—but many people aren’t even asking for help.”
Dr Wozniak presented findings from a survey of 2,003 adults in the US conducted in April 2024, and from an ongoing, international arm of the study conducted by Bausch + Lomb with more than 5,000 adults in the UK, France, Germany, Poland, and Saudi Arabia called the ‘Needs Unmet in Dry Eye: Symptoms, Treatment and Severity’ (NESTS) study. In June 2025, the NESTS international arm surveyed 2,580 adults in the general population and 2,572 dry eye patients.
“In the NESTS study, we found that 58% of the general population reported experiencing dry eye symptoms, yet only one in five has received a formal diagnosis from a healthcare provider,” he said. “The large size of this study makes these results robust.
“The study explored the patient journey in detail. What stood out was that up to one-third of patients had experienced symptoms for more than five years before seeking professional help. NESTS also found that around half of patients experience symptoms every single day. The delay in seeking treatment is concerning, especially since dry eye is a progressive disease and early intervention can prevent a vicious cycle of inflammation.”
Other results from NESTS showed that 60% of dry eye patients waited at least four months before seeking help, and 20% waited more than a year before talking to healthcare providers.
Many stopped driving at night (17.0%), no longer wore makeup (14.8%), or reduced their use of heat or air conditioning (15.2%) due to their uncontrolled dry eye symptoms. One in three (34.0%) reported that their symptoms had worsened over the past year, and only 9.0% noted an improvement.
“These findings highlight the widespread impact of dry eye disease on quality of life, showing many people suffering silently,” Dr Wozniak said.
“We need to educate patients and the public on the causes, consequences, and treatment options for dry eyes, as well as the importance of regular eye checks. In addition, we must support healthcare professionals in distinguishing between different types of dry eye and matching treatments appropriately. One person’s dry eye can be very different from another’s.”
Piotr Wozniak MD, PhD is a refractive surgeon and dry eye specialist at Optegra Eye Clinics and a lecturer and clinical instructor at Cardinal Stefan Wyszyński University, both of Warsaw, Poland.
The Second Global Consensus on Keratoconus
Defined standards for keratoconus care receive a new and long-awaited update.
TIMOTHY
TNORRIS REPORTS
en years after the landmark publication of the First Global Consensus on Keratoconus and Ectatic Disease, an updated Second Global Consensus is now available.
Organised by José Álvaro Gomes MD, PhD; Renato Ambrósio Jr, MD, PhD; and Farhad Hafezi MD, PhD, the new document brings together experts from 12 international societies across 6 continents. The project aims to distil the collective judgement of the world’s leading cornea specialists.
As Professor Hafezi explained, the project is a momentary snapshot of the current opinion of international leaders in the field. Using a modified Delphi methodology, only statements reaching at least two-thirds (66%) agreement were accepted. “That threshold ensures the conclusions represent a broad consensus rather than individual preferences,” he observed.
And its impact extends well beyond academic debate. “The Second Global Consensus on Keratoconus is [essentially] a guidelines document that provides clinicians with a practical framework for diagnosis and management, as well as helping societies and health systems to harmonise their standards of care,” said Prof Gomes. “By consolidating expertise into clear, evidence-based recommendations, the Consensus influences not only clinical practice but also training and even policy decisions around corneal health.”
The organisers shared several important updates during a Cornea Day session during the 2025 ESCRS Annual Congress in Copenhagen on new developments in keratoconus and cross-linking. Immediate treatment of children upon diagnosis, adoption of the Belin ABCD for staging and monitoring, new protocols such as ELZA-sub400 for thin corneas, and new techniques and technology such as ELZA-PACE, SLAK, and CAIRS were all presented and discussed.
“These updates reflect the continuous evolution and paradigm shift in keratoconus care,” Prof Ambrósio noted. “The Second Consensus expanded beyond stabilisation, integrating multimodal diagnostics for individualised management, ectasia prevention, vision rehabilitation, and guidance in therapeutic, elective, and refractive cataract surgery.”
The Cornea Day programme featured a structured overview of the Consensus. Prof Hafezi introduced the initiative, followed by Michael Belin MD presenting “Highlights of the Consensus, part 1,” which focused on diagnostic definitions and staging. Cosimo Mazzotta MD then delivered “part 2,” covering CXL protocols and treatment strategies.
Prof Hafezi noted that behind these highlights lies the work of seven expert panels, each addressing a major theme: definition and staging, non-invasive treatment, cross-linking, invasive visual rehabilitation, keratoplasty, refractive
surgery, and cataract in keratoconus. The forthcoming publication will detail both the agreements and the open debates that remain, he said.
If the First Consensus in 2015 helped establish cross-linking as the standard of care, the 2025 update reflects a broader ambition. “We can now move beyond stabilising the disease,” Prof Hafezi said. “With techniques such as PRK combined with CXL, PACE, CAIRS, and SLAK, we can offer patients meaningful visual rehabilitation. For many, that means not just stopping progression but regaining quality of life.”
As a result, the Second Global Consensus is expected to serve as both a practical roadmap for clinicians and a benchmark for future innovation in corneal surgery—an internationally representative document to guide the field until the next update.
Renato Ambrósio Jr, MD, PhD is Adjunct Professor of Ophthalmology at the Federal University of the State of Rio de Janeiro, Brazil.
José Álvaro Pereira Gomes MD, PhD is Adjunct Professor at the Federal University of São Paulo, Brazil.
Farhad Hafezi MD, PhD, FARVO is Medical Director at the ELZA Institute of Dietikon, Switzerland.
Bioengineered Endothelial Implant Shows Promising in vivo Results
Scaffold-based system is easy to deploy and has short learning curve.
