EuroTimes Vol. 20 - Issue 4 by EUROTIMES

The Essence of Perfection For Retina, Cataract and Glaucoma Surgery • Newly developed vacuum and flow tri-pump system • SPEEP® mode for very precise maneuvers • Active- and gravity infusion • Up to 10’000 cuts with Twin-Blade Cutters • Double light source with color adjustable LED technology • Fully integrated 532 nm green endolaser • Brand new phaco engine for even more efficiency and safety • Wireless, dual linear all-in-one foot switch • Intuitive user interface with Direct Access® • Designed for fast and sterile work flow • Utmost system performance thanks to latest Embedded Controller Technology

Ecknauer+Schoch ASW. Not available for sales in the US. ID1002.E-2015.02

www.oertli-os4.com

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon

CONTENTS

Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org 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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

4 Cover Story: Femto

Laser – the quiet intrastromal revolution

7 NEWSMAKER

INTERVIEW

ESCRS President-elect David Spalton on the future of the society

SPECIAL FOCUS CATARACT & REFRACTIVE 8 Femtosecond laser-assisted cataract surgery – continuing refinement

9 Predicting visual outcomes with different IOLs

10 Low astigmatism:

debates looks at the optimal strategy

12 Dr Norman S Jaffe,

the late surgeon who pioneered lens implants

MEETING REPORT 13 Delegates defy weather to make Istanbul meeting a success

FEATURES CORNEA 14 Treatment of severely

damaged ocular surfaces

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2014 and 31 December 2014 is 42,957.

GLAUCOMA 23 New imaging

technologies provide insights into engineering aspects

24 Safety and efficacy of ab

interno MIGS procedure

RETINA 27 RPE transplantation studies under way in humans

28 Novel device aims to make intravitreal injections more consistent and safe

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31 Taking a targeted

approach to uveitis treatment

33 Three-way comparison study of anti-VEGF agents shows significant benefits

GLOBAL OPHTHALMOLOGY 34 Education and intervention schemes tackling rural blindness

PAEDIATRIC OPHTHALMOLOGY 35 Retinopathy of

REGULARS 37 38 40 41 42 44 47 48

Young Ophthalmologists EUREQUO Resident’s Diary Book Reviews Review JCRS Highlights Travel Calendar

prematurity: refining screening and reducing risk

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16 Study outcomes support

acceptability of tissue from older donors

18 Advantages of synthetic

skirt with OOKP procedure

Included with this issue... Optovue Supplement

EUROTIMES | APRIL 2015

EDITORIAL A WORD FROM IOANNIS PALLIKARIS MD

PATIENTS ARE PRIORITY As intrastromal techniques gather momentum, we need to tailor our procedures to the needs of each individual

t is a genuine pleasure for me to be associated with for instance, we need to perfect the current algorithms this month’s issue of EuroTimes, devoted to the theme to ensure greater accuracy and predictability. We also of femtosecond lasers with a particular emphasis on need to pursue our research into corneal biomechanics in new intrastomal applications for the correction of order to improve the predictability of our procedures and myopia, hyperopia, astigmatism and presbyopia. help identify those eyes at risk of developing ectasia after For those of us who have been involved with the refractive surgery. evolution of LASIK and its predecessors, the concept Presbyopia remains a challenging issue for refractive of intrastromal refractive correction is certainly an surgeons and the latest intrastromal approaches are not interesting evolution. There is a clear appeal in being able going to provide a silver bullet solution here either. There to alter the shape of the cornea without creating remains some question marks a flap and not having to worry about subsequent over the predictability of the For those of us who have flap-related complications. outcomes and the stability of been involved with the As well as the possible biomechanical advantages the results achieved over the to the cornea of an intrastromal approach, the longer term. evolution of LASIK and its recent research by Dr Ganesh in India on the The fact that we now have predecessors, the concept cryopreservation of corneal lenticules extracted multiple techniques to provide of intrastromal refractive after ReLEx and SMILE procedures is particularly some kind of compromise correction is certainly an exciting. While it is still early days and we need refraction reflects the reality and interesting evolution more robust safety data and longer follow-up, limitations of our current range there is the tantalising possibility of being able to of treatments for presbyopes. implant the extracted lenticule into an unrelated The bottom line is that we need individual to treat conditions like aphakia, hypermetropia, to listen to our patients and to tailor our procedures to keratoconus and presbyopia. their needs using the most appropriate technique for each While intrastromal techniques have already been shown individual patient. to be feasible, there is still a long way to go before they become truly mainstream and are adopted by the majority of refractive surgeons. As physicians, safety should always be out first concern and we need to bear in mind that any procedure which alters the shape of the cornea is not reversible. So we definitely need more data on those patients who may, for one reason or another, be unhappy with their intrastromal procedure, and their potential options for retreatment. * Prof Ioannis Pallikaris, Professor in Ophthalmology, School of Other issues also need to be clarified. For the correction Medicine, University of Crete, and Director of the Institute of of astigmatism using femtosecond intrastromal incisions, Vision and Optics

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), 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), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | APRIL 2015

COVER STORY: FEMTO LASER

FLEx

SMILE

Intracor Presbyopia Correction

THE INTRASTROMAL REVOLUTION Beyond LASIK – more surgeons are converting to intrastromal refractive approaches. Dermot McGrath reports

he excimer laser has been the reliable workhorse of corneal refractive surgery practices for the past two decades, providing excellent visual outcomes and a high degree of safety for millions of satisfied patients worldwide. Yet while LASIK remains the undoubted gold standard for refractive correction, some surgeons are already taking the first steps into a post-LASIK era by embracing intrastromal femtosecond laser treatments for myopia, presbyopia and astigmatism. Techniques such as FLEx (femtosecond lenticule extraction) and SMILE (small incision lenticule extraction), Intracor presbyopia correction, and intrastromal astigmatic keratotomy (AK) have already won over a small but growing band of surgeons who cite predictable refractive EUROTIMES | APRIL 2015

outcomes, fast recovery and respect for corneal biomechanical integrity as among the main reasons for their conversion.

RELEX, FLEX AND SMILE Walter Sekundo MD, chairman of the Department of Ophthalmology at the Philipps University of Marburg, Germany, vividly remembers the American Academy of Ophthalmology meeting in Las Vegas in 2006 where he presented for the first time his vision of a refractive surgery procedure that could be performed intrastromally using a femtosecond laser and without ablating the cornea. “People were laughing and couldn’t believe that this idea of an intrastromal treatment was ever going to work. I told the audience that it might take a decade but that this procedure was eventually going to replace laser surgery. No one took it seriously. Eight years later, over

300 surgeons worldwide are now using this approach and nobody is laughing anymore. It is simply a better procedure than LASIK, even though there are still a few drawbacks and weak points that need to be addressed,” he told EuroTimes. Taking advantage of the properties of the VisuMax femtosecond laser (Carl Zeiss Meditec AG), Dr Sekundo’s vision was to perform refractive corrections by carving out an intrastromal lenticule that could be removed in one piece manually without having to resort to excimer laser ablation. Known initially as ReLEx, Dr Sekundo published the first results in 2008 of the FLEx procedure in which a lenticule was manually removed after lifting a flap. Evolving from that early success, a new procedure called SMILE was developed in which the lenticule interface could be separated through one or two small incisions, thereby eliminating the need for a flap.

COVER STORY: FEMTO LASER

Courtesy of Steve Schallhorn MD

This ability to dispense with the corneal flap and all its associated complications is one of SMILE’s biggest selling points, said Dr Sekundo. “The idea of not having a flap and being able to maintain a stronger cornea with an intrastromal approach is very appealing to patients. In my practice, I still perform femtosecond LASIK procedures but they are less than 10 per cent of the total volume. For patients with low myopia, it is always SMILE despite the fact that femtosecond LASIK gives a slightly faster visual recovery. But the patients tell me that they are prepared to have marginally slower visual recovery in order to have a flap-free procedure,” he said. Not surprisingly, patients are not the only ones who are happy to see the back of the LASIK flap. “The dream of over a decade ago was to eliminate the microkeratome and the LASIK flap – in effect to have the safety of a PRK procedure in terms of no flap-related complications, while achieving the visual recovery of LASIK,” said Steve Schallhorn MD, Professor of Ophthalmology at UCSF, and Chief Medical Director, Optical Express. “SMILE has no flap and the visual recovery profile is much closer to LASIK, so that is a huge advantage from my perspective,” he said. The biomechanical advantages of SMILE are also part of the procedure’s appeal, added Dr Schallhorn. “Because the procedure is intrastromal it respects the tensile strength of the cornea and reduces the risk of ectasia. This is not a smokeand-mirrors procedure with questionable physiological advantages – SMILE offers unique, solid science-based advantages, which is why so many surgeons are interested in its potential,” he said. By focusing the treatment exclusively on the stroma, SMILE preserves Bowman’s layer, which is inherently good for biomechanical stability, noted Tobias H Neuhann MD, Medical Director at AaM Augenklinik in Munich, Germany. “We know that Bowman’s membrane is tough and keeps the cornea from swelling forward. Treating purely corneal stroma means preserving corneal stability. Another positive effect of intrastromal treatments is the very low grade of infections compared to surface treatments,” he said. The ideal candidates for SMILE are patients with moderate to high myopia in the range of -5.0D to -10.0D, according to Jesper Hjortdal MD, PhD, Aarhus University Hospital, Denmark, who said it

This was an analysis of 72 eyes of 67 patients that underwent intrastromal femtosecond AK (7mm OZ) to correct an average of 1.27D of astigmatism compared to 48 eyes of 43 patients who underwent manual (blade) AK (7mm OZ) to correct an average of 1.44D of astigmatism. The chart shows the mean astigmatism over time (pre-op and one week, one month and three months post-op) and demonstrates greater stability for the intrastromal femtosecond AK procedure. This was presented at the 2012 ASCRS meeting

has now replaced LASIK as his treatment of choice for suitable patients. “Compared with LASIK, we have found that a SMILE procedure does not induce spherical aberrations in the cornea. This should have implications for the overall quality of vision and especially night vision, but proper prospective randomised or contralateral studies are needed to further clarify this,” he said. Nevertheless, evidence pertaining to the feasibility of SMILE is accumulating in the scientific literature, points out Dan Reinstein MD, FRCOphth, medical director of the London Vision Clinic. “The feasibility of the procedure has been proved by studies on the surface quality of the lenticules, wound healing and inflammation, and the accuracy of the lenticule thickness parameters have been verified using very high-frequency digital ultrasound and optical coherence tomography (OCT),” he said. Safety has also been demonstrated to be similar to LASIK, said Dr Reinstein. “Our recent publication has shown that there are no concerns in treating patients with SMILE for low myopia. In terms of safety, SMILE brings two advantages over LASIK, relevant to the most common complication, dry eye, and the most serious complication, ectasia,” he added.

We know that Bowman’s membrane is tough and keeps the cornea from swelling forward Tobias H Neuhann MD

On the debit side, SMILE demands a financial outlay, which may be dissuasive for smaller refractive practices. Furthermore, the fact that the procedure is currently limited to myopic treatments is another potential brake on its adoption. Dr Sekundo is optimistic, however, that this will be rectified in the near future. “We have been working on this and have shown that the hyperopia treatment works as well, so it will probably be available in the next year or two. We also need better control of cyclotorsion – not necessarily an eye tracker – but an electronic device within the system that monitors the eye after suction has been applied, and allows for an adjustment of the treatment zone if there is a misalignment of the axis. Once this has been achieved, then the astigmatic results will also improve,” he said. Dr Sekundo added that he expects FDA approval for the FLEx and SMILE procedures probably by the end of 2015. One other possible concern with SMILE is the difficulty of enhancement procedures, as unlike LASIK there is no flap that can be lifted to facilitate access. If retreatment is needed, Dr Hjortdal advises surgeons not to attempt a repeat SMILE procedure. “The options are to open the cap and convert the cap into a LASIK-like flap, and then use the excimer laser to ablate. Or one can also perform a surface ablation procedure. We prefer to perform the procedure transepithelially and we always use Mitomycin 0.02 per cent for 20 seconds after the procedure,” he said.

INTRACOR INNOVATION Intrastromal approaches have also been tried with some success for presbyopia. EUROTIMES | APRIL 2015

COVER STORY: FEMTO LASER

layer, there is less risk of infection and wound problems. “The level of precision is unsurpassed with the femto AK and that results in improvement in the predictability of the surgery. Not breaking the epithelium minimises the chance of an infection and the discomfort that the patient experiences,” he said. The singular disadvantage is the fact that the femtosecond laser technology is expensive, said Dr Schallhorn, who said it works best for regular corneal astigmatism below +2.0D. “I think this technology will really come into its own as we move more towards femtosecond cataract procedures. If we are using the laser anyway for IOL procedures then it really is a no-brainer to use that to correct the patient’s 1.0D of corneal astigmatism as well. With increased use will come better outcomes as well,” he added.

