2015 AECOS European Symposium: Meeting Highlights

In June, the American-European Congress of Ophthalmic Surgery (AECOS) convened for the fifth annual AECOS European Symposium. This dynamic meeting, which started in Cannes, France, and was held last year in Barcelona, Spain, took another leap to Berlin, Germany, to accommodate its growing international audience.

Kicking off the 2015 meeting, Michael C. Knorz, MD, President of AECOS Europe, provided an update on the European division of the organization. Subsequently, John A. Vukich, MD, President of AECOS Americas, delved into the history of the society. With 4 years since the launch of the American branch and 2 years since the launch of the European branch, AECOS has grown to over 200 members.


As an organization designed to foster collaboration between physicians and industry, AECOS began its European meeting with a session on innovation. The AECOS Innovation Forum—moderated by Dr. Knorz and William Link, PhD—featured a panel of notable innovators: Lucio Burratto, MD; Armin Scharrer, MD; and Rolf Schwind. These panelists led speakers and audience members alike in an interactive discussion on topics such as investment in the ophthalmic sector, emerging technologies, and new treatments in cornea and dry eye, as detailed below.

Investing in Ophthalmology: Current Trends

Dr. Link began the AECOS Innovation Forum with a look at venture financing in health care, which, despite being on a downtrend since 2012, has regained momentum, he reported. Discussing the areas in which venture capital is being invested today, Dr. Link explained, “Venture capital is invested where it is rewarded,” noting that the attractiveness of the ophthalmic sector is solid.

Next, Dr. Scharrer, President of the Congress of German Ophthalmologic Surgeons

(DOC), provided an overview of the ophthalmic investment landscape in Germany. Dr. Scharrer overviewed current investors, described the opportunities and risks, and shared his insight into why it makes sense to invest in the most valuable sense in human beings: sight. Following, Thom Rasche, of Earlybird Venture Capital, an international venture capital firm, discussed where private equity is currently being invested and shared investment strategies for health technologies.

Taking these talks into consideration, the panel then deliberated on a number of topics: whether it is better to invest in established businesses or to pursue early-stage investments, differences in innovation in Europe versus the United States and regulatory barriers in each region, the potential for grassroots efforts to bring new ophthalmic treatments to patients, and more.

Latest Innovations from Industry

After this comprehensive look at the state of investment and innovation came the Shark Tank session, in which early-stage companies introduced AECOS members to the products in their pipelines and the results seen thus far in their development. The panelists then concluded whether the products were positioned for success in the ophthalmic market or whether it was too early to tell.

The products discussed targeted a range of conditions and procedures. First, John Hendrick discussed the ZEPTO device for capsulotomy creation, highlighting a recent study of 46 cadaver eyes, in which investigators found that the edge strength achieved with ZEPTO was three times stronger than with femto. Matthias Elling, MD, discussed Avedro’s Photorefractive Intrastromal Cross-Linking (PiXL) procedure, detailing pearls for setup in the OR, surgical technique, and patient selection.

Next, Georg Bretthauer, MD, discussed mechatronic IOLs and their ability to restore accommodation. Roger Zaldivar, MD, explored tear film assessment with the AcuTarget HD (AcuFocus), stating that it may be the answer surgeons have been looking for in dry eye assessment for premium procedures. H. Burkhard Dick, MD, described the Argos Movu device for IOP monitoring following cataract surgery, and, last, Barry Cheskin discussed the PowerVision fluid-based accommodating IOL, describing recent improvements in the lens design and efforts to reduce incision size.

Innovations in Cornea and in the Treatment of Dry Eye

The Innovations in Cornea session launched with a keynote lecture by Claus Cursiefen, MD, who discussed new developments in corneal imaging and surgery. Dr. Cursiefen described how intraoperative optical coherence tomography is enabling minimally invasive, controlled procedures and discussed its indications for DMEK, corneal lamellar tattooing, pediatric patients, lamellar transplants, and more.

Kicking off the Innovations in the Treatment of Dry Eye session, keynote speaker Arthur Cummings, MD, described new technologies for identifying and treating dry eye disease (DED). Dr. Cummings provided audience members with an explanation of the core mechanism of DED and an overview of the measurements provided by each available diagnostic exam.

Next, Sathish Srinivasan, MD, described tear film osmolarity and dry eye, noting that only 60% of patients with evidence of DED are symptomatic. On behalf of Tal Raviv, MD, Dr. Cummings presented a talk on eyelid thermal pulsation for dry eye, defining mebomian gland dysfunction and its treatment. Following, Dr. Zaldivar shed light on the need for standardized objective measurements in DED and shared his experience with the HD Analyzer. Miguel Teus, MD, commented on the role of tear osmolarity in post-cataract surgery DED; as Dr. Teus described, cataract surgery does not change tear osmolarity, but tear osmolarity is a risk factor for DED signs and symptoms.