SEAN HENAHAN REPORTS
Abioengineered, 3D printed endothelial keratoplasty implant could offer an alternative to conventional donor tissue in diseases where the corneal endothelium fails, such as Fuchs’ dystrophy and bullous keratopathy, reported Michael Mimouni MD.
“Do we even need innovations in the area of endothelial keratoplasty?” he asked. “We already have excellent techniques, including ultrathin DSAEK and DMEK. These methods have limitations, with the main one being a lack of tissue availability. According to global reports, for every 70 patients who need a corneal transplant, there is one implant available.”
Surgical approaches to addressing the tissue shortage include techniques such as DSO, quarter DMEK, and hemiDMEK to optimise available resources. Newer technologies include artificial implants (such as EndoArt) and cell-based approaches, either scaffold-based or cell injection-based.
Dr Mimouni presented an update on a scaffold-based system called Precise-BIovision endothelial keratoplasty (PVEK). A monocellular layer of endothelial cells is printed at a density of more than 5,000 cells per square millimetre on an 8-micron-thin collagen tissue. Viability exceeds 90%.
It comes pre-stamped and preloaded in a Geuder cannula. After performing descemetorhexis, the implant is inserted through a small incision, unfolded, positioned, and held in place with a gas tamponade.
“This implant is very easily deployed with minimal manipulation,” Dr Mimouni reported. “It is much easier to unfold than a DMEK and reminiscent of an ultrathin DSAEK. We are able to produce 300 tissues from one donor.”
• Sham (control 1)
Severe corneal edema – Stromal scarring
Average CCT: 761µm
• Scaffold only (control 2)
– Subepithelial fibrosis
– 6 mo. detachment: 46%
– Average CCT: 630µm
• PVEK
– 6 mo. detachment: 16%
– Average CCT (attached): 391µm
Presenting results of in vivo research with 64 rabbits, Dr Mimouni explained one-third received the implant seeded with human corneal endothelial cells, one-third the scaffold alone, and the remainder underwent sham surgery. All underwent unilateral descemetorhexis of the right eye. Subacute (4-week) and chronic (26-week) endpoints were assessed.
“In the sham group that underwent descemetorhexis only, we found severe corneal oedema followed by stromal scarring. In the scaffold-only group, we saw that most animals developed subepithelial fibrosis and that there was a 46% detachment rate, with all those animals developing severe oedema,” he said. “The overall average central corneal thickness was 630 microns. In the PVEK group, at 6 months we saw a 16% detachment rate with a significantly lower average central corneal thickness of 391 microns.”
Some of the potential advantages of PVEK, according to Dr Mimouni, include the ability to choose the size of the implant, the shape of the marking, and the density of the endothelial cells. Moreover, the learning curve is shorter than with DMEK since the transplant is very easy to deploy.
A phase I clinical trial is in planning stages.
Dr Mimouni presented during a free paper session at the 2025 ESCRS Congress in Copenhagen.
Michael Mimouni MD serves as an attending physician and director of the Cornea Unit in the Department of Ophthalmology at Rambam Health Care Campus, Israel.
Animal
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:
• Extracapsular cataract extraction and PK
• Recentration of artificial iris
• Bimanual technique for anterior capsulorhexis in cases of weak zonules
MAKE EVERY SECOND COUNT
—PUT THE ESCRS 100 VIDEO SERIES ON YOUR LIST OF MUST-WATCH EDUCATIONAL RESOURCES ! ESCRS 100
Treatment for Macular Oedema
Secondary to Inflammation
Bispecific biologic shows early promise.
CHERYL
Preliminary results from a phase 1b clinical trial show that intravitreal treatment with KSI-101, a bispecific trap-antibody inhibiting both interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF), was associated with robust anatomic and visual improvement in patients with macular oedema secondary to inflammation (MESI), irrespective of the location of inflammation or the specific aetiology.
“MESI is a heterogeneous group of diseases with the shared pathophysiology of inflammation and blood-retinal barrier disruption and associated macular oedema with visual impairment. Diseases in this new category include the classic uveitic macular oedemas, as well as other aetiologies such as postoperative macular oedema and choroidal neovascularisation secondary to inflammation,” said Charles C Wykoff MD, PhD. “The encouraging first-time results in the phase 1b [trial] have led to the launch of two phase 3 trials investigating KSI-101 for MESI, PEAK, and PINNACLE that are actively enrolling.”
The phase 1b trial, named APEX, enrolled patients with MESI who had active or nonactive non-infectious intraocular inflammation (either acute or chronic) with active leakage on fluorescein angiography, central subfield thickness (CST) greater than or equal to 320 µm, and BCVA of 20/32 or worse. The study investigated three doses of KSI-101—2.5, 5.0, or 10.0 mg. Patients received four injections of their assigned dose at monthly intervals and were followed to the end of the study at 24 weeks.
Enrolment in APEX included 41 patients. About two-thirds of patients had posterior inflammation, and about one-fourth had panuveitis. Baseline mean VA was approximately 20/50 (63.5 ETDRS letters), and mean CST was 493 µm. The interim analysis Dr Wykoff presented included data from 27 patients who had reached week 12 by 14 July 2025.
Functional assessments showed that BCVA increased from baseline by week 4. Across the three dose groups at week 12, mean BCVA gains from baseline ranged from 7.8 to 11.8 ETDRS letters, and 50% of patients had gained 15 letters or more.
Anatomic improvement occurred rapidly, with the majority of patients having resolution of intraretinal or subretinal fluid by week 1. At week 12, CST was 300 µm or less in all eyes and decreased by 199 to 237 microns across the three treatment groups; 100% of eyes had resolution of both intraretinal and subretinal fluid.
