Volume 16_Issue 9 by EUROTIMES

VOLUME 16 ISSUE 9 SEPTEMBER 2011

Binkhorst Medal Lecture

Video Awards

Clinical Research Symposia

EUROTIMES Satellite Education Programme

Young Ophthalmologists Programme

Main Symposia

ePosters

JCRS Symposium

Refractive Surgery Didactic Course

Surgical Skills Training Courses

Practice Development

ESCRS Glaucoma Day

Instructional Courses

Free Papers

John Henahan Prize 2011

Surgical Video Symposia

2nd EuCornea Congress &

XXIX Congress of the ESCRS VIENNA, AUSTRIA

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ESCRS

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SEPTEMBER 2011 Volume 16 | Issue 9 This month... Cataract and Refractive

Retina

38 Highlights of EURETINA lecture

Corneal inlay demonstrates very good results in trial

5 New multifocal IOL can provide good level of spectacle independence 6 New procedures may provide better quality of vision than LASIK 8

Experts discuss viability of femtosecond lasers in cataract surgery

10 UK cataract complications highlighted 12 Optimised prolate ablation due to be used for presbyopes 13 Implant delivers safe results for presbyopia correction, trial shows 14 Two new studies highlight benefits of AcuFocus inlay 16 Environmental practices encouraged 18 Special consideration must be given to diabetic cataract patients 19 Ideal visual performance tests should be easy for patients to understand 21 PresbyLASIK algorithm shows promising early results for presbyopia

22 Four-year follow-up shows positive results for corneal inlay 25 New imaging technologies to aid surgeons

42 Advanced retinitis pigmentosa patients to benefit from prosthesis

Ocular 44 Lecture dispels some confusion surrounding optic neuritis 46 Blind people could see with their tongues with help of novel device 48 New technology could expand the use of advanced diagnostics

Global Ophthalmology 51 Vision Van brings help to survivors of Japanese earthquake

News 52 Congress delegates invited to donate to two worthy causes 55 Dr Emanuel Rosen to receive ESCRS Grand Medal of Merit

Features 58 Practice Development

Cornea 26 Combined procedure not without risks 27 French health authorities assist in lessening burden of keratoconus 28 Treating keratoconus with several approaches

61 Book Review 63 EU Matters 65 JCRS Highlights 66 Eye on Travel 66 Journal Watch

30 Improved keratoplasty techniques needed

69 Bio-Ophthalmology

32 Limbal stem cells play key role in emergencies

72 Calendar

Glaucoma

40 Dye for inner limiting membrane effective in surgical procedures

33 Better diagnostics should help to reduce ACG-related blindness 34 Cataract surgery for glaucoma

70 Industry News

CORRECTION: In an article on Presbyopic LASIK on page 15 of EuroTimes Volume 16, Issue 7/8 (July/August 2011), we stated that the Technolas laser was a Carl Zeiss Meditec product. We would like to clarify that the Technolas laser is manufactured by Technolas Perfect Vision and hence the Supracor procedure is by Technolas Perfect Vision. Where errors occur it is the policy of EuroTimes to correct them.

35 New device could deliver more effective drug treatment in future

With this month’s issue... 16TH escrs WINTER MEETING PRELIMINARY PROGRAMME, ADVANCING TECHNOLOGY IN CATARACT & REFRACTIVE SURGERY SUPPLEMENT, and glaucoma surgery: advances you & your patients will appreciate supplement

editorial staff

ESCRS

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Published by The European Society of Cataract and Refractive Surgeons Publisher Carol Fitzpatrick

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

Assistant Designer Janice Robb

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2010 and 31 December 2010 is 32,019.

EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 16 | Issue 9

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

welcome to vienna

ESCRS and EuCornea delegates can expect an outstanding programme

by Oliver Findl MD

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK

Peter Barry IRELAND

am very honoured to welcome friends and colleagues to the XXIX ESCRS Congress in Vienna, Austria. I am also delighted to welcome delegates to the 2nd EuCornea Congress on Friday 16 and Saturday 17 September. Some of you will have visited the city previously when it successfully hosted the congress in 1999. The new venue is the Reed Messe, which is easily accessible by public transport and located next to the Prater, the largest recreational area of Vienna as well as a historical fun park near the city centre. I believe the venue is excellent and we will again benefit from the professional organisation by the office in Dublin whose staff has worked very hard to ensure that everything will run smoothly. Delegates can look forward to an outstanding scientific programme of free papers, posters, videos and instructional courses. Like every year, the main symposia will cover some of the latest topics in the field of anterior segment surgery such as femtosecond cataract surgery, novel surgical approaches for corneal endothelial disease, refractive adjustments after ocular surgery and the different approaches to correcting presbyopia. Scientific symposia will address some hot research topics such as biotreatment of the cornea, posterior capsule opacification and the understanding of the optics of the eye. The latter is perfect to celebrate the 100th anniversary of the Nobel Prize of Allvar Gullstrand for his work on ocular optics. The programme is rounded off with the ESCRS Glaucoma Day on Friday, the Austrian Ophthalmology Society Symposium on Sunday and the numerous lunchtime symposia on newest developments from the industry. Special thanks go to the sponsors and exhibitors for their support, without which such a meeting would not be possible.

young ophthalmologists. At the conference this encompasses the fullday Young Ophthalmologists Programme with lectures on Saturday, the refractive didactic course and the EBO-accredited instructional courses during the meeting. Outside of the congress, we have established a Europe-wide Observership Programme, the podcast series “eyechat” and the new e-learning platform “iLearn” that has just been launched. Additionally we run a bi-monthly column in EuroTimes and a Facebook page to address young colleagues. We hope these developments will be well received and I urge the young delegates to give feedback to make this initiative even better in the future. Finally, even though the congress centre will be the main focus of attention, I would like to encourage you to visit some of the sites of this beautiful city. In 2010, Mercer rated Vienna as the most livable city among over 200 metropolitan cities worldwide. Vienna is known as the world’s capital of classical music and its royal palaces and museums are worth visiting. Being at the border of oxidant and orient, Vienna’s coffee house tradition dates more than 300 years back. Relax and enjoy a good cup of coffee and some nice pastries in one of the numerous Viennese cafes! Let me again welcome you to Vienna. I am looking forward to a very enjoyable congress, full of discussion and exchange between colleagues from such a large variety of countries and the opportunity to meet old friends and make new ones.

Education at the heart

Oliver Findl MD, Austria, is a member of the ESCRS Board and the EuroTimes International Editorial Board. He is also the chairman of the ESCRS Young Ophthalmologists' Forum.

Education is at the very heart of the activities of the ESCRS. In the past few years a special focus has been the development of a comprehensive educational programme for EUROTIMES | Volume 16 | Issue 9

Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM

OLIVER FINDL

Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

™

Update

Cataract & refractive NON PENETRATING APPROACH

MINIMAL INVASIVE NATURAL RESTORE OF IOP

Presbyopic inlay

Preliminary results with corneal inlay yields promising outcomes in presbyopic emmetropes

Roibeard O’hEineachhain in Istanbul

Courtesy of Antonio Limao Oliveira MD

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01-03-11 10:23

he initial European experience with the Vue+ corneal inlay (Revision Optics) demonstrates very good visual results at near and intermediate, with no significant loss of distance vision, according to Antonio Limao Oliveira MD. Dr Limao Oliveira reported the results achieved in 15 plano presbyopic patients implanted with the inlay as part of a multicentre European trial. The patients included nine women and six men ranging in age from 45 to 60 years. Their preoperative manifest spherical equivalent had a mean value of +0.43 D and was between -0.50 D and +1.00 D in all eyes. Their preoperative near addition had a mean value of 1.93 D and was between 1.00 D and 2.50 D in all eyes, and no eyes had more than 0.75 D of cylinder. In addition, all patients had experienced satisfactory results with contact lens-based monovision, and all had healthy corneas, free of dry eye, and all had clear crystalline lenses. All underwent implantation of the Vue+ hydrogel corneal inlay beneath a flap 150 microns thick and 8.5mm in diameter created with a femtosecond laser. The inlay is thinner than a human hair, has a diameter of 2.0mm and has a refractive index and water content similar to the cornea. “The Vue+ corneal inlay, with concurrent LASIK, may also restore near and intermediate vision in patients with myopic and hyperopic presbyopia. It enhances near vision by producing a region of increased curvature in the centre of the pupil,” Dr Limao Oliveira said.

Two animated eyes representing the inlay

At six months’ follow-up, uncorrected near acuity improved from a mean of 20/65 to 20/20, with a mean gain of five lines. The mean uncorrected distance visual acuity fell slightly from a preoperative value of 20/20 to 20/30. Most of the change in near visual acuity occurred by the first postoperative day, he noted. “We observed a real wow effect in terms of near vision which improved to 20/32 at day one. In contrast, distance vision was considerably reduced at day one from 20/20 to 20/55 but continued to improve towards normal values afterwards,” Dr Limao Oliveira said. In addition, the mean uncorrected intermediate visual acuity was 20/25 or better both in the operated eye alone and binocularly. Furthermore, no eyes lost any lines of best-corrected vision. Moreover, all patients expressed satisfaction with their vision at all distances and rated their satisfaction level at a mean of 3.8 on a scale from one to five. Patients reported a minimal amount of visual symptoms such as glare and haloes, he said. The study will continue for plano presbyopia and concurrent LASIK at centres in Portugal, Spain, Belgium, the UK, Germany and France. A US FDA trial is also under way.

contact Antonio Limao Oliveira - antoniolimao@imo.pt

Update

Cataract & refractive The new OCULUS Corvis® ST Pictures you have never seen before !

MULTIFOCAL LENS

Refractive/diffractive apodised IOL provides broad range of vision by Roibeard O’hEineachain in Istanbul

“

Clinical results demonstrate good patient satisfaction with bilateral implantation of the OptiVis lens, with good distance and near vision, and functional intermediate vision Matteo Piovella MD

EUROTIMES | Volume 16 | Issue 9

Courtesy of Matteo Piovella MD

he new OptiVis™ (Aaren Scientific) diffractive/refractive multifocal IOL can provide cataract patients with a good level of spectacle independence for most activities, said Matteo Piovella MD, Centro Microchirurgia Ambulatoriale, Monza, Italy. “Clinical results demonstrate good patient satisfaction with bilateral implantation of the OptiVis lens, with good distance and near vision, and functional intermediate vision,” Dr Piovella told the 15th ESCRS Winter Meeting. The new lens has a refractive-diffractive posterior surface design with 2.8 D effective add power. It also has a progressive central portion 1.5mm in diameter to allow for depth of focus at far and intermediate foci, an apodised diffractive bifocal portion 3.8mm in diameter and a non-prolate aspheric periphery to improve image contrast at distance, said Dr Piovella MD. He presented results of a study involving 76 eyes of 38 patients with a mean age of 70 years who underwent bilateral implantation of the OptiVis lens. At six months' followup, mean uncorrected distance visual acuity was 0.93 and mean uncorrected binocular vision was 20/40 (J4) at 40cm and 70cm. In addition, the best corrected distance visual acuity was (0.99) and the mean spherical equivalent was -0.11 D. The result of the IOL’s optical configuration is that with a small 2.0mm pupil the lens distributes light about equally in the near, intermediate and distant foci, with only two per cent of light outside its focal range, Dr Piovella said. With a

OptiVis™ MIOL

large 5.0mm pupil, the lens favours the distance focus, which receives 68 per cent of light, compared to only 20 per cent for the near focus and only six per cent for the intermediate focus, he explained. The advantages of the lens are that it has distant dominant focus, yet its diffractive optics allow for distance and near vision for a full range of pupil sizes while its refractive optics increase the amount of light that is actually in focus, he said. In addition, the apodised diffractive is designed to reduce halo for optimum vision at all distances, he noted. “Through-focus response curves for the OptiVis lens from optical bench testing shows a broad distance focus peak relative to other diffractive multifocal IOLs predicting greater depth of focus into the intermediate range and more forgiving distance power calculations and sharp near focus peak similar to simple diffractive bifocal IOLs,” Dr Piovella said, adding: “The OptiVis represents a new concept in multifocal IOL optics, combining benefits of both diffractive bifocal and progressive refractive designs, providing near, far and intermediate vision in one IOL.”

contact Matteo Piovella - piovella@piovella.com

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Update

Cataract & refractive

new techniques

Refractive procedure may rival excimer laser procedures in the treatment of myopia by Roibeard O’hEineachain in Istanbul

wo new corneal refractive procedures which involve removal of an intrastromal lenticule with a femtosecond laser can produce predictable refractive results with a better quality of vision than is achieved with LASIK, according to a pair of presentations at the 15th ESCRS Winter meeting. “What’s nice about these procedures, as we see from the long-term results, is that it has a small learning curve, it involves tissue removal instead of tissue ablation, it has less effect on wound healing and corneal biomechanics than LASIK or PRK,” said Osama Ibrahim MD, Alexandria University, Egypt. Dr Ibrahim presented the results of a study involving a series of 253 myopic eyes of patients with spherical equivalent values ranging from -1.25 D to 17.0 D. The patients underwent either of two femtosecond laser lenticule extraction techniques, FLEx (femtosecond lenticule extraction) and Smile (small-incision lenticule extraction), with a Visumax femtosecond laser (Carl Zeiss Meditec). In the eyes undergoing FLEx procedure the surgeon used the Femtosecond laser to create

a LASIK-like flap, which is lifted to remove the lenticule by mechanically peeling it from the stroma. In those undergoing the Smile procedure the surgeon removed the lenticule through a small incision created with the femtosecond laser, Dr Ibrahim said. At one week postoperatively, the mean overall spherical equivalent was -0.28 D, with individual spherical equivalent values ranging from +1.75D to -1.63 D, Dr Ibrahim noted. In addition, the mean sphere was -0.12 D and the mean cylinder was -1.5 D. In 116 eyes evaluated at three months, the postoperative spherical equivalent had a mean value of –0.12 D and ranged from +1.25 D to -1.88 D. The mean cylinder was -0.3 D and did not exceed -1.7 D. In the 54 patients who had a follow-up of one year, the mean spherical equivalent was -0.45 D. Dr Ibrahim noted that visual recovery following the procedure was rapid. By one week’s follow-up uncorrected visual acuity was 20/20 in around half of patients and 20/40 or better in 98 per cent. In terms of best corrected visual acuity, throughout the follow-up period around one-third to onehalf of eyes had no change, and around onequarter to one-third of eyes gained one line.

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However, there was loss of more than two lines of best-corrected visual acuity in some of the earlier patients when assessed at one week, although their best-corrected acuity appeared to improve over time. Of the 194 patients with a one week assessment, one per cent lost two or more lines, and 15 per cent lost one line. However, among 54 assessed at 12 months none had lost more than two lines. Predictability improved as the surgeons became more experienced with the technique. That is, at more than three months of follow-up only half of patients were within -0.5 D of attempted correction. That compared to around three-fourths of the 178 patients at three months' follow-up, a subgroup that included a higher proportion of later patients. “Refractive lenticule Extraction (ReLEx) with the femtosecond laser is a technology that is as effective, predictable, safe and stable as the excimer laser, if not even better, and it may be that in the next few years we will all be talking about these procedures,” Dr Ibrahim added.

Better quality of vision Another prospective study, presented at the Istanbul meeting by Jana Gertnere MD, The Dr Solomatin Eye Center, Riga, Latvia, indicated that the FLEx extraction technique induces less in the way of higher order aberrations, and provides better contrast sensitivity than that achieved with wavefront optimised LASIK. The first author of the study was Igor Solomatin, MD This consecutive clinical trial involved 82 myopic eyes of 41 patients aged 18

contacts

Osama Ibrahim - ibrosama@gmail.com Jana Gertnere - contacts@acucentrs.lv

to 40 years, with spherical equivalent values ranging from -2.0 D to -10.0 D and astigmatism from 0 to -3.0 D. In the femtosecond group, the preoperative spherical equivalent had a mean value of -5.57 D and ranged from -3.0 D to -8.13 D, and the cylinder had a mean value of -0.4 D and ranged from 0.0 D to -1.5 D. Dr Gertnere and her associates performed FLEx with the VisuMax Femtosecond Laser System in 42 eyes of 21 patients and Wavefront Optimised LASIK with MEL 80 excimer laser (Carl Zeiss Meditec) using a Moria II microkeratome for flap creation in the remaining 40 eyes of 20 patients. They performed pre- and postoperative aberrometry with a WASCA aberrometer (Carl Zeiss Meditec) and contrast sensitivity testing with the Vector vision system. Refractive predictability was good with both procedures, she noted. At six months' follow-up, 93 per cent of eyes in the FLEx group and 87 per cent of eyes in the LASIK group were within 0.5 D of the attempted correction, she said. However, the amount of induced spherical aberration and the mean root mean square of total higher order aberrations were significantly greater in the LASIK group than the FLEx group. The mean spherical aberration (Z4;0) values were -0.087 in the FLEx group, compared to -0.260 in the LASIK group. “The superior quality of vision and high satisfaction levels achieved with this technique may be because the femtosecond procedure is not affected by atmospheric conditions, particularly humidity and corneal hydration levels,” Dr Gertnere added.

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Update

Cataract & refractive

The next big thing?

Will femtosecond lasers be routine in cataract surgery in 10 years?

by Howard Larkin in Chicago

s the femtosecond laser the next big thing in cataract surgery? Multiple studies presented at the recent AAO annual conference suggest this could be the case, but some question the economic feasibility of this approach. One study was a 50-patient series using the Alcon LensX system presented by Stephen G Slade MD, Houston, Texas, US. He achieved a perfectly centrated, precisely-sized capsulorhexis in every case, with reduced phaco power, and was able to incorporate astigmatism correction with limbal relaxing incisions at the same time. The result was improved visual outcomes, with the standard deviation of achieved correction from target dropping to 0.4 D from a background rate of 0.6 D. Dr Slade also saw reductions in endothelial loss using the femtosecond laser. “We use it routinely on our premium lens cases and to treat astigmatism,” he said. And he thinks that within a decade most other surgeons will too. “Why? Two words – effectiveness and safety,” Dr Slade said. And the baby-boom generation will demand it, he added. Using FDA approval data he showed that on average LASIK trials generated better visual outcomes than IOL trials.“We are not giving cataract patients the same results that they are used to with refractive procedures.” Not everyone agreed. “Will it happen? Well, here’s my answer – Not in my ASC [ambulatory surgery centre],” said William Rich MD, Fairfax, Virginia, US. The cost will be prohibitive, and the government, which covers most patients over age 65 in the US, won’t pay for it, added Dr Rich, who is medical director for healthcare policy for the AAO. By giving surgeons a fixed payment for cataract surgery, the government puts surgeons at risk for the cost of technology. “We get paid the same if we use a bent 20-gauge needle or a Fugo blade for $2,000,” Dr Rich said. Unlike premium IOLs, which Medicare considers an extra, routine cataract extraction is considered a medically necessary covered procedure. Therefore, Dr Rich believes the programme will not pay extra for it. If femtosecond lasers reduce surgery times, Medicare may even reduce payments, Dr Rich said. Under current rules, surgeons also would have to quit the Medicare program for two

ad cornea protect EUROTIMES | 120x300 VolumeENG 16 |1107v1 Issuejmo 9 euro times.indd

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years to charge patients directly for any covered service, Dr Rich pointed out. This would not be practical because it would require ophthalmologists to bill patients directly for the entire cost of every service, instead of receiving the payment directly from the government. He also believes that few patients would pay the entire cost of cataract surgery, plus the facility cost, plus the $500 or $600 extra needed to cover the cost of the femtosecond laser. “In the end the femto laser is a great device in search of a viable business plan. I don’t see one,” Dr Rich said. Dr Slade disagreed. “The market will decide. PRK and LASIK are both good procedures, but people wanted LASIK more, so we do LASIK. People wanted femto flaps more than a steel blade, so we do femto flaps, and I bet you they will want femto cataract surgery.” At the end of the session the audience was deadlocked – 50 per cent each agreed and disagreed that femto cataract surgery would be routine in a decade. Douglas Koch MD, Houston, Texas, US, also addressed the issue in the Kelman lecture, “The Quest for the Perfect Cataract Surgical Outcome: 10 predictions for the next 10 years.” In fact, the integration of femtosecond laser technology into routine clinical practice was his first prediction. “It will open new doors. We haven’t even scratched the surface yet,” Dr Koch said. He also noted that femto lasers can cut a capsulorhexis precisely and predictably every time, and that the implications of perfecting even this one step in the procedure are unknown. “We don’t even know what the best capsulorhexis is or where we want it.” Dr Koch acknowledged that the expense of transitioning to femto technology and providing it broadly to patients would be high. He even suggested that the greater automation of surgery combined with a shortage of ophthalmologists could create pressure to allow optometrists or other nonphysicians to get involved. “The choices we make will have consequences. You can see how things could go. On the other hand, won’t our patients want the best technology? And won’t we want to give it to them?”

contacts Stephen Slade - sgs@visiontexas.com William Rich - hyasxa@aol.com

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Cataract & refractive

Corneal Transplant

complications

Moorfields comprehensive audit finds little improvement in 10 years

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EUROTIMES | Volume 16 | Issue 9

fter declining precipitously with the transition to phacoemulsification in the 1990s, UK cataract surgery intraoperative complication rates appear to have stabilised at about two per cent of cases throughout the 2000s, an audit performed at Moorfields Eye Hospital, London, suggests. The audit, which included cataract cases that were not part of a combined procedure done at Moorfields from 2005 through early 2011, also demonstrates the usefulness of standardised electronic clinical records for conducting large, prospective studies as well as individual performance evaluations, according to Göran Darius Hildebrand MD, FRCS, FRCOphth, consultant ophthalmic surgeon and lead investigator. “It’s a stable finding in the years examined,” Dr Hildebrand told a symposium of the 2011 ASCRS annual meeting. Cumulative annual rates for four major complications – posterior capsule tear, vitrectomy, zonular dialysis and dropped nucleus – fluctuated from a low of 1.7 per cent in 2010 to a high of 2.5 per cent in 2006, though the 2005 and 2011 results were nearly identical at 2.0 per cent and 2.1 per cent respectively. The cumulative rate for all of the 47,373 cases examined was 2.03 per cent. While covering only one large teaching hospital, both the number of cases examined and the complication rates were very close to an overlapping prospective study involving 12 National Health System Trusts, Dr Hildebrand noted. Conducted from November 2001 to July 2006, that study, known as the UK Cataract National Dataset, or CND, found an intraoperative complication rate of 1.92 per cent. That was quite an improvement over a 1997-1998 study of 18,454 cases that recorded a 4.4 per cent complication rate. Despite the differences in scope and methodology, Dr Hildebrand believes the two recent studies complement one another. And taken together they raise questions, he said. “What we see is in the 10 years there’s not much change. So one question is, is it possible to improve this further?” Dr Hildebrand believes the answer is unquestionably “yes,” and that electronic records can help. In teaching residents, Dr Hildebrand applies the five Ps – proper preparation prevents poor performance. He asks young surgeons to identify the specific challenges of each patient – whether it’s small pupils,

pseudoexfoliation or hard nucleus. “Then they are encouraged to develop a preventative strategy to address each issue in preparation for surgery. After the case, the outcome is reviewed and the strategy reconsidered. The loop is closed by applying modifications to the preventative strategy for the next case.” Dr Hildebrand calls this the ‘CPR cycle’ which he developed in 2007 and stands for ‘condition, preventative strategy, review and modification cycle.’ “I think it is a very powerful technique for improving outcomes,” he said. Auditing 1,000 consecutive cases he carried out himself from 2008 to 2010 using the CPR cycle technique, he reported exceptionally low complication rates: one posterior capsule tear, no vitreous loss and no vitrectomy or dropped nucleus. Having standardised electronic records with prospectively defined complications as well as patient condition and co-morbidities helps supply data for audits. At Moorfields, such a record system has been in place since 2003. “It requires electronic collection of complications to enter the record. It is not possible for the patient to leave theatre and go back to the ward without that being done,” Dr Hildebrand said. The newer electronic audit systems are also set up to calculate the odds of a complication in a specific patient based on their condition and previous experience with similar patients. “If you put in PXF, white cataract and small pupil and it predicts a risk of capsular tear, say 20 per cent, you can say this is not a good case for a resident and take it yourself. And then you can compare your own complication rate with the prediction. It gives a lot of justice to the surgeon who does a lot of complicated cases,” he said. Symposium moderator Lisa B Arbisser MD asked if the results might reflect the learning curve associated with training residents. “There’s a lot of research that shows complication rates go down with experience,” she said. “That’s a good point,” Dr Hildebrand responded. It may become a more important issue as the number of cases residents do in training declines. He reiterated the importance of teaching residents how to plan and prepare for as well as perform surgery.