Once the AECOS Innovation Forum concluded, the discussion moved toward another hot topic in ophthalmology: presbyopia. Moderators Francesco Carones, MD, and Dr. Dick led attendees through an in-depth analysis of methods for presbyopia correction, starting with a keynote lecture from Gerd Auffarth, MD. Dr. Auffarth explored whether surgeons are truly meeting patients’ expectations when it comes to treating presbyopia and shared his prediction that advances in multifocal IOL technology will serve to improve patient satisfaction.

Next, Dr. Vukich explored patient satisfaction with current lens options and discussed potentially more sophisticated solutions, such as a small-aperture IOL (AcuFocus). Pavel Stodulka, MD, described a new bioanalogic IOL, which, theoretically, may have less dysphotopsia and higher contrast sensitivity compared with bifocal and trifocal lenses, he explained. Switching gears from IOLs, John Doane, MD, offered a look at pharmaceutical interventions for presbyopia and whether a drop could truly be the future for presbyopia correction.

Then a series of case presentations highlighting the latest innovations in presbyopia correction ensued. Dr. Cummings; Matteo Piovella, MD; and Michiel Luger, MD, shared surgical cases in which corneal inlays, presbyopia-correcting IOLs, and laser vision correction, respectively, were used to achieve optimal results. Following these case presentations was a panel discussion on how to best meet patient expectations: with intraocular versus corneal-based approaches.


The field of ophthalmology is continuously advancing, thanks in large part to the partnerships between physicians and industry and the new treatments and approaches that result from this collaboration. Taking a look at these advances, surgeons discussed what they have changed in the past 12 months and why, offering fellow AECOS members a glimpse at real-world experience with new technologies and practice styles.

Leading off, Dr. Carones described his implementation of extended depth of focus IOLs and the benefits he has seen since adding this technology to his portfolio of treatment options, including improved quality of vision. In a similar vein, Dr. Dick discussed lens materials, offering an anecdotal explanation for his preference for hydrophobic acrylic IOLs and prompting an audience-wide discussion on the differences between hydrophobic and hydrophilic IOLs.

Next, Wolfgang Riha, MD, discussed the Physician CEO Course, a program conceived by Guy Kezirian, MD, and designed to teach physicians how to function as CEOs. Given that medical practices are businesses, Dr. Riha explained, the advantages of learning to be a CEO and hone his leadership skills have been of immense value. Following, Erik Mertens, MD, discussed his experience adopting a new treatment approach—combined cataract and glaucoma surgery—and the advantages of introducing this technique for his practice and his patients.


The Today’s Clinical Challenges session began with a look at dysphotopsia, a chief cause of patient dissatisfaction. Dr. Tetz opened with an overview on the prevailing opinions of dysphotopsia. Next, Shmuel Levinger, MD, and Dr. Auffarth shed light on the incidence of and solutions for negative and positive dysphotopsia, respectively. Following these talks, the panelists reviewed a range of cases in which patients complained of dysphotopsia and considered how to best manage these concerns.

Next, surgeons sought to tackle a variety of challenges associated with specific techniques and technologies. Anselm Jünemann, MD, presented on vitreolysis and whether this is best achieved via YAG laser, intravitreal injection, or vitrectomy. A. John Kanellopoulos, MD, detailed his perspective on measuring the back surface of the cornea, namely whether these measurements truly matter and which technologies are best for obtaining them.


Moving to the glaucoma space, Steven Vold, MD; Dan Reinstein, MD; and Dr. Tetz moderated a session on microinvasive glaucoma surgery (MIGS). First, Herbert Reitsamer, MD, discussed MIGS concurrent with cataract surgery, sharing an overview of the different stents and peer-reviewed literature; Dr. Reitsamer concluded that procedures utilizing Schlemm canal show larger reductions in IOP in combined procedures.

Dr. Vold discussed implantable drug delivery devices and the role they may play in enhancing patient compliance and, thus, patient outcomes. Dr. Jünemann offered insights into MIGS as a standalone intervention, citing good clinical outcomes in his 2-year experience. The session concluded with a discussion of the available treatments and technologies in the United States and Europe and a look at which physician group favors earlier intervention.


After MIGS, the meeting coverage moved toward another innovative procedure: corneal collagen crosslinking (CXL). The Innovations in Corneal Crosslinking session—moderated by John Marshall, PhD; Michael Mrochen, PhD; and William Trattler, MD—opened with a keynote lecture by Marco Lombardo, MD. Dr. Lombardo discussed the interaction of ultraviolet (UV) light with the cornea and how a precise understanding of the optimal concentration of stromal riboflavin would greatly enhance the efficacy of CXL.