The safety review showed KSI-101 was safe and welltolerated. There was a single case of vitreous haemorrhage, with this event occurring following anterior chamber paracentesis and before dosing of KSI-101. Intraocular inflammation occurred in two eyes and was attributed to underlying uveitis rather than KSI-101.
Dr Wykoff mentioned that a parallel arm of the phase 1b APEX trial is investigating KSI-101 in patients with diabetic macular oedema. This 24-week study enrolled 12 patients who received five monthly doses of KSI-101 in the same increments. Preliminary end-of-study results for these patients showed KSI-101 to be safe and well-tolerated with no cases of intraocular inflammation. From baseline to week 24, BCVA improved by a mean of 13.1 ETDRS letters. Mean CST was less than 325 µm by week 12 and remained stable through week 24, having decreased by an average of 175 µm from baseline.
Dr Wykoff spoke at EURETINA 2025 in Paris.
Charles C Wykoff MD, PhD is Deputy Chair of Ophthalmology, Blanton Eye Institute, Methodist Hospital and Director of Research, Retina Consultants of Texas, both of Houston, Texas, US. ccwmd@retinaconsultantstexas.com
GUTTMAN KRADER REPORTS
Privosegtor Shows Promise for AON
Improved low contrast visual acuity and reduced retinal ganglion cell loss seen in patients with acute optic neuritis.
CHERYL GUTTMAN KRADER REPORTS
An investigative neuroprotective agent, privosegtor (OCS-05), appears to be promising as an add-on to standard of care treatment for acute optic neuritis (AON), a recent clinical study suggests.
The drug met its primary safety endpoint and key secondary efficacy endpoints assessing structure and function in the phase 2 ACUITY trial, reported Sophie Bonnin MD, PhD.
Patients in the Privosegtor 3mg/kg/day Arm Achieved Clinically Meaningful Improvement in Visual Function
“The results in ACUITY provided positive proof of concept of a neuroprotective effect for this new class of drug, and its promising benefits for protecting vision and anatomy in AON suggest it could have benefits in multiple other conditions,” Dr Bonnin said.
Privosegtor (OCS-05) is a small molecule peptoid that penetrates the blood-brain and retinal barriers and activates neurotrophic factors. Data from various in vivo preclinical models validated preservation of neurons and axons in animals treated with privosegtor. Because AON is a very good model for neuroprotection and is an indication with no approved treatment, it was chosen as the target for the first clinical trial, Dr Bonnin said.
ACUITY was a double-masked study conducted at four tertiary care neurology and ophthalmology centres in France. Eligible patients had unilateral AON with onset of visual loss symptoms within 12 days prior to randomisation.
Thirty-six patients were randomised to once daily intravenous infusions of privosegtor or placebo in addition to standard of care steroid treatment. The infusions were given on five consecutive days, and patients were followed for six months after the last infusion.
The treatment groups were well-balanced in their baseline demographic and clinical characteristics. Consistent with the epidemiology of AON, the patients were young (mean age approximately 33 years), predominantly female, and 61% had multiple sclerosis.
Dr Bonnin presented results for 33 patients comprising a modified intent-to-treat cohort that included all patients who received at least one dose of their assigned study treatment. Cardiac safety was the primary endpoint in this first clinical trial, and the data analyses showed there were no between-group differences in shifts of electrocardiogram parameters. Adverse events were predominantly mild, transient,
and not clinically significant. There were no drug-related serious adverse events and no adverse events leading to treatment or study withdrawal.
Data on changes from baseline in ganglion cell/inner plexiform layer (GCIPL) thickness and peripapillary retinal nerve fibre layer (RNFL) thickness, as measured by optical coherence tomography, indicated privosegtor was protecting neurons and axons, respectively. At month three, GCIPL thinning was 43% lower in patients treated with privosegtor versus controls, and RNFL thinning was 28% lower in the privosegtor group. These differences were maintained at month six, Dr Bonnin reported.
Commenting on functional outcomes, she said, “We were very happy to see that the anatomic protection translated to functional benefits for patients.”
Function was assessed by measuring 2.5% low contrast visual acuity (LCVA). The results showed a clinically meaningful improvement from baseline to month three in the privosegtor group (+48.1 ETDRS letters) that was maintained at month six with a difference in LCVA improvement versus placebo of 18 letters at month three and 15 letters at month six (nominal P values for treatment group differences -0.004 and 0.012, respectively).
Bonnin presented at EURETINA 2025 in Paris.
Dr
Sophie Bonnin MD, PhD is Deputy Head of the Retina Department at the Rothschild Foundation Hospital, Paris, France. soph.bonnin@gmail.com
2.5% ETDRS LCVA in the Affected Eye: MMRM, LS Mean Change From Baseline, mITT
Targeting the Intravitreal Treatment Burden
Novel systemic nanomedicine agent shows promising safety and efficacy in patients with bilateral retinal disease.
CHERYL GUTTMAN KRADER REPORTS
Positive end-of-study outcomes in a phase 2 clinical trial appear to strongly support further development of subcutaneous migaldendranib (subQ MGB) for the treatment of diabetic macular oedema (DME) and neovascular age-related macular degeneration (nAMD).
“The top-line results show that over a 40-week duration, subQ injections of MGB in patients with active DME and nAMD were well-tolerated, associated with functional and anatomical improvements, and significantly reduced the need for supplemental intravitreal (IVT) anti-VEGF injections,” reported Arshad M Khanani MD. “Confirming a bilateral effect, fellow affected eyes had stable vision and anatomy as well as a marked reduction in need for supplemental IVT.”