contact Göran Darius Hildebrand - dariushildebrand@yahoo.co.uk

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Fast‡1-3 Powerful1

Convenient1,4 Well-tolerated§1,4

Yellox – a new standard in ocular NSAID efficacy Yellox® (bromfenac sodium sesquihydrate) 0.9 mg/ml eye drops, solution. Prescribing Information. Please refer to the Summary of Product Characteristics before prescribing Yellox®. Pharmaceutical form: Eye drops containing 0.9 mg/ml bromfenac (as sodium sesquihydrate) in clear yellow solution; one drop contains approximately 33 micrograms bromfenac. Indication: Treatment of postoperative ocular inflammation following cataract extraction in adults. Dosage and administration: For ocular use. Use in adults, including the elderly: The dose is one drop of Yellox in the affected eye(s) twice daily, beginning the day after cataract surgery and continuing through the first 2 postoperative weeks. The treatment should not exceed 2 weeks as safety data beyond this is not available. Paediatric population: Safety and efficacy in paediatric patients have not been established. Hepatic or renal impairment: Safety and efficacy have not been established in patients with hepatic disease or renal impairment. Contraindications: Known hypersensitivity to bromfenac, any of the excipients, or other non-steroidal antiinflammatory medicinal products (NSAIDs). History of asthma, urticaria or acute rhinitis precipitated by acetylsalicylic acid or by other medicinal products with prostaglandin synthetase inhibiting activity. Special warnings and precautions: Topical NSAIDs and corticosteroids may both slow or delay healing; their concomitant use may increase this potential. Yellox contains sodium sulphite, which may cause allergic-type reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible patients. Cross-sensitivity: There is the potential for cross-sensitivity to acetylsalicylic acid, phenylacetic acid derivatives, and other NSAIDs, so caution is required among patients with a history of sensitivities to these medicinal products. Susceptible persons: In susceptible patients, continued use of topical NSAIDs, including Yellox, may result in potentially sight-threatening complications (epithelial breakdown, corneal thinning, corneal erosion, corneal ulceration or corneal perforation). Patients with

evidence of corneal epithelial breakdown should immediately discontinue use of topical NSAIDs and be closely monitored. In at-risk patients, concomitant use of ophthalmic corticosteroids with NSAIDs may increase risk of corneal adverse events. Postmarketing experience with NSAIDs: Patients with complicated ocular surgeries, corneal denervation, corneal epithelial defects, diabetes mellitus and ocular surface diseases (e.g. dry eye syndrome), rheumatoid arthritis or repeat ocular surgeries within a short period of time may be at increased risk for corneal adverse reactions. Topical NSAIDs should be used with caution in these patients. There have been reports that ophthalmic NSAIDs may cause increased bleeding of ocular tissues (including hyphaema) in conjunction with ocular surgery. Yellox should therefore be used with caution in patients with known bleeding tendencies or who are receiving other medicinal products that may prolong bleeding time. Ocular infection: An acute ocular infection may be masked by the topical use of anti-inflammatory medicinal products. Excipients: Since Yellox contains benzalkonium chloride, close monitoring is required with frequent or prolonged use. Benzalkonium chloride is known to discolour soft contact lenses, and has been reported to cause eye irritation, punctuate keratopathy and/or toxic ulcerative keratopathy. Special instructions regarding drop instillation: Multiple topical ophthalmic medicinal products should be administered at least 5 minutes apart. Avoid contaminating the dropper-tip and solution, and tightly close the bottle when not in use. Contact lenses should not be worn during treatment with Yellox. Interactions: Formal interaction studies have not been performed, but no interactions with antibiotic eye drops used in conjunction with surgery have been reported. Fertility, pregnancy and lactation: Pregnancy: There are no adequate data from the use of bromfenac in pregnant women, and the potential risk for humans is unknown. In general, the use of Yellox is not recommended during pregnancy unless the benefit outweighs

the potential risk. Breast-feeding: It is unknown whether bromfenac or its metabolites are excreted in human milk. The use of Yellox is in general not recommended during breastfeeding unless the benefit outweighs the potential risk. Fertility: No pregnancy testing or contraceptive measures are required. Effects on ability to drive and use machinery: Transient blurring of vision may occur on instillation. If blurred vision occurs at instillation refrain from driving or using machines until vision is clear. Undesirable effects: In clinical trials (n = 973), a total of 3.4% of patients had ≥1 adverse reactions. The most common or most important reactions were abnormal sensation in eye (0.5%), corneal erosion (mild or moderate, 0.4%), eye pruritus (0.4%), eye pain (0.3%) and eye redness (0.3%). Summary of adverse reactions: Uncommon (≥0.1% to <1%): reduced visual acuity, haemorrhagic retinopathy, corneal epithelium defect (reported with QID use, off-label use, QID), corneal erosion (mild or moderate), corneal epithelium disorder, corneal oedema, retinal exudates, eye pain, eyelid bleeding, vision blurred, photophobia , eyelid oedema, eye discharge, eye pruritus, eye irritation, eye redness, conjunctival hyperaemia, abnormal sensation in eye, ocular discomfort, epistaxis, cough, nasal sinus drainage and face swelling. Rare (≥0.01% to <0.1%; isolated reports from post-marketing experience of more than 20 million patients): corneal perforation, corneal ulcer, corneal erosion – serious, scleromalacia, corneal infiltrates, corneal disorder, corneal scar and asthma. Please consult the Summary of Product Characteristics for a full list of side effects. Overdose: If Yellox is accidentally ingested, fluids should be taken to dilute the medicinal product. Pharmaceutical precautions: Do not store above 25°C. Legal Category: POM. Marketing Authorisation Number: EU/1/11/692/001. Marketing Authorisation Holder: Croma Pharma GmbH, Industriezeile 6, A-2100 Leobendorf, Austria. Date of preparation: April 2011.

† Yellox is the first and only twice-daily topical ocular NSAID indicated for the treatment of postoperative inflammation in patients who have undergone cataract extraction.4 In a large phase III trial, BID Yellox for 14 days controlled ocular inflammation (SOIS=0) in 59.3% of patients vs 26.9% with placebo (<0.0001).3 *Yellox has demonstrated clinical efficacy in 2 weeks with BID dosing. Treatment duration & dosing is relative to current clinical standards across Europe as well as older available NSAIDs.1,2,5-7

Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Bausch & Lomb UK Ltd on 01748 828864. References 1. Yellox, Summary of Product Characteristics 2. Donnenfeld ED et al. Ophthalmology 2007; 114(9):1653-62 3. Donnenfeld ED, Donnenfeld A. Int Ophthalmol Clin. 2006; 46(4):21-40 4. Baklayan GA et al. J Ocul Pharmacol Ther. 2008; 24(4):392-8 5. Nevanac, Summary of Product Characteristics: 2009 6. Acular, Summary of Product Characteristics: 16 Feb 2010 7. Voltarol, Summary of Product Characteristics: 04 May 2010 8. Committee for Medicinal Products for Human Use (CHMP) Assessment Report, 17 March 2011 035-2011-04-BMF Date of preparation: June 2011 Yellox is a registered trademark used by Bausch & Lomb Incorporated by permission of Croma Pharma GmbH. Bausch + Lomb is a registered trademark of Bausch & Lomb Incorporated. Yellox is licensed in all EEA member states, not in Switzerland © Bausch & Lomb Incorporated.

‡ Absorption occurs within 15 minutes, with peak aqueous humour concentration at 150–180 minutes;1,2 in a phase III, placebo-controlled trial significant clearance of ocular inflammation was as fast as 3 days in some patients (8.4% with Yellox vs 1.2% with placebo, p=0.0012), with significant efficacy persisting for 4 weeks3 § Millions of ophthalmic uses and very low incidence of adverse events (such as stinging and burning)1,4,8

EuroTimes_Dry_eye_ad 7/13/11 9:30 AM Page 1

Update

Cataract & refractive

DRY EYE

PROLATE ABLATION

TREATMENT

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EUROTIMES | Volume 16 | Issue 9

n optimised prolate ablation (OPA) profile significantly reduced spherical aberration in LASIK treatments both absolutely and compared with a more-standard optimised aspheric transition zone (OATz) ablation in fellow eyes in a prospective contralateral study of myopia and myopic astigmatism correction, reported Arturo S Chayet MD, at the 2011 ASCRS annual meeting. Even so, total higher order aberration values were similar, and there was no statistically significant difference in measures of vision quality, including corrected and uncorrected acuity, contrast sensitivity and subjective patient responses at six months after surgery. Refraction stability and safety also were comparable, he noted. “Refractive outcomes are excellent for both ablation profiles. There was better objective visual quality and no loss of contrast sensitivity in either group,” said Dr Chayet, director of the Codet Aris Laser Vision Institute in Tijuana, Mexico. While reduced spherical aberrations might be expected to produce better outcomes, particularly given its effect on central vision, Dr Chayet noted that the OPA-treated eyes also showed greater coma, which also affects central vision and may have offset this potential advantage. “The main conclusion seems to be that OPA, because of the prolate nature of the treatment, is due to be used in presbyopic populations,” said Dr Chayet, who is an investigator for NIDEK, which developed both profiles.

Induced higher-order aberrations The OATz algorithm and other approaches were developed in the early 2000s following the realisation that conventional LASIK and other laser refractive procedures induced higher-order aberrations that increased glare, haloes and other dysphotopsia even as they corrected lower order sphere and cylinder. These aberrations were thought to result largely from central islands, and abrupt transitions in peripheral treatment areas. OATz was designed to compensate by removing spherical aberrations in the central optical zone and aspherical aberrations in the peripheral transition zone by creating an overall aspheric corneal profile. Its success in improving visual outcomes has made it a more-or-less standard treatment for previously unoperated eyes without asymmetric astigmatism or other major irregularities, Dr Chayet noted. However, laser refractive procedures on myopes also tend to increase spherical aberration across the cornea because they tend to flatten the centre and steepen the periphery. This increases positive Q-values and shifts the surface towards an oblate profile. The effect may have been amplified by calibrating lasers on flat, rather than curved, surfaces. When applied on the curved surface, the resulting ablation algorithms did not adequately compensate for peripheral reductions in surface fluence due to the increasing laser reflectance and treatment area as the laser intersected the cornea at increasingly oblique angles. As a

“

Refractive outcomes are excellent for both ablation profiles. There was better objective visual quality and no loss of contrast sensitivity in either group Arturo S Chayet MD

result, less tissue was ablated peripherally than predicted. This oblate anterior corneal profile becomes increasingly troublesome as patients age. As the crystalline lens thickens, it progressively loses the negative asphericity that usually offsets positive corneal Q in youth. As total positive Q increases, so does spherical aberration, reducing contrast sensitivity and increasing glare and haloes, especially under mesopic conditions. The OPA ablation profile was developed to address this problem. It is designed to preserve the natural prolate profile to the anterior cornea, imparting a negative Q value that offsets the combined negative value of the posterior cornea and crystalline lens, or even over-corrects it anticipating the progressive positive shift. For this reason, older patients may be targeted with a more prolate, or negative Q, corneal profile, though achieving this requires ablation of more stromal tissue than a standard treatment. Centred on the visual axis, the OPA treatment also must cover the entire pupil to alleviate night-time visual problems, Dr Chayet said. Dr Chayet studied 28 patients with myopia ranging from 0.75 to 7.0 D and up to 3.0 D astigmatism, randomly assigning one eye to OPA and the other to OATz. Patients were evaluated for corrected and uncorrected visual acuity, contrast sensitivity, wavefront and satisfaction at one day, one week, one month, three months and six months after surgery. While there were no statistically significant differences in visual outcomes at six months, the OATz group performed slightly better in most categories. With 94 per cent of eyes within 0.5 D of attempted mean refractive spherical equivalent, OATz results were slightly more predictable than the OPA group, which achieved 88 per cent and showed a slight trend towards undercorrection. Refractive stability was nearly identical in both groups, as was safety, though 55 per cent of OATz eyes gained one or more lines of best corrected vision compared with 36 per cent for OPA. Conversely, only one OATz eye, or three per cent, lost one line of vision compared with two, or five per cent, in the OPA group, though none of these differences were statistically significant.

contact

Arturo S Chayet - arturo.chayet@codetvision.com

Update

Cataract & refractive

FRENCH STUDY

Corneal inlays show promise as reversible treatment for presbyopia by Dermot McGrath in Paris

arly trials of the KAMRA intracorneal inlay (AcuFocus Inc.) indicate that the implant delivers safe and effective results for the correction of presbyopia, according to a French study. “This was a small trial and we still need longer follow-up to confirm the results, but the outcomes were very promising. The technique is simple and reversible and is particularly suitable for presbyopic patients with mild myopia and astigmatism. It can also be easily associated with treatment for an existing ametropia and the implant is impossible to discern in the eye,” said Nader Robin MD, in private practice in Grenoble, France. Addressing delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting, Dr Robin explained that the KAMRA corneal inlay is designed to create a small aperture effect for the eye, allowing patients to see near and intermediate objects more clearly. The thickness of the inlay is just 5.0 μm with a 3.8mm outer diameter and a 1.6mm inner diameter. The inlay has a microperforated artificial aperture that is centred on the line of sight of the nondominant eye after a corneal flap is created with a femtosecond laser. The inlay is made of polyvinylidene fluoride with nanoparticles of carbon incorporated to make the inlay opaque. The most recent model incorporates 8,400 laser-drilled porosity holes, creating a visible light transmission through the annulus of the inlay of approximately five per cent. The perforations also enable sufficient nutritional flow through the inlay to sustain the viability of the anterior stromal lamella and prevent corneal thinning and epithelial problems. Dr Robin’s study included 15 presbyopia patients ranging from 44 to 57 years of age with a mean spherical equivalent of -0.75 D and a mean cylinder of -0.5 D and a maximum follow-up of nine months. All patients underwent the implantation procedure, involving the creation of a corneal flap of 180 microns using a femtosecond laser. The device was then positioned in the centre of the cornea after performing an excimer laser treatment of the initial ametropia.

EUROTIMES | Volume 16 | Issue 9

“

This was a small trial and we still need longer follow-up to confirm the results, but the outcomes were very promising. The technique is simple and reversible and is particularly suitable for presbyopic patients with mild myopia and astigmatism Nader Robin MD

There were no serious complications or adverse events during or after the surgery. Dry eye symptoms were quite mild in all patients, except one, who experienced severe ocular dryness in both the treated and non-treated eye. One implant in total was removed after three months because the patient was unhappy with the quality of vision. The refractive results were very good overall, said Dr Robin. He noted, however, that the distance vision in the operated eye was not as good as the non-operated eye, generating a sensation of slightly darker vision for some patients. Near vision also continued to improve for several weeks after surgery as the patients learn to adapt to the new implant. Dr Robin also advised corticosteroid treatment for several weeks after surgery and anti dry-eye treatment for several months postoperatively to maximise outcomes.

contact Nader Robin - nr38@wanadoo.fr ad-eye-cee one 120x300 1107v1 jmo Eurotimes jmo.indd 3

29.07.11 11:58

contacts

Update

Cataract & refractive

George Waring IV - georgewaring@me.com Vance Thompson - vance.thompson@sanfordhealth.org Kevin Waltz - klwaltz@aol.com Minoru Tomita - tomita@shinagawa.com

CORNEAL INLAY

Studies confirm AcuFocus insert improves near and intermediate vision over long term by Howard Larkin in San Diego

he KAMRA small-aperture corneal inlay (AcuFocus) improves near and intermediate visual acuity with minimal loss of distance vision in patients with presbyopia, according to two new studies reported during the 2011 ASCRS annual meeting. In studies involving more than 2,000 patients in the US and Japan, refractive results were stable and spectacle use was reduced 12 to 18 months after implantation in both emmetropic patients and those who underwent simultaneous LASIK to correct distance errors. Unlike most corneal presbyopia treatments, which rely on some type of multifocal arrangement that splits incoming light into zones of discrete focal lengths, the AcuFocus insert restores visual acuity across the entire range of near-to-intermediatedistance focal lengths by increasing depth of focus. It does so by inserting a 1.6mm aperture in the cornea along the visual axis in the non-dominant eye. This reduces the blur circle on the retina by blocking out oblique light rays coming through the corneal periphery, much as a mechanical camera does with a pinhole. The small aperture concept makes the AcuFocus implant stable against progression of presbyopia since it provides increased depth of focus regardless of changes in the power of the crystalline lens, George O Waring IV MD, Columbus, Ohio, US, and Atlanta, US said. “This is a unique characteristic for corneal-based presbyopia surgery,” said Dr Waring, who is world surgical monitor for AcuFocus.

Tradeoffs The tradeoffs include less light striking the retina at any focal length and increased diffraction, which reduce contrast sensitivity and limit distance visual acuity. Small but measureable reductions in mesopic contrast sensitivity were noted in all patient groups, and slight reductions in both uncorrected and best corrected distance vision were observed in emmetropic patients treated with the inlays in several studies. However, the mean postimplant values were well within the normal range for all reported patient groups. Also, the advantages of increased depth of field appear to outweigh these disadvantages when it comes to functional vision, said EUROTIMES | Volume 16 | Issue 9

Vance Thompson MD, Sioux Falls, South Dakota, US. His study of functional vision in 44 patients implanted with the AcuFocus device found that most were able to work on a computer and drive at night without glasses better than patients who undergo monovision procedures, which often improves near vision at the expense of intermediate vision, and reduces contrast sensitivity.

Near and intermediate vision

The product of several years development and testing, the current AcuFocus inlay is a ring of polyvinylidene fluoride and carbon 5.0 microns thick, 3.8mm in diameter with a 1.6mm aperture. This size was chosen to balance increased depth of focus against diffractive interference. To ensure easy movement of metabolites to the surface of the cornea, the implant has 8,400 randomly spaced microperforations. It is implanted 200 microns deep in the stroma in a pocket cut by a femtosecond laser or under a conventional LASIK flap. Dr Thompson’s patients were among 507 emmetropic patients implanted with the KAMRA device as part of a multicentre trial that may clear the way for FDA approval. Ranging in age from 45 to 60, these patients’ spherical equivalents ranged from +0.5 D to -0.75 D, had uncorrected distance visual acuity of no worse than 20/20, and near vision, measured at 40cm, between 20/40 and 20/100. The implant was inserted in a pocket in 92.5 per cent, with the remainder inserted under a conventional corneal flap. “Uncorrected near acuity started out quite poor and instantly improved,” said Kevin L Waltz OD, MD, Indianapolis, US, who reported the multicentre data. One day after surgery, mean uncorrected near visual acuity jumped from about J8 to about J2.5. Near VA dropped slightly in follow-up at one month, but improved gradually through 12 months for all patients, and continued to improve for the 99 patients followed for 18 months. Similarly, mean intermediate vision improved from about 20/35 pre-op to nearly 20/25 at 12 months. Conversely, mean distance vision dropped from about 20/16 to just over 20/20 in the treated eye. However, best-corrected distance vision still exceeded 20/20, as did binocular distance vision.

Slit lamp photograph of the KAMRA inlay

Courtesy of George O Waring IV MD

Contralateral optical quality assessment system analysis demonstrating broadened depth of focus and improved point spread function across refractive range

“We had excellent maintenance of visual acuity, especially binocular visual acuity, and a very low incidence of complications,” Dr Waltz said. Minoru Tomita MD, PhD, executive director of Shinagawa LASIK Center in Tokyo, Japan, reported similar results in a cohort study of the AcuFocus inlay after LASIK in 1,535 patients. On average, 1,146 myopic patients, with pre-op spherical errors up to -10 D, went from J7 pre-op to J2 uncorrected near, and from 20/200 to 20/20 uncorrected distance at one year. The 239 hyperopes, ranging up to +2.88 D pre-op, went from a mean J15 pre-op to J3 uncorrected post-op. The 150 emmetropes

went from J14 to J2. Hyperopes and emmetropes both measured 20/20 at one month, three months and one year after surgery. After one year, 84 per cent were highly satisfied, eight per cent satisfied and eight per cent not satisfied, Dr Tomita noted. Satisfaction was also high in the US study for emmetropic patients, which impressed Dr Waltz. “These are the most difficult patients in the world. These are people who spent 45 years never wearing glasses, never thinking about their vision never going to an eye doctor. If you can make these patients happy, you can make anybody happy.”

Update

Cataract & refractive

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French study weighs environmental impact of cataract surgery

by Dermot McGrath in Paris

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iPac_Eurotimes_120x300mm_0811.indd EUROTIMES | Volume 16 | Issue 91

8/3/11 11:33:30 AM

ataract surgeons are being advised to take proactive measures now to implement environmentally friendly practices in their operating rooms rather than wait for the enforcement of ever-stricter legislation in the future. Addressing delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting, Serge Zaluski MD said that there was no reason to believe that cataract surgery would escape the trend towards ever-tighter environmental controls at a national and European level. “Whether we like it or not, the changing regulatory context will force us to take action in terms of implementing environmentally friendly surgical practices,” he said. Such measures include the reduction and segregation of operating room waste, the reprocessing of single-use medical items, making environmentally conscious purchasing decisions, management of energy consumption, and the management of pharmaceutical waste. He noted that cataract surgery is the most frequent surgical intervention in France, with over 650,000 cataract operations performed in 2011. Dr Zaluski said that he had been prompted to conduct his study after reflecting on the large quantities of waste generated by the average cataract surgery. “What struck me is the contrast between the size of the crystalline lens and the enormous bags of waste that we remove after the cataract operation is over. It is surprising to see how much waste is generated by an operation on something as small as the human eye. I wanted to look closer at this paradox and see if we could perhaps reduce the waste by changing our practices somewhat,” he said. To carry out his study, Dr Zaluski called on the expertise of an agency specialised in sustainable development (Primum Non Nocere, http://www.primum-non-nocere.fr/) to measure the carbon emissions generated by a typical cataract operation. The data gathered by the agency gave Dr Zaluski a detailed breakdown of all aspects of the surgery. The average time of the cataract operation from preoperative check-in and anaesthesia, through to the operation itself and immediate postoperative care was about two and a half hours.