Following came a series of case presentations highlighting new insights and approaches to CXL. Dr. Kanellopoulos shed light on modified CXL protocols and discussed the need for standardization of CXL treatments, calling on industry to help. Professor Mrochen detailed innovations in drug delivery that affect CXL, touching on the epi-on versus epi-off controversy and urging surgeons, researchers, and industry to consider the role oxygen plays in the procedure. Andreas Behndig, MD, reported on PiXL, stating that the procedure showed significant refractive advantages over conventional CXL. Last, Farhad Hafezi, MD, discussed photo-activated chromophore for keratitis (PACK) CXL, which he described as a game changer for early treatment of corneal infiltrates.


With an increasing number of young ophthalmologist members, AECOS dedicated a session to recognizing these future leaders and their interests. Moderators Dr. Cummings and Dr. Link sat down with panelists Victor Derhartunian, MD; Mike Holzer, MD; Wolfgang Riha, MD; and Alain Saad, MD, for a discussion of their inspirations, aspirations, and projections for the field. These individuals weighed in on their motivations for becoming ophthalmologists, their experiences collaborating with industry, challenges encountered in building a practice, and new treatments they feel hold the most promise.

Then, highlighting the stellar accomplishments of another young ophthalmologist, the 2015 AECOS European Research Award was presented to Verena Prokosch-Willing, PhD, for her paper “Effects of specifically regulated crystallins in glaucoma.” With support from Alcon, Dr. Prokosch-Willing was awarded €20,000 to further her research.


Donning a white wig and carrying a gavel, The Honorable Professor Marshall took to the bench to judge the Technologies on Trial session. Beside him were jury members Drs. Cummings, Dick, Mertens, and Kanellopoulos. The first trial presented was corneal inlays versus monovision LASIK. Dr. Holzer argued that inlays carry too many side effects, preventing them from being an ideal solution, while Dr. Vukich maintained that inlays are safe and effective and should be considered for clinical use. After much debate, the jury voted that corneal inlays cannot yet be confirmed safe and effective.

Next on trial was laser cataract surgery. Ekkehard Fabian, MD, maintained that femto cataract is not necessary, while Dr. Knorz argued that femto is, in fact, the future of cataract surgery. Following some deliberation, the jury concluded that femto is not necessary but is preferred. Then came the much-discussed LASIK versus SMILE debate, with Miguel Teus, MD, proposing that SMILE is not ready for prime time and Dan Reinstein, MD, refuting that the time for SMILE is now. The jury sided with Dr. Reinstein, stating that SMILE is ready for widespread use.

Last up were multifocal IOLs versus extended depth of focus lenses. Matteo Piovella, MD, spoke in support of multifocal IOLs, while Dr. Tetz made the case for extended depth of focus lenses. Thomas Neuhann, MD, testified that neither of these options will work, citing limitations of both lens types. With solid arguments from all sides, the jury voted that the supporting evidence for the use of multifocal IOLs versus extended depth of focus lenses was equal.


In memoriam of the late Joseph Colin, MD, Dr. Buratto delivered the 2015 Joseph Colin Award Lecture on ophthalmic applications of Google Glass and other wearable devices. Dr. Buratto showcased his use of Google Glass in surgery and for educational purposes and discussed how new technologies will play an important role in the future of medicine but will require physician input.


Next, Drs. Link and Dick moderated a session on Integrated Surgical Platforms: The Business Case for Premium Technologies in Cataract Surgery. Presenters shared their experiences with devices offered by a range of manufacturers—Abbott Medical Optics, Alcon, Bausch + Lomb, LENSAR, and Ziemer—and shared keys to success for achieving optimal patient flow, growing more volume, and determining appropriate pricing. Rounding out the session, William Culbertson, MD, tackled the question, “Will integrated surgical platforms deliver better outcomes in cataract surgery?” offering key findings from around the world. Then the audience members voted “yes,” “no,” or “too early to know” on whether integrated surgical platforms deliver better outcomes in cataract surgery and whether they will drive procedure growth in the premium channel.


The Video Grand Rounds session, moderated by Dr. Buratto, featured interactive presentations on a variety of difficult cases. Covered scenarios included an opaque IOL on the retina, a complicated DMEK case, challenges in toric IOL alignment, polyfocal IOLs and the femtosecond laser, VHF digital ultrasound epithelial mapping with digital subtraction pachymetry for transepithelial phototherapeutic keratectomy, and more.


With a number of countries represented in Berlin, the AECOS European Symposium served as an ideal forum to delve into European regulation. Moderators Dr. Cummings and Professor Marshall led panelists Miguel Bernabeu, MD; Dirk Muehlhoff; Mr. Schwind; and David Tanzer, MD in a discussion of the regulatory landscape in Europe. Professor Mrochen delivered a talk on EU post-market device surveillance, in which he discussed the MED Council Agreement Update and described how new regulations could affect the CE Mark approval process.