Representing a new class of nanomedicine, migaldendranib is a systemic agent that covalently links a VEGF receptor tyrosine kinase inhibitor (TKI) to a hydroxyl dendrimer. It targets activated macrophages, microglia, and hypoxic retinal pigment epithelial cells, acting to shut down VEGF overexpression at the source and restore normal VEGF signalling, Dr Khanani explained.
“Migaldendranib is cleared through the kidney—avoiding liver toxicity—and [used] as a subcutaneous treatment,” he said. “It not only has the potential to treat both eyes, but is also intended to be administered at home with an autoinjector.”
The phase 2 trial investigated two regimens of MGB: 2 mg/ kg every 2 weeks or every 4 weeks. Dr Khanani presented data for 8 patients with DME and 14 patients with nAMD.
Study participants needed to have demonstrated a response to prior IVT anti-VEGF treatment with recurrence of intraretinal or subretinal fluid. Potential participants underwent a 12-week run-in phase to exclude non-responders (those with no improvement in fluid at week 4) and super responders (those who had no fluid return at 12 weeks). Patients who entered the trial could receive supplemental intravitreal anti-VEGF based on predefined criteria that reflected real-world practice.
In both the DME and nAMD groups, the majority of patients (88% and 57%, respectively) had bilateral disease. When both eyes were affected, the eye with the worse BCVA was designated as the study eye.
A review of study participant safety data showed no serious ocular or systemic adverse events related to MGB nor any clinically significant changes in renal, hepatic, or cardiac values. Localised, transient injection site reactions occurred in about 8% of patients, which were mostly mild, none severe, and primarily occurred on the first injection.
“The absence of systemic safety issues is in contrast to systemic TKIs used for other indications and is consistent
with MGB’s mechanism of targeting only activated cells,” Dr Khanani said.
Analyses of data from study eyes showed clinically meaningful improvements in both BCVA (+6.1 ETDRS letters) and central subfield thickness (CST; -23.3 µm) in DME eyes. Eyes with nAMD showed consistent improvement in BCVA (+4.7 ETDRS letters) and CST (-63.5 µm). Study eyes in both diagnostic groups benefited, with a marked reduction in the need for supplemental IVT anti-VEGF injections and the annualised rate decreasing from 8.4 to 1.6 injections per year. For fellow affected eyes, the annualised rate of supplemental IVT anti-VEGF injections fell from 8.3 to 0.9 injections per year.
Dr Khanani presented at EURETINA 2025 in Paris.
Arshad M Khanani MD, MA, FASRS is Managing Partner and Director of Clinical Research at Sierra Eye Associates and Clinical Professor at the University of Nevada, Reno School of Medicine, Reno, Nevada, US. arshad.khanani@gmail.com
CE Mark for Ciliatech’s Novel Glaucoma Implant
Cilioscleral interpositioning device lowers IOP in new way.
SEAN HENAHAN REPORTS
Ciliatech announced it received the CE Mark under the scope of the EU Medical Device Regulation (MDR) for Intercil, a uveal spacer offering a new approach to glaucoma treatment.
An ab externo device inserted between the sclera and ciliary body below the limbus, Intercil has been shown to provide reliable IOP reduction while lowering the risk of damaging the corneal endothelium, hyphaema, and postoperative inflammation, compared with procedures that penetrate the iris root.
“Ciliatech was created to develop an approach to glaucoma treatment that had never been considered previously: to lower IOP without entering the anterior chamber or creating subconjunctival filtration,” explained Ciliatech’s co-founder and medical director Philippe Sourdille MD. “This makes Ciliatech’s approach significantly different from existing surgical propositions. It provides procedural simplicity, with a fast learning curve. It does not inhibit future treatment options.”
The device is inserted through a penetrating 3.5 mm radial scleral incision 2.0 mm away from the limbus, which Dr Sourdille said offers the surgeon a precise view of the supraciliary body and allows creation of a space between the sclera and the muscle before inserting the device. It also leaves space for filtration surgery if that eventually is needed. The procedure takes about 15 minutes.
Intercil might be especially appropriate for phakic glaucoma patients, said Karsten Klabe MD, a member of Ciliatech’s key opinion leader advisory board. “In addition to reducing the risk to the corneal endothelial cells by not opening the anterior chamber, there is less risk of cataract or damaging the iris. It might be safer [than angle-based or filtering glaucoma surgery] for such a group of patients.”
“Ciliatech is thrilled to obtain CE certification for our Intercil Uveal Spacer under the scope of MDR. This critical step is the culmination of years of hard work and significant investment,” said Olivier Benoit, CEO of Ciliatech in a company press release. His company was included in the emerging company section of the “Interventional Glaucoma in the Cataract Practice” session of iNovation Day.
“In our steadfast commitment to offering a genuine solution to patients who endure the impacts of glaucoma, and thanks to new funding, we can now accelerate the commercial availability of Intercil, roll out its distribution in select European countries, and plan for future registrations in key markets, notably the US and China. We anticipate that glaucoma surgeons and early adopters of innovation will see the value in our ‘no-bleb-no-cleft’ approach in achieving robust IOP lowering with minimal postoperative care.”
We anticipate that glaucoma surgeons and early adopters of innovation will see the value in our ‘no-bleb-no-cleft’ approach in achieving robust IOP lowering with minimal postoperative care.
Intercil is the first in a brand-new class of glaucoma surgical procedure, ‘Cilioscleral Interpositioning Device’ (CID), designed to lower IOP by increasing uveoscleral outflow without penetrating the anterior chamber. This technique may preserve the integrity of the anterior chamber by using a ‘no-bleb-no-cleft’ approach, offering potential benefits in minimising the risk of corneal endothelial cell loss. CID transforms the way surgeons approach the supraciliary space of the eye, demonstrates a high safety profile, minimises complications, and provides a comfortable postoperative recovery for patients, the company reported.