Courtesy of Tobias H Neuhann MD

An Intracor slitlamp view post-op

The Intracor treatment uses the Technolas femtosecond laser (Bausch & Lomb) to create intrastromal concentric rings of different depths in the cornea of the patient’s non-dominant eye. The goal of the rings is to create a slight steepening of the central cornea while sparing the epithelium, Bowman’s membrane and Descemet’s membrane. The procedure works well in emmetropic and mild hyperop presbyopes, said Dr Neuhann. In a clinical study carried out at four German clinical centres, more than 70 per cent of patients could read J3 or better without glasses while the other 25 per cent could read with weaker reading glasses, said Dr Neuhann, who added that a new study using the latest-generation Victus femtosecond laser will be carried out for hyperopic and astigmatic eyes. While Intracor works well in a majority of patients, there is a sizeable minority (around five per cent to 15 per cent) that do not respond so well to the treatment, and it is this unpredictability which has held back the procedure’s adoption, according to Mike Holzer MD, University of Heidelberg, Germany. “Sometimes the effect is much higher than anticipated, and then there are other patients where the effect is minimal or non-existent,” said Dr Holzer. “The predictability certainly could be better, especially bearing in mind that we have other presbyopia-correcting procedures such as multifocal IOLs available to us that offer better predictability,” he said. For Dr Holzer, the likely cause of this erratic predictability stems from an inability to accurately determine individual corneal stability and how each patient will react to the intrastromal incisions. “I think once we have better preoperative diagnostics we can much better predict the outcome of such a procedure. Enhancements also pose a problem, because you can really only do these intrastromal incisions just once in my opinion, although I know some surgeons EUROTIMES | APRIL 2015

have retreated intrastromally using the laser,” he said. Dr Holzer said that Intracor works best in patients that are slightly hyperopic. “We have performed this in about 350 patients now with a high degree of success. When the treatment works as expected, there is minimal or no regression years after the procedure which is an advantage over LASIK. Patients also like it because we are not opening the cornea, there is no risk of infection, the healing is very quick and the patient can return to normal activities very quickly afterwards,” he said. For Dr Neuhann, the ideal Intracor candidate is a presbyopic patient around 50 years of age with objective refraction of +1.0 to +1.75D, less than 0.75D of astigmatism, realistic expectations, no corneal scars or other corneal or ocular pathologies. Dr Neuhann said that careful study of the Intracor underperformers has enabled him to elaborate a strategy to help such patients. “The key after a perfect treatment with no shape change is to understand individual biomechanical properties as well as the precise effect of the laser. In our group in Munich we could demonstrate that intrastromal bridges in the femtosecond laser channels could be broken after the treatment with careful manual deforming of the cornea with fingertip massage, resulting in a positive and wanted shape change,” he said.

ASTIGMATIC KERATOTOMY Intrastromal astigmatic keratotomy using femtosecond lasers such as the IntraLase (AMO/Visx’s) or LenSx (Alcon Inc) also gives surgeons a less invasive option for patients with astigmatism. There are several advantages to using the femtosecond laser for intrastromal astigmatic keratotomy with greater precision in incision length, depth and angle, said Dr Schallhorn. Moreover, because the incisions are made without breaking the epithelium or Bowman’s

Steve Schallhorn: scschallhorn@yahoo.com Jesper Hjortdal: jesper.hjortdal@dadlnet.dk Dan Reinstein: dzr@londonvisionclinic.com Mike Holzer: mike.holzer@med.uni-heidelberg.de Tobias Neuhann: dr.neuhann@email.de Walter Sekundo: sekundo@med.uni-marburg.de

LASIK’S LONGEVITY NOT IN DOUBT While the arrival of flapless intrastromal procedures gives refractive surgeons another viable tool in their surgical armamentarium, no one is predicting the demise of the excimer laser in the short to medium term. “In the near future LASIK and intrastromal techniques will co-exist for several reasons,” said Steve Schallhorn MD. “The SMILE procedure is under development to correct hyperopia, unlike LASIK where it is approved and widely used for this indication, but that may change in the future. In addition, there is the capital cost of the femtosecond laser, which will likely slow the adoption of intrastromal techniques for smaller refractive practices,” he added. Mike Holzer MD also sees the intrastromal techniques as a complement and addition to current treatment options. “With the femtosecond laser we are also seeing a move towards iris recognition and cyclotorsion control, and this is important if we want to treat astigmatism very precisely. The next step forward is that we stay intrastromally. Femtosecond technology represents a major advance because it can be used for the cornea and the lens, and we can perform any treatment depth and add OCT and iris recognition to help improve the outcomes. But it is a considerable financial investment,” he said.

NEWSMAKER

ESCRS PRESIDENT-ELECT David Spalton FRCS shares his views on the past, present and future of the ESCRS and ophthalmology in general with Roibeard O’hEineachain

We are now in a very exciting time. I’m sure that femtosecond laser-assisted cataract surgery is here to stay. All the present studies show that femto is no different from the visual outcome point of view, but it makes the surgery much easier, and as the technology improves the results will surely get better. The question is, how do you integrate that into a public health service? I think that's a major challenge, but I think it's going to happen and it will probably change how we practise. The economics of this and other expensive technology will probably force us into working in bigger, higher volume units. I think we’re also going to see accommodative intraocular lenses coming in over the next three to five years, where the change of focus will depend on the optic’s change of curvature rather than its change of position. That is really the Holy Grail and there are several of these

The powerhouse of the ESCRS is always going to be our meeting in September

In Britain, for example, it is forecast that the NHS (the public service, free at the point of delivery to patients) will have a shortfall of £8billion in six years’ time. So there’s not going to be a lot of spare money around, and already there are big financial pressures on the public and private systems. While our practice expenses go up, our reimbursement rates are going down. Therefore, we will really have to focus on what patients need and on patient reported outcomes. We have to think about what’s best for the patient and that will see us through.

Athens Athens

2016

D at

David Spalton: profspalton@gmail.com

The progress that ophthalmology has made since I first started doing cataract surgery is amazing. The quality of surgery has improved out of all recognition. When I trained as a resident in Moorfields, we were trained to perform intracapsular surgery with no intraocular lens. Over the years, I’ve seen the evolution from intra-cap to extra-cap to phaco and now to femto. Other major milestones during those years included the introduction of Healon, which made intraocular surgery safe, and posterior chamber lenses.

We should be promoting increasing quality of surgery with safer surgery and better outcomes. I think we are going in the right direction, but the financial challenges that we're going to face in the next few years are going to be a major problem.

26–28 February

Our involvement in research is also going to become very much stronger, building on the back of the endophthalmitis work, which has been absolutely fundamental. Our investment in research is something like €1.4million and we have two really big, heavyweight, excellent projects going on at the moment. Firstly there is the PREvention of Macular EDema after cataract surgery (PREMED) study. It is a massive multicentre project headed by Rudy Nuijts and we have just agreed to finance a project investigating the genes for keratoconus and ectasia.

I recently retired from St Thomas’ Hospital, but I continue to run a large private practice. I’m also a trustee of the major British eye research charity, Fight for Sight. We’re going to spend £20million in research over a five-year period. But you never have enough money for research. It is the same situation with the ESCRS.

It is a tremendous privilege to take over the presidency, but is also a big obligation to keep it running as well as it is at the moment with the changes that we face in the future. The powerhouse of the ESCRS is always going to be our meeting in September. It’s a superb meeting and I’m always amazed at the quality and expertise of the speakers and their presentations. I think it is very important so that we are not just a once-a-year thing, but a resource throughout the year, and I see us further consolidating our teaching and training role outside of the meetings by expanding the eLearning platform and our video libraries.

lenses under development at the moment. Glaucoma will also most likely become much more surgically treatable, and I think we should be moving away from keeping patients on lifelong drops and over to micro-incision glaucoma surgery using the new developments in stents and snorkels.

Sa v

I’

ve been involved with the ESCRS since the late 1980s when it was the European Intraocular Implant Club, and have been to every meeting over the past 25 years. Ophthalmology and cataract surgery has been my career but also my consuming interest too, and the lines between work and leisure don’t exist which is very nice. It is a wonderful career and I’m actually jolly lucky.

Athens 20TH

ESCRS

Winter Meeting In conjunction with the 30TH International Congress of HSIOIRS

www.escrs.org

David Spalton FRCS EUROTIMES | APRIL 2015

SPECIAL FOCUS: CATARACT & REFRACTIVE

ROBOTIC SURGERY

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Information on biomechanical response

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emtosecond laser-assisted cataract surgery (FLACS) may have the potential to mature into a procedure that can provide a safety advantage over ultrasound phacoemulsification and it has a prospect of evolving into surgeon-directed robotic surgery in the future, said Paul Rosen FRCS, FRCOphth, Oxford University Hospital, Oxford, UK. “FLACS increases the automation of cataract surgery procedures, and therefore offers a reduction in the variability and potentially improved safety of the procedures. An achievable benefit lies in its ability to reduce the ultrasound energy input required for phacofragmentation, which will in theory reduce endothelial cell loss, reduce inflammation and reduce complications,” Dr Rosen told the XXXII Congress of the ESCRS in London. He noted that in the types of cataracts surgeons most commonly encounter, phacofragmentation FLACS can reduce effective phaco time to a minimum, sometimes to zero. In fact, Bausch & Lomb have already designed a 20-gauge aspiration handpiece for removal of laser-fragmented lenses. However, the reduction in ultrasound input has to be weighed against the input of laser energy, which carries its own risks. With the simpler fragmentation patterns there is little risk, but also little benefit in terms of reduced ultrasound usage. With the more complex fragmentation patterns there is a greater reduction in ultrasound usage but also higher risk of gas bubble formation within the capsular bag, with the potential to cause posterior capsule rupture. FLACS may also lead to an increased inflammatory response, as demonstrated in a study conducted by Burkhard Dick MD, which showed an increased level of prostaglandins in ocular fluid following FLACS. “Many people perceived that the FLACS device is here now, in its developed form, but we are very much at the beginning of this exciting journey,” Dr Rosen said.

REFINING THE TECHNOLOGY A reduction in the hazards associated with phacofragmentation may be achieved through a refinement of the laser’s pulse frequency, beam structure, spot size and grid size, and the imaging systems used to guide the procedures, Dr Rosen said. He noted that a study conducted in Bochum, Germany comparing phacofragmentation patterns with different grid sizes showed that effective phaco time was only 0.03 seconds with a 350-micron grid, compared to 21 seconds with a 500-micron grid. The mean absolute phaco times were 2.05 seconds and 5.85 seconds respectively (Conrad-Hengerer et al, J Cataract Refract Surg. 2012 Nov;38(11):1888-94). Dr Rosen noted that robotic technology is already making inroads into other surgical disciplines. Such developments will come to ophthalmology, but they will be driven by surgeons as additions to the surgical toolkit like any other instrument. Surgeons will remain as the clinical decision makers, and such advanced technologies will be used to enhance our surgical skills. Paul Rosen: paul.rosen@orh.nhs.uk

EUROTIMES | APRIL 2015

Eurotimes Corvis ST Produkt 93x266 e 4c 02.15.indd 1

25.02.2015 17:29:38

SPECIAL FOCUS: CATARACT & REFRACTIVE

PREDICTING IOL OUTCOMES Adaptive optics simulator predicts visual outcomes with different IOLs. Roibeard O’hEineachain reports

inocular testing with an adaptive opticsbased vision simulator can accurately predict patients’ visual performance under binocular conditions with different monofocal and multifocal intraocular lens (IOL) designs, according to a study presented by Pablo Artal PhD at the XXXII Congress of the ESCRS in London. “Our findings validate the use of laboratory adaptive optics instruments as a useful tool for developing new IOL optics and implementing clinical scenarios for demonstrating the efficacy of new lenses,” said Dr Artal, Laboratorio de Optica, Universidad de Murcia, Murcia, Spain. The first part of the study involved five volunteers who underwent binocular high contrast through-focus visual acuity measurement with SLOAN letters, while using the adaptive optics visual simulator to induce phase profiles corresponding to five different IOL designs, two refractive monofocal lenses and four diffractive multifocal lenses. Later, Dr Artal and his associates compared the results obtained in the volunteers with the adaptive optics vision simulator to the clinical outcomes measured in three different clinical trials involving patients implanted with the corresponding IOL models. In all clinical trials, patients underwent binocular high contrast defocus visual acuity testing between one and three months postoperatively with an ETDRS chart using trial lenses, with a best distance correction in place, according to common clinical practice. “The purpose of this study is to compare the clinical visual outcomes measured in patients implanted with different IOL models to those previously obtained by visual simulation using the phase profiles generated by the same IOLs,” noted Dr Artal. Dr Artal noted that they carried out the Pablo Artal testing under laboratory conditions before the IOLs were available for clinical use and the actual clinical results with the lens only became available in recent years. All of the trials included at least 10 eyes implanted with the lenses under investigation. One of the refractive lenses had a spherical aberration value of +0.17 microns, the remaining IOLs had a negative spherical aberration of -27 microns. The multifocal IOLs had near adds of +4D, +3.25D and +2.75D. The average through-focus visual acuity measured in clinical studies correlated closely with that measured with the adaptive optics visual simulator for the IOL models evaluated. The cross correlation coefficient between visual simulation and clinical data ranged from 0.960 to 0.995. “Our findings show that through-focus high contrast visual acuity testing, using the phase profile provided by different IOLs with an adaptive optics vision simulator under binocular conditions, predicts the results that will be obtained in real patients implanted with the same IOLs,” Dr Artal concluded. This is a remarkable validation of the use of adaptive optics technologies to predict visual outcomes of newly developed IOL models.