Next, Professor Marshall led a conversation about regulation—both in Europe and the United States—and the role AECOS can play in influencing this process. Participants discussed varying study protocols, the basis for regulatory decisions (science vs politics), and whether new regulations will slow the pace of innovation. One overarching conclusion was that one of the greatest successes AECOS has had in the United States is the FDA Panel of Experts and that the European branch may be at a seminal moment where they can be proactive in shaping regulation


Following a visual tour of The Birth of LASIK, presented by Dr. Buratto, came the Late-Breaking News session, moderated by Thomas Kohnen, MD, and Dr. Mertens. First, Tim Schultz presented his findings on the cause of prostaglandin release in laser cataract surgery—the main inducer deemed to be capsulotomy—and what surgeons can do to address this issue. Next, Dr. Elling discussed Thermage, a radiofrequency treatment method for blepharoplasty, and the ideal candidates for this procedure: 35- to 65-year-olds who are not yet ready for “real” surgery.


Following the late-breakers came another hot topic: how to revive the lamellar refractive surgery market. Opening the discussion, Dr. Mertens shared an overview of the refractive surgery market in Europe today. As he described, the prevalence of myopia is increasing dramatically, and double-digit growth in the rate of phakic IOL implantation will be seen over the next 5 years as a result. Dr. Mertens also shared projections for a 40% growth rate of refractive lens exchange between 2014 and 2016. Correlating to this report, Dr. Doane discussed current trends in the US laser vision correction market. As he described, laser vision correction’s peak year was 2000, and it is unclear when the procedure will come back; however, Dr. Doane predicted that SMILE will be approved in 2016 or 2017 and reported an anticipated 25% increase in the number of IOLs in the United States in the next 7 or 8 years.

Next, Dr. Reinstein previewed a range of new devices for corneal screening, reviewing the evolution of keratoconus screening and why tomography and wavefront measurements may not be reliable for the stromal surface. Following, Dr. Cummings discussed wavefront-guided, wavefront-optimized, and topography-driven approaches, highlighting criteria for choosing among them.

Jørn Jørgensen, MD, explored whether technologies such as SMILE can evoke a renaissance in laser vision correction and how to best market these procedures and set appropriate patient expectations. The audience opened up a broad discussion of the reputation of LASIK, during which many agreed with Dr. Knorz’s stance that it is not beneficial for the field to pit one procedure against the other, as is often the case with LASIK and SMILE.

On the heels of several talks dedicated to assessing the refractive surgery market, Dr. Kohnen spoke about whether AECOS should lead the development of Pan-European guidelines for refractive surgery. Attendees concluded that although it may be hard to establish set guidelines, given the amount of refractive surgery techniques in use, surgeons can still be tasked with reducing their complication rates, updating their technology, and utilizing advanced diagnostics.


Moving from an evaluation of the ophthalmic marketplace as a whole, Drs. Jorgensen and Mertens lead a session on practice marketing and business decision-making. First, Dr. Mertens delivered a talk on utilizing social media to effectively diffuse a negative situation, rather than risking bad press; according to Dr. Mertens’ strategy, when faced with an unhappy patient customer, physicians should LEAP: listen, empathize, apologize, and problem-solve.

Next, Onur Birsen, MBA, shared critical website strategies for search engine optimization (SEO), discussing what SEO really means and encouraging attendees to never stop creating and distributing unique and original content for their products and services. Then Omid Kermani, MD, discussed the concept of an “all-premium” practice, detailing methods for converting patients into paying customers, educating both patients and comanaging doctors, and ensuring the sustainability of this practice model.

Given that part of creating a successful business is achieving an appropriate balance between responsibilities, Drs. Cummings and Vold rounded out the session with insights into how they divide their time between their research, clinic, and surgery, sharing pearls for others looking to prioritize these duties.


The final session of the 2015 AECOS European Symposium was dedicated to laser cataract surgery and contained insights from physicians and researchers alike. Holger Lubatschowski, PhD, shared a look at what the future of femto applications might bring, including advanced optics, intratissue refractive index shaping, and 3D cutting and imaging. Christian Rathjen, PhD, discussed the history of femtosecond laser technology to answer, “How did we get here?”

Next, surgeons shared their experience with a range of devices and treatments and provided a glimpse at the next frontier for a number of manufacturers, including LENSAR, Schwind eye-tech-solutions, Carl Zeiss Meditec, Abbott Medical Optics, and Alcon. With an emphasis on the continued advancement of devices in the companies’ portfolios and pipelines, it is clear that industry aligns with physicians on the AECOS ethos of innovation.

The AECOS European Symposium will reconvene June 23-26, 2016, in Rome, Italy.