Vol 17-Issue12_Vol 18-Issue 1

VOLUME 17 ISSUE 12 DECEMBER 2012 | VOLUME 18 ISSUE 1 JANUARY 2013

CATARACT &

REFRACTIVE

SURGERY

A New Feeling of Safety in Vitrectomy Oertli® has developed the principle of peristaltic to perfection. The result is impressive: with Oertli TrueFlowControl® you control the flow, precisely and in extremely subtle increments, and the vacuum

Ecknauer+Schoch ASW

independently with the upper limit set by you. This gives you absolute control in every situation. Enjoy becoming accustomed to a new feeling of safety and precision.

Oertli TrueFlowControl® – the physics of success.

ESCRS

EUROTIMES

™

december/january Volume 17/18 | Issue 12/1 This ISSUE...

4

Newsmaker Interview with Dr Jack Holladay

Special Focus: Cataract & Refractive

5 6 7 8 9 10

4

15

Endophthalmitis Study has led to increased usage of intracameral antibiotics Corneal inlay maintains good vision for presbyopes Errors found in data collection systems for reporting endophthalmitis Experience shows intraocular lens achieving same results as laser refractive surgery Dysphotopsias can be problem for patients after cataract surgery Post-LASIK ectasia can be successfully managed

Cornea

12 13

Mucin levels could be good diagnostic marker for dry eye syndrome Recurrent pterygia can be difficult to manage

Glaucoma

14 Effective treatments in primary angle-closure glaucoma discussed 15 Laser peripheral iridoplasty useful option for acute angle closure 16 Inaccurate diagnoses still a problem for glaucoma patients

Retina

21 Kreissig Lecture looks at exciting developments in AMD treatment 22 Gene therapy may provide new treatment options in diabetic retinopathy 23 Icelandic study looks at epidemiology of retinopathy

Paediatric Ophthalmology

30

28

25 26 27

Diagnosing JIA-associated uveitis can be difficult Prophylactic treatment for Stickler syndrome may be harmful Reducing preventable blindness in the Asia-Pacific region

Global Ophthalmology 28

ORBIS partners with physicians in developing countries to prevent blindness

News

30 31 32 33

New technology for AMD 12th AMD and Retina Congress covered broad spectrum of retinopathy Observership participant highly recommends programme to other trainees ESCRS continues fundraising initiatives in 2013

Features

38

34

34 35 36 38 39 42 43 44

Out & About JCRS Highlights EU Matters Industry News Resident’s Diary Book Review Ophthalmologica Highlights Calendar

Clarification: In EuroTimes Volume 17 Issue 9, September 2012, page 12, in an article titled ‘Spectacle Independence’, it was stated: “Patients underwent contrast sensitivity testing using a device called the functional visual analyser.” This sentence should have read: ‘Patients underwent contrast sensitivity testing using a device called the Functional Visual Analyzer™ (Stereo Optical Co, Chicago USA).’

With this issue... Improving Surgical Outcomes with Advanced Cataract & Refractive Technology & 2013 wall planner

editorial staff

ESCRS

EUROTIMES

™

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

Assistant Designer Janice Robb Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

Leigh Spielberg Pippa Wysong Gearóid Tuohy Colour and Print Times Printers Advertising Sales ESCRS, Temple House, Temple Road Blackrock, Co. Dublin, Ireland Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@escrs.org

Published by the European Society of Cataract and Refractive Surgeons Temple House, Temple Road, Blackrock, Co Dublin, Ireland.

No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance.

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

ISSN 1393-8983

As certified by ABC, the EuroTimes average net circulation for the 11 issues distributed between 01 January 2011 and 31 December 2011 is 32,332.

1

EUROTIMES

Editorial

ESCRS

2

EDITORIAL

Medical Editors

Volume 17/18 | Issue 12/1

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

A BRIGHT FUTURE

The development of cataract and refractive surgery will be guided by young ophthalmologists now in training

by Oliver Findl

International Editorial Board

I

am very pleased to have an opportunity to write the editorial for this month’s EuroTimes which focuses on Cataract and Refractive Surgery.

It is always interesting to read reports from the major international meetings which focus on the latest cutting-edge procedures and technologies.

This issue carries a number of reports from the XXX ESCRS Congress in Milan, Italy, where the excellent Scientific Programme gave us the opportunity to consider some of the major innovations which may change the nature of our ophthalmological practices in the future.