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Pablo Artal: pablo@um.es EUROTIMES | APRIL 2015

SPECIAL FOCUS: CATARACT & REFRACTIVE

ASTIGMATISM DEBATE

Debate highlights optimal strategy to tackle low astigmatism. Dermot McGrath reports

he question of how best to deal with low level astigmatism in cataract surgery was the subject of a lively debate during the JCRS Symposium held during the XXXII Congress of the ESCRS in London. Douglas D Koch MD, Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, US, argued the case for femtosecond laser correction as the optimal approach, while Oliver Findl MD presented the arguments in favour of toric intraocular lens (IOL) correction. Dr Koch said that, in his view, femtosecond laser-assisted cataract surgery (FLACS) represents the best approach currently available for astigmatic correction in cataract surgery. “The goal of astigmatic correction in general is to reduce astigmatism to 0.5D or less and I think the aim is to correct this simply, safely, efficiently and affordably. The femtosecond laser fulfils all of these criteria and it is available to us now,” he said. Dr Koch said that there are two types of incision that can be made with the femtosecond laser for astigmatic correction: penetrating astigmatic keratotomy (AK) and non-penetrating intrastromal AK (ISAK). Dr Koch said his own preference is to use non-penetrating incisions, which entail no wound gape, no risk of infection and no epithelial ingrowth. “One can also theoretically expect less inflammation, quicker visual recovery and enhanced patient comfort with this approach,” he said. In his own series of patients using the Catalys femtosecond laser (AMO), Dr EUROTIMES | APRIL 2015

Koch reported excellent results in 24 eyes of 21 patients using a modified version of a nomogram developed by Julian Stevens MD at Moorfields Eye Hospital, in order to account for posterior corneal astigmatism. In 19 eyes included in the final analysis, 63 per cent had 0.25D or less of manifest cylinder after treatment while almost 95 per cent of patients were 0.50D or less. Future work with femtosecond incisions will entail better standardisation of the depth of the cuts, evolution of the nomograms and longer-term follow-up, said Dr Koch. He added that the cost factor also works in the laser’s favour. “Femto laser costs about $850 an eye at a rate of 23 cases per month and $400 an eye once the laser is paid off. A toric IOL costs about $500 an eye and has none of the

other advantages of the femto laser such as capsulotomy, lens softening, incisions etc. So the choice is obvious – laser is safe, effective and cheaper in the long-term, and it is faster than aligning a toric IOL at the time of surgery,” he said.

GOOD DEFINITION Actually, the case for the laser is not so obvious at all, according to Oliver Findl MD, Vienna Institute for Research in Ocular Surgery, Austria. “The problem we have here is that we do not really have a good definition of low astigmatism. What is clear is that below 0.75D of astigmatism, especially when measured on the cornea, the measurements are so noisy and so variable from method to method and device to device that An OCT image of an intrastromal incision made with the Catalys

Courtesy of Douglas D Koch MD

SPECIAL FOCUS: CATARACT & REFRACTIVE

Surgeon’s view through the eyepiece of a toric IOL being aligned with a markerless tracking system (Zeiss Meditec AG, Germany)

Courtesy of Oliver Findl MD

it is difficult to speak about definite astigmatism,” he said. Looking at astigmatism correction techniques currently available, Dr Findl said that toric IOLs offer good astigmatism-reducing effect if well aligned and rotationally stable, while opposite clear cornea incisions (OCCIs) and peripheral corneal relaxing incisions (PCRIs) are easy to perform but produce variable results. Dr Findl noted that PCRIs seem to be so variable in their outcomes because of poor prediction of the corneal response to the incisions and also that the effect fades over time. “We believe that the reason for this is probably the variability in the viscoelastic properties of the cornea which varies a lot from one patient to the other and also the scarring reaction after surgery which is also very variable. The key point here is that this would also not be very different for FLACS in terms of predicting how the cornea might react, because we are still talking about incisions even if they are made by a laser,” he said. Looking at outcomes with toric IOLs in 250 eyes of 200 patients, Dr Findl noted that the most unpredictable outcomes were for those patients with low astigmatism. The reasons for poor astigmatic reduction with toric IOLs stem from factors such as inaccurate preoperative calculations of IOL power and posterior surface of the cornea, as well as intraoperative issues such as mislabelling

of the IOL, surgically-induced astigmatism and IOL misalignment, said Dr Findl. Of these factors, preoperative measurement errors, with large interdevice variability within and between different keratometric measurements and topographic measurements, represent the main source of error, said Dr Findl. Add in diurnal changes in corneal measurements over the course of the day and differences in postoperative refraction

measures and it is easy to see why there is so much variability correcting low-level astigmatism, he said. “There are so many prediction errors for residual astigmatism after toric IOL implantation and most of these factors are not influenced by FLACS at all,” he concluded. Douglas D Koch: dkoch@bcm.tmc.edu Oliver Findl: oliver@findl.at

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SPECIAL FOCUS: CATARACT & REFRACTIVE

NORMAN S JAFFE MD Eye surgeon and researcher, who passed away recently, pioneered cataract lens implants in the US. Howard Larkin reports on his legacy

hen Norman S Jaffe MD placed his first intraocular lens (IOL) into a cataract patient’s eye on December 4th, 1967, the ophthalmology establishment still took a dim view of lens implants. Over the next few years that opinion would reverse, due in no small part to Dr Jaffe’s efforts. Dr Jaffe’s pioneering work as a clinician, researcher, teacher and technology advocate helped to conclusively demonstrate – and improve – the safety and efficacy of IOLs. In doing so he paved the way for millions of cataract patients to see clearly once again. Over the course of his career Dr Jaffe performed more than 40,000 cataract surgeries himself, mostly at the Bascom Palmer Eye Institute at the University of Miami, US, and continued to see patients until shortly before passing away in February, at the age of 90. “With Norm Jaffe's passing, we lost a pivotal figure in the history of contemporary ophthalmology,” said Stephen A Obstbaum MD. “He understood that ophthalmology's vocal leadership opposed IOL implantation, yet his belief in this procedure was so strong that he forged an academic alliance to study the results of IOL surgery. His leadership made IOL implantation a credible procedure.”

THE MIAMI STUDY Dr Jaffe was among the first ophthalmologists to use lens implants in the US. He presented his initial patients at Grand Rounds at Bascom Palmer, where he served as a voluntary professor for

EYE CONTACT

STUDIO INTERVIEWS with leading ophthalmologists at the XXXII Congress of the ESCRS

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Simultaneous Bilateral Cataract Surgery Oliver Findl interviews Steve Arshinoﬀ Available at www.eurotimes.org/eyecontact and the EuroTimes App

EUROTIMES | APRIL 2015

several decades. Soon after implanting his first lenses, Dr Jaffe began training ophthalmologists in the Miami area in the new technique. But implants were controversial and still largely untested. After 243 implant cases were completed in the Miami area, Edward W B Norton MD, Bascom Palmer’s founding chairman, met with Dr Jaffe to develop a plan for evaluating and validating the new technique. The result was a two-year moratorium on implant surgeries by private practice ophthalmologists beginning on October 1st, 1969. During the hiatus the 243 patients were examined by ophthalmologists other than those who did the surgeries and their outcomes and complications assessed. The favourable report resulting from this early long-term outcomes study, along with new patient selection and procedure guidelines, lent new credibility and respectability to lens implant surgery. The practice quickly gained momentum in Miami and around the world. Dr Jaffe and colleagues conducted other large-scale cataract surgery outcomes studies. Beyond their own findings, these studies jump-started subsequent long-term research sponsored by the US National Eye Institute, and laid the groundwork for further development of lens implant technology. “Without his foresight and perseverance, the cause of IOL implantation would have been set back for many years. We’re all indebted to Norman as a leader, teacher, mentor and friend,” Dr Obstbaum said.

ORGANISING FOR PROGRESS As a firm believer in the benefits of lens implants, Dr Jaffe helped lead national and international efforts to promote the technology. As a teacher, he taught the technique to thousands of colleagues nationally and internationally. Author of 13 textbooks, in 1972 he wrote one of the most widely read ophthalmology texts, Cataract Surgery and its Complications, and over the years revised it through six editions. A noted researcher, Dr Jaffe published 238 articles in peer-reviewed journals. As an organiser within the profession, Dr Jaffe helped found the American Intra-Ocular Implant Society, now known as the American Society of Cataract and Refractive Surgery. As the organisation’s president in 1974 he helped convince the profession and the US Food & Drug Administration of the benefits of IOL implants, thus improving the quality of life of millions. Dr Jaffe received his medical degree from the New York College of Medicine in 1946, and was certified by the American Board of Ophthalmology in 1951. A gifted athlete, Dr Jaffe played minor league baseball while attending medical school. Three of Dr Jaffe's sons are also ophthalmologists. In 1988 he brought lens implant surgery to the People’s Republic of China, when he and his sons performed 23 lens implantations before an audience of 500 Chinese ophthalmologists. Dr Jaffe’s contributions to the field are now widely recognised, notably by the American Academy of Ophthalmology, which expressed its appreciation and welcomed him as the Guest of Honour at its annual meeting in San Francisco in 1997. In 2003 Dr Jaffe was inducted into the Ophthalmology Hall of Fame. “Dr Jaffe was truly a giant in the field of ophthalmology. It is impossible to overstate the contributions he has made not only in our field, but to medicine,” said David W Parke II MD, CEO of the American Academy of Ophthalmology. “He will be missed by many of us at the Academy, where we will remember him as a pioneering clinician, a wonderful teacher and a great friend.”

MEETING REPORT

19TH ESCRS WINTER MEETING ISTANBUL

Fatih Mehmet Mutlu (left) with ESCRS president Roberto Bellucci at the Winter Meeting in Istanbul

DOCTORS BRAVE SNOW AS MEETING PROVES A SUCCESS

elegates from 88 countries around the world defied snow to attend the 19TH ESCRS Winter Meeting in Istanbul, Turkey. More than 1,800 delegates registered for the meeting, and this number was especially commendable as many doctors had to change their travel plans after unseasonal blizzards forced the temporary closure of Istanbul’s Ataturk Airport in the run-up to the meeting. ESCRS president Roberto Bellucci said the society was very pleased to return to Istanbul for the second time in five years, and to once again join with colleagues from the Turkish Ophthalmology Society, Cataract & Refractive Surgery Section. “The scientific programme included an extended didactic programme, with courses in Basic Optics, Cataract, Refractive and Cornea,” said Dr Bellucci. “We also had a Young Ophthalmologists Programme which proved to be very successful. We hope these courses offered a valuable opportunity for residents and those in training to gain a deeper understanding of the basics of the different subspecialties,” he said. This year’s programme also included four main symposia, live surgery, free paper sessions, ePoster presentations and a range of surgical skills training courses. The annual Cornea Day meeting was organised once again in conjunction with EuCornea. The Turkish Ophthalmology Society presented their own symposium on the last day of the meeting. “We would like to thank Fatih Mehmet Mutlu and his colleagues at Istanbul University, Cerrahpasa Medical Faculty Hospital for their organisation of the live surgery session,” said Dr Bellucci. “I enjoyed meeting so many friends and colleagues in Istanbul and I hope you enjoyed the programme that we organised,” he added. For more news from Istanbul visit www.eurotimes.org EUROTIMES | APRIL 2015

CORNEA Figure 1: Total limbal deficiency secondary to acid burn. Preoperative visual acuity was 20/400. Corneal conjunctivalization and neovascularization

Figure 2: Ex vivo expansion of corneal limbal epithelial stem cells from the fellow eye of the same patient on fibrin gel

Courtesy of José Güell MD

STEM CELL EXPANSION Several steps necessary in treatment of severely damaged ocular surfaces. Roibeard O’hEineachain reports

cular surface reconstruction using expanded limbal stem cell culture combined with penetrating keratoplasty can restore good vision even in some cases with severe acid burns, said Merce Morral MD, PhD, Barcelona, Spain at the 19TH ESCRS Winter Meeting in Istanbul, Turkey. “Eyes with total limbal stem cell deficiency require several steps to restore good visual acuity,” Dr Morral added. She presented a case study involving a 31-year-old patient who had severe acidburns in both eyes. His right eye regained a visual acuity of 20/20 following several eyelid reconstructive surgeries. However,

his left eye had a vision of only 20/400 due to severe limbal stem cell insufficiency together with corneal conjunctivalization and vascularization. Dr Morral and her associates from the Institut de Microcirugia Ocular (IMO), Barcelona, Spain, therefore decided to treat the eye in a two-stage procedure. The first stage involved repairing the epithelial defect using tissue-culture expansion of limbal stem cells grown on fibrin gel. The second step was to perform penetrating keratoplasty after the cornea had re-epithelialised completely.