Philippe Sourdille MD is an ophthalmologist, researcher, inventor, and medical director and co-founder of Ciliatech in Chavanod, France. p.sourdille@cilia.tech
Karsten Klabe MD is an ophthalmologist specialising in glaucoma surgery at Breyer, Kaymak & Klabe Augenchirurgie in Düsseldorf, Germany. studien.k.klabe@augenchirurgie.clinic
Each year, young ophthalmologists are invited to participate in the John Henahan Writing Prize, responding to an essay prompt provided by the medical editors of EuroTimes. This year’s winner is Shady Atamniy MD, an ophthalmologist in training at Eye Clinic, Augenspezialist Wien, Vienna.
Applicants responded to the following prompt: Diversity, equity, and inclusion (DEI) programmes, however well-intentioned, stir a variety of responses in the corporate and political worlds and in the scientific and medical spheres. What DEI and unconscious bias issues are present in the current culture of ophthalmology training, practice, and clinical research? What are the potential benefits of addressing these issues for patients and ophthalmologists? What kind of meaningful changes need to happen to move beyond ‘talking the talk’ to ‘walking the walk’?
Thinking Beyond Optics: Diversity, Equity, and Inclusion (DEI) and Unconscious Bias in Ophthalmology
Indeed, diversity, equity, and inclusion (DEI) concepts have gained momentum across various fields. However, in the medical field, particularly in ophthalmology, they remain sporadically applied, poorly understood, and often seen as peripheral to clinical brilliance. Although well-intentioned, DEI programmes evoke varying responses within the medical community. Nonetheless, beneath the surface of this debate, a fundamental truth remains: unconscious bias and inequality continue to influence ophthalmology training, practice, and research, often to the disadvantage of clinicians and patients.
Diversity, equity, and inclusion in ophthalmology today
Traditionally, ophthalmology has been regarded as an exceptionally exclusive and competitive speciality. Securing a place in training remains heavily biased, with many individuals from lower socioeconomic backgrounds, underrepresented ethnic minorities, or without academic or family ties in medicine facing significant obstacles. When investigated, gender disparities among mentorship programmes in ophthalmology have shown that female trainees, compared to their male counterparts, reported significantly lower satisfaction. Furthermore, lower income, decreased rates of goal achievement, and less support in achieving these goals were among the concerns raised.1
Unconscious bias continues to affect recruitment decisions, assessments, interactions with patients, and even who gets access to prestigious cases. Research indicates that in surgical specialities, women experience less autonomy in surgeries compared to their male counterparts, even though their levels of expertise are similar.2 Similar disparities are also seen in academic authorship and research funding allocations. Racial and ethnic minorities are underrepresented as lead or senior authors in ophthalmology journals.3
The importance of addressing DEI
Adopting a DEI approach is not just a moral duty for ophthalmologists. It’s crucial for the long-term sustainability and quality of the field. Research has consistently shown that diverse teams make better clinical decisions, drive more innovative research, and achieve higher patient satisfaction.4
Figure 1 underscores how diversity, equity, and inclusion comprise a comprehensive institutional culture approach. Making trainees feel valued, supported, and mentored increases the likelihood of staying in the field, flourishing, and making a meaningful contribution. DEI promotes a sense of belonging, which helps reduce burnout—a growing problem in ophthalmology—and improves mental well-being. Equity in care should not be a luxury for patients; it should be a given. Tackling unconscious bias can result in
Figure 1: Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce, 2025 Snopko. 5
increased trust, earlier diagnoses, and improved treatment adherence. Additionally, involving more diverse patients in clinical trials ensures that healthcare innovations are safe and effective for all populations.6 Figure 2 illustrates a powerful analogy by Verna Myers, an author and lawyer, that underscores the importance of DEI.
From talk to action: What must change?
While raising awareness is crucial, the real priority should be taking concrete, measurable steps to drive meaningful change.
1. Transparency in recruitment and promotion
Implement a blind review process that can highlight the true qualities of training applicants in hiring and promotion decisions. This should be supported by accurate diversity data reporting and equity audits conducted by institutions to ensure oversight of the process.
2. Programmes for mentorship and sponsorship
Engage senior ophthalmologists with expertise in identifying and addressing unconscious bias to set up targeted mentorship for minority groups. Additionally, sponsorship
programmes should be created to motivate mentors to champion their trainees.
3. Research practices with a focus on inclusivity
Develop practical routes for publishing and co-authoring with clinicians from underrepresented minority backgrounds. Meanwhile, promote the use of DEI metrics in research designs for clinical trials to recruit diverse participants.
4. Compulsory DEI and bias training
Incorporating DEI education into curricula leads to meaningful, long-lasting change. This is necessary to tackle the deeply ingrained unconscious bias in our field. Regular assessment intervals are crucial for consistency and should involve clinical mentors and educators.
5. Environmental and policy reform
Institutional involvement is pivotal in facilitating flexible work arrangements, supporting caregivers, and employing proactive strategies to dismantle exclusive networks that restrict opportunities for minority groups. Invest in physical and cultural initiatives that promote inclusivity and implement anonymised and accessible feedback mechanisms. Biases and inequities in ophthalmology can be mitigated through DEI. This concept should not be dismissed as merely a quota that institutions must fulfil. Its implementation should stem from our collective desire as medical professionals to provide our patients with the best care. It goes beyond fostering a more diverse field and has clinical, educational, and ethical implications. Let us remove the barriers that prevent talent and compassion from reaching their full potential. It is high time we stop simply ‘talking the talk’ and begin ‘walking the walk’ with commitment, courage, and transparency.
