2017 - EuroTimes · 1 ESCR 2017 linica rend urv esults This supplement is a report of the results from the 2017 ESCRS Clinical Trends Survey. The 2017 ESCRS Clinical Trends Survey

2017Results

1

ESCRS 2017 Clinical Trends Survey Results

This supplement is a report of the results from the 2017 ESCRS Clinical Trends Survey. The 2017 ESCRS Clinical Trends Survey was performed at the XXXV Congress of ESCRS in Lisbon, Portugal. Delegates also had the option of taking the survey online on the ESCRS Congress website. More than 1,900 delegates responded to the 168 questions. These questions were developed and reviewed with the ESCRS leadership team and substantiated by a data scientist.

ESCRS delegates were surveyed on several different clinical areas, including general cataract surgery, presbyopia correction, astigmatism management and toric IOLs, ocular surface disease and glaucoma. To better identify the educational needs of the Delegates, ESCRS leadership will regularly review the results and feedback of these surveys. The data will also enhance the opportunities featured at the Annual Congress of the ESCRS, the ESCRS Winter Meeting and other educational channels like EuroTimes articles and online forums.

Please review the key findings and look for upcoming educational events. ESCRS encourages all delegates to participate in the upcoming 2018 ESCRS Clinical Trends Survey, which will be launched in September at the 36th Congress of the ESCRS in Vienna and online at www.escrs.org/2018survey.

Survey Background & Overview

?168 !1,900

63%

Male

37%

Female

Years in Practice

59%

26%

> 10 years

Currently in medical school, resident, fellow, 0-5 years in practice

11%

77%

12%

Yes

No

No, but I plan to at the end of my residency training

Have you completed the Fellow of the European Board of Ophthalmology (FEBO) exam?

37%

21%15% 11%

Public Hospital

Private Hospital

Surgeon- Owned Clinic

Academic Institution/ Non-Profit

Primary surgery location

Over Delegate

respondents Questions on key clinical opinions and practice patterns

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General Cataract Surgery

Average annual volume of cataract surgery eyes414

3% Other

4% Lens manufacturer formula

18% Barrett

4% Olsen

17% Holladay II

11% Holladay I

20% Hoffer Q

27% Haigis

75% SRKT

What is your preferred lens formula for the majority of your cataract surgeries?

How often do you perform bilateral/same-day cataract surgery?

61% I don’t perform bilateral cataract surgery

5% More than 50% of all cases

3% 10 to 25% of all cases

2% 26 to 49% of all cases

6% Less than 10% of cataract cases

23% Only for extenuating circumstances (general anaesthetic/mentally challenged patients, etc.)

Do you routinely optimise your A-constants every time you use a new lens?

67%

36%

Yes

No

1.25 - 1.75D0.50 - 0.75D 0.75 - 1.25D

What is your most common level of dioptre correction you target for monovision?

1.75 - 2.25D >2.25D

33% 37% 21% 9% 0%

3


Presbyopia Correction

of current cataract procedures involve a presbyopia-correcting IOL

of current cataract procedures are targeted for monovision or mini-monovision43%6%

Top 3 concerns about performing more presbyopia-correcting IOL procedures

Cost to patient Concern over night-time visual quality

Concern over loss of contrast visual acuity

60% 48% 40%

What type of presbyopia-correcting IOL technology is used in the majority of your presbyopia-correction patients?

2016

ESCR

S Sur

vey

2017

ESCR

S Sur

vey

25%

45%

22%

4%4%

34%

39%

15%

4% 8%Bifocal

Trifocal

EDOF

Accommodating

Other

What presbyopia-correction technology are you most interested in integrating in the next 5 years?

In patients implanted with a presbyopia-correcting IOL, what residual astigmatic outcomes do you believe you can realistically achieve on a regular basis?