TISSUE EXPANSION They obtained the stem cells for tissue expansion from the patient’s right eye

Figure 3: Complete ocular surface reconstruction and visual rehabilitation involving implantation of the cultivated stem cells on fibrin gel and amniotic membrane patch, first, and penetrating keratoplasty and amniotic membrane patch on a second stage. Corrected distance visual acuity at last follow-up was 20/20

and allowed it to grow for three weeks on the fibrin gel substrate. Prior to placing the tissue in the patient’s limbal stem cell-deficient left eye, they performed 360-degree peritomy of the conjunctival tissue and removed all of the fibrovascular outgrowth from the ocular surface by means of blunt dissection with scissors. They then placed the autologous epithelial tissue graft over the denuded cornea and underneath the conjunctival peritomy. To enhance epithelialization and limit inflammation, they sutured amniotic membrane on top of the graft and performed a temporary tarsorrhaphy. One week postoperatively, the epithelium had regenerated and the eye was calm and without epithelial defects and the patient was pain free. However, three months postoperatively vision remained at 20/400 because of corneal scarring. The patient subsequently underwent a penetrating keratoplasty. Because of the danger of poor re-epithelialization, they again placed an amniotic membrane patch and, to make it last longer on the eye, the patient wore a bandage contact lens on top of it. At one year’s follow-up, when all the sutures had been removed, the eye had an uncorrected visual acuity of 20/25. The patient continues to use a bandage contact lens to protect the cornea from abrasions that might result from continual contact with the patient’s eyelids, which could not be repaired completely. Merce Morral: merce.morral@gmail.com

EUROTIMES | APRIL 2015

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CORNEA

EXPANDING DONOR POOL Cornea Donor Study 10-year outcomes support acceptability of tissue from older donors. Cheryl Guttman Krader reports

onor age is not an important factor in graft survival for most penetrating keratoplasty procedures performed for endothelial disease, suggest the 10-year data from the Cornea Donor Study. Mark J Mannis MD, Co-Principal Investigator, presented the findings on behalf of the Cornea Donor Study Research Group at the 5th EuCornea Congress in London, UK. Sponsored by the National Eye Institute and representing the largest and longest multicentre study of corneal disease, the Cornea Donor Study was a double-masked, multicentre study that enrolled 1,090 patients with a moderate risk condition. The transplanted corneas were from donors aged 12 to 75 years, met Eye Bank Association of America criteria, and had an endothelial cell density between 2,300 and 3,300 cells/mm2. The corneas were randomly assigned to participants without respect to recipient factors, and both the participants and surgeons were masked to graft donor age. The primary analysis compared 10-year success rates in procedures performed with corneas from donors aged 12 to 65 years versus from donors aged 66 to 75 years, and found there was no statistically significant difference in the outcomes. An analysis of donor age as a continuous variable did show a significant association between higher donor age and lower graft survival rate beginning at five years post-transplantation, reported Dr Mannis, professor and chair, University of California Davis Eye Center. When 10-year success rates were then analysed with the cohort divided into three groups based on donor age, the results showed evidence of a donor age effect at the extremes of age range. While the 10-year success rate of grafts from donors aged 12 to 33 years (n = 80) was 96 per cent, it was only 62 per cent for grafts from donors aged 72 to 75 years (n = 130), and 75 per cent for donors aged 34 to 71 years (n = 880). The latter group represents the vast majority of donors. EUROTIMES | APRIL 2015

“Approximately 75 per cent of corneas available for transplant in the United States are from donors aged 34 to 71 years, and the 10-year success rate of grafts from donors in that age group was fairly constant at 75 per cent,” said Dr Mannis. “In addition, transplants from donors 34 to 71 years and those from donors 72 to 75 years had similar survival through six years, and even after 10 years the difference in survival between those two groups was modest.”

OTHER PROGNOSTIC FACTORS In analyses examining the prognostic significance of other variables, no other donor-related characteristics predicted graft failure. However, several recipient-related features were associated with the outcome. The data showed the 10-year cumulative probability of graft failure was significantly lower among patients with a diagnosis of Fuchs’ dystrophy compared with those whose indication for surgery was pseudophakic/aphakic corneal oedema (20 per cent versus 37 per cent). Suturing of a corneal graft

CORNEA

...transplants from donors 34 to 71 years and those from donors 72 to 75 years had similar survival through six years...

Penetrating corneal graft with 16 interrupted sutures

Courteasy of Mark J Mannis MD

In addition, existing glaucoma at the time of transplantation independently predicted increased risk of graft rejection. The 10-year cumulative probability of graft failure was 58 per cent among patients with a history of glaucoma surgery and who were using IOP-lowering medications at study entry, but 22 per cent among those with no history of glaucoma surgery or medication use. The results also showed trends for recipient age, race, and smoking status to be associated with graft survival. Specifically, success rates were lower in recipients aged 70 years and above versus those less than 60 years old (71 per cent vs 81 per cent). Success rates were also lower in African-Americans compared with white/non-Hispanic patients (62 per cent vs 76 per cent), and in individuals who were smokers relative to those who were non-smokers (65 per cent vs 76 per cent). Dr Mannis also presented data on long-term endothelial cell loss that showed it continued over time, but at a much slower rate after the first five years. â&#x20AC;&#x153;Donor age slightly influenced endothelial cell density over the longterm, but that was driven by the youngest donors with the least cell loss and best graft survival. For the vast majority of corneas from our donor pool, age was not a factor in long graft survival,â&#x20AC;? Dr Mannis said. Mark J Mannis MD

Clear penetrating graft with combined interrupted and running sutures

Mark J Mannis: mjmannis@ucdavis.edu

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IMPROVING THE OOKP Synthetic skirt aims to circumvent disadvantages of the procedure. Cheryl Guttman Krader reports

he osteo-odonto-keratoprosthesis (OOKP) is associated with the greatest long-term anatomical and functional success among the different approaches available. However, like all keratoprostheses, the OOKP has limitations. In particular, the complexity of the multi-staged surgery, its cost, and the need for harvesting tooth and bone are major obstacles to its more widespread use. Speaking at the 5th EuCornea Congress in London, UK, Ganesh C Ingavle PhD discussed work under way at the University of Brighton to develop a polymeric OOKP skirt using interpenetrating network (IPN) hydrogels. Dr Ingavle is Marie Curie Experienced Researcher, School of Pharmacy and Biomolecular Sciences, University of Brighton, UK. A synthetic OOKP skirt would overcome these drawbacks and offer other advantages as well, including the potential for replacement if needed and for enhancing the optical cylinder design. With those issues in mind, various groups have been working to develop a synthetic analogue substitute for the dental lamina in the OOKP.

BASIC REQUIREMENTS

Dr Ingavle said that to be successful, a synthetic OOKP skirt should mimic the alveo-dental tissue in porosity, bone-like mineral composition by encapsulating nano-hydroxyapatite coated polymer microspheres, mechanical strength, biostability and the ability to support cell integration and migration. Considering these attributes, hydrogels are an attractive material because of their excellent biocompatibility and high permeability. In addition, hydrogels are amenable to surface modification and can be formed into any desirable shape. However, hydrogels suffer from having low mechanical strength and they provide relatively low support for cell adhesion. Use of the IPN approach overcomes those limitations, said Dr Ingavle. He explained that an IPN is a combination of two Ganesh C Ingavle networks that are independent of each other, but physically interlocked. The main advantage of the IPN is that it provides a mechanism for modifying the properties of the hydrogel to achieve those that are desired. “A combination of biological and synthetic polymers can result in a material with dramatically improved characteristics,” reported Dr Ingavle. He demonstrated this feature by reviewing results from laboratory studies looking at different iterations of IPN hydrogels, and showing how the physical and biological properties of the IPN hydrogel can be controlled by manipulating the composition. The studies have included experiments evaluating the materials’ swelling properties, mechanical properties, and the migration, adhesion, proliferation, and viability of keratocytes and fibroblasts.

CMY

Ganesh C Ingavle: G.C.Ingavle@brighton.ac.uk EUROTIMES | APRIL 2015

Less than % of people diagnosed with cataracts are getting surgical treatment. 1,2

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1. Market Scope Annual Report, 2014. 2. Visual impairment and blindness. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs282/en/. Accessed November 19, 2014. 3. National Eye Institute. “Facts About Cataract.” Retrieved February 26, 2015 from https://www.nei.nih.gov/health/cataract/cataract_facts.

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GLAUCOMA

BIOMECHANICS Imaging innovations give insights into engineering aspects of glaucoma. Roibeard O’hEineachain reports

ew imaging technologies that allow visualisation of the lamina, sclera and choroid are providing new insights into the anatomical aspects of glaucomatous optic neuropathy, said Claude Burgoyne MD, Devers Eye Institute, Portland, Oregon, US. “The challenge is to predict the level of engineering stress and strain within a particular optic nerve head for a given level of eye pressure. The amount of that engineering stress and strain can either be very high or very low, depending on the geometry of the connective tissues and their material properties,” Dr Burgoyne said at the 11th Congress of the European Glaucoma Society in Nice, France. He said that the sharper pictures the technologies provide, not only of the optic nerve head, but also of surrounding tissues and structures, will contribute to a more precise and detailed distinction between the anatomical characteristics of normal eyes and of eyes prone to or affected by glaucomatous damage.

NEW PARAMETERS BECOMING AVAILABLE There is an increasing amount of research into the assessment differences of lamina cribrosa thickness between diseased and non-diseased eyes. Although the consistency of such imaging is controversial, recent studies with emerging developments in imaging technology, such as spectral domain optical coherence tomography with enhanced depth imaging (EDI-OCT), adaptive optics compensation, swept-source OCT and OCT at new wavelengths (1050nm), are yielding encouraging findings. Another development has been the use of anatomical landmarks such as axis between the entrance to the optic nerve head (Bruch’s membrane opening or BMO) and the fovea (FoBMO axis) for optic nerve head, retinal nerve fibre layer and macular phenotyping. It is now possible for BMO and the foveal pit to be identified in real time allowing consistent datasets for the optic nerve head and the peripapillary retina and the fovea to be acquired in every human eye. These new approaches show promise in identifying other elements of laminar anatomy, such as where and how deeply the lamina inserts into the sclera. Researchers are now extending FoBMO phenotyping to the peripapillary sclera, scleral flange and even to the posterior

ciliary arteries. Such imaging capability may in the future shed light on the underlying pathological mechanisms of glaucoma. “It is our working hypothesis that peripapillary atrophy of the RPE in ageing and glaucoma is a manifestation of the posterior ciliary artery blood flow changes within the sclera that also affect laminar capillary outflow,” he explained. Researchers are now also using adaptive optics imaging to characterise changes in beam diameter and pore diameter and evaluate macular choroidal thickness in different subsets of glaucoma.

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DETECTION OF EARLY DISEASE Dr Burgoyne noted that, in studies he and his associates carried out, FoBMO phenotyping with SD-OCT imaging revealed deformation of the lamina cribrosa in the eyes of monkeys with modest unilateral experimental intraocular pressure (IOP) elevation very early on in the course of their neuropathy – well in advance of detectable retinal nerve fibre alterations (Invest Ophthalmol Vis Sci. 2014 Jan 29; 55(1):574-86). In addition, a team in South Korea using EDI-OCT have been able to show that disc haemorrhages in humans are related to changes in how the lamina inserts into the sclera (Lee et al, Invest Ophthalmol Vis Sci. 2014 Apr 28;55(4):2805-2815). Researchers using EDI-OCT have also been able to detect the presence of lamina cribrosa defects and pits earlier than was previously possible. The research also suggests that the micro-lesions are related to adjacent rim-thinning and retinal nerve fibre layer defects (Tatham et al Ophthalmology. 2014 ;121:110-118). Others, using swept-source OCT, have linked lamina cribrosa defects and pits to optic disc haemorrhages (Takayama et al Invest Ophthalmol Vis Sci. 2013 ;54(7):4798-807). Dr Burgoyne said the increasingly detailed visualisation and quantification of optic nerve head’s anatomy combined with clinical estimates of material properties should furnish the data necessary to build engineering finite element models of the tissues involved. “If we can achieve this kind of modelling we could then predict, in an individual eye, where to look for pathologic events which would follow from a given combination of stresses and strains and the level of IOP at which they might occur,” he said.

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Claude Burgoyne: cfburgoyne@deverseye.org EUROTIMES | APRIL 2015

GLAUCOMA

MICRO-STENT SURGERY Single centre experience documents safety and efficacy of ab interno MIGS procedure. Cheryl Guttman Krader reports Slit lamp image of the CyPass

Courtesy of Magda Rau MD

b interno implantation of a supraciliary micro-stent (CyPass Micro-Stent, Transcend Medical) alone or in combination with cataract surgery is a safe microinvasive procedure for treatment of open angle glaucoma that provides significant and sustained lowering of intraocular pressure (IOP) and medication, reports Magda Rau MD. Speaking at the XXXII Congress of the ESCRS in London, UK, Dr Rau reported one-year outcomes for her series of 33 eyes operated on between May 2009 and July 2011. All eyes had best corrected visual acuity (BCVA) better than 0.3. Twenty-four eyes underwent concomitant phacoemulsification and intraocular lens (IOL) implantation. All glaucoma medications were stopped postoperatively and reintroduced if needed to control IOP. Mean IOP was 22.3mmHg in the combination glaucoma-cataract surgery group at baseline. At 12 month follow-up mean IOP was 15mmHg. Mean medication use was reduced from 1.8 at baseline to 0.8 during the same period.

For eyes undergoing implantation of the stent as a standalone procedure, mean baseline IOP was 26mmHg on a mean of 1.3 medications. Five eyes were seen at 12 months and had a mean IOP of 13.2mmHg while on an average of 0.8 medications.