“

Whether we like it or not, the changing regulatory context will force us to take action in terms of implementing environmentally friendly surgical practices Serge Zaluski MD

In terms of waste products, a cataract operation generated 1.5kg of medical waste, 830 grammes of cleaning waste and 340 grammes of packaging. The consumption of energy and water were also quantified, with 63 kWh of electricity and 124 litres of water used for an operation. Bringing all the data together, the total carbon emissions for a cataract operation were calculated at 17.45kg CO2 equivalent. Additionally, the freight was evaluated from the European point of sending, even for extra European products. To put that data into context, Dr Zaluski pointed out that 460kg CO2 equivalent emissions is the same as a return air trip from Paris to New York or driving about 5,000km in a small car in city conditions. With over 650,000 operations per year, and using Dr Zaluski’s figures as a guide, cataract operations in France represent about 3,093 tonnes of carbon emissions – the equivalent in energy terms of 1,500 households. Summing up, Dr Zaluski said that there is clearly room for progress on all fronts: waste, energy and water consumption. Measures that could be taken to reduce the environmental impact of cataract surgery include separation of waste products, with recycling where possible, and careful disposal of potentially toxic liquids, with specific procedures for disposing of pharmaceutical waste. Awareness-raising exercises and education would also go a long way to enabling purchasing centres and clinics to cut down on unnecessary packaging, labelling and inserts. Ophthalmological companies will have to take into consideration the environmental impact of their products, including the packaging and the different ways of delivery, he concluded.

contact

Serge Zaluski - s.zaluski@gmail.com

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Update

Cataract & refractive

Henderson Instruments for toric IOLs

marking pattern

CATARACTS IN DIABETICs

Visualisation of the retina must be retained and inflammation avoided in diabetic cataract patients

Mark the patient

by Roibeard O’hEineachain in Istanbul

Using this marker the surgeon impresses three dot-shaped landmarks at the 3, 6, & 9 o’clock positions. The tips of the prongs are flattened to prevent damage to the epithelium even if the patient inadvertently moves. K3-7908 Henderson Alignment Marker

Orient the gauge to the marks To correctly position the gauge, the surgeon simply aligns the notches on the inside edge of this instrument with the dots produced by the Henderson Alignment Marker. K3-7904 Henderson Degree Gauge

Mark the axis of astigmatism

Once the gauge is oriented, the surgeon simply aligns the marks of this instrument with the desired degree lines on the gauge. This produces two thin lines along the axis of astigmatism which can be used to correctly align the toric IOL. K3-7912 Henderson Toric IOL Marker

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Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts

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EUROTIMES | Volume 16 | Issue 9

iabetic patients undergoing cataract surgery require special consideration in terms of surgical technique, IOL choice and postoperative care in order to avoid exacerbation of the retinal pathology and to insure its optimum care, said Rupert Menapace MD, Medical University of Vienna, Vienna, Austria. “What is true for the normal patient is specifically needed with the diabetic patient. Meticulous surgery is necessary to ascertain lasting full visualisation of the retina for retinal diagnostics, laser treatment, and/or vitreoretinal surgery. In addition, even uneventful cataract surgery has the potential of exacerbating macular oedema in patients with diabetes,” Dr Menapace told the 15th ESCRS Winter Meeting. He noted that both anterior and posterior capsule opacification can compromise visualisation of the retina, especially the periphery. In addition, diabetic patients have a 10 per cent risk of developing macular oedema after uncomplicated cataract surgery. Nonetheless, choices made at each stage of surgery can reduce the risk of those complications.

Surgical strategy Outlining his recommendations for the ideal cataract surgery in the diabetic eye, Dr Menapace said that the cataract incision used should be as small as possible to insure maximum resistance to deformation when combining cataract surgery with vitreous surgery. In addition, the incision should be located in avascular tissue at the limbus or in clear cornea, in order to keep inflammatory response to a minimum, he said. “In the case of clear corneal incisions, micro-incision cataract surgery is the preferred approach in order to provide optimum wound and corneal stability,” he said. When performing the capsulorhexis, it should circumferentially overlap the optic periphery, to prevent PCO, but the amount of rhexis-optic overlap should be minimal, to prevent fibrotic whitening and shrinkage, both of which conditions reduce the free optic zone, Dr Menapace said. If the overlap of the anterior capsule over the IOL’s optic is excessive, the surgeon should re-fashion the rhexis at the end of the surgery with the IOL in situ, he recommended. If excess anterior capsule fibrosis develops later, postoperative excision with a high frequency-capsulotome (eg, by Oertli) is a simple and safe option. With YAG-laser anterior capsulotomy a heavily fibrosed anterior capsule leaf can often not be incised or will not retract, and endothelial damage may ensue. Dr Menapace noted that while anterior capsule polishing can prevent fibrosis, it significantly increases the rates of PCO and YAG laser capsulotomies with bag-fixated IOLs. Therefore, surgeons using anterior capsule polishing should combine it with a posterior capsulorhexis. Performing a posterior capsulorhexis inhibits PCO formation and also allows easy and complete silicone oil removal during the cataract surgery if required. However, the rate of re-closure of the capsular opening by lens epithelial ongrowth can be up to 30 per cent.

For maximum PCO and anterior fibrosis prevention, Dr Menapace recommended the “posterior optic buttonholing technique”, which involves placing the IOL in such a way that the haptics are placed in the bag, while the optic is trapped behind a posterior capsulorhexis. “The posterior optic buttonhole technique creates a permanent 100 per cent barrier to retro-optical lens epithelial cell invasion. In addition, it inherently reduces fibrosis and allows anterior capsule polishing without any negative impact on the PCO-preventive effect. Furthermore, it allows secondary temporary buttoning-out of the optic for silicone oil removal,” Dr Menapace said. Buttonholing creates a tight IOLcapsule diaphragm which functions as a hermetic metabolic barrier against posterior dissipation of cytokines and other inflammatory agents.

Acrylics vs silicone The best IOLs to use in the eyes of diabetic patients are acrylic IOLs with large optics, 6.5mm to 7.0mm in diameter, with truly sharp edges to inhibit PCO and a looped three-piece design IOL to avoid breaches in the barrier at the optic/haptic junction when placed in the bag, Dr Menapace said. Three-piece IOLs also lend themselves to posterior optic buttonholing, he noted. The different IOL materials have their pros and cons for use in diabetic eyes he said. While surgeons should refrain from the use of silicone IOLs in eyes that may require silicone oil tamponade because of the tendency of silicone oil to adhere to the lens material, one should keep in mind that silicone oil adhesion also occurs with acrylic IOLs. Silicone oil adhesion is minimal with hydrophilic acrylic IOLs. However, such lenses are prone to calcium deposits in vitrectomised eyes, Dr Menapace pointed out. When silicone oil adhesion occurs, lens exchange may be necessary since silicone oil removal is difficult with all optic materials. The soft and pliable silicone IOLs are then often easier to remove from the capsular bag to be then exchanged for a secondary sulcus IOL compared to acrylic IOLs. Dr Menapace noted that in cataract patients with diabetic macular edema (DME) there are several good arguments for combining anti-VEGF treatment of the condition with cataract extraction. A dense cataract, if left in place, may interfere with diagnosis, treatment and follow-up of DME, by compromising fundoscopy, OCT, angiography and laser penetration. Moreover, according to DRCR network guidelines, treatment of the cataract should be delayed by six months when anti-VEGF pre-treatment of DME is carried out. Meanwhile there are several reports in the literature supporting the use of anti-VEGF treatment during surgery for the management of DME and as postoperative prophylaxis against the condition. To prevent cystoid macular edema, NSAIDs and corticosteroids can achieve a prolonged anti-inflammatory effect.

contact Rupert Menapace - rupert.menapace@meduniwien.ac.at

Update

Cataract & refractive

QUALITY OF VISION

Ideal visual performance tests should fulfil a number of basic criteria by Dermot McGrath in Geneva

EUROTIMES | Volume 16 | Issue 9

Courtesy of Joaquim Neto Murta MD, PhD

recise, reproducible and accurate methodologies to obtain objective evaluation of quality of vision after presbyopic IOL implantation are essential in order to create surgical techniques which will eliminate postrefractive visual disturbances, according to Joaquim Neto Murta MD, PhD. “The ideal refractive and lens surgery would allow patients to detect and recognise large and small objects, of high and low contrast, at all distances and under all lighting conditions. The quality of vision should be evaluated by contrast sensitivity, colour vision, glare and night vision testing,” he said. Speaking at the joint meeting of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO), Dr Murta, director of the Department of Ophthalmology, University Hospital Coimbra, Portugal, said that there are 45 different glare and contrast sensitivity testing methods currently available. “The problem is that the majority of the available techniques lack standardisation and scientific validity. They are hard to interpret for both physician and patient, they often lack correlation with symptoms, they tend to be time-consuming, costly and often superfluous,” he said. With this in mind, Dr Murta said that the ideal visual performance tests should fulfil a number of basic criteria. It should be easy to use for clinicians and technical support staff, as well as being easy for the patient to understand. It should ideally be quick to perform, test variable contrast and spatial frequency, allow for small increments in task difficulty, and perform multiple trials in each test level. It should also be computer generated and scored and permit random generation of test targets, he said. Finally, it should permit the pupil to physiologically dilate and to include infrared pupil size monitoring. For contrast sensitivity testing, Dr Murta stressed the importance in terms of quality of vision to analyse separately the patient’s magnocellular and parvocellular systems. “The magnocellular system is very important in night vision and above all in terms of peripheral vision, while the parvocellular system plays a more important role in photopic vision, colour, texture,

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shape discrimination and central vision,” he said. To demonstrate the utility of a computerised psychophysical assessment method under photopic and mesopic conditions (Metrovision), Dr Murta presented the three-month results of a prospective study comparing the AcrySof ReSTOR +3 Add lens (Alcon Inc), the Lentis Mplus IOL (Oculentis) implanted bilaterally in two groups of 30 patients and a monofocal aspheric IOL (Alcon) as a control. He noted that while the ReSTOR lens has an extensive publication history in the scientific literature, the glare and contrast sensitivity tests to which the lens had been subjected have not always met the rigorous standards needed to fully assess the performance of a multifocal lens. As one of the newer multifocal IOLs on the market, the Lentis Mplus IOL features an innovative approach in multifocal lens technology, without Fresnel rings, by combining an aspheric, asymmetric distance-vision zone with a 3.00 D sectorshaped, near-vision zone. Looking at the overall visual acuity outcomes, Dr Murta said that no significant difference was found in the mean distance, intermediate and near uncorrected visual acuity between the ReSTOR and the Mplus IOLs. However, the Lentis Mplus recorded worse outcomes for contrast sensitivity with medium and high spatial frequencies under both photopic and mesopic conditions. The stability of the Lentis Mplus was also a concern as a rotation of a multifocal IOL with such design can negatively impact the postoperative quality of vision, added Dr Murta (see figure).

contact Joaquim Neto Murta - jmurta@netcabo.pt

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Cataract & refractive

promising results

The moment ﬂapless surgery becomes clearly visible: in a smile. This is the moment we work for.

Bilateral P Curve technique offers patients better quality of vision by Dermot McGrath in Geneva

customised ablation algorithm has shown promising early results for the correction of presbyopia, according to Roberto Pinelli MD. “For the past nine years we have been working on different multifocal laser approaches, starting with quite a primitive nomogram, which has now evolved into this sophisticated algorithm that has been delivering excellent results for our presbyopic patients,” he said. Addressing delegates attending the joint meeting of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO), Dr Pinelli, scientific director of Istituto Laser Microchirurgia Oculare, Brescia, Italy, explained that the algorithm, called P Curve, does not aim to produce a multifocal cornea but instead takes into consideration a combination of parameters, including the corneal asphericity (Q value), changes in corneal asphericity (P value) and other parameters as well. “We currently hear a lot of talk about Q value adjustment and custom Q correction and so forth. However, we have learnt from our own clinical experience that inducing negative spherical aberrations through Q value customisation alone is not sufficient for optimal results. This is because the Q value is a shape factor that does not consider the size of a surface. Since patients have different corneal sizes and different radii of curvature, this means that the effect of a Q value on any one eye may yield slightly different results in another,” said Dr Pinelli. One of the advantages of the P Curve is that the algorithm can be applied using different excimer laser machines, he said. “It is performed as a single step ablation in most cases, and it can also be applied to other laser surgeries such as EpiLASIK, LASIK or PRK. Another advantage is that it can also be used for enhancements after a primary treatment,” he said. Dr Pinelli explained that the lens in presbyopic patients loses its ability to induce negative spherical aberrations and the eye is left with larger positive spherical aberrations that degrade the image quality. The P Curve algorithm procedure works by inducing negative spherical aberrations by which the patient acquires near vision. EUROTIMES | Volume 16 | Issue 9

“

I have used a monovision approach in the past and I appreciate its benefits if it is well done. Indeed, I have had LASIK monovision performed on my own eyes and I would consider myself a happy patient Roberto Pinelli MD

A fundamental point about treatment with the P Curve is that it is a bilateral procedure, said Dr Pinelli. “This is important and distinguishes it from monovision. Our approach is to treat both eyes at the same time with the same technique, because we think that the brain needs to have a balanced vision for a presbyopia solution to be most effective. When young people accommodate, they use both eyes, so we believe the right approach is to mimic nature and try to do the same with our treatment,” he said. Early results of the algorithm in over 1,500 patients indicate that it works very well in a majority of cases and that it can be used to remove more than one visual defect, said Dr Pinelli. “I know I have patients coming to the clinic asking for this treatment. I have used a monovision approach in the past and I appreciate its benefits if it is well done. Indeed, I have had LASIK monovision performed on my own eyes and I would consider myself a happy patient. However, I am conscious that this bilateral P Curve technique would give me a much better quality of vision, as my patients see much better than I can,” he concluded.

contact Roberto Pinelli - pinelli@ilmo.it

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Update

Cataract & refractive

SMALL APERTURE INLAY

Novel design presbyopic corneal inlay provides improved near and intermediate vision by Roibeard O’hEineachhain in Istanbul

Gunther Grabner - g.grabner@salk.at

“

The KAMRA inlay is an effective and safe treatment for presbyopia with improvement of near visual acuity without refractive change or significant loss of distance visual acuity after 48 months

Courtesy of Gunther Grabner MD

Gunther Grabner MD

KAMRA implant

he KAMRA corneal inlay (AcuFocus™) continues to show promise at four years’ follow-up in the treatment of presbyopia in emmetropic patients, said Gunther Grabner MD at the 15th ESCRS Winter Meeting. “The KAMRA inlay is an effective and safe treatment for presbyopia with improvement of near visual acuity without refractive change or significant loss of distance visual acuity after 48 months,” said Dr Grabner, University Eye Clinic, Paracelsus University, Salzburg, Austria. Dr Grabner presented the results achieved in a series of 32 patients who underwent the procedure as part of a multicentre FDA study that is taking place at centres in the US and Europe. All of the patients had completed three years of follow-up, attending all follow-up visits, and 15 patients have completed four years of follow-up, he said. The patients in the study were presbyopic emmetropes aged between 45 and 55 years of age. All had a spherical equivalent within half a dioptre of emmetropia, required a reading add between 1.0 D and 2.5 D and uncorrected visual acuity 20/20 in both eyes, he said. None had undergone prior eye surgery or had any other eye disease or cycloplegic

EUROTIMES | Volume 16 | Issue 9

refraction greater than 0.5 D, he said. At 36 months’ follow-up, eyes receiving the inlay had a mean gain of 4.6 lines of uncorrected near visual acuity. Almost all patients, 98 per cent, achieved J3 or better and half achieved J1. In addition, the patients gained a mean of 2.3 lines of intermediate visual acuity and their intermediate visual acuity improved from 20/40 preoperatively to 20/25 from the first month follow-up visit onward. Moreover the gains in near intermediate visual acuity came at a cost of only a slight loss of mean uncorrected distance visual acuity, which was 20/20 from three months onward at all follow-up visits, with a mean loss of 0.8 lines from pre-op. In addition, among the 15 patients who had achieved 48 months of follow-up there was slightly less improvement in near intermediate visual acuity, possibly because they were the earliest patients. At 48 months they had a mean uncorrected near visual acuity of J2 with a mean gain of 3.8 lines. Their mean intermediate visual acuity was 20/25 with a mean gain of 1.6 lines. The mean uncorrected distance visual acuity was 20/20, with a loss of one line. Binocular uncorrected distance acuity remained unchanged at 20/16. Complications included one case of epithelial ingrowth, which was treated

36-month results at the University Eye Clinic, Salzburg

with flap lift plus suturing. There were also two cases with inlays decentred from the time of implantation. In those patients Dr Grabner lifted the flap and re-centred the inlay about half a millimetre towards the line of sight. Over the following two years, near and distance visual acuity steadily improved to acceptable levels. There were also a couple of patients who had problems with dry eye after the procedure.

Contrast sensitivity normal

Another study presented by Dr Grabner, involving 24 presbyopic patients with 18 months' follow-up after implantation of the KAMRA inlay, showed that contrast sensitivity was only slightly reduced and was still within normal range.

The patients in the study received the newer version of the inlay implanted at a depth of 200 microns in the nondominant eye. The preoperative refraction ranged from - 0.75 to + 0.50 D. Contrast sensitivity testing was conducted with best distance correction using the Optec 6500P Vision tester (Stereo Optical) with the F.A.C.T. chart under photopic, mesopic and mesopic with glare conditions. At 18 months, mean uncorrected near visual acuity was J2, compared to J8 preoperatively, and uncorrected intermediate visual acuity was 20/25, compared to around 20/32 preoperatively. Moreover, mean uncorrected visual acuity though not as good as the preoperative 20/16, was 20/20. In response to a postoperative questionnaire, 96 per cent of patients said they had a reduction in their need for reading glasses and all said they would have the treatment again. In addition 82 per cent said they could read a newspaper without glasses, and 88 per cent said they could view a computer screen without glasses. Other developments include a new pocket technique with a target depth of 200-220mm, available with the Ziemer femtosecond laser. The IntraLase also has new pocket software which looks very promising, Dr Grabner said.

Focus: The KAMRA intracorneal inlay has an overall diameter of 3.8mm with a 1.6mm central aperture. It is based on the same principle as an f-stop camera, and is designed to increase the depth of field by blocking unfocused light and only allowing focused light into the eye. The procedure involves creation of either a corneal pocket or flap in the nondominant eye with a femtosecond laser at a depth of 200 microns. Implantation of the inlay can be combined with a LASIK procedure simultaneously correct ametropia. The inlay is composed of a polyvinylidene fluoride material. In its original design it had a thickness of 10 microns and 1600 random holes to allow nutrient flow. The current design is only five microns thick, with 8400 random holes.

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Update

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TORIC IOL ALIGNMENT

New imaging tools smooth the path for toric IOL implantation by Dermot McGrath in Geneva

ptimal toric IOL alignment has taken a significant leap forward with the development of a new generation of imaging technologies to assist the surgeon in achieving precise lens positioning in cataract or refractive procedures, according to Beatrice Cochener MD. “About 15 per cent to 20 per cent of the population is estimated to have corneal astigmatism greater than +1.5 D, which is why toric IOLs have served a real need in giving surgeons a safe and effective option to treat these patients. Perfect axis alignment has always been essential to achieve optimal results for these premium IOLs, but this was not always possible using traditional methods of preoperative astigmatism measurement and ink marking to align the lens,” she said. Addressing delegates attending the joint meeting of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO), Prof Cochener, professor of ophthalmology at the University of Brest, France, said that the consequences of a misalignment are particularly punitive in a toric lens. “Each degree of misalignment equates to a 3.3 per cent error of correction. Stability is crucial for any toric IOL because if it is 30 degrees off axis the astigmatic correction will be negated and any more than that will actually increase the astigmatism,” she said. The traditional methods used for toric IOL placement – visual marking of the limbus, cross cylinder calculation of the keratometric cylinder and the use of an assumed value, usually 0.5 D, for induced cylinder at the phacoemulsification incision axis – inevitably led to errors, said Prof Cochener. “This approach is sub-optimal for three reasons. First, visual marking of the eye is inherently inaccurate; second, the keratometric cylinder is centred on the corneal apex and not the patient’s visual axis. And finally, each cornea will respond differently to the phacoemulsification incision and can deviate from the assumed amount,” she said. Prof Cochener said that a range of new technology platforms, such as the Ocular (Möller-Wedel International), Callisto (Carl Zeiss Meditec AG), ORange (WaveTec Vision), and Surgery Guidance (SensoMotoric Instruments), should help to significantly reduce the risk of misalignment. Discussing each system in turn, Prof Cochener said that the TOCULAR is a wide-angle ocular device with an angular scale at the periphery of the visual field for toric IOL alignment. “The determination of preoperative astigmatism is based on the astigmatism angle and it still uses conventional inkmarking. The astigmatism angle is calculated using the keratoscope or biometer using a cross hair and angular scale at the periphery of the visual field. The device can also be manually rotated using a sterilised knob to an accuracy of one-degree,” said Prof Cochener. A more advanced suite of tools, the Zeiss Toric Solution, offers an integrated workflow system that combines EUROTIMES | Volume 16 | Issue 9

individual components such as the IOLMaster, Z Calc, Z Align/Callisto eye, and Opmi Lumera 700, said Prof Cochener. Preoperative biometry with IOLMaster delivers the data needed for toric IOL calculations including K-readings, axial length and anterior chamber depth. The type of toric IOL required can then be calculated using the Z Calc online calculator, which allows customisation of the values for sphere and cylinder in 0.50 D increments. Carl Zeiss also provides a choice of two toric IOLs – the monofocal bitoric aspheric AT.Torbi and the multifocal AT.Lisa toric lens. Prof Cochener explained that the Z Align feature is a video-supported tool for intraoperative alignment of toric IOLs. The touch screen operation enables the surgeon to accurately position the toric IOL using an integrated eye tracking system. Overall, Prof Cochener said that her own clinical experience over two years with the Zeiss Toric Solution has been very positive. “It represents a gain in reliability, accuracy, simplicity and safety and the system is being continually enhanced with additional features,” she said. Turning to the ORange Intraoperative Wavefront Aberrometer (WaveTec Vision Systems Inc.), Prof Cochener explained that the system allows real-time analysis of refraction, astigmatism and aphakic lens power during procedures so that adjustments can be made intraoperatively. The device determines the true cylinder value and based on the analysis provided by the system in real-time the surgeon rotates the toric IOL to the recommended position. An additional measurement confirms if the placement is correct or if an adjustment is required. To get the best from the device with toric IOLs, Prof Cochener advised using viscoelastic or BSS for aphakic power calculation and to maintain intraocular pressure between 20 mmHg and 30 mmHg to ensure accurate measurements. Other tips, said Prof Cochener, are to make sure that there are no air bubbles in the visual pathway, to avoid excessive wound hydration and to check to make sure that the lid speculum is not pushing on the eye near the corneal limbus, especially in small eyes. The Surgery Guidance 3000 (SMI) combines two main components: the Reference Unit and the Surgery Pilot. The Reference Unit outside the OR is used to take the presurgery reference image and measures relevant diagnostic data of the patient’s eye. The Surgery Pilot is then used in the OR to plan the precision steps before surgery and provide the real-time registration and tracking overlay on the microscope camera live image during surgery. The system supports capsulorhexis, toric IOL, multifocal IOL and limbal relaxing incision procedures.

contact Beatrice Cochener - beatrice.cochener@univ-brest.fr

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CORNEA

CXL adverse events

Review of CXL/PRK combo patients reveals its potential for side-effects

by Roibeard O’ hEineachain in Istanbul

Is it really Keratoconus? The new Ocular Response Analyzer® (ORA) version 3.01 software unleashes the power of ORA waveform analysis, resulting in two new normative database-derived indices: Keratoconus Match Index (KMI) and Keratoconus Match Probabilities (KMP). Topography and pachymetry provide “static” information about the current shape of the cornea. However, Keratoconus is a slowly progressing disease and diagnosing it is not always black and white. Now clinicians can assess the biomechanical risk of Keratoconus with greater confidence than ever before!