21%

57%59%

EDOF IOLs Trifocal/ Quadrifocal IOLs

Light-adjustable IOLsAstigmatism below

1.0D0.0D 0.25D 0.5D 0.75D

2%

14%

55%

25%

5%

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Presbyopia-Correcting IOL Use in ESCRS Clinical Trends Survey

H. Burkhard Dick MD, PhD, FEBOS-CR

In the 2017 Clinical Trends Survey, ESCRS delegates reported that 6% of their current cataract procedures involve presbyopia-correcting IOLs. Forty-three percent of respondents say they target monovision. I am currently the president of the DGII, the German Society of Cataract & Refractive Surgeons, and 6% use of presbyopia-correcting IOLs among the membership is slightly higher than what we have seen in our surveys.

Delegates were asked what type of presbyopia-correcting technology they use in the majority of their patients receiving presbyopia correction; 45% favour trifocal lenses. This is an increase of 6% over last year’s survey results. Twenty-five percent of respondents use bifocal technology, a decrease of 9% compared with last year. Extended-depth-of-focus (EDOF) lenses are favoured by 22% of respondents, a 7% increase from the 2016 survey. Other technology is used by 4% of respondents, and the least-often employed IOL is accommodating.

WINNERS AND LOSERSBifocal lenses are the only “loser” so to speak in the survey; accommodating technology never really took hold in Europe. Trifocal technology is gaining in popularity, and I believe the use of these lenses will only increase. The lenses offer excellent intermediate vision that is important to patients for reading their phones and laptops. The current EDOF portfolios the companies offer are plentiful, and these options continue to evolve and spread out beyond diffractive lenses.

The IC-8 small-aperture IOL (AcuFocus) for example, uses an advanced pinhole mini-ring design to eliminate refractive error. This type of lens is tolerant of astigmatism and other errors, and is not associated with glare and halo. Pinhole-type implants enrich the options and offer a solution for postkeratorefractive patients, a demographic that will continue to play a bigger role in the future. In my practice, I implant trifocal, EDOF, and, depending on the patient, IC-8 lenses as well.

BARRIERS TO IMPLANTING PRESBYOPIA-CORRECTING LENSESDelegates expressed their top three barriers to implanting presbyopia-correcting technology to be the cost to the patient (60%), concern over night-time visual quality (48%) and concern over a loss of contrast visual acuity (40%). Although there is no question that cost is a major hurdle, a loss of contrast sensitivity is more of an academic question and not something patients experience as having any impact in their daily life.

No lens is perfect, and certainly even monofocal implants can be associated with night-time visual disturbances. Such side effects are a consideration, but maybe not to the extent that warrants it being in the “top three” concerns, especially in case of EDOF IOLs.

ASTIGMATISMDelegates reported on the amount of residual astigmatism they believe they can realistically achieve on a regular basis among patients implanted with a presbyopia-correcting IOL. More than half say they can achieve astigmatism below 0.50D, and almost 25% say they achieve astigmatism below 0.75D. Slightly under 14% of ESCRS delegates report that they regularly achieve astigmatism below 0.25D, 4.8% report below 1.00D and 1.8% below 0.

Residual astigmatism of 0.50D as a target is consistent with the literature that shows that patients’ satisfaction drops when there is more than that amount. At 0.75D, residual astigmatism degrades vision. There is still a long way to go regarding surgeons’ treating astigmatism, and patients’ outcomes are improved when we correct toricity.

Looking to the next five years, 59% of delegates said they were most interested in incorporating EDOF IOLs, 57% said trifocal/quadfocal implants and 21% responded light-adjustable lenses.

FUTURE DIRECTIONSThe concept of an IOL that can be adjusted after it is implanted has long been hypothesised, and the first approved from RxSight is a first dramatic step in this new direction. Postoperative adjustment of an implant makes many aspects of cataract surgery that were so important almost irrelevant. In vivo IOL fine-tuning represents stratified medicine.

Another cutting-edge concept, refractive index shaping, uses a femtosecond laser to change the refractive index of targeted material inside an IOL. The refraction could be adjusted throughout one’s lifetime.

Although there is no question that cost is a major hurdle, a loss of contrast sensitivity is more of an academic question and not something patients experience as having any impact in their daily life.

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Toric IOLs/Astigmatism

of current cataract procedures involve a toric IOL

of cataract patients with clinically significant astigmatism that would receive a toric IOL if cost were not an issue

Most common procedure to manage astigmatism in a monofocal cataract patient with the 1.25D of cylinder:

What are the primary preoperative measurements that drive your astigmatism axis decisions when implanting a toric IOL?