ADVERSE EVENTS Dr Rau reported there were no sightthreatening adverse events in the series or cases of inflammation. Minor intraoperative bleeding was observed in three eyes without development of hyphaema, and two eyes developed transient hypotony that resolved within one month. Early migration of the implant occurred in one patient, due to renal colic attack with according vomiting postoperatively, and was addressed with a repositioning procedure. The patient recovered without any clinical sequelae and had an IOP of 13mmHg at 24 months. “We know that glaucoma remains the leading cause of blindness in industrialised countries and that maximally tolerated medication does not sufficiently reduce IOP

Implantation of this supraciliary micro-stent appears to be a promising alternative... Magda Rau MD EUROTIMES | APRIL 2015

in many patients,” said Dr Rau, head of Eye Clinic Cham, Germany. “Although conventional glaucoma surgery can be very effective, it also has a high risk of sight-threatening complications. Implantation of this supraciliary micro-stent appears to be a promising alternative to meet our need for less invasive surgical interventions that can control IOP while reducing dependence on medications,” she said. The micro-stent creates a permanent pathway for aqueous drainage from the anterior chamber towards the suprachoroidal space by harnessing the natural negative pressure gradient in the eye. It is made of a biocompatible, non-degradable polyimide material. It measures 6.2mm in length, has an inner diameter of 0.3mm, and features proximal retention rings that help to stabilise its position in the supraciliary space. The device is implanted through a clear cornea incision (minimum 1.5mm), thus sparing the conjunctiva and sclera. Dr Rau said that she usually uses a 2.0mm incision when performing the implantation as a standalone procedure, while in combination cases she places the device through the 2.2 to 2.8mm cataract incision after the IOL implantation is done. “Operating through a 2.0mm or larger incision gives me a little more flexibility in choosing the optimal place for the microstent,” she said. Magda Rau: info@augenklinik-cham.de

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FOUR EVENTS

ONE VENUE Fira Barcelona Gran Via, Spain

North Access Hall 8

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

3rd World Congress of Paediatric Ophthalmology and Strabismus

The 7th International Conference on Ocular Infections

4–6 September www.wspos.org

3–4 September www.ocularinfections.com

RETINA

REGENERATIVE MEDICINE Stem cell-derived RPE transplantation studies now under way in humans. Leigh Spielberg reports

hotoreceptors and retinal pigment epithelial (RPE) cells are key candidates for transplantation therapy of retinal disease, said James Bainbridge PhD, FRCOphth at the 14th EURETINA Congress in London. Dr Bainbridge, of Moorfields Eye Hospital and the UCL Institute of Ophthalmology, discussed the recent results of early clinical trials using RPE cell transplantation. His work focuses on transplanting RPE cells derived from human embryonic stem cells (hES-RPE) into the eyes of patients with end-stage Stargardt Disease, an early-onset hereditary macular dystrophy characterised by decreased central vision and atrophy of the macula. It is the most common form of juvenile macular degeneration, and is associated with mutations in ABCA4 and ELOVL4, resulting in RPE dysfunction and subsequent loss of photoreceptors. “These pluripotent cells can be matured in the laboratory into RPE cells. Donor hES-RPE cells can survive in the mouse, and can protect retinal function,” said Dr Bainbridge. RPE cells have been derived from both induced pluripotent stem cells and embryonic stem cells, the latter of which can provide an unlimited source. It has been clearly demonstrated that transplanted cells can provide anatomical and functional photoreceptor rescue in animal models. After transplantation, survival of human embryonic stem cell-derived RPE cells can be proven via fluorescent staining with antibodies directed against human cellular structures, while protection of retinal function can be demonstrated via b-wave amplitude of a mouse electroretinogram. Dr Bainbridge and his team are working with Ocata Therapeutics (previously Advanced Cell Technology) on a clinical trial to assess the safety of the procedure in humans. Twelve patients with Stargardt Disease have been included in four sequential cohorts of three subjects. Each cohort received a single subretinal injection of 50,000, 100,000, 150,000 or 200,000 hES-RPE cells suspended in 0.15ml medium. Immunosuppression was achieved with three months of tacrolimus/mycophenolate treatment. “The rationale is to promote photoreceptor survival and function by replenishing degenerate RPE with functioning RPE,” said Dr Bainbridge. Retinal progeny derived from either pluripotent stem cells or tissue-specific retinal and RPE stem cells have the potential capacity both to replace damaged retina and to provide trophic support that might slow disease progression. “The process faces many challenges,” said Dr Bainbridge. “The first among these is safety, which encompasses potential immunogenicity as well as the potential tumorgenicity of cells that retain some potential for proliferation. Patients must also be able to tolerate the three-month immunosuppression.” Current results indicate that the procedure is safe in the short-term, as there have been no significant ocular or systemic adverse effects to date in this study. Although functional improvement has not yet been observed, this was not an expectation and may not be anticipated given the advanced stage of the disease of the eyes included in the study. James Bainbridge: j.bainbridge@ucl.ac.uk EUROTIMES | APRIL 2015

RETINA

INTRAVITREAL INJECTIONS

New device aims to make intravitreal injections safe and repeatable. Dermot McGrath reports

novel device shortlisted for the EURETINA Innovation Awards 2014 may provide a simple, easy-to-use solution to the problem of making intravitreal injections safer and more consistent. “We’ve developed a better way to administer intravitreal injections in terms of safety for the patient and also for the person giving the injection. This becomes particularly relevant as the volume of injections increases and we are now seeing more non-surgical staff being asked to give injections,” Sam Evans FRCOphth, ophthalmologist and a director of Salar Surgical ltd told delegates attending the 14th EURETINA Congress in London. The solution was to design a plastic moulding which is bonded onto a standard 30-gauge intravitreal needle. The device consists of a spring with a caliper at the bottom end providing position, depth and angle control for the needle, he said. “The device, which is called SP.eye™, is designed to provide perfect three-dimensional control of the needle so that irrespective of who is giving the injection it will always go to the same place,

at the same depth and the same angle and always through pars plana. In contrast to other devices on the market, SP.eye™ reduces the steps in the workflow, as it is integrated with the needle – streamlining the injection process and reducing discomfort and anxiety for the patient,” he said.

ENHANCED SAFETY As well as allowing for more consistent injection methods, Dr Evans said that SP.eye™ offers enhanced safety for medical personnel. “In the UK, the Royal College of Ophthalmologists have recently directed that nurses may give intravitreal injections under the supervision of a clinician. Using SP.eye™, nurses may deliver injections in complete confidence, whilst the supervising clinician will also know that the precision of the injections is guaranteed. Up until now, there has been no provision for needlestick protection to avoid sharps injuries in intravitreal injections. This device offers active and passive sharps safety and is the first intravitreal needle in the world to offer such enhanced safety for medical personnel,” he said.

Figure 1: The SP.eyeTM device fits both Luer-Lock and Push fit syringes, and provides passive and active sharps safety – the only intravitreal injection aid to do so

EUROTIMES | APRIL 2015

RETINA

Courtesy of Sam Evans FRCOphth, Salar Surgical

Figure 2: The SP.eyeTM locates the needle at the correct injection position by aligning the calliper with the limbus

Figure 3: The SP.eyeTM precisely controls angle, position and depth of injection

Dr Evans added that eight per cent of intravitreal injectors have reported sharps injuries in studies, and that British and European law now decrees that sharps-safe devices should be used where they are available. In terms of market potential, there is a clear demand for such a device worldwide, said Dr Evans. “There were around 600,000 intravitreal injections in the UK alone for 2013. We estimate the market worldwide to be approaching 15 to 20 million injections. There is no sign of this

slowing down as newer agents come on to the market and existing treatments are licensed for wider indications,” he said. Beyond ophthalmology, there are also potential applications in the wider medical market for such a device, said Dr Evans. “The core technology that underscores this device is applicable not just for the eye but across all sorts of different medical fields, for instance providing custom-made patient specific devices for biopsy or injections. The technology is protected by patents pending in multiple territories around the world,” he said. To bring the device to market, Dr Evans and his company, Salar Surgical ltd, have teamed up with Spectrum Ophthalmics in the UK, with an anticipated launch date of May in the UK. European distribution is expected to follow shortly thereafter. Enquiries should be directed to Salar Surgical or Spectrum Ophthalmics.

The device... is designed to provide perfect three-dimensional control of the needle... Sam Evans FRCOphth

Salar Surgical: info@salarsurgical.co.uk Spectrum Ophthalmics: enquiries@spectrum-uk.co.uk

6th EuCornea Congress

BARCELONA 4–5 September 2015

Fira Barcelona Gran Via, Spain North Access Hall 8 /EuCornea @EuCornea

Registration & Hotel Bookings Open

www.eucornea.org

EUROTIMES | APRIL 2015

NICE 15th EURETINA Congress

17â&#x20AC;&#x201C;20 September 2015 Acropolis, Nice, France

www.euretina.org /EURETINA

@EURETINA

EURETINA

Registration & Hotel Bookings Open

RETINA

TARGETED APPROACH

Henderson Instruments for toric IOLs

Care to enhance patient quality of life should be key goal of uveitis treatment. Priscilla Lynch reports

arly diagnosis, referral to a uveitis specialist and therapeutic aggressiveness employing a ‘stepladder’ approach that is both steroid-sparing and individually tailored offers the best approach to successfully treating uveitis, a dedicated symposium on uveitis at the 2014 Irish College of Ophthalmologists Annual Conference heard. Stephen Foster MD, Harvard Medical School, US, noted that uveitis is the third leading cause of worldwide blindness and currently accounts for 10 per cent of vision loss in the US and 15 per cent worldwide. There is an increased incidence of uveitis worldwide, attributable to the increase in the ageing population. Generally, infectious entities of uveitis carry a poorer overall prognosis than non-infectious posterior uveitides, Prof Foster noted. To prevent irreversible structural damage and crippling blindness, the guiding principle of management of patients with uveitis is the philosophy of diagnostic and therapeutic vigour: early diagnosis, referral to a uveitis specialist and therapeutic aggressiveness employing a stepladder algorithmic approach which is both steroid-sparing and titrated to the severity of intraocular inflammation, Prof Foster stated. Acute aggressive medical therapy should include topical, regional and/or systemic corticosteroids, as well as topical cycloplegics and mydriatics when appropriate, he said. While corticosteroids remain a mainstay of treatment and are valuable in the control of inflammation, when used long-term they have a wide array of potential toxicity, Prof Foster acknowledged.

marking pattern

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. Also available with teeth for better fixation. K3-7904 Henderson Degree Gauge K3-7905 Henderson Degree Gauge, with teeth

THERAPEUTIC OPTIONS It is pivotal to recognise intolerability or early failure of a regimen to control inflammation in order to “move up the ladder” on to other therapeutic options by escalating treatment, Prof Foster stressed. Other options such as NSAIDs and immunomodulatory therapy (IMT), such as conventional, biologics, cytotoxics, should then be initiated depending on the indication. The addition of IMT may benefit patients with sight-threatening uveitis or patients who are resistant to or intolerant of corticosteroids. However, he stressed a therapeutic response may not occur for several weeks after initiation of IMT and therefore most patients need to be maintained on corticosteroid therapy until the immunomodulatory agent begins to take effect, at which time the corticosteroid dose may be gradually tapered. Because of the potential side effects with IMT, patients on such medications require close monitoring, he added. Meanwhile, Conor Murphy MD, PhD, ophthalmic surgeon, RVEEH, Dublin, noted that infectious uveitis diagnosis requires a thorough history and targeted investigations based on the clinical findings and history. The approach of delivering carefully timed, targeted therapy in order to achieve steroid-free durable remission, and providing individualised care that enhances patient quality of life should be the key goal of uveitis treatment, Prof Foster added. Stephen Foster: sfoster@mersi.com Conor Murphy: conorcmurphy@rcsi.ie

Mark the patient

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

Instruments designed by Bonnie Henderson, MD of Boston, Massachusetts

973-989-1600 • 800-225-1195 • www.katena.com

EUROTIMES | APRIL 2015

RETINA

THERAPY FOR DME Comparison study of anti-VEGF agents shows significant treatment benefits. Sean Henahan reports

he top three anti-VEGF agents – aflibercept (Eylea, Regeneron), bevacizumab (Avastin, Genentech/ Novartis) and ranibizumab (Lucentis, Genentech/ Novartis) – all appear to provide substantial clinical benefit for patients with diabetic macular oedema (DME), with aflibercept providing the greatest visual improvements, a large US comparison study concludes. “This comparative effectiveness study will help doctors and patients make informed decisions when choosing treatments for diabetic macular oedema,” said Paul A Sieving MD, PhD, director of the US National Eye Institute, commenting on the study which appeared online in the New England Journal of Medicine. The randomised trial, conducted by the Diabetic Retinopathy Clinical Research Network, enrolled 660 people with macular oedema at 88 clinical trial sites across the United States. The Type I and II diabetic patients had 20/32 or worse at the beginning of the trial, with half having 20/50 or worse. The patients received intravitreal injections in one eye with either aflibercept (2.0 milligrams/0.05 millilitre), bevacizumab (1.25mg/0.05mL) or ranibizumab (0.3mg/0.05mL). All were evaluated monthly and received intravitreal injections until the DME resolved or stabilised. If the second eye required treatment the same drug was used. Patients with persistent DME at six months also received laser photocoagulation treatment. At the one-year point, patients who began the trial with 20/40 or better visual acuity improved on average almost two lines in all three treatment groups. A significant difference favouring aflibercept was seen in patients who began the trial with 20/50 or worse visual acuity. Those patients saw an average of four lines of improved vision, compared with three lines for ranibizumab and 2.5 for bevacizumab. All three drugs reduced macular oedema, with aflibercept and ranibizumab producing greater reductions than bevacizumab. Patients in the aflibercept group also were significantly less likely to require laser photocoagulation therapy for persistent oedema. At one year, central subfield thickness had decreased an average of 169μm in patients receiving aflibercept, 101μm with bevacizumab, and 147μm with bevacizumab. Two-thirds of eyes receiving aflibercept had a central thickness of less than 250μm, compared with 36 per cent and 58 per cent for bevacizumab and bevacizumab respectively. Adverse ocular events included two cases of endophthalmitis, one in the aflibercept group and one in the ranibizumab group. There were also two cases of nonendophthalmitis ocular inflammation in each study group. “The results clearly remove any doubts about anti-VEGF drugs’ efficacy in treating DME. All three drugs improved vision substantially, with aflibercept showing more visual gains in patients with worse vision at the start of the trial. Physicians now have robust data to help them counsel patients and make informed decisions regarding treatment options,” said study co-author Lloyd P Aiello MD, PhD, Professor of Ophthalmology at Harvard Medical School, Director of Joslin’s Beetham Eye Institute, Co-head of Joslin’s Section of Vascular Cell Biology, and Founding Chair of the DRCR Network.