For citation notes, see page 40.
Beyond Sight: A Clearer Vision for Equity in Ophthalmology
In a specialty defined by precision, clarity, and vision, ophthalmology has made extraordinary strides in science and technology. But beneath the surface of these advances lies a less visible challenge—our collective blind spot when it comes to diversity, equity, and inclusion (DEI). As a female ophthalmologist training in the Middle East, I’ve seen firsthand how unconscious bias shapes who gets to lead, who gets chosen, and who gets seen—not just in the operating
theatre, but in our systems, language, and even the patients we serve.
I currently train and practice at Watany Eye Hospital in Egypt, a hub of excellence in our region. But despite the clinical sophistication, I still encounter an invisible obstacle: genderbased bias. I’ve had patients bypass me as a surgeon solely because I am a woman. I’ve walked into operating rooms where the unspoken assumption is that the lead surgeon must
Figure 2: “Diversity is being invited to the party: Inclusion is being asked to dance,” 2015 Myers.7
Each year, young ophthalmologists are invited to participate in the John Henahan Writing Prize, responding to an essay prompt provided by the medical editors of EuroTimes. Noha Fawky Abdelfattah MD’s essay scored among the top three in a very competitive field.
be male. And I’ve seen the hesitation in patients’ eyes—not because of my skill, but because of my gender.
This isn’t just a Middle Eastern issue. Around the world, women in ophthalmology still face slower promotion, unequal pay, and underrepresentation in leadership roles. And those from minority ethnic or socioeconomic backgrounds often face even steeper climbs. These aren’t isolated cases—they are symptoms of a system built on centuries of imbalance.
Yet, [through] these barriers, I was fortunate. I found a mentor who saw my potential before I could fully see it myself.
Professor Ahmed Assaf didn’t just teach me how to perform surgery. He taught me how to edit surgical films, how to explain complications with humility and confidence, how to make patients feel safe. He brought me to international conferences, pushed me to contribute to papers, and opened doors that would have otherwise remained closed. His mentorship didn’t just shape my skill—it shaped my belief in what I could become. Every young ophthalmologist deserves a mentor like that.
When bias reaches the bedside
Bias in ophthalmology isn’t limited to career trajectories—it affects patients, too. One of my most unforgettable cases was a man with a single functioning eye, clouded by a dense brown cataract. He had been turned away by others because he couldn’t afford the surgery. His world had narrowed to shadows and shapes, and yet, no one had offered him hope. I performed the surgery for free.
A week later, he returned beaming. For the first time, he could see his grandchildren’s faces. That moment reminded me why equity matters—not just in who gets to train, but in who gets to see.
It is far too easy for disadvantaged patients to fall through the cracks of our healthcare systems. Whether because of poverty, language, disability, or culture, countless patients are underserved, misdiagnosed, or delayed in care. And when the physicians who treat them do not reflect their diversity, communication gaps only widen.
A narrow lens in research
These disparities echo into our research, where many clinical trials still lack representative samples. In global ophthalmology studies, patients from the Middle East, Africa, and South Asia are underrepresented. So are female patients, especially in interventional trials. Without diversity in data, our conclusions are biased before the first statistic is run.
Worse still, diverse investigators are often left out of leadership roles in research. We risk building the future of eye care on incomplete evidence—and leaving millions behind.
The case for change
We often say that ophthalmology is about restoring vision. But real vision isn’t just about what the eye sees—it’s about what the mind perceives. Addressing unconscious bias and embedding DEI into our profession is not an ethical add-on; it is essential to clinical excellence.
When patients see themselves in their doctors, trust deepens. When diverse trainees are supported, the entire system benefits. When research reflects the full spectrum of humanity, our innovations gain power.
From words to action
To move from ‘talking the talk’ to ‘walking the walk,’ we must:
1. Reimagine training: Blind reviews, structured interviews, and mentorship programmes must be standard. Diversity should be seen as a strength, not a checkbox.
2. Confront clinical bias: Patients should choose surgeons based on skill—not gender or ethnicity. Institutions must educate patients and empower all doctors equally.
3. Decolonize research: Funders and journals must demand inclusive trial design and diverse leadership. Global data should represent global people.
4. Create mentorship pipelines: Every young ophthalmologist deserves a Professor Assaf—someone who lifts them as they rise.
5. Measure and report: DEI metrics in hiring, publishing, and outcomes must be transparent and acted upon. What we do not measure, we cannot improve.
A new lens
To the young ophthalmologist reading this: find a mentor who believes in you—and be that mentor for someone else. Challenge what is assumed. Advocate for who is excluded. Equity is not a destination; it is a discipline.
In the end, we are a specialty of visionaries. Let us sharpen our lens—not just to treat cataracts, but to clear the cultural fog that holds our field back. Let us make it possible for every patient to see, and for every doctor to be seen.
Because true vision demands more than sight—it demands insight.
Noha Fawky Abdelfattah MD is a post-residency fellow, Watany Eye Hospital, Egypt.
Each year, young ophthalmologists are invited to participate in the John Henahan Writing Prize, responding to an essay prompt provided by the medical editors of EuroTimes. Anuj Kodnani MBBS’s essay scored among the top three in a very competitive field.
Refractions of Bias: Seeing DEI Clearly in Ophthalmology
“The eye sees only what the mind is prepared to comprehend.”
– Henri Bergson
In a discipline that celebrates clarity of vision, it’s ironic that we sometimes fail to see our own blind spots. Diversity, equity, and inclusion (DEI) in ophthalmology is not just a matter of optics—it’s a matter of outcomes. Whether in the clinic, the classroom, or the research lab, unconscious biases subtly distort the lens through which we view talent, treat patients, and design studies.