16%

28%

35%

On Axis Incision

Toric IOL

Glasses or Contact Lenses

After implanting a toric IOL, how many degrees of postoperative rotational error is acceptable before visual quality and degradation of visual acuity are significantly affected?

13% <5

40% 5 - 9

47% ≥10

Do you consider posterior corneal astigmatism in

your toric power calculation?

61%

39%

YesNo

22% Manual keratometry

67% Optical biometry

43% Tomography (Scheimpflug)

36% Tomography (Placido disc)

8% OCT

3% Others

3% Intraoperative aberrometry

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ESCRS Clinical Trends Survey 2017: Toric IOL Decisions

Sathish Srinivasan FRCSEd, FRCOphth, FACS

In the toric IOL portion of the 2017 Clinical Trends Survey, ESCRS delegates reported using the technology in 7% of their cataract procedures. When asked what percentage of their patients with clinically significant astigmatism would receive a toric implant if cost were not an issue, however, that number increased to 33%.

To manage astigmatism in a monofocal cataract patient with 1.25D of cylinder, 35% of the ESCRS survey respondents would use a toric IOL, 28% would perform an on-axis incision and 16% would prescribe glasses or contact lenses.

A majority of delegates, 60.7%, do consider posterior corneal astigmatism in their toric IOL calculations.

The respondents were asked to cite their primary preoperative measurements that drive their axis of astigmatism decision when implanting a toric IOL. The responses were:

• optical biometry = 67.1%• tomography (Scheimpflug) = 42.7%• topography (Placido disc) = 36.0%• manual keratometry = 22.3%• optical coherence tomography = 7.7%• intraoperative aberrometry = 3.1%• others = 3.0%

Among the surgeons implanting toric IOLs during cataract surgery, 46% use ink marking with the aid of manual axial instruments to align the preoperative axis with the intraoperative axis and 30% perform ink marking at the slit lap with no additional instruments. There were 14% who use digital image registration, 9% employ anatomical landmarks without preoperative marking and 1% has access to intraoperative wavefront aberrometry.

Delegates were asked, after implanting a toric IOL, how many degrees of postoperative rotational error is acceptable before visual quality and degradation of visual acuity are significantly affected? Almost half, 47%, believe 10 degrees or more of rotation is acceptable, 40% responded 5 to 9 degrees, and 13% said less than 5 degrees is acceptable. In my practice, if the patient’s vision is good and the rotation is less than 4 degrees, I do nothing. If the vision is poor and the IOL is rotated more, I will reposition it.

I believe a lack of education and training are also barriers to surgeons’ current use of toric IOLs. In my practice, my threshold is 1.00D of astigmatism. I consider all of these patients as potential candidates for toric implants if I can achieve agreement among measures on different devices. I screen patients using biometry and corneal topography.

Posterior astigmatism plays a critical role in total astigmatism, and it the main reason for residual error in the postoperative period. Surgeons can measure posterior astigmatism using corneal tomography or use a modern IOL calculator that derives the amount using a regression calculation.

In my practice, if the patient’s vision is good and the rotation is less than 4 degrees, I do nothing. If the vision is poor and the IOL is rotated more, I will reposition it.

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Of your surgical cataract patients with glaucoma, which of the following best describes your use of/interest in MIGS?

45% Do not plan to offer MIGS in next 12 months

12% Perform MIGS in 1-10% of my cataract patients




29% Plan to offer MIGS in next 12 months

Do you perform any glaucoma surgery (including MIGS) or laser procedures?

What percent of your cataract surgery patients, currently on topical therapy for glaucoma, would you estimate are candidates for a minimally invasive glaucoma surgery (MIGS) device?Even if you do not perform MIGS

9%

39%

29%

16%

5.5%

2%

0%

1-10%

11-20%

21-40%

41-60%

Over 60%

GlaucomaApproximately, how many

patients do you see PER MONTH that you would

consider as having glaucoma?

What percentage of ALL your cataract patients

would you estimate have glaucoma?