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EUROTIMES | APRIL 2015

GLOBAL OPHTHALMOLOGY Left: The forward-stooping posture adopted by agriculture workers in developing countries while harvesting paddy by hand predisposes them to ocular injury from the paddy stalk Below: Agriculture workers wearing goggles that provide them with safety from ocular injuries

Courtesy of Samrat Chatterjee MD

SCHEMES REDUCE RISK Education and intervention can tackle rural blindness. Roibeard O’hEineachain reports

rogrammes that provide protective eyewear to agricultural workers in developing countries can significantly reduce the risk of eye injuries, said Samrat Chatterjee MD, MGM Eye Institute, Raipur, Chhattisgarh, India, who received the Orbis Medal for his presentation at the Orbis free paper session at the XXXII Congress of the ESCRS in London. “Agricultural workers in developing countries are prone to eye injury. Such injuries if severe can lead to penetrating eye injuries, or if trivial can lead to corneal abrasions. Corneal abrasions can get secondarily infected and cause corneal ulcers, bacterial or fungal, which is a significant cause of blindness in developing countries,” Dr Chatterjee said. Dr Chatterjee presented the results of a prospective randomised interventional study, in which 575 agriculture workers in central India received clear plastic goggles with side covers for the purpose of eye protection while engaged in harvesting activities. Another 575 workers served as controls. Those in the safety-goggles group also received counselling on eye protection in one-to-one meetings and group discussions with community health workers. A survey carried out immediately after the harvesting season showed that the frequency of eye injury was significantly lower among those in the eye-goggles group than it was in the control group (0.73 per cent vs 11.30 per cent, p< 0.0001). However, the survey also showed that the goggles were not universally accepted by the workers. EUROTIMES | APRIL 2015

That is, 76 per cent said they wore the goggles most or all the time during work, nine per cent used them half the time, 13 per cent used them some of the time and two per cent did not use them at all. The reasons cited for poor acceptance of the protective eyewear included clouding of vision, discomfort, slowing down of the pace of work, breakages, an awkward appearance particularly amongst the female workers, forgetfulness and the perception that they provided no real benefit. “This primary intervention was well accepted by the majority, although there were certain issues in the design and usage of the safety eyewear which need to be addressed to make this measure of prevention gain a still wider acceptance,” Dr Chatterjee concluded.

PRESCHOOL VISION SCREENING A related presentation demonstrated how enlisting the aid of community health workers for the screening of preschool children’s vision could contribute to earlier, sight-preserving interventions in cases of high refractive errors or eye disease. The retrospective community-based study was a part of Ramakrishna Mission Hospital-Orbis International, Country Office India Childhood Blindness Project conducted in Papumpare District, Arunachal Pradesh, India from 2008-2010, said Lobsang Tsetim MD, Ramakrishna Mission Hospital, Itanagar, Arunachal Pradesh, India. Dr Tsetim and associates recruited 93 community health workers, known as Anganwadi workers, from 53 community/ Anganwadi centres and trained them in screening preschool children for eye

problems, who in turn screened all of the preschool children in their centres and villages. Those with eye problems were then further examined by orthoptists and/ or ophthalmologists. “Anganwadi workers are female health workers chosen from the community and given training in health, nutrition and childcare. They are well aware of the ways of the people, are comfortable with the language and know the rural folk personally. They were chosen to participate due to the shortage of trained ophthalmic manpower,” Dr Tsetim said. The Anganwadi workers screened a total of 3,563 children. Of those, 624 (17.5 per cent) children were referred to the eye screening camp for further assessment. Some 63 per cent of these required more than one examination by the orthopist and 28 per cent were subsequently referred to an ophthalmologist for further assessment. Dr Tsetim and his associates found that 178 required spectacle correction and received free glasses, and 58 children had significant refractive errors. They detected amblyopia in four children, five had squints without amblyopia, four children had Vitamin A deficiency, three patients had corneal opacity and one had ptosis. “Vision screening for preschool children by health visitors is an effective alternative to primary screening by orthoptists. The findings suggest that using health visitors to screen vision in preschool children makes efficient use of existing routine checks,” Dr Tsetim concluded. Samrat Chatterjee: samrat@mgmeye.org Lobsang Tsetim: lobeyets@yahoo.com

PAEDIATRIC OPHTHALMOLOGY

ROP STRATEGY Research identifies possibilities to refine screening and lower risk. Cheryl Guttman Krader reports

INROP (www.winrop. com), a new web-based surveillance system, could be a valuable tool for predicting the development of severe retinopathy of prematurity (ROP) in extremely preterm infants. WINROP is an acronym for Weight, IGF-1, Neonatal, Retinopathy Of Prematurity. It was initially developed with the goal of improving ROP screening so that it could target infants at the greatest risk for developing sight-threatening disease. Results from initial testing and from subsequent studies involving cohorts of children in the US, Europe, Asia and South America validated its performance. However, findings from thesis research conducted by Pia Lundgren, doctoral student, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden, suggest an opportunity to improve the specificity of WINROP as well as a strategy for reducing a child's risk for developing severe ROP. “Current guidelines for ROP screening are based only on gestational age at birth and/or birth weight. However, only five per cent to 10 per cent of infants who become subjects for screening based on those criteria go on to develop severe ROP requiring treatment. Limiting the screening to children most at risk would reduce unnecessary exposure of many fragile infants to the stress of frequent screening examinations and burden on the healthcare system,” said Ms Lundgren. “To our knowledge, WINROP is the first and only validated web-based surveillance system for estimating an individualised risk of developing severe ROP. However, its performance may be improved through the addition of novel risk factors. Validation testing of a new prototype will be undertaken in the near future.” In its original iteration, WINROP incorporated serum levels of IGF-1 and weekly weight measurements. Subsequent study determined that IGF-1 data could be removed from the algorithm without compromising its performance, and so WINROP currently calculates risk of developing severe ROP based only on birth weight, gestational age and weekly weight measurements. With an interest in evaluating growth and nutrition variables as predictors of severe ROP, Ms Lundgren undertook a series of analyses looking at potential roles

of infant weight and weight gain at first detection of ROP, birth weight deficit, and energy and macronutrient intake during the first weeks of life.

RISK PREDICTION First undertaking a validation study using data from 407 extremely preterm infants, Ms Lundgren corroborated previous research showing the algorithm had very high sensitivity, identifying 96 per cent of children who went on to require treatment for ROP. However, its specificity was only 24 per cent. A retrospective analysis led to the determination that risk prediction could be improved by incorporating weight gain at the time the algorithm first signals an infant is at high risk of developing severe ROP. Analyses performed using another cohort including 147 children determined that an algorithm including gestational age at birth and weight standard deviation score at first detection of ROP predicted ROP requiring treatment with high accuracy. Looking at nutritional intake as a risk factor for severe ROP, Ms Lundgren’s research showed that macronutrient intake during the first four weeks of life was poor overall. Logistic regression analyses identified associations between low intake of energy, fat and carbohydrates and an increased risk of developing severe ROP. Compared with their counterparts who did not develop severe ROP, infants who did were also found to have a lower mean energy intake during the first four weeks of life. A multivariate regression analysis incorporating a variety of other risk factors unrelated to age, weight, growth or nutrition showed that energy intake independently predicted severe ROP risk. According to the results, the odds of developing severe ROP were reduced 24 per cent for each 10kcal/kg/day increase in energy intake. “Improving nutrition intake is challenging in these babies who are likely to have feeding difficulties, although it may be possible through enteral and parenteral nutrition. Nevertheless, further research is needed to determine if it could be an effective strategy for reducing the risk of severe ROP in extremely preterm infants,” Ms Lundgren said.

World Society of Paediatric Ophthalmology and Strabismus

3rd

World Congress of Paediatric Ophthalmology and Strabismus 4–6 September 2015 Fira Barcelona Gran Via, Spain North Access Hall 8

www.wspos.org

/WSPOS @WSPOS

Registration & Hotel Bookings Open

Expertise Resides ALL Around the World

Pia Lundgren: pia.lundgren@gu.se EUROTIMES | APRIL 2015

XXXIII Congress of the ESCRS 5–9 September 2015

Fira Barcelona Gran Via, Spain North Access Hall 8

Registration & Hotel Bookings Open

www.escrs.org /ESCRS @ESCRSOﬃcial

ESCRS

YOUNG OPHTHALMOLOGISTS

CALL FOR ENTRIES

‘15 RS#2545 C S th See

Boo

John Henahan writing prize open to ESCRS Young Ophthalmologists

ntrants to the John Henahan Prize are invited to write a 900-word essay on the topic of “How do I learn surgery?” The essays will be judged by Emanuel Rosen, chairman of the ESCRS Publications Committee; José Güell, former president of ESCRS; Oliver Findl, chairman of ESCRS Young Ophthalmologists’ Forum; Sean Henahan, editor of EuroTimes; Paul McGinn, editor of EuroTimes; and Robert Henahan, contributing editor of EuroTimes. The main criteria for consideration by the judges are the clinical content of the story and the writing style, including punctuation and grammar, which should reflect the high standard of material published in EuroTimes. The winner will receive a travel bursary worth €1,000 to attend the XXXIII Congress of the ESCRS in Barcelona later this year, as well as a special trophy which will be presented during the Video Awards ceremony at the Congress.

2014 WINNER The 2014 John Henahan Prize winner was Lampros Lamprogiannis, a resident ophthalmologist in the 4th Ophthalmology Department of AHEPA Hospital in Thessaloniki, Greece. His winning entry was on the topic of “How Do I See Cataract Surgery in 30 years?” The chairman of the judging panel, Emanuel Rosen, said the high standard of entries revealed the latent talent in the next generation of ophthalmic surgeons. “The task was to predict what cataract and refractive surgery would be like in 2044. The winning entry showed imagination and reality in equal measures,” he said. “Extremely well written, the winning entry was not least impressive for the use of language from a non-English native speaker,” said Dr Rosen. “The content was easy to understand as well as being capable of being realised without being extravagant in its predictions.”

ENTRY FORMS The prize is named in honour of John Henahan, who edited EuroTimes from 1996 to 2001. “John’s work has inspired a generation of young doctors and journalists, many of whom continue to work for EuroTimes. The prize will not only bring satisfaction to the winner and credit to all the contributors, but may enhance all their prospects of pursuing a medical writing aspect to their future careers. We look forward to their further contributions to EuroTimes and the Journal of Cataract & Refractive Surgery,” said Dr Rosen.

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* Entry forms are available from Colin Kerr, Executive Editor, EuroTimes at: henprize@eurotimes.org. The closing date for entries is Friday, 29 May 2015. For further information see: www.escrs.org

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EUROTIMES | APRIL 2015

EUREQUO

EUREQUO INNOVATIONS Exciting new changes are being planned to improve the EUREQUO database

urther improvements are being planned for the EUREQUO database to make it more userfriendly for the doctors inputting their results into the system. “The discussion is still ongoing,” Mats Lundstrom, clinical director of EUREQUO, told EuroTimes. “At the end of the discussion I am hopeful that the database will be even more attractive,” said Prof Lundstrom. After the present review the database should be more flexible, said Prof Lundstrom. This means that a surgeon/ clinic signing up for participation is not forced to stick to the same follow-up for all cataract patients. “If there is follow-up data to be entered in the registry we need to know the date of surgery and the date of follow up,” he said. Prof Lundstrom explained that in the existing system for cataract surgery there is

one form for short-term follow-up (one to six days) and another form for long-term follow-up (seven to 60 days). “In the new system we will have one form for all follow-up records irrespective of the follow-up time. For example, central corneal oedema the day after surgery may be transient but corneal oedema two months after surgery is persistent. It is therefore the follow-up time that decides what kind of corneal oedema we are dealing with. The same goes for elevated IOP, uveitis etc. When we take out a report for statistics we have to group the followup time in a way that is meaningful to understand what kind of complication we have,” he said.