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8/3/11 12:54:12 PM

ombining a partial photorefractive keratectomy (PRK) with collagen crosslinking (CXL) can produce very good visual outcomes in patients with progressive keratoconus, but the treatment is not without its risks said Anastasios John Kanellopoulos MD, Athens, Greece, at the 15th ESCRS Winter Meeting’s Cornea Day. Dr Kanellopoulos presented his findings regarding the short- and long-term complications that have occurred among 412 keratoconus eyes with 2-7 years of follow-up after undergoing combined topography-guided PRK and CXL treatment according to the Athens Protocol. “The core concept of this technique is to treat ectasia with this combination treatment, involving partial hyperopic PRK and partial myopic PRK to normalise the cornea, and then cross-linking to stabilise its shape,” Dr Kanellopoulos noted. The Athens protocol involves first performing a phototherapeutic keratectomy using the corneal epithelium as a masking agent, then carrying out a topographyguided partial PRK, removing a maximum 50 microns, and then applying mitomycin-C 0.02 per cent for 20 seconds before carrying out the CXL. “We have argued that by removing Bowman’s and the epithelium we get better cross-linking. Comparisons with OCT clearly show that compared to standard cross-linking using the Athens protocol results in a more intense and wider crosslinking over a greater diameter of the cornea,” Dr Kanellopoulos said. As an example of a best-case scenario Dr Kanellopoulos described the case of a US Air Force pilot who developed post-LASIK ectasia with a refraction of +1.50 D sphere and -2.50 D cylinder at 135 degrees and a best-corrected visual acuity of 20/40. He underwent the combined topographically guided PRK and cross-linking procedure and at three years’ follow-up his uncorrected visual acuity is 20/15 and he remains on active duty. However, the combined PRK and CXL procedure also brings with it an increase in the potential for side effects and complications. Although in his series

there were very few cases in which the cornea failed to stabilise, there were several cases of postoperative haze and delayed epithelial healing. Moreover, there have also been reports in the literature of infection, herpetic keratitis, and corneal melts. In addition, he noted that regression requiring re-treatment occurred in 1.5 per cent of his patients. Paradoxically, the reverse of that, a continuing flattening of the cornea, has occurred in several of his patients. In one case, there was 2.5 D hyperopic shift over four years of follow-up, during which time visual acuity fell from 20/20 immediately postoperative to 20/40. “We have followed these patients seven years out and we have seen continued flattening, even at seven years out. So special caution needs to be taken on the refractive side to not over-correct these eyes,” Dr Kanellopoulos emphasised. The epithelium may take longer to heal in some cases, requiring longer use of bandage contact lens. When scarring is also present Dr Kanellopoulos said he now removes the scar to let the epithelium heal over again. Another epithelial abnormality that can occur are Salzman-like nodules which persist despite intensive lubrication for up to three months. In one case a young man who underwent the combined treatment developed PRK-like haze one year afterwards. He had spent the whole summer at the beach and the heavy sunbathing resulted in delayed scarring on the Athens-protocol-treated eye. However, it improved somewhat with steroids. Some permanent haze is possible. He added that the worst case he has seen there was scarring with white spots, which were possibly a result of over-cross-linking. “In the cases with complications we have employed autologous serum. We will also in some cases extend the use of a bandage contact lens all the way to six weeks. Ample Lubrication is also very important, as is treatment of blepharitis where it is present and we use Cyclosporine A drops for persistent dry eye,” he added.

contact Anastasios John Kanellopoulos - ajkmd@mac.com

Don’t miss Practice Development, see page 58

Update

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CORNEA

Self-defenSe Safety Doesn’t Happen By Accident

KERATOCONUS PLAN

France is establishing a network of contact lens experts to deliver more effective care by Dermot McGrath in Paris

uilding a dedicated network of specialist centres for keratoconus patients and putting increasing focus on research into the causes and management of the disease are part of a recent drive by the French health authorities to lessen the burden of the disease, according to Joseph Colin MD. Addressing delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting, Dr Colin said that the idea of a national support structure for keratoconus patients was first floated during the presidency of Jacques Chirac. “This took the form of a national plan for rare diseases from 20052008 whose goal was to ensure fairness in access to diagnosis, treatment and management of patients with rare diseases. This led to a national reference centre for keratoconus, combining the expertise of two centres in Bordeaux and Toulouse, as well as other centres of competence in Amiens, Brest, Clermont-Ferrand, Nantes, Nice, Rouen and Paris,” said Dr Colin. This initial initiative was followed by a more comprehensive national plan for 20112014, comprising 47 measures based around three main axes, said Dr Colin. “The main goals of the plan are to strengthen the quality of care of keratoconus patients, encourage research into the disease, and enhance cooperation at European and international levels. One of the priorities of the plan was to put in place a national protocol for diagnosing and managing rare diseases, including keratoconus,” he said. In practical terms, the protocol resulted in the elaboration of a keratoconus “decision tree”, which guides patient care taking account of factors such as the stage of advancement of the disease, the patient’s tolerance for contact lenses, corneal transparency, the advancement of the cone and the severity of any associated ametropia, among other criteria, explained Dr Colin. The current therapeutic options for keratoconus include contact lenses, intracorneal ring implants with or without corneal collagen cross-linking, crystalline implants, and lamellar or penetrating corneal grafts. “While we have more options available to us today, the contact lens remains the basic treatment of choice which

EUROTIMES | Volume 16 | Issue 9

delivers satisfaction in 90 per cent of our keratoconus patients,” said Dr Colin. With this statistic in mind, part of the strategy in France has focused on putting in place a network of contact lens experts in order to deliver more effective patient care at a regional level. In terms of treatment options, Dr Colin emphasised the importance of a clear cornea as a prerequisite for successful management of the disease. “If the cornea is clear of opacities we can consider a range of therapeutic options, otherwise we will have to perform some form of keratoplasty followed by other modalities such as contact lens or toric lens implantation to improve visual acuity,” he said. For contact lens-intolerant patients with a stable cone and a clear cornea, the treatment of choice is to use an intracorneal ring such as Intacs or Ferrara rings to stabilise the cornea. In those cases where the keratoconus cone continues to progress, Dr Colin said that corneal collagen crosslinking (CXL) has effectively revolutionised the treatment of keratoconus in recent years. “With a follow-up of over five years now, cross-linking has been shown to halt the progression of keratoconus in 97 per cent of cases. Those three per cent who failed were young patients. A major advantage of crosslinking is that re-treatment is possible if the initial results do not achieve a stabilisation of the cornea or halt the progression of the disease,” he said. In addition to the traditional cross-linking approach, surgeons now have the option to treat with the KXL System (Avedro Inc.), which speeds up the process considerably, said Dr Colin. Rapid intervention with collagen crosslinking is particularly important in children with keratoconus, advised Dr Colin. “This was one of the outcomes of the meeting of the keratoconus expert group at the ESCRS Winter Meeting in Istanbul earlier this year. Dr Colin concluded by reminding delegates that the second Eurokeratonus conference will take place in Bordeaux on 23 and 24 September 2011. Further information is available at: http://www. keratocone.eu/site_europe/index_uk.html.

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Update

CORNEA

KERATOCONUS TREATMENT

A combination of modalities stops keratoconus progression and provides improved refraction by Roibeard O’hEineachain in Istanbul

succession of refractive treatments involving intracorneal ring segments, collagen cross-linking and a toric ICL can stop the progression of keratoconus, reduce corneal irregularity and fine-tune refraction if the patient is contact lens intolerant, said Efekan Coskunseven MD, at a special meeting at the Dunya Eye Hospital, Istanbul, Turkey, devoted to the treatment of keratoconus. “Our first choice when dealing with keratoconus should be contact lenses and cross-linking. In patients who are not good candidates for contact lenses, we can combine the ring with cross-linking. There are many studies about this combination. We can also combine the ring, cross-linking, and implantation of a phakic IOL,” he said. Dr Coskunseven presented the results of a study in which 14 eyes of nine patients with keratoconus underwent intracorneal ring segment implantation, using the Keraring (Mediphacos), followed by corneal crosslinking and implantation of a toric ICL over a period of around 13.5 months. He noted that the mean uncorrected visual acuity improved from a preoperative value of 0.01 to 0.06 following intracorneal ring segment implantation, to 0.08 following collagen cross-linking and to 0.46 following implantation of the toric ICL. Bestcorrected visual acuity improved from 0.16 preoperatively to 0.41 following implantation of the intracorneal ring, to 0.48 following cross-linking and to 0.58 following ICL implantation. Furthermore, mean cylinder improved from a preoperative value of -4.73 D to -2.36 D following intracorneal ring segment implantation, to -1.8 D following

ICL and Keraring

ICR and Keraring

cross-linking and to -0.96 D following ICL implantation. In addition, spherical equivalent improved from a preoperative value of -16.4 D to -9.81 D following intracorneal ring implantation, to -9.56 following cross-linking, and to -0.8 D following ICL implantation. The inclusion criteria for the study were stage I through stage III keratoconus, age of more than 18 years, contact lens intolerance, corneal thickness of at least 400 microns where the tunnels were created for implantation of the intracorneal ring segments, and anterior chamber depth greater than 2.8mm. Patients were excluded from the study if they had keratometry readings of 65 D or more, or if they had corneal dystrophies, hydrops, corneal opacities, or herpetic keratitis. Also excluded were severely atopic patients and those with collagen, vascular or autoimmune diseases or other systemic diseases. The mean interval between the

Efekan Coskunseven - efekan.coskunseven @dunyagoz.com

Many combined approaches possible Dr Coskunseven noted that

Courtesy of Efekan Coskunseven MD

implantation of the intracorneal ring and collagen cross-linking was seven months and the mean interval between collagen cross-linking and ICL Toric implantation was 8.4 months. The mean follow-up period was 7.2 months. Dr Coskunseven created the channels with an IntraLase FS 60 femtosecond laser in a procedure that took 15 seconds with the depth adjusted to 80 per cent of the thinnest point at the tunnel’s location. He created the corneal incision at the steep axis and implanted ring segments ranging from 4.4 to 5.6mm in length. He performed collagen cross-linking by applying to the cornea 0.1 per cent riboflavin in 20 per cent dextran T-500 for 30 minutes and then exposing it to three milliwatts/cm² ultraviolet light at a wavelength of 370 nm for 30 minutes. He based his ICL calculation refraction on the eye’s refraction following intracorneal ring implantation and collagen cross-linking.

the Keraring, cross-linking and toric phakic IOL combination is only one of several approaches that employ a combination of modalities for the treatment of keratoconus. Another approach that has shown efficacy is the use of a simple combination of the toric ICL and collagen cross-linking. In a study by Mohamed Shafik MD, PhD, University of Alexandria, the mean bestcorrected visual acuity increased from 0.56 to 0.89 and the mean uncorrected visual acuity increased from 0.3 to 0.88, Dr Coskunseven noted. However, he pointed out that in some cases the irregularity of cornea in some keratoconus patients would be too much for this treatment to work. In stable keratoconus patients, intracorneal ring segments and toric IOLs without cross-linking can produce good results, he noted. In a study he and his associates conducted the combination of Intacs and the toric ICL brought two highly myopic keratoconus patients to within one dioptre of emmetropia. The treatment combination also reduced the mean manifest refractive spherical equivalent refraction from −18.50 D to 0.42 D and improved uncorrected visual acuity by seven lines and best corrected visual acuity by four lines. Another approach Dr Coskunseven has used is intracorneal ring segment implantation followed by collagen cross-linking and topography-guided transepithelial PRK. In a study involving 16 eyes of 10 patients with keratoconus that underwent that combination of treatments UCVA improved from 0.1 to 0.58, and BSCVA improved from 0.21 to 0.74. Dr Coskunseven noted that the range of treatments now available are bringing keratoconus patients with high amounts of irregularity and refractive error closer and closer to emmetropia, with all of the treatment options having an additive effect when used in combination. “Maybe we should combine all of them to get better results,” he said.

What is EUREQUO? EUREQUO is a European Quality Registry for visual outcomes of cataract and refractive surgery

EUREQUO European Registry of Quality Outcomes for Cataract & Refractive Surgery

with the kind contribution of

Join the network

The project aims to:

1 2 3

Improve treatment and standards of care for cataract and refractive surgery

EUREQUO gives a unique opportunity to monitor and compare results

Develop evidence-based guidelines for cataract and refractive surgery across Europe Make significant impact on the exchange of best practice between practitioners in relation to patient safety

Quality registries create a sufficient basis for studying rare diseases, treatments and complications Collecting data will support you to make an audit report The collection of your data will facilitate the analysis of surgical outcomes and the development of evidence-based European Quality Guidelines

See www.eurequo.org for more information EUROTIMES | Volume 16 | Issue 9

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Update

CORNEA

PENETRATING KERATOPLASTY

Full thickness grafts retain their usefulness in select cases

by Roibeard O’hEineachain in Istanbul

amellar keratoplasty (LKP) techniques are continuing to gain wider acceptance but there will likely remain a place for penetrating keratoplasty (PKP) for the foreseeable future, said ESCRS president Jose Güell MD, Autonomous University of Barcelona, Barcelona, Spain, in a keynote lecture at the 15th ESCRS Winter Meeting’s Cornea Day. He noted that there is an urgent need for improved keratoplasty techniques. Cornea transplants are the most common solid organ transplants performed in the world. However, although the success rate is 90 per cent in low-risk patients, it is only 30 per cent to 50 per cent in more complex, higher risk cases, and overall, 30 per cent of cases have a rejection episode. Moreover, re-grafting has become the most common indication for corneal transplantation in the US and some places in Europe. The more recently developed LKP techniques are designed to overcome some of the problems of corneal transplantation by leaving as much of the healthy cornea in

place as possible. For example, endothelial keratoplasty procedures replace only the endothelium but leave the patient’s cornea’s refraction fairly intact, he noted. Anterior lamellar keratoplasty, on the other hand replaces all or nearly the entire cornea except Descemet’s membrane and the endothelium, which all but grossly eliminates the chance of immune rejection. “Techniques that substitute only the damaged corneal layers have obvious theoretical advantages over penetrating surgery, but these advantages must be demonstrated through properly designed comparative long-term studies, the results from which are not yet available, and they must be superior to the better known and more widely practised techniques,” he said

Lamellar graft update Dr Güell noted that, regarding endothelial keratoplasty, the data available to date suggests that despite much better postoperative refraction and more rapid functional rehabilitation, the visual acuity is still slightly better after PKP,

Eye Chat with Oliver Findl

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Capsule Tears

Dr Oliver Findl talks with Boris Malyugin MD, PhD about capsule tears, perhaps the most dreaded intraoperative complication of cataract surgery.

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Boris Malyugin

in some series probably as a result of issues related to the interface between host and donor tissue. In addition, early endothelial cell loss is also greater after endothelial keratoplasty techniques than after PKP, although rejection rates are similar with the two techniques. The cases where endothelial keratoplasty may not be the best option include eyes where the anterior stroma is seriously compromised, and eyes that are likely to need multiple intraocular procedures, Dr Güell added. Eyes that have undergone deep anterior lamellar keratoplasty (DALK) techniques have, as expected, a greatly reduced incidence of rejection and a better-preserved endothelium than is the case with PKP. Generally fewer patients achieve a visual acuity of 20/20 with DALK than do with full thickness grafts, he said. However, visual acuity and visual quality following DALK is partly dependent on the surgeon’s success in baring Descemet’s membrane in the host and removing Descemet’s membrane and the endothelium in the donor button. Apart from obvious endothelial disease, contraindications for DALK include doubts about endothelial health as in some cases of herpetic disease, where there may be difficulty in evaluating the posterior corneal layers, and also some cases of keratoconus where the cornea is very thin after an hydrops episode. Moreover a certain percentage of cases must be converted to full thickness procedures because of perioperative complications. Eyes with penetrating corneal injuries are also unsuitable for lamellar approaches, as are many cases with chemical burns, which frequently require limbal transplants to facilitate post-grafting rehabilitation. In paediatric keratoplasty cases the use of posterior or anterior lamellar surgery is possible but the endothelial layer’s postoperative transparency is less reliable.

Case reports Dr Güell described several cases where he considered full thickness grafts to be the best option. One was a patient who developed a severe case of infectious keratitis following a LASIK procedure. The infection penetrated through most of the cornea’s layers and may have compromised the endothelium. “In cases like this we are unable to consider

Jose L Güell - güell@imo.es

“

So until the ‘artificial cornea’ becomes a reality, the corneal surgeon must be trained to use the best surgical approach for every single case Jose Güell MD

any lamellar option but we need to do full thickness transplantation usually combined with some other reconstructive surgery, as in this case, trying to avoid any surgical damage to the iris tissue and the crystalline lens,” Dr Güell said. He described another case of severe infection where it was necessary to wait until the eye was quiet, at which point the cornea’s posterior layers could not be properly evaluated. In this particular case, a full thickness keratoplasty procedure was necessary in combination with an amniotic membrane transplant because of epithelialisation problems. In another case, the patient’s eye had longstanding endothelial failure because of silicone oil tamponade and central band keratopathy, which ruled out both endothelial keratoplasty and DALK. In this case, Dr Güell first used a temporary keratoprosthesis to enable the vitreoretinal surgeon to take out the silicone oil and finally repair the retina and afterwards he replaced the keratoprosthesis with a full thickness graft. Another reason some surgeons might prefer to use PKP is lack of training and experience in lamellar techniques, he noted. However, such surgeons may serve their patients best in many cases by referring them to surgeons experienced in lamellar techniques. Exceptions to that would include practices in remote locations and emergency situations. The situation with lamellar keratoplasty techniques is similar to the situation that once prevailed regarding phacoemulsification and ECCE, when many surgeons were slow to adopt the newer technique, he said. However, he pointed out that PKP is not a static technique, but continues to evolve just as does endothelial keratoplasty and DALK. “Penetrating keratoplasty will continue to improve with technological advances involving femtosecond lasers, bioadhesives, and biological approaches such as regular HLA matching and the use of new immunosuppressants. So until the ‘artificial cornea’ becomes a reality, the corneal surgeon must be trained to use the best surgical approach for every single case,” Dr Güell concluded.

a a

a ae

C o r n

www.eucornea.org

C o r n

European Society of and and European Society ofCornea Cornea Ocular Surface Disease Specialists Ocular Surface Disease Specialists

MILAN 6 - 7 September 2012

Corn

E Eu

3rd EuCornea Congress

Corn

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Update

CORNEA

EPITHELIAL STEM CELLS

Research shows that epithelium regenerates itself without assistance of limbal stem cells Courtesy of Harminder Singh Dua FRCS, FRCOphth, FEBO, MD, PhD

by Roibeard O’hEineachain in Istanbul

Central island of surviving corneal epithelium in a patient with aniridia. The patient has been followed for five years

lthough the central corneal epithelium does not contain stem cells, it does contain cells that act like stem cells and are in fact the primary cells responsible for maintaining the corneal epithelial surface, said Prof Harminder Singh Dua FRCS, FRCOphth, FEBO, MD, PhD, University Hospital, Queens Medical Centre, Nottingham, UK. “The hypothesis is that the limbus with all its content of stem cells plays only a minimal role in normal epithelial homeostasis in normal epithelial turnover” (Dua HS et al. Ophthalmology. 2009;116:856), said Prof Dua in a keynote lecture at the 15th ESCRS Winter Meeting’s Cornea Day. He noted that numerous laboratory studies have demonstrated that the limbus is a key repository of stem cells and there is a vast amount of evidence that a limbal stem cell deficiency will have an adverse effect on re-epithelialisation of eyes with damaged surfaces. However, there are also cases where a central island of the corneal epithelium has survived and has persisted for up to 12 years, despite a complete absence of any limbal cells in the periphery.

Tales from the crypts Evidence of the presence of stem cells in the

limbus and of the absence of stem cells in the central cornea comes from several sources, Prof Dua said. Impression cytology shows that the cells from the two sites are very different in terms of their nucleocytoplasmic ratios, which are higher in the case of stem cells and in a high proportion of cells from the limbal area. In addition, staining with antibodies that are negative for stem cells shows the cells to be in their highest concentration in the several crypts, or niches, located around the limbus, and at an increasingly lower concentration as one moves centrally until they are absent around the mid-periphery. “On that basis it has been proposed for many years now that at the limbus, at the basal epithelium, we have the stem cells and these cells form the transient amplifying cells as they migrate centrally and then they migrate in the anterior direction forming the post-mitotic cells and the terminally differentiated cells,” Prof Dua said. He added that the limbal epithelial crypts from which the stem cells emanate are not simply a repository for the stem cells but also have the special physiological function of maintaining the “stem-ness” of the stem cells through chemical mediators and growth factors. The crypts are solid

Don’t miss Eye on Travel, see page 66 EUROTIMES | Volume 16 | Issue 9

Central island of surviving corneal epithelium in a female patient whose initial injury was with hydrogen peroxide contained in a hair dye solution. The patient has been followed for over two years

“

What this study tells us is that the central cornea in that species is capable of behaving like a limbus and that the limbus has a role to play in response to injury but not in normal homeostasis

Harminder Singh Dua FRCS, FRCOphth, FEBO, MD, PhD

cords of cells that arise from the palisades of Vogt. In most human eyes there are around six or seven limbal endothelial crypts, located around the limbus, he said (Dua HS et al. Br J Ophthalmol 2005;89:529).

Limbal stem cells mainly for emergencies The presence of

stem cells in the limbus has led to the assumption that the limbus is the source of all of the new corneal epithelial cells which replace the dead epithelial cells.

Harminder Singh Dua - profdua@gmail.com

However, research now suggests that the central corneal epithelial cells provide most of the replacement of dead cells and that it is only following trauma to the corneal epithelium that the limbus becomes involved, Prof Dua noted. For example, in an experiment where athymic mice were implanted with portions of limbus from β-galactosidase transgenic mice with blue corneal and conjunctival epithelium, there was no in-growth of blue cells into the central cornea over a period of several months. However, following an abrasion of the central corneal epithelium there was an immediate migration of blue cells towards the centre (Majo et al, Nature November 13 2008; 456). Moreover in the same study, when the researchers transplanted the blue central cornea from a transgenic mouse to the peripheral cornea of the brown-eyed mouse the blue transplanted cells rapidly colonised the central cornea in response to the removal of the epithelium. “What this study tells us is that the central cornea in that species is capable of behaving like a limbus and that the limbus has a role to play in response to injury but not in normal homeostasis,” Prof Dua said. In another study, following laser ablation of the limbus and peripheral epithelium in organ culture corneas leaving only the central cornea, there was a centrifugal migration of cells from the central intact epithelium towards the periphery (Chang et al, IOVS, 2008, 49:5379-86). In another study, Prof Dua and his associates conducted a microarray analysis comparing the transcription profile of the limbal epithelial crypt to that of the limbus and the central cornea. This showed that cells of the central corneal epithelium had a gene expression profile related to proliferating stem cells, transient amplifying cells and differentiated cells (B. Kulkarni et al, BMC Genomics 2010, Sept 29;11:526). “The central cornea can maintain the central cell mass and these cells are either stem cells or their immediate descendants, termed “Transient cells” that are different from the Transient amplifying cells (TAC) which are more differentiated. So the limbus plays an important role in ocular surface regeneration in cases of injury or insult and can be quiescent in normal homeostasis,” Prof Dua added.