12% average

28 average

23%

For your patients who are currently prescribed MORE THAN TWO medications to control their

glaucoma, what percentage do you believe are NOT compliant?

For your patients who are currently prescribed ONE or

TWO medications to control their glaucoma, what percentage do you believe are NOT compliant 28%

42%

13% Yes, I perform glaucoma laser procedures

18% Yes, I perform glaucoma surgery

27% Yes, I perform glaucoma surgery and laser procedures

No, I only have a medical glaucoma practice

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Glaucoma Surgery: MIGS and Laser in Cataract Patients

Boris E. Malyugin, MD

Delegates responding to the 2017 ESCRS Clinical Trends Survey report seeing an average of 28 patients per month with glaucoma. Respondents said that an average of 12% of their cataract patients also have glaucoma. About 15% to 20% of my patients have IOP issues, are on medications, or have had previous glaucoma surgery. We also know that glaucoma can induce cataract, adding to the prevalence of the conditions being encountered together.

Almost 30% of the ESCRS members said they perform glaucoma surgery, including minimally invasive glaucoma surgery (MIGS) and laser procedures. More than 40% of the respondents have a medical glaucoma practice only.

Compliance with treatment regimens is a foremost and constant concern when caring for glaucoma patients. Delegates said more than 20% of their patients prescribed one or two IOP-lowering medications to control their glaucoma are not adherent to therapy. That noncompliant number increased to closer to 30% for patients prescribed more than two glaucoma agents.

Delegates were asked what percentage of their surgical patients they estimate are candidates for a MIGS procedure – even if they do not currently perform the technique. About 40% of the respondents said ≤10% of their patients are candidates, and about 30% of surgeons said 11% to 20% are likely candidates for MIGS.

When a patient has glaucoma and cataract, there are three options on the table. If the IOP is very high, the surgeon usually favours performing glaucoma surgery and then removing the cataract. If, however, the IOP is in the mid-range or even if it is controlled with medication, the surgeon may have the option of treating the glaucoma at the same time as the cataract surgery, depending on the type of disease, ie, open-angle.

Current evidence reveals that MIGS procedures have modest effects in terms of IOP lowering, in the range of 2mmHg to 3mmHg over the long term. I believe MIGS devices can be helpful for controlling early IOP spikes that occur after cataract surgery. These pressure spikes can damage the optic nerve in patients with advanced glaucoma. It is important to note that the potential for reducing medication use is also a benefit of MIGS.

Delegates responded to a question asking about their level of interest in using MIGS techniques in their cataract patients with glaucoma. Almost 45% said they have no plans to offer MIGS in the next 12 months, and almost 30% said they do plan to offer MIGS in the next 12 months. About 12% of delegates perform MIGS in ≤10% of their cataract patients.

There is a lot of excitement around the MIGS category, but the clinical evidence and value to patients still needs to be more clearly demonstrated. It is important we surgeons take care in defining the best treatment for individual patients to control IOP over the long term.

I favour targeting the MIGS procedure based on the specific anatomy of the patient’s outflow system. The stent-based procedures provide different ways to drain fluid from the anterior chamber, via Schlemm’s canal, the suprachroidal space or the subconjunctival space. Defining what procedure is best for each individual patient will help us to improve the results. Future research will seek to better understand how we can personalise MIGS procedures.

Compliance with treatment regimens is a foremost and constant concern when caring for glaucoma patients.

9


Ocular Surface Disease

Yes in most cases

Only when the patient presents

dry eye symptoms

Yes, in all cases

Rarely to never

Are you systematically checking the ocular surface in your preoperative cataract surgery examination?

Top therapies and treatments for managing the following (beyond artificial tears and lid hygiene)

Key objections to including advanced tear film diagnostics in a practice

When do you use a dry eye questionnaire?