NEW VARIABLES It is also planned, said Prof Lundstrom, to include new variables. “We have been testing variables for femtosecond laser-assisted cataract surgery in more

than 3,000 surgeries by now. These variables will be included. Other variables that could be discussed are CME as a complication after cataract surgery, types of IOL in RLE surgery, the inclusion of new types of refractive surgery (for example SMILE) and the inclusion of Mitomycin C in corneal refractive surgery,” said Prof Lundstrom. The presentation of the statistics in the existing report system can also be improved, he said, and they are also looking at ways of giving surgeons better access to reports. “This is a very exciting project for EUREQUO,” said Prof Lundstrom, “and if EuroTimes readers who are using the database have any suggestions to the changes that they would like to see in the database, I can be contacted at the email address at the end of this article.” Mats Lundstrom: mats.lundstrom@karlskrona.mail.telia.com

European Society of Cataract & Refractive Surgeons

Clinical

Call for Research Proposals Awards 2015

ESCRS has made available funding of €750,000 over three years for clinical research projects in the ﬁeld of cataract and refractive surgery

Additional information available at www.escrs.org Deadline for receipt of expressions of interest: 28 May 2015 EUROTIMES | APRIL 2015

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RESIDENT’S DIARY

HERO HELMET

Leigh Speilberg explains how it sometimes pays off

to invest in the gadget yourself

“

o, what did you see?” Previous trainees had I asked the most recommended getting a BIO. junior resident, “Why would you want to look who thought monocularly,” said Rudolf he had a retinal Reyniers when he was a VR detachment case in fellow at the Rotterdam Eye the emergency room. Hospital, “when you could “Well, I saw a detached look with two eyes? There’s no retina,” he answered. I wasn’t comparison!” he said, referring convinced. The patient had to the monocular indirect experienced no flashes or ophthalmoscope favoured by floaters, was not myopic and had some. “You have more light, a come to the ER for other reasons better view, stereopsis and an entirely. I suggested he go back extra free hand.” to the patient and take another I used it as much as I look while I finished examining could, often when it wasn’t my own patient. It was a calm even strictly necessary, just day in the ER. I was supervising to practice. Peter van Etten, the younger residents that day, a former optometrist, current and we all had enough time trainee ophthalmologist and to incorporate some teaching future vitreoretinal surgeon, moments into the flow. had showed me how to use it “Check for tobacco dust!” I to find a lost contact lens and called out to him as he exited retrieve it from the superior my exam room. “And I’ll drop fornix using some fluorescein by your exam room in a few and the blue light filter. I minutes.” had begun using it for every “Will you bring your hero bedside examination during my helmet?” he asked as he popped community hospital general his head back into the doorway, ophthalmology rotation, and referring to my binocular occasionally for wheelchairindirect ophthalmoscope (BIO). bound patients who needed “Will you bring your hero helmet?” I would. My Keeler had funduscopy, whether for he asked as he popped his head back quickly become my favourite suspected grade 4 hypertensive piece of equipment and I rarely retinopathy or simple screening into the doorway... went anywhere in the hospital for DRP. without it. Victor had begun The three months of daily calling it the “hero helmet” after I’d used it to locate a few small, practice with my BIO yielded its results on my first day in peripheral retinal tears in a particularly difficult-to-examine, the operating room. The four years I had spent using a threewheelchair-bound patient. mirror contact lens and a monocular BIO to locate retinal I had bought my Keeler BIO a few months earlier at a retina tears did not prepare me for this, so I was happy to have made meeting in London. My major vitreoretinal rotation was coming the investment. That isn’t to say my first attempt at buckling up and I wanted to have enough time to practise using it before went smoothly, but at least I could locate the break and keep it I started. After having tested all the available BIOs in the within view while struggling with the buckle itself. I promised exhibition hall at the meeting, I choose the newest Keeler with myself I’d free up some extra time to practice scleral sutures in the LED light. Sleek! the wetlab. Coincidentally, it's the same model the VR specialists in my Back in the emergency room, I was getting ready to examine training hospital in Rotterdam use for scleral buckling procedures. the junior resident’s patient, who looked on with great interest as I Along with the BIO, I decided to spoil myself and also purchase strapped the BIO onto my head. The image of an ophthalmologist a Volk Digital Clear Field, which has a similar field of view as a with a bright light on his head seems to conform to patients’ standard 30D lens. expectations. Maybe it reminds them of the classic head mirrors of the past. Maybe it projects knowledge and authority. Maybe it just looks cool. SERIOUS INVESTMENT Nevertheless, the first thing he said was: “Is this going to hurt?” It was a serious investment, but it was definitely worthwhile. “On the contrary,” I answered. “I don’t need to touch your eye Having done retinal research in New York, I had noticed that at all for this examination.” all ophthalmology trainees, even those not considering a future There was no tobacco dust. Further, the patient was career in retina, routinely used BIOs. But use in my country of slightly hyperopic and had lesions in both eyes, both located training, the Netherlands, is less common. I wish I had started inferotemporally. No breaks, no haemorrhage, no pigmentation using it earlier, because I was worried I might soon be struggling line. We diagnosed retinoschisis and discharged the patient, to his to see the retinal break while assisting during buckling surgery. great relief. Courtesy of Eoin Coveney

EUROTIMES | APRIL 2015

BOOK REVIEWS

SIMPLE & DETAILED Like Francis Ford Coppola’s The Godfather and The Beatles’ Abbey Road, Gass’ Atlas of Macular Diseases is a classic. As classics, each is considered among the bestknown examples of the respective genre. Classics are rare, so when I was offered the chance to review the most PUBLICATION recent edition of Gass’ classic, FIFTH EDITION GASS’ ATLAS I gladly accepted. Now that I OF MACULAR DISEASES have it in my possession, I can AUTHORS barely put it down. DR ANITA AGARWAL The Fifth Edition Gass’ Atlas AND DR ARUN D SINGH of Macular Diseases (Elsevier Saunders) is a two-volume, PUBLISHED BY ELSEVIER SAUNDERS 1300-page tome that is loaded with high-quality photographs collected over many decades. Updated by Dr Anita Agarwal and her co-author Dr Arun D Singh, the atlas is 50 per cent images and 50 per cent supporting text. It is both a pleasure to read and, due to its clinical classification system, a useful reference text. For example, chapter titles such as “Folds of the Choroid & Retina” allow the reader to refer to a single chapter when faced with a diagnostic challenge. The foreword notes that the hallmark of the teaching style of John Donald MacIntyre Gass was his “simple yet detailed description of clinical observations”. This style has been preserved in the current edition of the atlas, making it accessible to those well-versed in retinal disease as well as those whose primary interests lie elsewhere in ophthalmology. The scope of the atlas is remarkable, covering everything from diseases seen in daily practice to those we’ve never heard of, like Bothnia dystrophy and Leigh syndrome. Gass’ Atlas is most appropriate for highly ambitious residents, retina fellows and specialists, and general ophthalmologists who are looking for an excellent reference book with a proud lineage and impeccable reputation.

BOOK

REVIEWS

QUICK REFERENCE GUIDE As a senior resident, I will soon be performing cataract surgery independently, without the comfortable assurance of an experienced staff surgeon at my side. It is thus with great interest that I have been reading the Slit Lamp Biomicroscopy Atlas for Assessment in Cataract Surgery (Jaypee), by Dr Navneet Toshniwal. Organised by clinical situation, such as “Diabetic Cataract”, “Traumatic Cataract”, “Cataract with Corneal Opacity + Hazy Cornea”, and “Cataract with Iris Coloboma”, the “Advice” sections are most interesting and often ring true. Discussing various types of extremely hard cataracts, the advice is: “One can consider performing phaco surgery in this case, but real expertise is needed. Remain very open-minded to the necessity of conversion to ECCE during surgery.” This 200-page atlas seems best suited as a quick reference guide for any ophthalmologist (in training) who is planning on performing challenging cataract surgery cases. LEIGH SPIELBERG Books Editor

If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | APRIL 2015

REVIEW

DIVIDE AND CONQUER Everything you ever wanted to know about the divide and conquer technique of nucleofractis. Dr Soosan Jacob reports

he divide and conquer technique of nucleofractis is the basic technique that every phaco surgeon starts their training with. It is essentially ideal for denser nuclei and is not suitable for soft nuclei where the probe may punch a hole in the capsule before the surgeon can react.

SCULPTING Once the nucleus rotates freely, a pair of cross-grooves are created in the nucleus. Sculpting is started with moderate flow, low vacuum and continuous ultrasound power. Power used is based on nuclear density. Hard nuclei need higher power as insufficient power causes the phaco probe to push the nucleus forwards with resultant zonular stress. Higher vacuum levels, on the other hand, can cause the nucleus to stick to the phaco tip and may inhibit smooth movement of the tip through the nucleus. During superficial grooving, sculpting should be stopped short of the rhexis to avoid accidental damage to the rhexis rim and the anterior capsule. Subsequent grooves are taken beyond the rhexis rim. During each sculpting motion, the morphology of the lens should be kept in mind and downslope sculpting initially should be followed by upslope sculpting beyond the centre of the nucleus. Following the curve of the posterior capsule (PC) in this manner gets an even trench through its length while also avoiding accidental perforation of the PC. Ultrasound power should be used only during forward movement of the tip and the foot pedal should return to position 1 during the reverse movement. Once a sufficiently deep trench is created, the nucleus is rotated 180 degrees and the EUROTIMES | APRIL 2015

trench is lengthened as well as deepened in the other hemi-nucleus. A clear red reflex in comparison to the rest of the nucleus indicates a satisfactory depth to the trench. However, as newer microscopes have excellent coaxial illumination, the red reflex is generally bright from the beginning of the surgery even in dense nuclei and this sign may not be absolutely depended on. The thickness of the adult lens is about 4-5mm and the phaco tip is slightly less than 1mm. Another important indicator for adequacy of depth is therefore an approximate three phaco tips deep groove which leaves a thin enough posterior plate which is easy to crack. The width of the groove is kept at about one and a half phaco tips width, to allow two instruments to go down into the depth of the trench for cracking the posterior plate. Once the first groove is created, the second groove is made at 90 degrees to the first. The nucleus may also be rotated by 90 degrees at a time to create and deepen the cross grooves.

NUCLEAR ROTATION A longer lever arm eases rotation. Less force is required when the instrument is

Figure A: The first groove being initiated

placed in the peripheral groove rather than in the centre. Rotating closer to the centre results in application of more force and consequent increased stress on zonules.

CRACKING Once both grooves are created, the nucleus is cracked into four quadrants. This is done either by conventional cracking or cross cracking. Conventional cracking is preferable when main and side port incisions are placed at acute angles or at less than 90 degrees to each other, whereas cross cracking is preferable with incisions that are at 90 degrees to each other. The crack is initiated at the distal end and widened towards the proximal end. Once the crack has gone full thickness, the nucleus is rotated to complete the crack through the opposite end. This is repeated for the second groove in order to divide the nucleus into four quadrants. While cracking, the two instruments should be kept in the depth of the groove and the quadrants separated with a slight upward motion. The natural tendency to push downwards can lead to zonular stress and should be avoided.

Figure B: The cross-grooves created

REVIEW

QUADRANT REMOVAL Settings are now changed to a higher vacuum and pulse or hyperpulse phaco. The first quadrant is generally more difficult to extract as the pieces are aligned together as in a jigsaw puzzle. Once the first quadrant is removed, the remaining quadrants are no longer packed as tightly together and subsequent ones are easier to remove. Quadrants are embedded at the tip at mid-depth in foot position 3, and once the tip is adequately buried the piece is gently manoeuvred into the anterior chamber with foot pedal position 2.

COMPLICATIONS Not performing upslope sculpting beyond the midpoint of the lens can cause the nucleus to rupture the PC. Not performing downslope sculpting ahead of the midpoint can leave a thick posterior plate which prevents the crack from propagating. Using insufficient power while sculpting can push the nucelus and cause zonular stress. Inability to crack the nucleus can result from the groove not being deep enough, leaving behind a thick posterior plate or because the forces are not applied in the right manner. Cracking may also be difficult if the instruments havenâ&#x20AC;&#x2122;t been placed deep enough in the groove. Zonular dialysis and nucleus drop may occur if excessive posteriorly directed force

Figure C: Cracking is done with instruments at the base of the first groove. In conventional cracking, both instruments move to ipsilateral side whereas in cross-cracking, both instrument push to contralateral side

Figure D: The second groove is also cracked to create four quadrants which are then removed one-by-one

is applied while grooving or cracking. Not maintaining the cruciate shape of the grooves can result in a large central crater with dense walls that becomes difficult to disassemble. The width of the groove should therefore be limited to one and a half phaco tips.

decrease the amount of phaco energy at the endothelial level. It is difficult to perform in soft nuclei as the tip eats through the nucleus very fast and the two instruments cheesewire through the quadrants on attempting a crack.

ADVANTAGES AND DISADVANTAGES The divide and conquer technique is the basic technique learned by the beginner surgeon. It is easy, effective and breaks the nucleus into smaller quadrants that are more easy to manage. It can be used effectively in denser nuclei as well and can help

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SCIENCE RELAXATION FRIENDSHIP Brazilian Association of Cataract and Refractive Surgery

Brazilian Congress of Cataract and Refractive Surgery - 2015

WHERE: Costa do SauĂpe, Bahia - Brazil WHEN: June 3 to 6, 2015

brascrs2015.com.br EUROTIMES | APRIL 2015

JCRS

JCRS SYMPOSIUM CONTROVERSIES IN OPHTHALMIC SURGERY: HEAD TO HEAD

– Prevention of Endophthalmitis: – U.S. Versus Rest of the World David F. Chang, MD Peter J. Barry, MD

– Femtosecond Lenticule Extraction – Versus LASIK Steven E. Wilson, MD Jodhbir S. Mehta, MD, FRCS(Ed)

– Astigmatism Correction: – Femtosecond Laser or Blade? Elizabeth Yeu, MD Eric D. Donnenfeld, MD

MONDAY, APRIL 20, 2015 1:00–2:30 PM Moderators: Nick Mamalis, MD William J. Dupps Jr, MD, PhD

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 3 MONTH: MARCH 2015

OCT AND ACCOMMODATION The mechanisms of accommodation and presbyopia are not yet fully understood. Swept-source anterior segment optical coherence tomography (AS-OCT) could help by providing high resolution real-time measurement of the accommodation process, report Italian researchers. They analysed 14 eyes of 14 patients aged 18 to 46 years. AS-OCT revealed that during accommodation the decrease in the anterior chamber depth was statistically significant, as were the increase in the lens thickness and the slight movement forward of the lens central point. The central cornea thickness and anterior chamber width measurements did not change statistically significantly during accommodation. A Neri et al, JCRS, “Dynamic imaging of accommodation by swept-source anterior segment optical coherence tomography”, online, March 2015.