As an Indian ophthalmologist who has trained in both London and the US, I’ve experienced this first-hand. While my fellowships were academically enriching, they also came with a sense of cultural distance. In clinical discussions, I was often the only non-Western fellow in the room. Teams rarely reflected the diverse communities they served. It made me ask: in a global specialty, why is the representation within our training and leadership so limited?
This isn’t just about optics. It’s about patients. Data shows diverse medical teams foster trust and improve outcomes, especially for underrepresented groups.1 And yet, women in ophthalmology still face subtle—but damaging— barriers: fewer surgical opportunities, being mistaken for nurses, or having their leadership ambitions quietly dismissed.2 Similarly, Black and Asian populations continue to be underrepresented in trials, even though they bear a disproportionate burden of diseases such as glaucoma and diabetic retinopathy.3
Clinical research also reflects this inequity. Despite the global burden of blindness being highest in low- and middle-income countries, most randomised trials are designed, funded, and published in the Global North.4 These studies then dictate global guidelines, often ignoring socioeconomic or cultural nuances. As a result, interventions may be technically sound but practically ineffective or even inappropriate in local contexts.
Even our DEI initiatives sometimes feel performative. Diversity panels filled with the same voices. Committees with no power. Tokenism is easy. Transformation is hard.
So how do we ‘walk the walk’?
First, we widen the pipeline. Let’s reach out to underrepresented students early—with mentorship, shadowing, and scholarships. Diversity must begin before the residency interview.5
Second, we commit to transparency. Let’s publish anonymised data on applicant demographics, pay gaps, and promotions. If we track visual acuity so precisely, why not track equity with the same rigour?
Third, we embed bias training into real clinical life. Not just box-ticking modules. We need reflective storytelling, real mentorship, and debriefs on microaggressions. We train our eyes to spot retinal tears—why not train our minds to spot systemic ones?6
Fourth, research must reflect reality. Funders and journals should prioritise diversity in trial recruitment and reward innovation that addresses health disparities.7
And finally, leadership must reflect the world we serve. That means rethinking who gets the microphone, who gets promoted, and whose voices get heard.
This is not about lowering standards. It’s about understanding that the current standards may have been built to exclude. Just as we correct distorted corneas to sharpen sight, we must correct distorted systems to sharpen fairness.
My vision is of an ophthalmology community where a hijab-wearing woman, a first-gen student, a queer Black doctor, and a disabled surgeon feel not just included, but empowered; where diversity is not performative—but profound.
Until then, DEI must not be an agenda item. It is our collective responsibility.
For citation notes, see page 40.
Alcon extends support
Alcon announced an expansion of its Global Medical Affairs website, www.AlconScience.com, to now support eye care professionals in Brazil, Canada, Germany, India, Italy, Spain, UK, and US. The site consolidates information about Alcon’s scientific, academic, and related activities into one portal. Visitors may download clinical science publications, submit grant applications for investigator-initiated trials (IITs), and apply for independent medical education support, among other activities. alconscience.com
New phaco-vitrectomy systems
Oertli Instruments AG introduced its surgical platform, the OS 4 Up™. This platform is designed for vitreoretinal and cataract surgery and is enhanced by new instruments, such as the Caliburn Trocar System and the Continuous Flow Cutter. Additionally, the OS 4 Up features dynamic infusion technology for enhanced intraoperative intraocular pressure control. oertli-instruments.com
Virtuoso in Europe
BVI Medical introduced its Virtuoso dual-function phaco-vitrectomy system to the European market. The platform is equipped with an advanced fluidics system designed to maintain intraocular pressure throughout cataract procedures. Virtuoso will be commercially available in select European regions initially, with a broader global release planned pending relevant market approvals. bvimedical.com
Streamlined export feature for Heidelberg’s Anterion
Heidelberg Engineering released an update for the ANTERION® software that includes a Cataract App Key Measurements Export feature. This enhancement enables the transfer of essential biometry data from the Cataract App to DICOM format, facilitating seamless integration with Electronic Medical Records, intraocular lens calculation software, and other DICOM-compatible third-party applications, as well as HEYEX 2—Heidelberg Engineering’s platform for image management and device integration. heidelbergengineering.com
Virtual IOL preview for patients
VirtuaLens™ launched the Immersive IOL Simulator, a virtual reality platform that lets cataract patients compare intraocular lens options in simulated environments before surgery. Through a new partnership, Virtual Vision Health will distribute the simulator and add it to its suite of pre- and postoperative screening tools. virtualens.health
Upgrade for ICL sizing
Lumibird Medical introduced an upgrade to its ABSolu ultrasound platform, integrating ICL Guru (REVAI) for improved implantable collamer lens sizing. The system features a 50 MHz linear ultrasound biomicroscopy probe for precise sulcus-to-sulcus measurements. ophthalmology.lumibirdmedical.com
PROMISING RESULTS WITH NEW IOL MATERIAL
A new IOL composed of a novel material is showing promising results, notes Dr Liliana Werner. Called xPIB IOL (Eyedeal Company), the material is made from cross-linked polyisobutylene using SIBS as a thermoplastic elastomer, forming a 3D network structure that enhances mechanical strength, thermal stability, and chemical resistance—ensuring long-term durability. The hydrophobic material has a refractive index of 1.52, is highly flexible, and has low chromatic aberration with an Abbe number of 50. The September 2025 issue of the JCRS reported that, in a prospective, parallel-controlled, randomised clinical study, the lens demonstrated equivalent results with a commercially available single-piece hydrophobic acrylic lens (model SN60WF) in terms of safety and stability. “The new IOL material described here shows promising results. Studies describing larger series and longer clinical follow-up will ultimately establish its place as another viable option in IOL manufacture,” Dr Werner concluded.