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Harry A Quigley - hquigley@jhmi.edu

Update

Glaucoma

PREVENTING BLINDNESS

“

This study will allow us to see whether these dynamic measurements predict who will develop angle closure glaucoma and if there is a benefit of iridotomy in everyone with narrow angles

Development of better diagnostics and therapeutics key to progress by Cheryl Guttman Krader in Fort Lauderdale

EUROTIMES | Volume 16 | Issue 9

Harry A Quigley MD

Choroidal Thickness

Courtesy of Harry A Quigley MD

he development of new diagnostic methods should help to reduce the toll of angle-closure-glaucoma (ACG)-related blindness before the decade concludes. However, preventing blindness from open-angle glaucoma (OAG) presents a more difficult challenge, according to Harry A Quigley MD. Dr Quigley is A. Edward Maumenee Professor of Ophthalmology, The Johns Hopkins University School of Medicine, Baltimore, MD. He spoke at the annual meeting of the Association for Research in Vision and Ophthalmology during a minisymposium focusing on research priorities to enable Vision 2020 to reach its goal of eliminating avoidable blindness. Dr Quigley noted that the biggest challenge to preventing ACG blindness is a lack of predictors for identifying what patients with angle closure will develop the disease. Only about 10 per cent of persons with a narrow angle develop ACG, and about three-fourths of persons with ACG are asymptomatic, he explained. Recent research suggests that measuring changes in choroidal volume and iris volume during provocative testing may better identify angle closure suspects at risk for developing disease compared with current approaches using gonioscopy and ultrasound biomicroscopy to study angle anatomy. “We know we should be measuring something physiological, and gonioscopy and ultrasound biomicroscopy are inadequate because they provide only a static view of a dynamic process,” Dr Quigley said. Research conducted by Dr Quigley and others using anterior segment OCT has shown that iris volume after pupil dilation changes less in eyes with ACG than in controls with normal angles or even in fellow eyes having narrow angles without ACG. “The iris is like a sponge that loses water to the aqueous with pupil enlargement, and it’s not surprising that the amount of water lost may differ among eyes depending on iris structure. Minimal change in iris volume during pupil dilation in an eye with a narrow angle can predispose to angle closure glaucoma,” Dr Quigley explained. Choroidal expansion is also being considered as a pathogenic mechanism for

ACG Prevalence

the development of angle closure glaucoma and a potential diagnostic target for identifying angle closure suspects. Research has shown the presence of a space between the choroid and sclera in eyes with ACG but not in normal eyes. This space may represent choroidal expansion that has also been observed to be more common in ACG eyes than normal controls. Choroidal expansion could increase pupillary block in an eye with a narrow angle as a result of increased IOP causing anterior movement of the lens and iris. Validation of the role of these new diagnostic approaches requires their investigation in longitudinal studies. One such trial is currently under way in Guangzhou, China. The study has enrolled 850 subjects with narrow angles who undergo iridotomy in one randomly selected eye after baseline physiological measurements of iris volume and choroidal thickness. The subjects will be followed for the development of ACG. “This study will allow us to see whether

these dynamic measurements predict who will develop angle closure glaucoma and if there is a benefit of iridotomy in everyone with narrow angles,” Dr Quigley said.

OAG more challenging Success in reducing the blindness burden of OAG faces more complex challenges considering the deficiencies of existing therapies. Results from numerous studies highlight that poor adherence limits the effectiveness of medical therapy among affluent populations in Western countries as well as in the developing world. This issue may be overcome by novel delivery methods, and technologies are being developed, but are not yet in human trials. Various strategies have also been shown effective for motivating patients to take their drops more often, but while adherence improves, it remains suboptimal. Laser angle surgery is a well-tolerated procedure with a favourable safety profile. However, it causes minimal IOPlowering, and with its high instrument

cost and requirement for operator skill, its applicability in the developing world is limited. Nevertheless, en masse laser treatment might be worthwhile even if the benefit is IOP-lowering by a few mmHg, Dr Quigley said. An alternative to trabeculectomy that does not require high-level training, causes fewer side effects, and has higher success rates, is needed for surgery to become a viable solution. Dr Quigley proposed that building experience with new surgical techniques in the developing world might be achieved by focusing on regions with established cataract treatment programmes where patients receiving cataract surgery and who are found to have co-morbid glaucoma can simultaneously undergo glaucoma surgery. Dr Quigley’s list of research priorities for successful elimination of glaucoma-related blindness also included a need for more data on the risk and cost of glaucoma treatment, the development of better tools to guide selection of treatment that will maximise outcome and minimise cost, and conduct of clinical trials of potential neuroprotective agents. He noted that results from animal studies suggest a host of candidate compounds with dual activity for lowering IOP and protecting retinal ganglion cells. Recognising the lack of industry interest in developing neuroprotective drugs for glaucoma, Dr Quigley encouraged academicians and clinicians to establish their own clinical trial networks to investigate the efficacy and safety of new drugs for preventing glaucoma blindness. “It’s said that neuroprotective trials take too long and need too many patients,” he noted. However, using data published by Chauhan et al., Dr Quigley estimated that a 50 per cent treatment effect could be detected in two years in a study enrolling fewer than 200 patients if the visual fields are repeated quarterly.

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Glaucoma

Cataract surgery

Long-term IOP reduction makes lens extraction a top glaucoma procedure by Howard Larkin in San Diego

ince the intraocular pressure-lowering effect of phacoemulsification in clear cornea incisions was first reported in 1996 by Debra Tennen MD and Samuel Masket MD, several studies have documented reduced IOP in many patients up to 10 years after cataract surgery. These include studies by Poley, Issa, Lindstrom and Suzuki that show not only long-term relief, but also correlate greater mean reduction with higher preoperative pressures. “Cataract surgery really does have an impact on intraocular pressure,” Bradford J Shingleton MD, Boston, US told attendees of the 2011 ASCRS Glaucoma Day. As a result, surgeons are increasingly looking to cataract surgery to help control open- and closed-angle glaucoma, ocular hypertension and pseudoexfoliation, Dr Singleton said. “I firmly believe that cataract surgery is the most commonly performed glaucoma procedure in the world today.”

IOP after cataract surgery While the mechanism of IOP reduction in cataract surgery isn’t completely understood, Dr Shingleton believes it may be largely due to remodeling of anterior segment anatomy when an eye is rendered pseudophakic. Because the replacement lens is thinner, the anterior chamber deepens, which opens the angle. Reduced lens mass behind the iris also relaxes compression of the iris root, scleral spur and trabecular meshwork. “So there’s obviously a potential increase in normal outflow and uveoscleral outflow. And who knows? It might even alter inflow.”

And while the impact of cataract surgery on IOP varies by patient, and should be monitored, IOP reduction correlates with preoperative pressure and angle status. “Narrow angles with high pressure and uncomplicated surgery often show even greater reduction in pressure,” Dr Shingleton said. IOP also follows a characteristic pattern over time. Within the first 30 minutes after uncomplicated surgery, hypotony is a potential risk that should not be ignored. Depending on the type of anaesthesia and incision, five per cent to 20 per cent of patients will go below 5 mmHg, Dr Shingleton noted. The highest elevation typically occurs between two to eight hours after surgery, and very high pressure spikes are most likely in open-angle glaucoma (OAG) and pseudoexfoliation eyes, with some studies showing a mean pressure of 31 mmHg at four hours for these patients. Pressures exceed 40 mmHg in four per cent of normal eyes, but 19 per cent of OAG and pseudoexfoliation eyes. In these higher risk categories, 17 per cent to 30 per cent are above 30 mmHg the day after surgery, even with intraoperative medications to control pressure. “Beware of this,” Dr Shingleton warned. At one month, Dr Shingleton cautions to watch for IOP increases related to steroid response, though overall IOP is typically much lower. At one year, mean IOP reduction is about 1-2 mmHg, and remains relatively stable from three to five years. Patients who require medications to control

“

I firmly believe that cataract surgery is the most commonly performed glaucoma procedure in the world today Bradford J Shingleton MD

pressure before surgery typically see a 50 per cent reduction in medications initially, trending back to baseline at about three years. Over the last two years in Dr Shingleton’s practice, patients with a pre-op IOP of 20 mmHg or less saw a drop of nine per cent at one month, were down 6.2 per cent at seven years and 6.4 per cent at 10 years, for a typical reduction of 1-2 mmHg. By comparison, those with 21-25 mmHg before surgery were down 29 per cent at one month and 21 per cent at seven years, for a drop of between 5-8 mmHg. Those higher than 25 mmHg pre-op were down 40 per cent at one month and 31 per cent at five years for a reduction of 7-12 mmHg. “This was with cataract surgery alone,” Dr Shingleton said. Cataract surgery alone may be particularly effective in cases of primary acute angle-closure glaucoma (ACG), Dr

Brad Shingleton - bjshingleton@eyeboston.com

Shingleton noted. “It relieves pupillary block, opens the angle and eliminates the phacomorphic and phacolytic components.” In chronic ACG, cataract surgery may also work for the same reasons, though goniosynechialysis may also be required, he added. Cataract surgery is also notably effective in patients with pseudoexfoliation, typically requiring no additional treatment for those without glaucoma symptoms.

Operating technique To spare conjunctiva for future ab-interno or ab-externo procedures, Dr Shingleton uses a clear corneal temporal incision when operating on patients with active or suspect glaucoma, ocular hypertension or other glaucoma risk factors. He notes that many glaucoma patients have small pupils, particularly those with narrow angles, and emphasises the need to control the pupil during surgery. He implants a posterior chamber IOL in the bag and is careful to preserve intact zonules, and to avoid vitreous loss. If there is any question of acute or chronic angle closure, Dr Shingleton performs gonioscopy intraoperatively. Goniosynechialysis is performed if needed. The angle can be directly visualised and angle synechia reduced with a spatula or intraocular forceps. Dr Shingleton typically uses topical betablockers, alpha-agonists and miotics at the completion of the cataract procedure in glaucoma patients. Intraoperative carbachol may be particularly effective in blunting postoperative IOP spikes. He then follows patients and prescribes medications, laser and other therapy as indicated. “All of these patients can use medications of any type after surgery,” he notes. “Cataract surgery in itself is a glaucoma surgical procedure,” Dr Shingleton said. But he emphasised that its suitability should be evaluated in each case, and that patients at risk should be followed-up afterwards.

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Update

Glaucoma BEST WOUND STRUCTURE

DRUG DELIVERY

Novel delivery system targets unmet needs in glaucoma treatment by Dermot McGrath in Paris

EUROTIMES | Volume 16 | Issue 9

Schematic of the placement of the Replenish Drug Delivery System with tube insertion through the pars plana for drug delivery into the posterior chamber for disease such as macular degeneration, diabetic retinopathy and diabetic macular oedema

can recharge the power needed to deliver the drug into the eye and it will also be possible to use small or large molecule drugs with this kind of device, or a mixture of the two as required,” he said. The implant design incorporates an electrolysis chamber that generates gas bubbles which when activated raises a diaphragm into the drug chamber to squeeze out the drug through a one-way cannula into the eye, he explained. The surgical procedure for implanting the device is similar to an Ahmed shunt, said Dr Varma, and it can be placed in the supero-temporal quadrant in between the rectus muscles, with cannula placement in either the anterior or posterior chamber. In animal studies, the device has shown very good biocompatibility and stability over the long term. Summing up the potential of the device, Dr Varma said that while it should address some of the current unmet needs in glaucoma therapy, it is unlikely to provide a “silver bullet” solution for glaucoma. “With this device we can introduce drugs into the eye in a stable fashion over a long period of time. We are now working to link the device to an IOP sensor in order to give a feedback loop so that we can introduce the drug at the time when the IOP is elevated and try to modulate IOP fluctuations. While this will be able to reduce the impact of IOP on the retina and optic nerve, it may not be able to control other factors such as connective tissue elasticity that play a role in glaucomatous optic nerve damage,” he said.

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Courtesy of Rohit Varma MD

controlled and programmable mini-pump drug delivery system may have the potential to deliver more effective drug treatment for chronic ocular diseases such as glaucoma in the very near future, according to Rohit Varma MD. Addressing delegates at the World Glaucoma Congress, Dr Varma, professor of ophthalmology at Doheny Eye Institute at the University of Southern California said that one of the clear unmet needs in current glaucoma treatment is finding a therapy that addresses issues of patient non-compliance and fluctuations in intraocular pressure. “One approach to this is to have a longterm drug delivery device, something which can be placed in the eye which over a long period of time can introduce a drug into the eye at various times in an active manner. This will address the issues of non compliance, issues relating to ocular surface problems which eye drops can cause and potentially reduce other systemic side-effects which these drugs may have,” he said. Dr Varma noted that current drug delivery devices targeting ocular diseases, including Retisert (Bausch + Lomb), Posurdex (Allergan), Medidur (Alimera Sciences), iVation (Surmodics) and encapsulated cell technology (ECT, Neurotech) all have the disadvantage of being “passive” devices. “One of the limitations of these type of devices is that you cannot change/slow/ increase/stop the rate of drug delivery once it has been introduced into the eye. I believe that for a chronic condition such as glaucoma or AMD, it would be optimal to be able to modify the rate of drug delivery based on the therapeutic response and disease progression,” he said. The new device, which Dr Varma and his team (including Drs Mark Humayun, Y C Tai and Sean Caffey) have been developing over the past five years, is about the size of an Ahmed implant and should be commercially available in three to five years, he said. “Our goal has been to develop an implantable drug delivery device which is similar in profile to a standard glaucoma drain implant and which can deliver programmable rates of drug intraocularly. It is envisaged to be able to wirelessly change the rate at which the drug gets delivered into the eye and it can be refilled over time in a routine outpatient procedure. The physician

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Rohit Varma - rvarma@hsc.usc.edu 109-436_ADV_Transconjuctival_120x300_tbv_Eurotimes.indd 1

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Delivering the accuracy of a femtosecond laser to Refractive Cataract Surgery, the LenSx® Laser is designed to predictably perform many of the most challenging aspects of traditional cataract surgery. Creating highly reproducible capsulotomy, lens fragmentation and all corneal incisions with image-guided surgeon control, Alcon’s LenSx® Laser is Putting the Future in Motion. To learn more about LenSx® Laser technology for Laser Refractive Cataract Surgery, visit lensxlasers.com.

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Update

retina

goals of surgery

Prof Corcostegui’s lecture looks at diabetic retinopathy by Roibeard O’hEineachain in London

t this year's annual EURETINA meeting Borja Corcostegui MD, Spain, a past president and founding member of the society, delivered his EURETINA lecture, titled "Modern Directions for the Surgery of Diabetic Retinopathy". He said the goals of surgery in proliferative diabetic retinopathy are to remove the posterior hyaloid membrane and vitreous attachment in order to clear the opacity and traction. In his lecture he outlined a grading system for proliferative diabetic retinopathy based on the amount of vitreoretinal attachments and its relationship to the likely prognosis of the disease. In eyes with type zero proliferative diabetic retinopathy there is a total posterior vitreous detachment, he said. The main indication for surgery in such cases would be a vitreous haemorrhage, in which case a core vitrectomy should be performed to clear the opacity. In type 1 disease there are at most just a few focal vitreoretinal attachments located at the optic disc or at the vascular arcades, he noted. The results of surgery in both type 0 and type 1 disease is generally pretty good with a low likelihood of retinal detachments or epiretinal membranes, he added. However, the incidence of post-surgical complications increases to around five per cent in eyes with type 2 proliferative diabetic retinopathy, Prof Corcostegui said. The diagnostic features of that stage of disease include a broad vitreoretinal attachment of at least two disc diameters. There may or may not be an underlying traction or combined traction under a rhegmatogenous retinal detachments In type 3 disease the vitreous is attached at the disc along the vascular arcade and over the macula but is detached between the arcades and the vitreous base attachments in the macula. In this group of patients the rate

EUROTIMES | Volume 16 | Issue 9

“I think the size of the instrumentation is less important. What is most important is to leave the retina completely free of traction”

Gisbert Richard presents Borja Corcostegui with his certificate at the EURETINA Lecture during the 11th EURETINA Congress

of complications is about seven per cent. In a patient with grade 4 disease the vitreous is attached to disc out to the vascular arcade and the only area of vitreous detachment is over the macula. In such cases the risk of epiretinal membrane and retinal detachment reaches eight per cent to 10 per cent. In type 5 disease there is a total vitreous attachment and the risk of the complications rises to 12 per cent to 15 per cent. Prof Corcostegui said that in eyes with type 2 to type five disease he generally injects an anti-VEGF agent four to seven days prior to performing surgery, to dampen down the neovascularisation and reduce bleeding. He then proceeds to remove the proliferative tissue using one of three techniques. In the simpler cases he will use of the vitreous cutter on its own, in the more difficult cases he will use bimanual dissection with vitreous cutter and forceps or bimanual dissection with vitreous cutter and scissors. All cases can be assisted with viscodissection. He noted that in most cases patients are unlikely to require more than three sclerotomies. He added that modern vitreoretinal surgical technology has several advantages including more efficient vitreous cutters with faster duty cycles which can be used in cannulas from 20 gauge to 27 gauge. “But the most important thing is to not break the retina and to remove the proliferative tissue. I think the size of the instrumentation is less important. What is most important is to leave the retina completely free of traction,” he added.

12th EURETINA Congress 6-9 September 2012

for further information visit: www.euretina.org

Abstract Submission Deadline:

15 March 2012

Update

retina

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taining of the inner limiting membrane (ILM) using a latestgeneration dye seems to provide a safe and more effective means of removing the membrane in vitreoretinal surgical procedures, according to Yannick Le Mer MD. “Do we need dyes for ILM peeling? The answer is undoubtedly yes if we want to be sure that we have removed everything. It is the only objective way to assess peeling quality. It makes ILM removal safer and it is easier to remove something that you can actually see than something which is supposed to be there but is difficult to identify clearly,” Dr Le Mer told delegates attending the 11th EURETINA Congress. Explaining the rationale for his study, Dr Le Mer, an ophthalmologist at the Fondation Rothschild in Paris, France, said that while ILM is routinely removed during macular surgery, it is not always clear if the procedure is useful, safe and complete for all patients. “The use of dyes has been proposed as a means to improve visualisation, safety, and the quality of ILM removal. We wanted to see if that is the case and what might be the best way to assess these improvements,” he said. Dr Le Mer’s prospective study included a total of 70 patients undergoing vitrectomy for macular epiretinal membrane in 36 cases, vitreomacular traction syndrome in 19, idiopathic macular holes in 11 patients and diabetic macular oedema in four cases. “The idea was to perform vitrectomy with ILM peeling without dye, then with injection of dye to assess the quality of ILM removal, and then to repeat the ILM dissection if needed. The primary endpoint of the study was the number of cases with an incomplete dissection and the secondary endpoint was the number of peeling-related complications before and after staining,” said Dr Le Mer. Patients excluded were those with highly myopic foveo-schisis and those who had undergone previous ocular surgery even if the ILM had been left intact. In choosing the most appropriate dye for the study, Dr Le Mer and colleagues (Drs Devin, Morel and Morin, Clinique Monticelli in Marseille, France) opted for a relatively new dye, Brilliant Blue (Brilliant Peel, Fluoron GmbH). The dye is supplied ready for injection in a vial and does not require mixing before use. After vitrectomy the dye is injected over the macular area without the need to perform a fluid-air exchange.

“We opted for Brilliant Blue because it was the only dye with a CE marking specifically for ILM peeling when the study began. It is widely used in the food industry and has no known clinical toxicity. Indeed some studies have shown that it may even have some beneficial effects on neural tissue with only minimal side effects,” he said. Looking at the results, Dr Le Mer noted that it was necessary to peel the ILM again in 38 per cent of cases, with cosmetic peeling necessary in 20 per cent of patients and no further peeling required in 42 per cent. The indications seemed to have a bearing on the necessity for re-peeling, with an even distribution of epiretinal membranes requiring a second attempt compared to all four cases of diabetic macular edema. Complications were also more common without staining. In 33 per cent of the eyes, either retinal pinches or localised superficial haemorrhages occurred, and were practically eliminated after staining. Dr Le Mer said that the clear conclusion was that using dyes for ILM removal was definitely beneficial. “I think this is purely down to better visualisation of the ILM using the dye rather than any positive biological effect of the dye on the adherence of the tissue to the retina,” said Dr Le Mer. Another benefit is that the use of staining actually speeds up the overall surgery time, he said. “After vitrectomy and the direct injection of Brilliant Blue after infusion closure, the removal of the dye is very fast and only takes about 30 seconds,” he said. The only real downside of using Brilliant Blue, said Dr Le Mer, is the cost. “It is an expensive product and the price is too high. However, this is really the only viable argument for continuing with indocyanine green (ICG) use bearing in mind concern about its possible phototoxicity and the fact that there is no CE mark for ICG either,” he said. Dr Le Mer added that staining is mandatory when the surgeon needs to completely remove the ILM. “Studies comparing surgical outcomes with or without ILM peeling should always use a specific dye in order to properly assess the outcomes. Brilliant Blue is expensive but it is the only dye with CE marking which helps to avoid any possibility of a ‘kitchen pharmacy’ approach to its use in surgery,” he said.

contact

Yannick Le Mer MD – ylemer@fo-rothschild.fr

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Update

retina

RETINAL PROSTHESIS

Formal testing demonstrates significant improvements in variety of visual tasks by Cheryl Guttman Krader in Fort Lauderdale

he Argus II retinal prosthesis (Second Sight Medical Products Inc, Sylmar, CA) provides longterm major improvements in the lives of patients with advanced retinitis pigmentosa, reported Mark S Humayun MD, PhD at the annual meeting of the Association for Research in Vision and Ophthalmology. Dr Humayun presented results from 30 patients implanted for a mean of 2.4 years as part of a prospective, single-arm, international study currently ongoing at 10 centres. The patients have severe to profound outer retinal degeneration secondary to retinitis pigmentosa or related dystrophies with remaining visual acuity of bare light perception or worse. He reviewed safety data and presented outcomes of structured performance testing with high-contrast environments that consistently showed use of the system was associated with significant improvements in localisation and direction of motion tasks, visual acuity, character recognition, orientation, and mobility. Some patients also recovered colour perception and reading ability. “All implanted patients detect phosphenes and are using the system outside of the clinic where they report it improves their daily lives. With the Argus II, patients are able to locate and find objects indoors and outside, and they are able to localise their position and pass through doors and into elevators without hitting door frames. As a first achievement for any retinal prosthesis, some patients are even reading short sentences, and with continued training they have been able to quickly increase their reading speed. Now efforts to develop a rehabilitation programme have begun,” said Dr Humayun, professor of biomedical sciences, ophthalmology, biomedical engineering, cell and neurobiology, Doheny Eye Institute, University of Southern California, Los Angeles. He told EuroTimes: “The development of a retinal prosthesis has been extremely challenging but also very rewarding. After being involved for almost 25 years from the inception of the project, it is truly wonderful to see that the retinal implant has gotten CE mark approval and will be available in Europe for patients for whom otherwise there was no foreseeable cure.” In a square localisation task, subjects identify a static square, 2.8 x 2.8 inches, displayed on a touch screen monitor. Results from testing performed with the retinal prosthesis system on versus off showed 86 per cent of the 30 patients performed significantly better using the system. Motion detection was tested using a touch screen monitor displaying a moving 1.4-inch wide bar. For this task, 54 per cent of subjects performed significantly better with the system on versus off. “Motion detection is a more difficult test because of the temporal aspect, and the results give us insight on where we need to be working to improve device functionality,” Dr Humayun said. Visual acuity is tested using square wave gratings on a CRT. Using the Argus II, 27 per cent of patients had improved visual acuity, with the best achieved being 20/1260. “These are encouraging results. With the first generation of our retinal prosthesis, which had 16 electrodes, the best visual

EUROTIMES | Volume 16 | Issue 9

acuity was about 20/4000. We would predict that a future generation device with 1000 electrodes might provide visual acuity of 20/80. Of course, there are many variables,” Dr Humayun commented. For character recognition, patients were presented with a series of letters and numbers organised into four sets according to recognition difficulty. Across all four sets, a subset of patients were able to accurately identify only about 10 per cent of characters when the testing was performed with the system switched off. However, when using the retinal prosthesis, they accurately identified 80 per cent of characters in the most difficult set and up to 95 per cent in the easiest series. Orientation and mobility testing was performed by having subjects perform walking tasks involving finding a door and following a line, and the testing conditions were varied to increase difficulty. Even in the more challenging tasks, performance was significantly better with the system on versus off. Perception of eight different colours was achieved in a subset of patients who underwent testing of this function. Elicitation of colour perception is provided through frequency-based stimulation using specific electrical patterns for different colours. The information being gathered in this initial testing will be applied in the future design of the electrode array where various electrodes will represent different colours. “If something is red, the visual processing unit will stimulate the electrode array with a corresponding pattern that allows the patient to perceive that colour,” Dr Humayun said.