FIVE-YEAR FOLLOW-UP OF CORNEAL INLAYS Corneal inlays are increasingly being used for the treatment of presbyopia. They are additive and do not require tissue to be removed, they preserve future options for presbyopic correction, some of them can be used in the setting of pseudophakia and/or combined with laser refractive surgery, and they are removable. However, as yet there are very few studies reporting results even out to two years. In what may be the longest follow-up reported for these products to date, researchers now report visual acuity results, patient satisfaction and postsurgical complications in cases followed for 60 months after monocular implantation of the ultrathin Kamra small-aperture corneal inlay (model ACI7000). The long-term results indicate stable increased uncorrected near visual acuity (UNVA) and uncorrected intermediate visual acuity (UIVA), and slightly compromised uncorrected distance visual acuity (UDVA) at three years. However, a statistically significant decrease in UNVA, UIVA and UDVA was observed between 36 months and 60 months. AK Dexl et al, JCRS, “Long-term outcomes after monocular corneal inlay implantation for the surgical compensation of presbyopia”, online, March 2015.

MEASURING ACCOMMODATION USING UBM CONCLUSIONS Ultrasound biomicroscopy (UBM) could also prove useful in evaluating the mechanisms of accommodation and presbyopia. US researchers evaluated anterior segment biometric changes in response to 0D to 6D accommodative stimuli in 1D steps in 26 patients. UBM-measured accommodative anterior segment biometry parameters had smaller variance and good repeatability. Radius of curvature of intraocular structures calculated from UBM images required distortion correction. The researchers believe this study has demonstrated the utility of automated image analysis to perform objective measurement of the accommodative biometric changes from UBM image sequences. V Ramasubramanian et al, JCRS, “Objective Measurement of Accommodative Biometric Changes Using Ultrasound Biomicroscopy”, online, March 2015.

During the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA EUROTIMES | APRIL 2015

THOMAS KOHNEN European editor of JCRS

Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

INDUSTRY NEWS

Ophthalmic Imaging:

from Theory to current Practice Organization : Michel Puech

New congress in Paris

INDUSTRY

NEWS

October 16th, 2015

CE MARK EXTENSION

Spoken languages: English/French (simultaneous translation)

The Oraya IRay® Radiotherapy system has received a CE Mark extension for the treatment of choroidal metastases. The new indication of use expands upon Oraya’s prior approval for the treatment of wet age-related macular degeneration (AMD). “This oncology indication demonstrates the breadth of possibilities that are enabled by the proprietary aspects of the IRay platform,” Oraya CEO Jim Taylor said. “While Oraya’s primary focus remains on treating wet AMD, we continue to identify and evaluate other uses of the technology that may benefit patients and clinicians,” he said. www.orayainc.com

MARKETING AUTHORISATION Santen Pharmaceutical has announced that the European Medicines Agency (EMA) has accepted the company’s Marketing Authorisation Application (MAA) filing for the use of intravitreal sirolimus, an investigational mTOR inhibitor, for the treatment of noninfectious uveitis (NIU) of the posterior segment. “Given the risks associated with currently available therapeutic options for NIU of the posterior segment, a chronic inflammatory condition in many cases, there is a significant need for novel treatments that could be used,” says Dr Naveed Shams, Chief Scientific Officer and Head, Global R&D, Santen Ltd. www.santeninc.com

LEADERSHIP TEAM Rayner has recently announced several changes to its senior management team. The leadership team now includes Tim Clover, Joint CEO and New Projects Director; Darren Millington, Joint CEO and CFO; and Andrew Webb, Global Vice-President, Commercial. “Over the last number of years, these leaders have made significant contributions to the success of their respective organisations, and I am very pleased that they have agreed to join me in leading Rayner into an exciting new future,” said Niels de ConinckSmith, Chairman of Rayner Surgical Group. www.rayner.com

12 Courses • Fiber and Optic Nerve OCT • Macular OCT • OCT Angiography • Intra Vitreal Injection • Lasers • Radiology

• • • •

Corneal Topography Biometry Visual Fields Anterior Segment and Corneal Imaging • Ultrasound Imaging • Electrophysiology

Workshops • Ultrasound Imaging • UMB

• OCT

Additional one day session • Ophthalmic Imaging for technicians (Orthoptists, nurses, optometrists, ophthalmic photographers...)

Contact VuExplorEr InstItutE Isabelle Marsilio contact@vuexplorer.fr Tel.: +33 1 40 26 30 30 Fax: +33 1 40 26 13 26

Registrations on www.vuexplorer.fr/en

AP-93X266mm-150305.indd 1

EUROTIMES | APRIL 2015

06/03/2015 11:39

SAN DIEGO APRIL 17–21 ADDITIONAL PROGRAMMING WORLD CORNEA CONGRESS VII ASCRS GLAUCOMA DAY ASOA WORKSHOPS TECHNICIANS & NURSES PROGRAM

REGISTER TODAY ·Crossover access to 1,300 ASCRS and ASOA presentations and post-meeting resources ·Roundtables, a comprehensive coding track, and special guest speakers ·Spanish language symposia and courses ·Innovative panels, discussions, and lectures on the latest techniques and technologies ·Unique networking events with ophthalmology’s physician and industry leaders ·3-day entry to the ASCRS•ASOA Exhibit Hall featuring over 300 leading vendors FOLLOW @ASCRSTWEETS AND @ASOATWEETS ON TWITTER. #ASCRSASOA2015

AnnualMeeting.ascrs.org All programming will be held in the San Diego Convention Center.

A joint meeting with

TRAVEL

The magnificent ceiling in the Palau Guell

Barcelona

TO TRY IN...

BARCELONA

AIRPORT: El Prat, 14km from the city SPANISH COUNTRY CODE: 34 (no area codes) TIME: UTC + 1

The third major restoration of Gaudi’s Casa Mila (nicknamed La Pedrera, the stone quarry) was finished at the end of 2014. For the previous 11 months scaffolding and netting obscured the amazing exterior. Visits include the roof with its astounding chimneys, the attic housing architectural models and audiovisual material, a period-style apartment and the former residence of the Mila family. Arrange a visit online at: www.lapedrera.com. The Cafe de la Pedrera, open to all from 8.30 to midnight, offers a tour package, The Secret Pedrera, combining dinner with a visit of the building for €55. To book: phone +34 93 488 01 76 Barcelona’s cathedral, the church at which the Bishop preaches, is not the Sagrada Familia as many suppose; it is the Church of the Holy Cross and of St Eulalia. Begun in 1298, over the crypt of a former church and completed 150 years later, its neo-gothic facade was added during the late 19th Century. Visit the interior of the cathedral to admire the 15th Century choir stalls, the magnificent organ and the few but sumptuous treasures in the church museum. Even more widely admired is the cloister, completed in 1448, which harbours 13 white geese. Free entry to the church and cloister, except for some hours in the afternoon when a €6 donation is requested. See the cathedral’s website at: www.palauguell.cat The first mass in the church of the Sagrada Familia took place in 2000 to mark the millennium but regular masses did not begin until 2010. Now the building that is Barcelona’s most popular tourist attraction is also a parochial church with mass celebrated daily in the crypt. A timetable is published on the website at: www.sagradafamilia.cat. Entrance for these ceremonies is at Carrer Sardenya. Approximately once a month mass is celebrated at the high altar of the basilica. Times are subject to change and to attend you must hold an invitation. For upcoming dates and to apply for an invitation, contact the “Seminari Conciliar”, Diputació Street, 231. Open 10.00-12.00 and 16.00-20.00. Phone: +34 934 54 16 0

A FRESH LOOK AT GAUDI

Old favourites welcome us to the XXXIII Congress of the ESCRS in Barcelona. Maryalicia Post reports SAGRADA FAMILIA You may have seen it before, but Barcelona’s astonishing “expiatory temple”, the Sagrada Familia, continues to evolve and surprise. Visit it now as the principal and final frontage, the Glory Facade, nears completion. The architect Antoni Gaudi was entrusted with the Sagrada Familia project in 1883 when he was 31 years old, and it became his life’s work. Gaudi’s passionate spirit continues to guide the architects who, in the absence of models or sketches (most of which were destroyed in the Spanish Civil War) use space age technology to explore the innovative architectural paths Gaudi developed by instinct. In 2010, Pope Benedict XVI consecrated the Sagrada Familia as a basilica. It is hoped that the church will be finished by 2026, in time for the centenary celebration of Gaudi’s death. For more information and ticket options visit: www.sagradafamilia.cat

the Raval district, just off the Ramblas at Carrer Nou de la Rambla. Purchase tickets at the office 20 metres from the entrance, or online at: www.palauguell.cat

PALAU DE LA MUSICA CATALANA While Gaudi is the best remembered practitioner of Catalan Modernisme, he wasn’t without rivals. Among the most important was Lluís Domènech i Montaner, architect of the exuberant Palau de la Musica Catalana (www.palaumusica.cat/). Domènech designed the house at the corner of “the street of discord” (so called for its competing styles of architecture) for the Lleo Morera family; some areas in this Moorish-influenced gem are let as offices, but the glorious reception rooms on the first floor have recently been opened to visitors. Tickets are not sold on site; to book guided tours online, visit: www.casalleomorera.com

PALAU GUELL The Palau Guell, one of Gaudi’s most splendid achievements, reopened to visitors in 2011 after seven years of refurbishment. The private residence of Eusebi Guell, a wealthy industrialist and Gaudi’s devoted patron, provides a fascinating glimpse of domestic life in high society. Visitors entered the ground floor of the mansion in their carriage, the horses would be led down to the basement stables, while the guests ascended to the magnificent reception rooms. Holes pierced in the ceiling of the 17-metre high parlour could be lit by external lanterns to give the effect of starlight. Private family rooms on the second and attic floors can also be visited, as can the roof with its 20 fancifully decorated chimneys. The mansion is in

The Glory Facade, Sagrada Familia

EUROTIMES | APRIL 2015

CALENDAR

MAY

6th Baltic Congress 1–3 May Kiel, Germany www.baltic-congress.de

LAST CALL

3–7 May Denver, Colorado, USA www.arvo.org

5th Balkan Ophthalmic Wetlab Course 20–23 May Sofia, Bulgaria www.bow.bg

APRIL 2015

Trends in Surgical and Medical Retina 3rd Meeting

1st San Raﬀaele OCT Forum

29–30 May Barcelona, Spain www.imo.es/retinabarcelona2015

NEW ENTRY

11 April Milan, Italy www.octforum2015.eu

World Cornea Congress VII (WCCVII) 15–17 April San Diego, US http://corneacongress.org

Barcelona Oculoplastics Meeting 17–18 April Barcelona, Spain www.imo.es/barcelonaoculoplastics

JUNE

13th Meeting of European Society of Neuro-ophthalmology (EUNOS) 21–24 June Ljubljana, Slovenia www.eunos2015.org

53rd Symposium of International Society for Clinical Electrophysiology of Vision (ISCEV) 23–27 June Ljubljana, Slovenia www.iscev2015.org

SOE 2015 Congress 6–9 June Vienna, Austria www.soe2015.org

113th DOG Congress

28–30 June Paris, France www.maculart-meeting.com

1–4 October Berlin, Germany http://dog2015en.dog-kongress.de/

AUGUST

5–8 August Kuala Lumpur, Malaysia http://www.apacrs.org

11–13 June Florence, Italy www.symposiacongressi.eu

International Conference on Ocular Infections (ICOI) 3–4 September Barcelona, Spain www.ocularinfections.com

ASCRS.ASOA Symposium and Congress

6th EuCornea Congress

NEW ENTRY

3rd World Congress of Paediatric Ophthalmology and Strabismus

4–5 September Barcelona, Spain www.eucornea.org

28–30 April Khartoum, Sudan Email Khalidhashim73@gmail.com or badawi1000@hotmail.com

Scientific Programme organised by

4–6 September Barcelona, Spain www.wspos.org

XXXIII Congress of the ESCRS 5–9 September Barcelona, Spain www.escrs.org

Barcelona

Friday 4 September

Glaucoma Day 2015

ESCRS

17–21 April San Diego, CA, USA www.ascrs.org/meetings-and-events

19th Meeting of the Sudanese Ophthalmic Society

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 5–9 October Naples, Italy www.echography.com

SEPTEMBER

Retina in Progress 2015: Present and Future

17–20 September Nice, France www.euretina.org

OCTOBER

Maculart Meeting

28th APACRS Annual Meeting

JUNE

SEPTEMBER

15th EURETINA Congress

Immediately preceding the XXXIII Congress of the ESCRS 5–9 September

www.escrs.org

Save the Date!

↙

ARVO Annual Meeting

↙

The LenSx® Laser: Smarter. Better. Faster.

1,2

Delivering uncompromised precision and consistency, the LenSx® Laser has maintained its global leadership through continuous innovation in laser refractive cataract surgery. The LenSx® Laser leverages the power of The Cataract Refractive Suite by Alcon with tools designed to further streamline and improve the entire procedure.

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FASTER*

– Pre-population of patient and incision data – Advanced pre-positioning of incisions and capsulotomy – Platform design enables continued innovation and rapid enhancements

– Customizable lens fragmentation for easy lens removal – SoftFit™ Patient Interface for easy docking, secure fixation3 and lower IOP4 – Compatible with the VERION™ Digital Marker L for surgical planning and execution

– Laser procedure efficiency with reduced programming and suction time – Designed for maximum procedural flexibility and ease of patient flow and transfer – Simpler, easier patient docking3

* LenSx® Laser systems have undergone continuous improvement since launch to reduce both laser time and procedure time. Alcon data on file. 1. Software upgrade from LenSx® Laser 2.2 to LenSx® Laser 2.23. 2. LenSx® Laser System Operator‘s Manual. 3. Multicenter prospective clinical study (n=882 eyes). Alcon data on file. 4. ER13 - 098 - SoftFit Patient Interface - IOP Assessment. Alcon data on file.

THE CATARACT REFRACTIVE SUITE BY ALCON