L Werner. “New class of material for intraocular lens manufacture: polyisobutylene-based polymer” 51(10): 837–838; Y Zhao, et al. “Evaluation of safety and stability after intraocular lens implantation using a novel material-crosslinked polyisobutylene: a preliminary study,” 51(9): 756–761.
HIGH SPECTACLE INDEPENDENCE WITH NEW FVR IOL
A prospective, randomised trial found that the new full visual range (FVR) enVista Envy IOL offers high patient satisfaction, spectacle independence, and similar distance acuity to monofocal IOLs. Among 165 cataract patients (111 FVR, 54 monofocal), the FVR IOL matched monofocal lenses for uncorrected distance vision and outperformed them in intermediate and near vision. FVR patients maintained about 4.0 D of vision at 0.2 logMAR or better, with a 0.1 logMAR plateau (20/25) for intermediate/near tasks; monofocal group acuity declined at these ranges. After surgery, 92.7% of FVR patients were satisfied with near vision, and 91.7% no longer needed spectacles for near tasks.
A Muzychuk, et al. “Efficacy and safety evaluation of a new full visual range vs monofocal intraocular lens in patients with cataract: randomized, controlled Canadian clinical trial,” 51(10): 867–875.
NUMBER OF IOL EXCHANGE PROCEDURES INCREASING
The number of IOL exchange procedures performed among US Medicare beneficiaries has increased over the past decade, according to a retrospective cross-sectional analysis. The study’s authors reviewed the charts of Medicare beneficiaries aged 65 years or older who underwent IOL exchange surgery from 2011 to 2020. Their analysis showed that during those years, the annual number of IOL exchange surgeries rose from 4,621 to 6,114. The main indications were mechanical lens failure (51.4%) and lens displacement (21.1%), with other causes including posterior and anterior lens dislocation and anisometropia. Most surgeries occurred in urban settings, suggesting limited access for rural patients.
J Huang, et al. “Trends in patient, surgeon, and procedural characteristics of intraocular lens exchange among Medicare beneficiaries 2011 to 2020,” 51(10): 882–888.
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.
12. European Union of Medical Specialists, https://www. uems.eu/.
Patients Worth Fighting For
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1. “The Rise of Cocaine Usage in the UK,” UK Addition Treatment Centres, 29 Apr 2025, https://www.ukat.co.uk/blog/ substance-abuse/the-rise-of-cocaine-usage-in-the-uk/
Thinking Beyond Optics:Diversity, Equity, and Inclusion (DEI) and Unconscious Bias in Ophthalmology
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2. Bond EC, Whiting FH, Larsen PD, Chan G. N Z Med J, 2023 Jul 21; 136(1579): 36–48.
3. Chander S, Luhana S, Sadarat F, Leys L, Parkash O, Kumari R. Annals of Intensive Care [Internet]. 2023 [cited 2025 Jun 8];13(1). Available from: https://link.springer.com/ epdf/10.1186/s13613-023-01157-2
4. Davuluri K, Goyal N, Gomez Acevedo H, Folt J, Jayaprakash N, Slezak M, et al. J Am Coll Emerg Physicians Open, 2022 Sep 17; 3(5): e12798.
5. Snopko A. Vynamic LLC [Internet]. 2025 [cited 2025 Jun 8]. Available from: https://vynamic.com/insights/integrating-diversity-equity-inclusion-throughout-clinical-trials/
6. Serchen J, Doherty R, Hewett-Abbott G, Atiq O, Hilden D. “Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce.”
7. Myers V. Diversity & Inclusion [Internet]. 2015 [cited 2025 Jun 8]. Available from: https://www.bu.edu/diversity/ resource-toolkit/diversity-is-being-invited-to-the-party-inclusion-is-being-asked-to-dance/
Refractions of Bias: Seeing DEI Clearly in Ophthalmology
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1. Saha S, Beach MC, Cooper LA. J Natl Med Assoc. 2008; 100(11): 1275–1285.
2. Royal College of Ophthalmologists. Facing workforce shortages and backlogs in the aftermath of COVID-19: The 2022 Census. 2023. https://www.rcophth.ac.uk/wp-content/ uploads/2023/03/2022-Ophthalmology-census-Facing-workforce-shortages-and-backlogs-in-the-aftermath-of-COVID-19.pdf
3. Adams DR, et al. Ophthalmology, 2022; 129(5): 458–460.
5. Capers Q, et al. Acad Med, 2017; 92(3): 365–369.
6. Sukhera J, Watling C. Acad Med, 2018; 93(1): 35–40.
7. Chen MS, Lara PN, Dang JH, Paterniti DA, Kelly K. Cancer, 2014; 120(Suppl 7): 1091–1096.
Upcoming Events
March 6–8
ESCRS Winter Meeting 2026 Helsinki, Finland
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June 26–29
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ESCRS Annual Congress London, UK
November 12–14
UKISCRS Annual Conference London, UK
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4
OVERALL SAFETY PROFILE SIMILAR TO CATARACT SURGERY ALONE1
Pivotal data and real world studies show that intraoperative and postoperative complications are rarely observed1-3
THE TRUSTED AND PROVEN SAFE TECHNOLOGY FOR GLAUCOMA
PROVEN TO BE SAFE AND TRULY TISSUE-SPARING6 FAVOURABLE SAFETY PROFILE4
iStent inject® W was demonstrated to have a favourable safety profile when compared to other MIGS procedures4
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