Reliability and safety As of May 2011, time postimplantation ranged up to four years, and during that time, the system has continued to perform dependably except for one device that was affected by a communication failure after 10 months. In the latter case, the telemetry coil was believed to have been damaged during implantation, but the system functions intermittently, and the epiretinal electrode array remains implanted in this patient. Complications have included 10 per cent rates of both conjunctival erosion and endophthalmitis. Recurrent conjunctival erosion accounts for the single case of device explantation in the series. “Problems with conjunctival erosion have been addressed with modifications to the device and its placement, and we’ve learned to better maintain sterile techniques intraoperatively so that the electrode array is protected from contamination. The risk of endophthalmitis is something that concerned us early on, but with institution of new practices, there have been no cases in the last 15 patients implanted,” Dr Humayun said. The Argus II system received the CE mark in February 2011, and Second Sight plans to submit an application for FDA approval this year.

contact Mark S Humayun – humayun@usc.edu

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Ocular

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EUROTIMES | Volume 16 | Issue 9

Keynote lecture at SOE Congress sheds new light on controversial pathology by Dermot McGrath in Geneva

escribing optic neuritis as a prevalent medical problem that generates a fair degree of confusion and fear, Jonathan Trobe MD used his keynote lecture at this year’s SOE/AAO Joint Congress to try to dispel some of the mystery surrounding one of ophthalmology’s more controversial pathologies. “Optic neuritis is an extremely prevalent problem and I doubt that there is anyone here today who has not seen a case of this and who has been confused and a bit frightened by it. Perhaps the confusion is partly the fault of those of us who write about this disease because we have done nothing but make the issue more complicated and less understandable,” he said. Dr Trobe, head of neuro-ophthalmology and professor of ophthalmology and neurology at the University of Michigan Medical Centre, Ann Arbor, Michigan, US, said that optic neuritis can be divided into two forms: “typical” and “atypical”. “Typical optic neuritis is unfortunately not treatable, but fortunately it is usually benign. By contrast, atypical optic neuritis is often treatable and is usually not benign, so this is why it is so important to distinguish between the two,” he said. To help in this process, Dr Trobe described the profile of optic neuritis based on more than a quarter of a century of research and scientific studies on the disease, and in particular the groundbreaking Optic Neuritis Treatment Trial (ONTT) which ran from 1998 to 2006. “Optic neuritis is now considered to be a primary auto-immune attack on optic nerve myelin and/or oligodendrogliocytes. We are still not sure which is the target. It is also believed to be an auto-immune disorder, although that is still not completely confirmed,” he said. The role of T cells in the disease has also been highlighted in recent years, said Dr Trobe. “If the T cells cannot traffic across the blood-brain barrier then this disease will not happen and most of the newest work is focusing on preventing the adhesion of these T cells to the appropriate receptors on the endothelial cells of the blood vessels,” he said. In terms of the clinical profile of typical optic neuritis, Dr Trobe said that it is usually found in patients aged between 15 and 45, two-thirds of affected patients are female, and it is usually present unilaterally. There are manifestations of multiple sclerosis in one-in-five patients, the onset occurs over two-to-five days, with afferent pupil defect and nerve fibre bundle defect present. There is normal fundus in twothirds of cases or slightly swollen optic disc in one-third.

“Optic neuritis is now considered to be a primary auto-immune attack on optic nerve myelin and/ or oligodendrogliocytes”

There are several facts to bear in mind about vision in cases of typical optic neuritis, said Dr Trobe. First, the vision should not continue to get worse after 14 days. If it does, it is atypical optic neuritis. The vision should also begin to improve within four weeks, and recovery of vision is completed within six months. Visual acuity returns to normal or close to normal in 85 per cent of patients, he added. Long-term studies have also helped to shed light on the link between typical optic neuritis and multiple sclerosis. “Many studies show that MS develops in about 60 per cent of cases but we must bear in mind that almost half of the patients will not develop MS and to give them the fear of MS is not justified. You have to tell them about it, but make sure that they get the balanced view on it. The other good news is that of the patients who develop MS, 95 per cent of them are walking without assistance after 15 years and that is very important news for patients who are going to be frightened when you give the diagnosis of optic neuritis,” he said. Magnetic resonance imaging also has a valuable role to play in establishing the diagnosis, said Dr Trobe. The presence of white matter lesions on the initial magnetic resonance image of the brain has been identified as the strongest predictor for the development of MS. “Data from the ONTT showed that the more lesions are present in the brain so the likelihood of MS increases. Zero lesions with optic neuritis means the patient has a 25 per cent 15-year risk of developing MS, compared to 75 per cent with one or more lesions present. Interestingly, the studies indicate that just one lesion is enough to change a patient over from a low risk to a high risk of developing MS,” he said. Other ancillary studies, such as lumbar puncture, chest X-ray or visual evoked potentials, are completely trumped by the MRI scan in cases of typical optic neuritis and will not add additional information, he said. Using high-dose corticosteroids for typical optic neuritis has limited impact on the course of the disease and should not be encouraged, said Dr Trobe. Compared to the typical form of the disease, the pathogenesis of atypical optic neuritis is quite complicated, said Dr Trobe. “The inflammation may start in the optic nerve or come from the meninges, the orbit or para-nasal sinuses. Moreover, these are probably B cell mediated disorders,” he said. Atypical optical neuritis presents diagnostic dilemmas for ophthalmologists, said Dr Trobe and they should be alert to warning signs that deviate from the clinical profile of typical optic neuritis. In addition, Dr Trobe said that numerous diseases have been found to mimic typical optic neuritis, including compression by tumour, aneurysm or cyst, retinal diseases, infiltrating cancer, toxic optic neuropathy, ischemia, radiation, medication toxicity, malnutrition, Leber’s optic neuropathy, systemic infections and various inflammatory disorders.

contact Jonathan Trobe – jdtrobe@med.umich.edu

www.wcpos.org

Update

Ocular

VISION RESTORATION

Novel device allows patients to 'see' via tongue stimulation By Cheryl Guttman Krader in Fort Lauderdale

to walk the course with no obstructions divided by the time needed to navigate the obstructed course wearing the SSD, was the primary outcome measure. After completing about 20 hours of training with the SSD, the blind patients’ PPWS worsened initially. However, this result was attributed to the fact that enabled by their video review, the participants were searching for objects within their environment. With additional experience navigating the course, the time needed to complete the course improved and the subjects were bumping into fewer obstacles. On the various courses, they were able to identify about half to almost twothirds of light obstacles present and almost half of dark obstacles. There appear to be no adverse effects associated with the SSD. Patients describe a bubbly sensation on the tongue, but the effect is not something that users complain about. “Compared with implantation of a retinal prosthesis, sensory substitution with this non-invasive device offers a safer, less expensive method for providing blind patients with some semblance of ‘vision’, particularly if they were previously sighted and have some remembrance of what sight was like. It might also be considered for patients who are interested in retinal chip surgery as a means to provide some simulation of what their vision would be like,” said Thomas Friberg MD, director, medical and surgical retinal services, and professor of ophthalmology, UPMC. He is working with Amy Nau OD, director of UPMC Low Vision Services, in the assessment of the device.

contact Thomas Friberg – friberg@pitt.edu

Courtesy of Thomas Friberg MD

n innovative sensory substitution device (SSD) that allows patients to ‘see’ with their tongues could provide functional vision to blind people, reported researchers from the Louis J Fox Centre for Vision Restoration, University of Pittsburgh Medical Centre (UPMC), Pennsylvania, at the annual meeting of the Association for Research in Vision and Ophthalmology. The BrainPort (Wicab) device couples a spectacle-mounted video camera to an electrotactile display residing on the tongue. Image capture by the camera results in stimulation of the intraoral electrode array. User interpretation of the stimulation pattern allows perception of basic images in the ambient environment. The device is currently being evaluated in FDA clinical trials. The present iteration features a one-inch square array containing 400 electrodes. The video camera has a field of view of 73 degrees. Results from testing in blind patients using a modified tangent screen showed the device provided a visual field averaging about 60 degrees in both the horizontal and vertical meridians. The extent of the visual field was comparable in blind and sighted, blindfolded subjects, and remained unchanged with continued at-home use of the device by blind patients. Testing to evaluate how well the device enhanced perception of one’s surroundings was performed by having blind subjects (light perception or worse vision) navigate a standardised, 40-foot obstacle course. Three different courses were constructed using life-sized objects and representing varying levels of difficulty. Percentage of the preferred walking speed (PPWS) achieved, calculated as the ratio of the time needed

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Ocular

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EUROTIMES | Volume 16 | Issue 9

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3-D ultrasound scanner similar to one now used in small animal labs could give ophthalmologists a new tool for quickly evaluating ocular conditions and injuries, Gholam A Peyman MD told the innovators symposium of the ASCRS annual meeting. In a test on enucleated pigs’ eyes and a human volunteer, the Vevo 2100 (VisualSonics, Toronto, Canada) generated 2-D and 3-D images of the complete anterior and posterior segments, as well as corneal surface topography and details of surrounding structures such as Meibomian glands in just 10 seconds. The solid-state array of 256 ultrasound transducers is also capable of measuring physiological function, including blood flow in the temporal and central retinal arteries, lesion vascularity and tissue oxygenation throughout the eye. Rapid data acquisition, ease of use and ability to image through opaque media would make the device ideal for emergencies, such as detecting intraocular foreign bodies and injuries, scleral rupture and detached retinas, Dr Peyman said. Its quick and reproducible results also would make it practical for routine screening as well as initial assessment and follow-up for conditions including angle closure, ocular lesions, focal vitreous attachments, and retinal conditions. “The unit’s capabilities exceed current imaging equipment,” said Dr Peyman, who holds 124 US patents including the first 23-gauge vitrectomy system and the original concept for LASIK. He is investigating ocular uses for the device with colleagues (Prof R S Witte, Mr P Ingram and Mr L G Montilla) at the Department of Radiology at the University of Arizona in Tucson, where he is a professor at College of Optical Sciences in Tucson and BMS in Phoenix campus.

Beyond B-scans Ocular ultrasound was introduced more than 60 years ago with the A-scan. Using one fixed transducer, this one-dimensional device remains valuable for measuring the length of the eye for IOL power calculations, and for differentiating tissue based on the amplitude of reflected signals, Dr Peyman noted. About 10 years later the B-scan was introduced, using an oscillating piezoelectric element creating a 2-D image at 10-30 Hz. While contact B-scans are valuable for differentiating intraocular lesions, locating

intraocular foreign bodies and assessing the vitreous and retina, the image field is limited to 50-60 degrees. Imaging lesions requires carefully positioning the probe on the opposite side of the eye. A complete scan requires repositioning the probe around the sclera to capture the 360 degrees, a process that takes an unskilled operator 10-20 minutes. But the anterior segment and ciliary bodies are missed and low frequencies limit resolution, Dr Peyman said. The 2-D images produced can make it challenging to interpret the location of lesions. High resolution automated scanners in the 50-100 MHz range have been developed for anterior segment, topography and refractive surgery imaging, including the ArcScan Artemis (Topcon, Oakland NJ, US). While these instruments provide very high resolution, and can produce 3-D images, their high frequency prevents imaging deeper than the posterior capsule. The advent of fixed arrays of hundreds of high frequency transducers opens the door to real-time imaging and quicker scans at a variety of depths, Dr Peyman said. He noted that the probe he used is long enough to cover the entire equator of the eye. In his study Dr Peyman used two probes; one at 25 MHz for imaging the entire eye and a second at 50 MHz for the anterior segment only. Pig eyes with and without traumatic injuries or intraocular foreign bodies were examined. Dr Peyman volunteered to have his eyes imaged with the device, which is not approved for use with living humans. Data from the transducers is transformed into 3-D images that can be rotated to any angle, providing clinicians with very clear pictures of the location and size of any anatomical feature. In this test, the images readily revealed traumatic injury to the anterior segment of the eyes as well as lens dislocation and a traumatic protrusion of the vitreous into the anterior chamber. The system can provide volumetric analysis of any feature of the eye, making it valuable for assessing the ciliary body lesions, the tumours located in the posterior pole, cupto-disc ratios and cross sections of the optic nerve at each desired plane. Dr Peyman believes this technology could expand the use of advanced diagnostics.

contact Gholam Peyman – peyman1@yahoo.com

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www.euretina.org

Update

global ophthalmology

VISION VAN HELPING JAPAN

US and Japanese eye surgeons work together at disaster area

Standing in front of the Vision Van as it was being loaded into a cargo jet at Miami International Airport are Richard Lee MD, PhD, who accompanied the Vision Van to Japan; Eduardo Alfonso MD, chairman of Bascom Palmer Eye Institute; and Kazushi Miyatake MD, medical attaché of the consulate general of Japan in Miami

A volunteer paediatric ophthalmologist from Iwate, Japan who travelled for hours to assist survivors. Her father was an ophthalmologist in the same area who was among those who died during the tsunami

hen Japanese ophthalmologists asked for help after the disastrous Tohoku earthquake and tsunami, the Bascom Palmer Eye Institute of the University of Miami Miller School of Medicine sent a rolling eye clinic directly to the troubled area.

EUROTIMES | Volume 16 | Issue 9

Kazuo Tsubota MD, PhD, chief of the Department of Ophthalmology, Keio University School of Medicine, Tokyo, requested assistance from Richard Lee MD, PhD, associate professor of ophthalmology and glaucoma specialist, at the Bascom Palmer Eye Institute. The Institute immediately offered the services of the

12-metre-long Vision Van, and with the help of Volga-Dnepr Airlines and the financial support of the government of Japan, shipped the vehicle on an Antonov An-124, the world’s largest cargo plane. “I really appreciate Bascom Palmer’s support for the healing of Japan. I went with my team to north-eastern Japan to assess the damage and find ways to help the survivors with their ocular needs. I knew, just as you have seen on the news, that many towns had been destroyed. But when I was there I was so shocked that it brought me to tears. From the bottom of my heart I feel that I want to help,” Dr Tsubota said. The Bascom Palmer Vision Van has three screening rooms, an examination room, and a small operating room. Diagnostic capabilities include autorefractometry, keratometry and tonometry. The van also carried more than 1,000 ready-made replacement eyeglasses, which were donated by Eye Care Centres of America, for the people who lost them when they fled. Dr Lee accompanied the Vision Van and provided training to a team of ophthalmologists of the Department of Ophthalmology, Tohoku University School of Medicine and Department of Ophthalmology, Iwate Medical University. One of the Japanese volunteers was a young paediatric ophthalmologist whose father, also an ophthalmologist, had died right after the tsunami occurred. The team began providing mobile treatment in the Sendai area in April. “The Japanese eye MDs were amazingly organised and were ready to take over the Vision Van and efficiently provide eye services such as refraction to replace lost or broken eyeglasses and replacement medications in addition to eye screenings and chronic eye care for those patients whose eye doctors lost their offices and work places. The Vision Van not only provides acute care for immediate needs but also chronic care for patients. For the eye MDs who lost their workplaces, the Vision Van provided them with a mobile eye clinic to provide services and allow them to continue to practise until they can find new or rebuild their practices,” Dr Lee told EuroTimes. On the very first day it arrived the Vision Van team saw approximately 80 people at an evacuation centre in Onagawa, Miyagi, which was wiped out by the tsunami. Many patients presented with eye infections associated

Courtesy of Bascom Palmer Eye Institute

by Sean Henahan in Japan

A survivor (right) who exclaimed: “I can see!” after being helped by ophthalmologists

with contaminated water and with wearing contact lenses for long periods of time. In addition to acute care, the Vision Van is equipped to help patients with chronic conditions such as glaucoma, diabetic retinopathy and macular degeneration. “The perseverance, dignity and humble manner in which Japanese people have dealt with this disaster should be an inspiration to people in other areas of devastation, and for people seeking to understand what the Japanese are experiencing in the face of such devastation,” commented Dr Lee. The Vision Van provided mobile emergency eye care services in Haiti following the massive earthquake last year, and in New Orleans, Louisiana, after Hurricane Katrina in 2005. When it is not providing emergency services, the Vision Van travels in underserved parts of Florida providing essential eye care services. “I hope that by making every effort to promptly support Dr Tsubota and the people of Japan in this time of crisis, we help to improve the medical conditions in Japan and help facilitate a rapid recovery. Knowing the success we had with the Vision Van in New Orleans following Hurricane Katrina, I believe the Bascom Palmer Vision Van will prove to be an invaluable resource for Dr Tsubota’s team,” said Eduardo Alfonso MD, chairman of Bascom Palmer Eye Institute and former classmate of Dr Tsubota’s. The death toll from the Tohoku earthquake and subsequent tsunami and nuclear power plant emergency now exceeds 15,000. At least 10,000 people are listed as missing and 160,000 have been displaced from their homes. Dr Tsubota and colleagues, suitably impressed by the Vision Van’s utility, are already putting plans in place to create similar vehicles for Japan.

contacts

News

Orbis & oxfam

two worthy causes

ESCRS congress delegates in Vienna are encouraged to donate to charities in developing countries

rucial funding is being raised to support projects in Ethiopia and Uganda, sponsered by ORBIS and Oxfam, as part of a new initiative launched by the ESCRS.

ORBIS in Ethiopia The first of these projects, sponsored by ORBIS, is the Gondar University Referral Hospital in Ethiopia. Ethiopia has one of the highest blindness prevalence rates in the world, around twice that of other developing countries, with 1.2 million blind people out of a population of 82 million. Gondar is located 725km north west of Addis Ababa in Amhara regional state. Like the rest of Ethiopia, the main causes of blindness in Amhara are cataract, trachoma and refractive error. There are an estimated 6,300 blind children in Amhara, and another 31,500 children with low vision. The government-funded Gondar University Hospital is located 725km north of Addis Ababa, in the town of Gondar, servicing an estimated population of around 14 million in the region and 3-4 million in the project area. ORBIS partnered with Gondar University from December 2004 until December 2010 to implement an innovative and cost-effective approach to increasing levels of eye care in rural areas.The project was designed to train mid-level health professionals, such as nurses or optometrists, to effectively treat cataract blindness in the rural setting,

to screen and prescribe eye glasses and to prevent blindness caused by the late effects of trachoma. The deployment of newlytrained eye care workers to the rural areas has significantly improved access to and use of services. The ORBIS partnership with Gondar University Referral Hospital concluded at the end of 2010. However, following on from the strong success of this project, ORBIS has committed to work with Gondar University Hospital to establish a Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia. “The goal of this project is to support the development of a paediatric eye care service at Gondar Referral Hospital. This will provide children with access to high-quality eye care, which in turn will contribute to a decrease in childhood blindness and low vision in North West Ethiopia,” Allan Thompson of ORBIS told EuroTimes.“It is very important to stress the fact that we are identifying and recruiting training doctors from the region to work on the project,” said Mr Thompson. “Training is a key component of the ORBIS programme and we want to establish projects that are sustainable by ensuring that local doctors receive the best possible instruction. As part of our training programme, we are also sending these doctors on fellowships to centres of excellence in Europe and other international centres.”

Over the next four years, with the support of the ESCRS, the ORBIS Gondar Project aims to establish a fully equipped CEHTF with a trained paediatric eye care team at Gondar University Referral Hospital to ensure delivery of high-quality eye care. It is hoped this will strengthen the referral network and follow-up system within North West Ethiopia to ensure that children have access to eye care, and will ultimately increase awareness amongst adults, parents, guardians and the wider community, of the importance of seeking prompt medical advice for children’s eye conditions to ensure early detection and treatment.

Oxfam in Uganda After more than 20 years of conflict between rebels and government forces in Uganda, the victims of the conflict who were forced to flee their homes and live in camps are slowly starting to rebuild their lives. As a result of a new initiative launched by the ESCRS, urgent funding is being raised to support an Oxfam project to bring clean, safe drinking water to the people in the Kitgum district. “A lack of clean, safe drinking water and proper sanitation facilities, together with a general lack of knowledge about the importance of good hygiene, leads to unnecessary illnesses and preventable deaths from water-borne diseases such as cholera and diarrhoea,” said Peter Anderson, head of fundraising, Oxfam Ireland.

Support ORBIS and Oxfam by pledging a donation when you register for the XXIX ESCRS Congress in Vienna Visit www.escrs.org

EUROTIMES | Volume 16 | Issue 9

Allan Thompson – athompson@orbis.org.uk Deirdre Miller – deirdre.miller@oxfamireland.org

“Lack of water for bathing also facilitates the spread of ‘water-washed diseases’ that affect the eyes, such as trachoma and conjunctivitis. “The security situation has significantly stabilised in Uganda and many people are returning to their home villages. Average access to latrine and sanitation facilities in Kitgum district is just 31 per cent in the villages that people are returning to. Oxfam will be working to set up water facilities in these villages and then teach the community how to maintain the facilities and to promote safe hygiene practices,” Mr Anderson said. While the communities have emphasised the need for latrines, the actual construction of these facilities has been relatively low due to lack of knowledge and skills and the materials for construction. To meet this need Oxfam has helped establish Community Water Management committees in the villages of Kitgum. The local people in these committees are being taught the skills needed to maintain water sources and sanitation facilities in the long term. Motorised water pump systems are also being repaired and modified to provide a water supply to the local communities. Oxfam is also coordinating communitybased sanitation and hygiene promotion to educate villagers about the importance of safe hygiene practices which will help reduce incidences of intestinal diseases. An important part of this campaign is the support for School Health Committees which are helping to educate school children in the importance of safe hygiene practices. “I am delighted that the ESCRS has decided to support these very important projects,” said José Güell MD, president of ESCRS, “and I would urge members and delegates attending our XXIX Congress to pledge a donation to support ORBIS and Oxfam.”

Tropical Breezes, Exceptional Education AND Shorter Flights, Lower Costs than other Winter Meetings! Next winter, join us for the 5th Annual ASCRS Winter Update and discover all Playa del Carmen, on Mexico’s ‘Riviera’ has to offer. Hosted at the AAA Five Diamond® Fairmont Mayakoba once again, the 2012 program will continue the tradition of excellent education in a spectacular location. Make your plans for next winter now for extra savings! Register today!

For registration, housing and program updates, visit:

www.WinterUpdate.org

“

The meeting was great. The casual atmosphere allowed open discussion. My family loved the resort and our day trips to Xcaret to snorkel and to Coba to see Mayan ruins.

”

Gary J. Foster, MD, Fort Collins, Colorado

Program Chairs

Program Committee

Edward J. Holland, MD Stephen S. Lane, MD Roger F. Steinert, MD

David F. Chang, MD Eric D. Donnenfeld, MD Richard A. Lewis, MD Keith A. Warren, MD

Faculty Clara C. Chan, MD Vincent P. de Luise, MD Lisa Gangi, COE Terry Kim, MD W. Barry Lee, MD Richard L. Lindstrom, MD Nancey K. McCann Tina Pinke, COT, COE E. Ann Rose

Program at a Glance Thursday, February 16 • Networking & Welcome Friday, February 17 • Complicated Cataract • Cornea • Luncheon Workshops • Evening Session: Legislative Update Saturday, February 18 • New Technology in Cataract and Lens-Related Surgery • Retina • Luncheon Workshops • Evening Session: Video Complications Seminar • Attendee Networking Dinner

Jonathan B. Rubenstein, MD Thomas W. Samuelson, MD Paul Stubenbordt R. Doyle Stulting, MD, PhD Vonda Syler, COE Jonathan H. Talamo, MD Maureen L. Waddle, MBA Liliana Werner, MD, PhD more to come...