42%5%

30%

23%

Cataract patients who present for their

preoperative consult with ocular surface

dysfunction that requires treatment

At the initial point of care

On a case-by-case situation, during consultation

Cataract patients that develop symptoms

postoperatively but were asymptomatic

prior to surgery

19%

40% tear breakup time (TBUT), 37% staining

69% Schirmer’s60% meibomian gland expression

28%

Conventional/commercial warm compress and

meibomian gland probing

Moderate dry eye

Severe dry eye MGD

Oral omega-3, topical corticosteroid,

punctal occlusion

Ciclosporin, punctal occlusion, oral omega-3

and topical corticosteroid

17% Safety and efficacy – I do not see any differences

41% Cost to me

33% Technologies not paid by health system

27% Increases my chair time

12% Practice flow disruption

25% Limited access to technologies

9% None, I use advanced tear film

Timing of diagnostic testing

14% I don’t see any value in incorporating this into my practice

31% No access to this technology

41% On a case-by-case situation, as decided during the consultation

14% At the initial point of care in most patients

10


Ocular Surface Disease Survey Results and Implications for Surgery

Carina Koppen MD, PhD

The ESCRS Survey asked delegates about the frequency with which they check the ocular surface during their preoperative cataract surgery examination: 42% said yes in all cases; 30% said yes in most cases; 23% replied only when the patient presents with symptoms of dry eye disease; and 5% said rarely to never.

The average percentage of cataract surgery patients who present for their preoperative consult with sufficient ocular surface disease (OSD) to require some treatment is about 19% among the ESCRS delegates. A much higher average percentage of cataract patients, 28%, present as asymptomatic of OSD before surgery but develop symptoms postoperatively, according to the survey respondents.

The health of the ocular surface plays a major role in the planning and outcomes associated cataract surgery. Dry eye disease (DED) can cause visual acuity to fluctuate and it causes preoperative measurements to be less accurate. Left untreated before surgery, OSD can lead to postoperative discomfort, below-expected visual results and ultimately, unhappy patients.

The top therapies and treatments for managing ocular surface disease among the ESCRS delegates (beyond artificial tears and lid hygiene) are oral omega-3 supplements, topical corticosteroids and punctal occlusion. For severe dry eye, the delegates favour ciclosporin in addition to the previously mentioned treatments. For patients with meibomian gland disease, the respondents most often prescribe conventional or commercial warm compresses and conduct meibomian gland probing. It is important to note that meibomian gland disease is involved in approximately 80% of DED.

The survey participants were asked about when they implement diagnostic testing among their OSD patients and which tests they use. At the initial point of care, 40% of the delegates test for tear break-up time and 37% perform staining. Depending on the patient as determined during consultation, 69% use Schirmer’s testing and 60% perform meibomian gland expression.

Fewer than 10% of respondents said they use advanced tear film diagnostics in their practice.

The survey sought to identify members’ objections to incorporating these tools, and the most common reasons are:

• 41% cost to me• 33% technologies not paid for by health system• 27% increases my chair time• 25% limited access to technologies

Slightly more than 14% of respondents use a DED questionnaire at the initial point of care in their practice, while more than 40% use one on a case-by-case basis, as decided during the consultation. More than 30% said they do not have access to this technology.

Because often there is little correlation between the signs and symptoms of DED, the most valuable thing we physicians can do in terms of detecting that something is wrong is to listen to our patients. They will complain about a gritty feeling and tiredness even though you see nothing wrong at the slit lamp or with further testing. If patients report that have trouble reading or watching television, ask if the problems are there from the start or only after a longer time of sustained visual activity. We must pay attention to these clues that patients can give us, if we ask them the right questions.

No single test or therapy works for every patient. DED is multifactorial and practitioners must have more than one option in their tool kit. Develop a personal algorithm for testing and treatment, employing a staged management strategy to restore homeostasis to the ocular surface, and do not hesitate using therapies concurrently. It is important to take a step-wise approach beginning with simple therapies and progressing to the more complex.

Ultimately, although it may sound old fashioned, if you have to choose one test among the many technologies becoming available, asking the right questions and listening to our patients during the examination remains the cheapest and most effective test of them all.

Left untreated before surgery, OSD can lead to postoperative discomfort, below-expected visual results and ultimately, unhappy patients.

Documents

2017 - EuroTimes · 1 ESCR 2017 linica rend urv esults This supplement is a report of the results from the 2017 ESCRS Clinical Trends Survey. The 2017 ESCRS Clinical Trends Survey