Sunday, February 19 • Challenging Cases for the Comprehensive Clinician • Glaucoma • Luncheon Workshops • Evening Session: Medicare Update Monday, February 20 • Keratorefractive • Faculty Roundtables/Wrap-Up

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News

escrs award

GRAND MEDAL

Dr Emanuel Rosen will receive the ESCRS Grand Medal of Merit in Vienna

manuel Rosen BSc, MD, FRCSEd, FRCOphth, FRPS, will be awarded the ESCRS’s highest accolade, the ESCRS Grand Medal of Merit, at the XXIX ESCRS Congress in Vienna, Austria. The medal will be presented at the Opening Ceremony of the congress on Sunday September 18, 2011. The medal is being awarded in recognition of his pioneering work as an ophthalmologist and for his outstanding contribution as a founding father of the ESCRS. As an ophthalmic surgeon Dr Rosen’s initial interests were centred on retinal

disorders. In 1964-65 he was able, as a consequence of his life-long interest in photography, to refine the newly discovered technique of fundus fluorescein angiography. In 1969 having collected a unique portfolio of retinal disorders through the medium of angiography, he produced the first English language textbook on the subject. In 1973 he performed his first IOL implant after removing a cataract. Lens implants allowed modification of the focus of an eye, thus initiating a new era of ophthalmic surgery. 30 years after joining the Royal Eye Hospital in Manchester, UK, as a

junior trainee, having spent 22 years as a consultant surgeon, Dr Rosen was approached by the management of the Pinderfields Health Care Trust in Wakefield Yorkshire, to advise them on the modernisation of their ophthalmic facilities. He advised them to create a cataract surgery day care centre where the nursing team members would play extended roles. The system maximised use of surgical skills in the operating theatres. This system has operated with dramatic effect on local eye care, for the past 10 years. In the private sector, Dr Rosen pioneered the establishment of a unique facility of the practice of refractive surgery, culminating in the construction of a purpose-built unit at the Alexandra Hospital, Manchester, UK which opened in 1999.

ESCRS In 1983 Dr Rosen was the instigator and first editor of the European Journal of Implant and Refractive Surgery, a peer-review journal which established international recognition of European cataract and refractive surgery. In 1995, the

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Alcon in Vienna Saturday, 17 September Live Surgery: Presenting Advancing Technologies for Advancing Techniques Main Hall A ~ Messe Wien Congress Center 18:00-18:30 Registration & Refreshments 18:30-21:00 Live Surgery Broadcast from Semmelweis University

Learn from world-renowned surgeons as they manage challenging cases using the latest advancements in Alcon’s cataract, refractive, and glaucoma surgery technologies. Featured technologies will include: • LenSx® Laser • INFINITI® Vision System with OZil® Intelligent Phaco (IP) and ULTRACHOPPERTM Tip • EX-PRESS® Glaucoma Filtration Device • AcrySof® CACHET® Phakic Lens • Advanced Technology IOLs including • AcrySof® IQ ReSTOR® + 3.0 D • AcrySof® IQ ReSTOR® Multifocal Toric • AcrySof® IQ Toric

Save the date for these symposia during the XXIX Congress of the ESCRS in Vienna.

Surgical Faculty

Faculty Panel

Prof. Zoltán Zsolt Nagy Host Surgeon Hungary

Dr. Donald N. Serafano Moderator USA

Dr. Ike Ahmed Canada

Dr. Edward J. Holland USA

Dr. Francesco Carones Italy

Prof. Dr. Michael C. Knorz Germany

Dr. Philippe Crozafon France

Dr. Ozana Moraru Romania

Dr. Khiun Tjia Netherlands

Dr. Rudy M.M.A. Nuijts Netherlands

Dr. Robert H. Osher USA

Sunday, 18 September MGD: The Most Common Ocular Surface Disease and Its Surgical Implications Lehar 1 Room ~ Messe Wien Congress Center 13:00-14:00 (lunch boxes will be provided) Faculty Moderator: Dr. James McCulley, USA Pr. José M. Benitez del Castillo, Spain Pr. Gerd Geerling, Germany Dr. Elizabeth Messmer, Germany

Sunday, 18 September Innovations in Cataract Surgery

Strauss 1 Room ~ Messe Wien Congress Center

13:00-14:00 (lunch boxes will be provided) Faculty Moderator: Mr. David Allen, United Kingdom Dr. Rosa Braga-Mele, Canada Prof. Dr. Michael C. Knorz, Germany Dr. Abhay Vasavada, India

Sunday, 18 September Innovations in Advanced Technology IOLs and Laser Systems Imperial Palace*

18:15-19:00 – Registration 19:00-20:00 – Symposium 20:00-21:00 – Reception Faculty Moderator: Prof. Dr. Michael C. Knorz, Germany Faculty Moderator: Prof. Dr. Theo Seiler, Switzerland Dr. Arthur Cummings, Ireland Dr. Bonnie Henderson, USA Prof. Zoltán Zsolt Nagy, Hungary Dr. Rohit Shetty, India

*Ground transportation from the Messe Wien Congress Center to the Imperial Palace will be provided. Visit the Alcon booth (B410) for more details.

Monday, 19 September Innovations in Glaucoma Surgery: Improving Predictability in Filtration Surgery Strauss 1 Room ~ Messe Wien Congress Center

13:00-14:00 (lunch boxes will be provided) Faculty Moderator: Dr. Tarek Shaarawy, Switzerland Dr. Ike Ahmed, Canada Dr. Elie Dahan, Israel Dr. Leo DeJong, Netherlands Dr. Stefano Gandolﬁ, Italy

Feature

PRACTICE DEVELOPMENT

MIND YOUR MONEY

by Howard Larkin

“W

make adjustments. By managing practice finances on a monthly basis the practitioner can react with greater speed to unforeseen events,” says Mr McCaffrey of MedAccount Services, Dublin, Ireland. He will present a seminar on financial issues at the ESCRS/EuroTimes Practice Development Workshop and Masterclass, which will be held on November 12 and 13 in Dublin.

Separate business and personal accounts While most doctors’

personal and practice finances are closely interrelated, it is critical that they be managed separately, Mr McCaffrey says. “Many practitioners run all of their business and personal income and expenditure through one account and this can cause difficulty in trying to manage a practice.” A separate practice account makes it easier to track expenses, which in turn facilitates planning, Mr McCaffrey notes.

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EUROTIMES | Volume 16 | Issue 9

David McCaffrey – david@medaccount.ie

our clients have our mobile phone numbers and regularly contact us after hours. The accountant or financial advisers should be used as part of the business support team.”

Managing personal and practice funds is an essential practice-building skill here is all my money going?” It is one of the most common questions that Irish accountant David McCaffrey hears from doctors. And the economic downturn has lent the question new urgency. With practice receipts down, it’s more important than ever to manage overheads. If you don’t, your private practice efforts could easily cost more than you bring in. The first step toward understanding and controlling costs seems obvious – though Mr McCaffrey says it’s one many practitioners overlook. It is simply to regularly review your practice operations and cash flow. “We prepare monthly or quarterly management accounts for our clients and these form the basis of regular meetings during the year. This helps practitioners better understand their operations and

contact

“Management accounting cash flow figures can be used to create forecasts for the following 12 months, and models created with different levels of income and expenditure. This allows you to be proactive in managing the difficult trading environment that many practitioners operate in today.” It may also be wise to separate your retirement finances from your practice finances as well, Mr McCaffrey says. “In the past many practitioners viewed their practices as their retirement plan. But with the fall in practice valuations and pension fund values, retirement planning is now a real issue.” He recommends consulting with a qualified pensions adviser to develop a realistic plan. Payroll can also be a difficult issue for practitioners – and one that can land you in trouble if you fail to properly report it and pay any appropriate fees and taxes. “It is not uncommon to find actual staff wages paid being different to amounts recorded in payroll systems,” Mr McCaffrey says. He notes that few practitioners have the capacity to manage complex practice finance issues, particularly if they are in solo practice. Therefore, he advises private practitioners keep in regular contact with a business support team so that any issues that arise within the practice can be dealt with early.

Finding a qualified financial adviser Given the financial and even

legal stakes, it’s clear that your accountant or financial adviser must be well versed in financial management practices as well as applicable laws and regulations. Chartered, registered or certified professionals generally possess these skills. But Mr McCaffrey says an adviser also should be familiar with your business. “It is important that an accountant or financial adviser should be suitably qualified and has the experience to understand the business model being operated. By understanding the clinical care pathway the accountant can provide more specific advice.” Access is also important, Mr McCaffrey says. “Accountants and financial advisers should be providing advice and support throughout the year and should be readily accessible. For example, in our practice all of

Legal protection Similarly, it may be wise to consult a lawyer experienced in healthcare issues to review practice operations for legal compliance and defence of possible malpractice claims, says Dublin barrister Paul McGinn. “Documentation is especially important. When a case comes to trial, what is in the record often matters far more than what you actually did.” Mr McGinn will present a model for reviewing legal documents and procedures that practices should have in place to ensure you meet requirements in employment, data protection, confidentiality, consent, health and safety and clinical documentation. He strongly advises checking with a lawyer familiar with your national and local laws to ensure such an audit covers all necessary topics. Practice planning London-based marketing expert Rod Solar, of LiveseySolar Practice Builders, will offer practical advice on overcoming common barriers to growing a practice, and a seminar on practice planning. He will share a case study of how an ophthalmology practice used e-marketing to increase revenues and market share. Even public practices may be threatened as government health programmes face shrinking budgets, adds Keith Willey BSc, MBA, associate professor of strategic and international management and entrepreneurship at London Business School. “Public health is coming under such pressure that hospitals and other centres of excellence will be given less resources in the future and could even face closure. In this scenario, they may find that they would be wise to look for new management ideas developed by those working in private medicine.” Ophthalmology as a business Prof Willey will supply attendees with a unique focus on ophthalmology as a business, and how to build a practice that meets individual needs, using a case study developed by London Business School. “Health services, whether private or state funded, need a strong managerial and financial base to progress and provide all the support our patients deserve,” says Paul Rosen FRCOphth, MBA, chair of the ESCRS Practice Development Committee. “This is particularly relevant in a fast developing specialty such as ophthalmology, where technological advancement has been stunning, but which requires rapidly rising funding in what is becoming a highly competitive market.”

ESCRS

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Practice Development

Workshop and Masterclass

12–13

Four Seasons Hotel, Dublin, Ireland

November 2011 Registration fee: Ð300

(includes Lunch at the Four Seasons Hotel and Dinner at The Royal College of Physicians)

To register visit: www.escrs.org/dublin2011

Sunday

Saturday Morning Session

Afternoon Session

08.30 – 08.45

14.00 – 15.00

Welcome and Introduction

Planning for the Future

Paul Rosen, chairman ESCRS Practice Development Committee

Rod Solar, LiveseySolar Practice Builders

08.45 – 09.30

Driving Innovation in Ophthalmology Keynote Lecture with Tim Clover, CEO Optegra Tim Clover will discuss how the industry has worked with ophthalmologists in developing innovative services.

Rod Solar will share an ophthalmology e-marketing case study and a to-do list to help you claim your online territory and start promoting your practice online using search, email and social media marketing. 15.00 – 16.00

Legal Audit

Paul McGinn BL, editor of EuroTimes

10.00 – 12.00

Paul McGinn will review legal documents and procedures helping to ensure that ophthalmologists meet legal requirements in employment, data protection, conﬁdentiality, consent, health and safety etc.

Rod Solar, LiveseySolar Practice Builders

16.00 – 16.30 Break

09.30 – 10.00 Break

Practice Building Rod Solar will offer practical advice on how to solve the four most common hurdles blocking you from growing your practice. 12.00 – 13.00

Practical Financial Issues David McCaffrey, partner with MedAccount David McCaffrey will explore the internal controls that should be applied to cash management within a practice. 13.00 – 14.00 Lunch

16.30 – 18.00

Ask the Experts and the Way Forward Our panel of speakers will take questions from the ﬂoor. This discussion will form the framework for a position paper to be discussed and agreed by delegates on the future direction of the ESCRS’s Practice Development Programme. 18.00 End of Saturday session 20.00 Gala Dinner at The Royal College of Physicians

Keith Willey, London Business School 09.00 – 10.00

Practice Development Masterclass Sharing our Profiles How are we as a group of ophthalmologists similar or different from each other? 10.00 – 11.00

Ophthalmology as a Business How do we differ from other professional groups or businesses? 11.00 – 11.20 Coffee/Tea 11.20 – 12.30 Case Study (To be conﬁrmed) 12.30 – 13.30

Planning for Growth How can we develop our practices to meet our individual needs? 13.30 – 14.25

Last Thoughts Building a plan for the future 14.25 – 14.30 Concluding remarks from Peter Barry, incoming president ESCRS

BREAKFAST WITH THE EXHIBITORS at the XXIX Congress of the ESCRS

Enjoy a complimentary breakfast on Monday morning from 10.00 â&#x20AC;&#x201C; 11.00 in Exhibition Hall B Choose from a selection of teas, coffees and snacks

Feature

Book review

Easy Conversations

Practical advice for oculoplastics

The curbside consultation is another term for the kind of informal chat that doctors have always had and probably always will have about challenging cases. In this age of evidence-based medicine and clinical guidelines, the curbside consultation is the kind of thing that is probably not supposed to happen anymore. Happen they do, however, and Slack has used the concept as the “hook” for a series of ophthalmic books. Each of these books takes a similar format – 49 clinical questions, generally ones which will face advanced practitioners rather than trainees, with an accompanying essayistic explanation. Each of these is written by an expert in the field, and is lavishly illustrated with fullcolour photographs as well as tables and schematic diagrams. The aim is to combine comprehensive, practical, evidence-based advice with the informality and ease of a conversation with a helpful colleague. This particular book focuses on oculoplastics and is divided into 10 sections. The first is on upper eyelid malposition and related disorders. The four chapters focus on blepharoptosis, both general management and more specific issues such as congenital blepharoptosis and the risk of upper eyelid retraction following blepharoptosis repair. The second section deals with lower eyelid malposition and related disorders – ectropion, entropion and lower eyelid retraction. The third section is on eyelid neoplasms. Firstly, the thorny issue of when an eyelid lesion requires biopsy is considered. Then there are discussions on therapeutic interventions – when should Mohs surgery be employed, the management of chalazia and actinic keratosis, and lentigo maligna. The fourth section is entitled “miscellaneous” and deals with a medley of topics such as tarsorrhaphy, trichiasis, facial nerve palsy, and the ever-vexing question of when to order an MRI or CT. The fifth section, divided into five chapters, is on orbital inflammation and infection. Moving on to the sixth section, we return to neoplasms, this time of the orbit. The section discusses the recommended EUROTIMES | Volume 16 | Issue 9

clinical approaches to lacrimal gland tumours, orbital lymphomas, conjunctival malignancies, and benign reactive lymphoid hyperplasia. A section on trauma covers orbital fractures, orbital foreign bodies, traumatic optic neuropathy, orbital haemorrhage and canalicular lacerations. All the advice is direct and practical as is required for traumatic clinical presentations. One of the most emotive and consequential procedures an ophthalmologist may be called upon to perform is an enucleation or evisceration. A whole section is devoted to this issue, and to that of the anophthalmic socket. The penultimate section deals with the lacrimal drainage system, and the final one with another emotive and consequential area, that of cosmetic oculofacial plastic surgery. This section has the most individual chapters, from “How do I manage the unhappy cosmetic patient?” to “What are the current thoughts on blepharoplasty?” Overall, this book covers a wide range of topics of interest to all practitioners.

books editor: Seamus Sweeney

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Feature

eu matters The difference is inside...

LEGAL COSTS

British government proposes law to reduce payments to lawyers who sue ophthalmologists by Paul McGinn

he British government has proposed a new law to reduce the fees that lawyers receive for suing ophthalmologists and any other doctor for malpractice. The proposed law, which should spur discussion of legal cost reforms throughout Europe, could significantly curtail the number of and overall cost of all so-called “personal injury” lawsuits. The proposal is expected to reach parliament in October. In announcing the proposal, British Justice Minister Jonathan Djanogly said that by limiting legal costs in such cases, the government was committed to ending “the perverse situation in which lawyers can be awarded a greater proportion of payouts than claimants,” and “the fear of a compensation culture which has put a stranglehold on the activities of businesses and public bodies.” Currently, lawsuits against the National Health Service are costing the British taxpayer about €1bn per year. Of that figure, only 40 per cent actually goes to injured patients. The rest goes to the patients’ lawyers. The two main indemnifiers of doctors in the UK, the Medical Protection Society and Medical Defence Union, have welcomed the proposals to help reduce costs. According to the latest statistics from the NHS Litigation Authority, the British taxpayer paid out £312m in compensation to injured patients and £456m in fees to their lawyers in 2008-2009. The proposed law would go a long way to reducing legal costs in England and Wales, where the majority of UK citizens live. The proposal would not affect lawsuits in Scotland or Northern Ireland, which have separate legal systems. A number of factors contribute to the lopsided expenditure on legal costs in medical malpractice cases and cases involving personal injury. One factor that affects the cost of malpractice lawsuits in England and Wales is that the loser of a case almost invariably pays the legal costs of the winner of the case. In addition, if a patient’s lawyer accepts compensation for the patient before the case is heard in court, the lawyer generally does so only if the hospital or doctor agrees to also pay the patient’s legal costs. Another factor that increases legal costs is the conditional fee agreement that a patient usually enters with her or his lawyer when commencing the legal process of EUROTIMES | Volume 16 | Issue 9

suing a doctor or hospital. Under such fee agreements, also known as “no foal, no fee” agreements, the patient does not pay the costs of his or her own lawyer if he or she loses. If the patient wins his case at trial or if the doctor’s indemnifier agrees to compensate the patient before trial, the patient’s lawyer receives his fees from the NHS or doctor’s indemnifier. In addition to receiving a base fee for running the case, the patient’s lawyer is also entitled to a so-called “success” fee, which can double the overall legal fee. Under current English and Welsh law, the success fee is paid by the losing side. Under the proposed law, a patient’s lawyer will not be entitled to recover a success fee from the losing side. Instead, the lawyer will only be able to recover the success fee directly from the patient, to be paid out of the patient’s own personal injury award from the court and only if the lawyer and patient have agreed to such payment beforehand. The proposed law will also allow patients’ lawyers to charge clients a percentage of the compensation they receive for the lawsuit. To reduce the risk that such legal fees don’t consume too large a proportion of a patient’s compensation, the proposed law provides for the country’s chief law officer, the Lord Chancellor, to introduce regulations to set the percentage and exclude from the calculation of such fees any compensation awarded for future care and loss. The proposed law would limit the circumstances in which patients can recover the cost of any premium paid for insurance against the risk of having to pay the costs of the doctors or hospitals if they lose their case and of any costs incurred by experts retained on patients’ own behalf for their case. Many lawyers will advise clients to take out such insurance to ensure that if they lose their case the insurance company will indemnify them. Under current law and practice in England and Wales, a patient who takes out legal costs insurance and wins can recoup the insurance premium as part of legal costs. Under the proposed law, a patient who wins would only be able to recoup the insurance premium in limited circumstances. To offset any injustice to the patient, the proposed law would allow the Lord Chancellor to introduce regulations to allow judges to award extra compensation to successful patients for the personal injury to assist them in paying additional legal fees to lawyers.

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28.07.2011 14:28:06

Registration now open! www.EyeWorld.org Check online for program updates.

Sunday, October 23, 2011 Laser-Assisted Cataract Surgery: The Discussion Continues Rosen Centre Hotel – Grand Ballroom 9840 International Drive

Adjacent to the Orange County Convention Center

Program Chairs: Stephen S. Lane, MD & Roger F. Steinert, MD 5:30 – 6:00 pm Registration (and reception) 6:00 – 7:30 pm program Register Now!

This session is designated for AMA PRA Category 1 CreditsTM.

Review

JCRS Highlights Journal of Cataract and Refractive Surgery Femto cataract surgery

The most recent conferences of the ESCRS and ASCRS saw many presentations on potential uses of the femtosecond laser in various aspects of cataract surgery. These included the creation of clear corneal incisions, correction of astigmatism, creation of the capsulotomy, softening the lens nucleus, and even restoration of accommodation. Many questions on the efficacy, safety and economics of these new approaches still need to be addressed, notes JCRS co-editor Nick Mamalis MD in an editorial. Clinical issues will also need to be reported in the peer-reviewed journals. One such study looking at the performance of the continuous curvilinear capsulorhexis (CCC) appeared in the JCRS recently. n N Mamalis, JCRS, “Femtosecond laser: The future of cataract surgery?” Volume 37, No. 7, 1177-1178

Femto capsulotomy

After preclinical work performing capsulotomies with an OCT-guided femtosecond laser in porcine and human cadaver eyes, researchers performed the same procedure in 39 patients as part of a prospective randomised study of femtosecond laser-assisted cataract surgery. The femtosecond laser-created capsulotomies were more precise in size and shape than manually created capsulorhexes, they report. In the patient eyes, the deviation from the intended diameter of the resected capsule disk was 29 μm ± 26 (SD) for the laser technique and 337 ± 258 μm for the manual technique. The mean deviation from circularity was six per cent and 20 per cent, respectively. The centre of the laser capsulotomies was within 77 ± 47 μm of the intended position. All capsulotomies were complete, with no radial nicks or tears. The researchers also were able to assess the strength of laser capsulotomies in the porcine eyes. They found that the strength decreased with increasing pulse energy: 152 ± 21 mN for 3 μJ, 121 ± 16 mN for 6 μJ, and 113 ± 23 mN for 10 μJ. The strength of the manual capsulorhexes was 65 ± 21 mN. Even in the most experienced hands, an optimal capsulorhexis is not always achieved with the standard approach. Femtosecond lasers are able to create precise, customisable incisions in ocular tissue without collateral damage. The current study using the OCTintegrated femtosecond laser system allowed placement of cutting patterns in ocular tissue, allowing the surgeons to achieve a level of precision unattainable with manual and mechanical techniques. n N. Friedman et al., JCRS, “Femtosecond laser capsulotomy”, Volume 37, No. 7 1189-1198.

New diagnostic tool

Postoperative bacterial endophthalmitis requires prompt intervention. However, EUROTIMES | Volume 16 | Issue 9

conventional microbiology techniques are time consuming and have low sensitivity. Brazilian researchers report that real-time polymerase chain reaction testing is useful in distinguishing between contamination and infection based on the cycle thresholds value. They evaluated 11 patients with infectious endophthalmitis, 12 control vitreous samples, and 50 control aqueous samples. Gram and culture identified 80 per cent and 75 per cent, respectively, of patients with infectious endophthalmitis. Real-time PCR assays were positive in 91 per cent of patients with a clinical diagnosis of endophthalmitis using aqueous samples, vitreous samples, or both. None of the 12 vitreous controls were positive by PCR. Two aqueous control samples were positive by real-time PCR. The cycle threshold cut-off value was 36 for universal PCR (sensitivity 93.8 per cent; specificity 100 per cent) and 38 for gram-specific PCR (sensitivity 93.8 per cent; specificity 100 per cent). Gram-positive microorganisms prevailed, and visual acuity varied according to the causative bacteria. n G Barreto Melo et al., JCRS, “Realtime polymerase chain reaction test to discriminate between contamination and intraocular infection after cataract surgery,” Volume 37, No. 7, 1244-1250.

KAMRA results

Four-year follow-up with the AcuFocus ACI-7000, now known as the KAMRA, intracorneal inlay suggest long-term safety and efficacy for the device. A study of 39 presbyopic patients aged 45-60 years showed lasting improvement in uncorrected near visual acuity, with most patients able to read J3 or better. Uncorrected distance acuity was 20/40 or better in all patients. Four inlays were explanted during the study. Reasons included refractive shift, thin flap and detection of a buttonhole flap. There were no severe corneal complications that affected final vision. n Ö Yılmaz et al., JCRS, “Intracorneal inlay to correct presbyopia: Long-term results,” Volume 37, No. 7, 1275-1281.

Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and jcrs journal

JCRS Symposium

CONTROVERSIES in Cataract and Refractive Surgery

2011

Sunday, September 18, 2011 14.00 –16.00 Chairs:



Emanuel S. Rosen, MD, FRCSEd Thomas Kohnen, MD, PhD, FEBO

Will femtosecond-assisted cataract surgery supersede microincision phaco cataract surgery?

Zoltan Nagy, MD, Takayuki Akahoshi, MD



Will the advantages of modern phakic intraocular lenses reduce the applications of laser vision correction?

Thomas Kohnen, MD, PhD, FEBO Julian D. Stevens, MD



If I were having cataract and IOL surgery today, my choice of IOL would be . . .

Emanuel S. Rosen, MD, FRCSEd Thomas F. Neuhann, MD Richard B. Packard, MD Douglas D. Koch, MD Hiroko Bissen-Miyajima, MD Gerd U. Auffarth, MD

DURING THE XXIX CONGRESS OF THE ESCRS, VIENNA, AUSTRIA

Feature

eye on travel

GOLDEN WARMTH

Journal Watch

Romantic capital of Czech Republic at its best in winter

Vitamin D and AMD Potential protective effect in older women

by Maryalicia Post

inter visitors to Prague are lucky; they see the city at its best. Cafés and restaurants are warm and welcoming, free of the crowds that invade them in summer. Theatres and concert halls come alive. And a stroll across the Charles Bridge is a walk into a fairy tale landscape that is for the moment all your own.

Charles Bridge This majestic stone span over the Vltava River has connected Prague’s Old and Lesser Towns since 1402. Building began in 1357 under Emperor Charles IV, who had a flair for the dramatic. He even had the roof of the city's defensive towers gilded, contributing to Prague's renown as the “Golden City.” In the 17th century the bridge was lined with 30 statues. Though some of the originals are in Prague's Lapidary Museum for safekeeping, the copies ensure that the enchantment of this unique bridge lives on. Today, the Charles Bridge is a magnet for every tourist, busker and souvenir seller in Prague. To see it at its best, visit early or late in the day. The Charles Bridge museum opened in 2007. The highpoint of the exhibition is a model of the bridge in the 14th century, depicting its construction. Located at the foot of the bridge, near the Lesser Town Square ESCRS Meets at Hilton Prague The hotel in which the ESCRS will meet in Prague from 3-5 February – the Hilton Prague – is one of the city’s most prestigious hotels. Guests will enjoy five in-house restaurants and bars, a fitness centre, pool and spa, shops and a casino. For the past three winters there’s been an added attraction; each February an ice bar has been constructed on the rooftop terrace of the Cloud 9 bar. A fantasy grotto, the Cloud 9 is a magical place to chill out’ while overlooking the lights of the city. If the weather isn’t cold enough for an ice bar, Cloud 9 is still a glamorous setting in which to sip a cocktail and enjoy the view. Weather permitting, the ice bar is open daily from 18:00 to 24:00. Closed on Sunday. The entrance fee of 590 czk includes a glass of champagne, welcome refreshments and unlimited vodka shots. EUROTIMES | Volume 16 | Issue 9

the museum is open daily from 10:00 until 20:00 in summer and to 18:00 in winter. For details, visit, www.charlesbridgemuseum.com. Prague Castle Don’t miss Prague Castle. Not a single castle, but more of a small town, which includes the home of the Czech president and St Vitus Cathedral. There are courtyards and streets, among them the charming “Golden Lane,” built in the 15th century to house the King's marksmen. The writer Franz Kafka once lived in No 22. A changing of the guard takes place at the castle's main gate on the hour, with a fanfare at noon. The only privately owned building in the complex is the Lobkowicz Palace, home to one of the most influential ancient families of Bohemia. Their fabulous art collection was twice stolen – first by the Nazis, then by the Communists. The recorded guided tour brings the story to life. Classical recitals begin at noon in the Lobkowicz Palace Concert Hall. The attractions of the castle complex are open from 9:00 to 18:00 April through October and until 16:00 November through March. The Lobkowicz Palace museum is open daily 10:00 to 18:00 year round. The café is a picturesque setting for coffee or lunch. For details, visit: www.lobkowicz-collections.org. For a visit to the world famous attractions of the “Golden City,” Hilton cars wait at the door. A walk to the city centre takes only about 15 minutes.

Micro-surgery to micro-art Many of the micro-instruments used in Svatoslav Fyodorov’s eye microsurgery centre in the 1980s were devised by a Siberian craftsman named Anatoly Konenko. He later turned his skills to producing micro-miniature art works. Prague’s Museum of Miniatures is devoted exclusively to his works. Even if you’ve never felt the urge to see a flea that’s been fitted with golden shoes, you might be surprised at how long you linger over the exhibits in this new museum. They are set out side by side on shelves, each with its accompanying magnifying glass or microscope.

Saint Vitus Cathedral and the castle complex overlooking the Vltava river

Jewish Quarter

Prague's 12th century Jewish Quarter, Josefov, houses five synagogues including the “New-Old Synagogue,” the oldest in use in Europe. According to legend, the remains of the Golem are in the attic. Rabbi Judah Loew ben Bezalel, the 16th century scholar who created the Golem fable, is buried in the nearby cemetery. Ironically, Josefov survived World War II because Hitler planned to turn its Jewish Museum into a “Museum of an Extinct Race.” The Jewish Museum is open every day except Saturday and Jewish Holidays 09:00 - 16.30 in winter and until 18:00 in summer. Buy a single admission for the New-Old Synagogue or a combination to include five synagogues and the cemetery. Every day except Monday, the Strahov Monastery Library, the museum’s neighbour, is open from 9:00 to 12:00 and from 13:00 to 17:00. Borrow a printed guide from the library custodian. Go to: www.360cities.net/gigapixel/ strahov-library for a preview. The monastery’s website is at: www.strahovskyklaster.cz.

Women with lower vitamin D levels may be at increased risk of developing early AMD, a large-scale study suggests. The findings come from the Carotenoids in Age-Related Eye Disease Study (AREDS), an ancillary study within the Women's Health Initiative Observational Study. An analysis of serum 25(OH) D levels, a biomarker for vitamin D status, showed that in women younger than 75 years, higher levels of serum 25(OH)D were associated with a significant decreased risk of early AMD. The study included measures of vitamin D intake from sunlight, foods and nutritional supplements. While higher oral intake of the vitamin was associated with reduced AMD risk, duration of sun exposure was not. Lutein and zeaxanthin intake appeared to add to the benefit. Vitamin D is believed to have anti-inflammatory and immune modulation properties. The researchers hypothesise that vitamin D may suppress the cascade of destructive inflammation that occurs at the level of the retinal pigment epithelium–choroid interface in early stages of AMD. A possible role of vitamin D in ocular functioning is supported by evidence that the vitamin D receptor is located in vertebrate retinal tissue and is expressed in human cultured retinal endothelial cells. n A Millen et al., Archives of Ophthalmology, ‘Vitamin D Status and Early Age-Related Macular Degeneration in Postmenopausal Women’, 2011;129(4):481-489.

Amy Millen

Library of Strahov Monastery

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Feature

bio-ophthalmology

LANDMARK 3-D MODEL

Formation of self-assembling retina from embryonic stem cells is a ‘game changer’ by Gearoid Tuohy

emarkable research has shown for the first time the formation of a three-dimensional retina in a laboratory dish beginning with no more than a culture of floating embryonic stem cells. While sounding more like science fiction than fact, the breakthrough is set to fundamentally impact on both academic studies of retinal biology and on the pharmacological testing of new compounds and treatment strategies for a broad range of retinal disorders, including retinitis pigmentosa and agerelated macular degeneration (AMD). The self-assembly of a murine retina from 3-dimensional cultures of embryonic stem cells is among the most complex tissue engineering achievements yet. While of immediate interest to the field of ophthalmology, the advance has already made an impact on stem cell biology and regenerative medicine, disciplines keen to explore the potential application of the research for brain and other tissues. Research data showed that the use of embryonic stem cells in assembly of the retina emerged spontaneously in vitro suggesting the capability of self-assembly may be applied to many other organs and, as such, may radically alter not only basic research but also the cost and development timelines for introducing new drugs for retinal degenerations. The researchers behind the new development, Dr Mototsugu Eiraku and Prof Yoshiki Sasai of the RIKEN Center for Developmental Biology, in Kobe, Japan, published their findings in the journal Nature [2011;472:5156]. In a series of time-lapse images of laboratory culture – available on the Nature website (www.nature.com) – the self-assembling retina begins as a floating “cloud” of embryonic stem cells (ESCs) which, in the presence of matrigel, begins to express genes known to be markers of the retinal fate. Within approximately six days, the cloud becomes a hollow sphere containing polarised epithelial cells. Specific cells self-associate into islands that form vesicles that eventually involute to the classic C shape of the developing retina. A rudimentary retinal pigment epithelium slowly

The self-assembly of a murine retina from 3-dimensional cultures of embryonic stem cells is among the most complex tissue engineering achievements yet. The success, reported from the Organogenesis and Neurogenesis Group at the RIKEN Center for Developmental Biology, is likely to have a fundamental impact on both research and drug development in the field of retinal medicine

becomes discernible, and between days 20 to 24, the full neuro-sensory retina is complete with photoreceptors, all in their correct anatomical location. While the lab-based self-assembly appeared to follow the natural temporal sequence of retinal formation and the differentiated cells appeared to be organised into the correct cellular layers, whether or not the organ functions in capturing and processing light inputs remains to be tested. Regardless, the supplementary videos accompanying the paper are in themselves worth viewing if only to see first-hand the incredible assembly of one of the body’s most complex organs. A number of research groups around the world had previously shown retinal differentiation from ESCs and the formation of lens-like structures and retinal rosettes from a variety of studies all of which were homing in on defining the illusive elixir of protocols and culture conditions aimed at optimising the development of more organised tissues. The RIKEN research team themselves have demonstrated the self-formation of cerebral cortical tissues in culture from

floating aggregates of ESCs and of retinal differentiation from similar ESCs however, formation of retinal epithelial structures was not happening. A key step in the process that led to the successful self-assembly was the addition of basement-membrane matrix components – matrigel – to support the formation of a stable epithelial structure. According to Prof Sasai, without the matrigel, “cells tend to fall apart,” presumably due to the absence of the mechanical support which would be available under normal organogenesis in vivo. Given the significant cost and timelines involved in developing new therapeutic strategies, the availability of 3-D models could provide a considerable resource in accelerating the testing of new compounds. Furthermore, one of the significant challenges in tackling disorders such as retinitis pigmentosa is that as time progresses the patient loses first rod and then cone photoreceptors which are not replaced. Any viable treatment needs to apply a potential therapy to a dwindling number of photoreceptors. If the RIKEN research successes can be replicated in the development of self-assembling 3-D human retinas then clinicians and patients may benefit from a renewable source of photoreceptors to be transplanted at an optimal development stage. Dr Eriaku and Prof Sasai commented that “self-formation of fully stratified 3-D neural retina tissues heralds the next-generation of generative medicine in retinal degeneration therapeutics, and opens up new avenues for the transplantation of artificial retinal tissue sheets, rather than simple cell grafting.” Projecting such technology onto the broad landscape of many other degenerative disorders, while many years away, may open numerous new approaches for treatment. While the medical and research applications of the studies are destined to attract much commentary, the evolutionary context of the findings is notable. The eye has long represented a major battlefield in historical and contemporary debates on evolution by natural selection. If, as the argument goes, such a slow gradual piecemeal process underlies the formation of organs of such exquisite perfection as the human eye, then what use was there for the endless varieties that preceded the finished product in humans? While modern scientific thought universally accepts that half an eye or even a fraction of an eye is fundamentally better than none at all, we witness in the RIKEN research, unfolding frame by frame, the ontogeny of a mammalian eye in a laboratory dish. We see several million years of evolution condensed into 24 days – for this alone the studies are destined to represent a major scientific landmark.

Jazz For Sight

Thomas Pfleger

EUROTIMES | Volume 16 | Issue 9

Dan Reinstein

A charity jazz concert featuring ophthalmologists Thomas Pfleger and Dan Reinstein will be held in Vienna on Monday 19 September. Dan Reinstein, who lives and works in London and is internationally known in the field of refractive surgery, and Thomas Pfleger, who is an ophthalmologist in Vienna, are experienced jazz musicians. Together with Vana Gierig, who is one of New York’s premier jazz pianists and composers, they will perform at Porgy & Bess Jazz & Music Club, one of the top venues on the European jazz scene. Drs Reinstein and Pfleger met in 1998 for the first time when they performed together with Vana Gierig in Fort Lauderdale, US.

The upcoming show will be their reunion. The concert will support the help organisation "Light for the World” and is sponsored by CROMA. The lineup of musicians are: Dan Reinstein (sax); Thomas Pfleger (guitar), Vana Gierig (piano), Matthew Parrish (bass), Joris Dudli (drums), Jose Brito (perc), special guest: Jacqueline Patricio (vocal). n Monday,

19 September, 20.30, Porgy & Bess, Riemergasse 11, A 1010 Vienna. Admission: €18.

Feature

industry news

Recent developments in the vision care industry

Moria launches new system

Moria has developed a system to create ultra-thin, planar corneal lamellar grafts. The new system consists of seven singleuse microkeratome heads ranging from 50 to 300 microns, a single-use artificial chamber, special inflation tubing and syringe sets, and the turbine-driven Moria CB Microkeratome with control unit.

Rhein Medical instrument for dry eye Rhein Medical has launched a new Maskin Meibum Expressor developed in coordination with Steven L Maskin MD. “The new instrument is designed to remove meibum from lids,” said a Rhein Medical spokesman. “The instrument is reusable, autoclaveable and available with a complimentary instructional movie and offered for a 30-day surgical evaluation without obligation,” he said.

FDA clearance for TearScience thermal pulsation system

Allergan receives authorisation for uveitis treatment

TearScience has announced that it has received US Food and Drug Administration (FDA) clearance for its LipiFlowThermal Pulsation System for the treatment of meibomian gland dysfunction (MGD). The clearance enables TearScience to market and sell LipiFlow to eye care physicians in the US. LipiFlow will be available immediately, but on a limited basis in the US through the end of 2011.

Carl Zeiss at XXIX ESCRS Congress in Vienna

Reichert releases new Advantage Plus unit

Reichert Technologies has released their new Advantage Plus Chair and Stand. The Advantage Plus unit features the same construction as the original Advantage Chair and Stand. “We have had such great success with the original Advantage Chair and Stand that we felt it was time to update the overall look while maximising functionality,” said Teresa Wozniak, product manager for Reichert.

New contact lens solution

Alcon has launched its new contact lens solution, OPTI-FREE PureMoist Multi-Purpose Disinfecting Solution (MPDS) in the US. “Silicone hydrogel lenses have undergone tremendous advances in the past 10 years and OPTIFREE PureMoist MPDS was designed to address the need for progressive technologies to help improve the performance of these lenses,” said Howard Ketelson PhD, director of Vision Care Product Research, Alcon. EUROTIMES | Volume 16 | Issue 9

Allergan has announced that the European Medicines Agency (EMA) has extended the Marketing Authorisation for OZURDEX in the 27 member states of the EU to include the treatment of inflammation of the posterior segment of the eye presenting as non-infectious uveitis. OZURDEX is already available in many countries in Europe as the first treatment licensed for macular oedema in patients with retinal vein occlusion (RVO).

Tonosafe now available around the globe

The Tonosafe disposable prisms are a convenient, effective method of reducing the risk of cross infection between patients when performing contact tonometry, according to a spokeswoman for Haag-Streit. “Based on the success in some European countries as well as in the US and for the benefit of eye care professionals worldwide, Haag-Streit is now making Tonosafe available around the globe,” said the spokeswoman. Tonosafe™ has been developed by Haag-Streit for single patient use and is supplied as a sterile product.

Carl Zeiss Meditec has invited delegates to the XXIX ESCRS Congress in Vienna from September 17-21. “We are aware of the increasing cost pressure in healthcare and aspire to break new ground with our state-of-the-art innovations. The breadth of our product portfolio allows simple, uninterrupted workflows. These generate efficiency in treatment and even offer additional clinical benefits through optimally synchronised system components,” said a Carl Zeiss spokeswoman.

Geuder 60th anniversary

Geuder commemorated its 60th anniversary during its symposium at this year’s DOC. The symposium, which was held by Prof Dr Lars-Olof Hattenbach of Ludwigshafen, first reviewed Geuder’s last 60 years before concentrating on the newest developments in cataract and vitreoretinal surgery. “Geuder, which began as a small workshop in 1951, soon began to produce innovative products such as the first atraumatic corneal needle and the first motor-powered Mikro-Keratron. In the meantime this traditionally based company has grown rapidly, and nowadays Geuder markets its comprehensive product portfolio all over the world,” said a Geuder spokeswoman.

KAMCommunications achieves PR industry standard

KAMCommunications has achieved the Consultancy Management Standard. “The internationally recognised Consultancy Management Standard (CMS) is the PR industry’s quality certification system for public relations firms in the United Kingdom,” said Kris Morrill, managing director of KAMCommunications. “The CMS is an assurance to clients that KAM Communications adheres to strict quality standards in management,” she said.

What are your fellow surgeons talking about today? Are you missing out on something new? Need a quick answer or consultation? Got a suggestion for a fellow surgeon? Just want to stay in the loop? Discussions are taking place right now on ASCRS’ eyeCONNECT — one of ASCRS’ most popular member benefits. Ask questions, help others, or just follow the engaging discussions from around the world. But don’t be left out!

Here’s what members say about eyeCONNECT: “It provides instantaneous feedback that benefits my patients.” Warren E. Hill, MD, FACS

“There is simply no better way for tapping into the expertise of my colleagues.” Uday Devgan, MD “It’s like having grand rounds with ophthalmology’s best thinkers.” W. Lee Wan, MD

“There’s not an ophthalmologist in the world that won’t learn from this forum.” Richard L. Lindstrom, MD

Subscribe to ASCRS’s eyeCONNECT today and connect with colleagues in a worldwide virtual community. Visit www.EyeSpaceMD.org and click the eyeCONNECT tab. Login (it’s the same as logging in on the ASCRS website) Click “My Subscriptions” Choose the list(s) you wish to subscribe to, the delivery method, and click “save.”

Not yet a member of ASCRS? Visit www.ASCRS.org and join online today. Click the “Membership” tab.

EWAD4

www.EyeSpaceMD.org

Reference

Calendar of events Dates for your Diary

September

5-8 Porto Alegre, Brazil

23-24 Vilnius, Lithuania

16-17 17-21

October

November

2011

XXXVI Ophthalmology Brazilian Congress www.cbo2011.com.br/

Gothenburg, Sweden 8-9 1st World Congress on Surgical Training www.surgicon.org

23-24 Bordeaux, France Eurokeratoconus II www.jbhsante.fr

SOIE Uveitis Course and Symposium www.balticconference.com/soie

February

2011

2012

prague, czech republic

6-7 DUBLIN, IRELAND

3-5

13th International Paediatric Ophthalmology Meeting Dublin

SEOUL, KOREA 13-16 2011 APACRS-KSCRS Annual Meeting

16th ESCRS Winter Meeting www.escrs.org

www.apacrs.org

22-25 ORLANDO, FL, USA American Academy of Ophthalmology Annual Meeting www.aao.org

December

1-4

2011

vienna, austria

International Symposium on Ocular Pharmacology and Therapeutics www.isopt.net

February

January 2012

13-15

Athens, Greece

7th Pan-Hellenic Vitreo-Retinal Meeting www.gvrs.gr

rome, ITALY

2nd EURETINA Winter Meeting www.euretina.org

June

July

2012

14-17

2012

Nurnberg,

germany

25th International Congress of German Ophthalmic Surgeons www.doc-nuernberg.de

22-27

berlin,

germany

ISER 2012 XX Biennial Meeting of the International Society for Eye Research www2.kenes.com/iser/pages/home.aspx

3-5

2012

PRAGUE,

CZECH REPublic

16th ESCRS Winter Meeting www.escrs.org

23-25

2011

vienna, austria 2nd EuCornea Congress www.eucornea.org

XXIX Congress of the ESCRS www.escrs.org

2011

12-13

DUBLIN, IRELAND

23-26

MILAN, ITALY

Practice Development Workshop and Masterclass www.escrs.org/dublin2011

91st SOI National Congress www.soiweb.com

April

2012

Belgrade, Serbia

International Symposium on Glaucoma – New Insights and Updates www.glaucoma –belgrade2012.org

rome, italy

XVI National Congress of Italian Society of Corneal Transplant www.sitrac.it

September

MILAN, ITALY

6-7 8-9

2012

3rd EuCornea Congress www.eucornea.org

2nd World Congress of Paediatric Ophthalmology and Strabismus www.wcpos.org

2012

6-9 8-12

12th EURETINA Congress www.euretina.org

XXX Congress of the ESCRS www.escrs.org

Advertising Directory: Abbott Medical Optics Page: IFC; Alcon Laboratories: Pages: 7, 15, 23, 36-37, 43, 56-57, 67, OBC; Angiotech Page: 44; ASCRS / Eyeworld Pages: 53, 64, 71; ASICO Page: 25; Bausch + Lomb Pages: 11, 19, 29; Benz Research and Development Page: 49; Carl Zeiss Meditec AG Page: 21; Croma-Pharma Pages: 8, 13; D.O.R.C International BV Pages: 4, 35; Frontier Vision Page: 55; Geuder AG Page: 40; Haag-Streit International Page: 63; Hoya Surgical Optics Page: 62; iCare Page: 46; IROC Page: 58; Katena Products Inc Page: 18; Medicel AG Page: 6; Medicontur International SA Page: 17; moria Page: 10; NIDEK Page: 38; Oasis Page: 12; Oculus Optikgeraete GmbH Page: 5; Oertli Instruments AG Page: 9; OPKO Instrumentation Page: 54; Rayner Intraocular Lenses Ltd Page: IBC; Reichert Inc Pages: 16, 26, 61; Schwind Eye-Tech Solutions Page: 24; Sidapharm Page: 42; Surgistar Page: 27; Technolas Perfect Vision Page: 41; VSY Biotechnology Page: 3; Ziemer Ophthalmic Systems AG Page: 48

Please visit us at booth B312 at the ESCRS congress, Vienna, 17-21 September

RAYNER Toric IOL experts, the world over.

M-flex® T

Sulcoflex® Toric

T-flex®

The most complete toric IOL family • Toric, multifocal toric and pseudophakic supplementary IOL ranges • Haptic designs that ensure uncompromising centration and stability • Manufactured from Rayacryl®, with superb handling characteristics

and high biocompatibility • Accurate, predictable and sustainable refractive outcomes • Extensive power ranges, including customised cylinders up to 11.0D* • Online calculation and ordering available at www.raytrace.net * Full power range information and more available on www.rayner.com

rayner.com

Note: These products are not available for sale in the US. 07/11 Copyright Rayner Intraocular Lenses Limited.

At the Tip of Performance The 25+™ Probe. Designed for Uncompromising Rigidity and Offering Outstanding Performance. + Stiffer Needle + Ultra-High Speed Cutting Performance up to 5000 CPM + Improved Duty Cycle & Higher Aspiration Flow Rates + Port Optimization

25+™ 25G

– Larger Cutting Port Area – Cutting Port Closer to End of Tip works ideally with

See the Complete Alcon® MIVS Plus Solution Available in 23 and 25G

Fully Integrated with Grieshaber DSP 25+™ Instruments. ®