As chairman of the ESCRS Young Ophthalmologists’ Forum I was very pleased with the increasing participation of trainees at the Milan congress. They are the future of the ESCRS and they will also determine the future of ophthalmology.

The Young Ophthalmologists’ Programme at the congress was very well attended and I would like to take this opportunity to thank our excellent speakers who discussed a wide range of topics including Refractive Aspects of Lens Surgery and Decision Making in Refractive Surgery. A special thanks also to Zoltan Nagy who delivered a stimulating Guest Lecture on the topic of “Femtosecond Cataract Surgery for Young Ophthalmologists.”

In this issue of EuroTimes and over the next few months you will be able to read reports from the Young Ophthalmologists’ Programme and the other key presentations and as always we welcome your correspondence if you wish to comment on any of the issues raised in our articles.

ESCRS Winter Meeting While we will have fond memories of the congress, it is important to look forward to the future and to the 17th ESCRS Winter Meeting (in conjunction with the Polish Society of Cataract and Refractive Surgery) which takes place in Warsaw, Poland from 15-17 February 2013.

I would urge all of my colleagues to try and attend this meeting which also includes the Annual Cornea Day organised by ESCRS and EuCornea and Live Surgery organised by the Polish Society of Cataract and Refractive Surgery.

I am also very pleased to announce that for the very first time the Young Ophthalmologists have their own programme at the Winter Meeting. This is a three-hour programme which is aimed specifically at ophthalmologists in training and will highlight several topics that will recur through the meeting.

“Learning from the Learners,” is an interactive session on cataract surgery for trainees which I will moderate alongside my colleague Simonetta Morselli, Italy.

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA The programme will offer advice on preparing for your first cataract surgery before you enter the operating room and also case studies presented by the young ophthalmologists themselves. Junior surgeons will share their cases with the group, opening the case up for discussion by the experts.

The aim of this session will be to demonstrate common mistakes made during the learning curve of cataract surgery and how these mistakes can be avoided.

We will also have a session on “How to Teach Cataract Surgery” looking at different approaches to teaching.

Finally, as this is the first issue of EuroTimes for 2013, I would like to wish all of my colleagues a very Happy New Year and I hope that there are good times ahead for all of you.

Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM

oliver findL Oliver Findl MD, MBA is chairman of the ESCRS Young Ophthalmologists’ Forum

EUROTIMES | Volume 17/18 | Issue 12/1

Jack Holladay USA Vikentia Katsanevaki GREECE

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

™

17th ESCRS Winter Meeting in conjunction with the Polish Society of Cataract and Refractive Surgery

Warsaw, Poland 15 – 17 February 2013 Welcome Reception Friday 15 February 19.00

Forteca, 12 Zakroczymska Street, Warszawa

EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS

Registration, Hotel Booking and Programme Overview at www.escrs.org

4

Newsmaker Interview

Jack Holladay

AVOID PROPAGANDA and LISTEN

Dr Jack Holladay MD, MSEE, FACS, who retired after a life-threatening medical crisis, looks back on his life and times and offers advice to young ophthalmologists

D

r Jack Holladay’s many accomplishments include the invention of the Brightness Acuity Tester and the development of the "Holladay IOL Consultant" and "Refractive Surgery Consultant" software programs. He has received virtually every plaudit available in the world of ophthalmology including the Binkhorst Medal, the Ridley Award and the John Pearse Memorial Award. He was recently inducted into the ASCRS Hall of Fame. In 2010 he suffered a Type 1 aortic aneurysm. Luckily he went to the ER in the hospital where the cardiac surgeon was on hand to perform the high-risk surgery that saved his life. He subsequently retired from performing surgery and seeing patients, but maintains a busy schedule teaching and lecturing on the international conference circuit. He spoke with EuroTimes editor Sean Henahan at the ESCRS Congress in Milan.

Doing fine. I’ve retired from patient care but I’m still quite active. Recovery was painstaking but my cognitive and quantitative skills have come back. I notice I probably have to rehearse my talks a little more than before. Honestly, I’m just happy to be here.

Where we’ve been, where we’re going.

The past 40 years in ophthalmology have seen a remarkable evolution in everything we do. When I started in the mid-1970s we were doing intracapsular cataract extraction and giving people aphakic glasses. At that time you would wait until they had a white cataract before you would consider surgery.

Even with 20/100 vision with a cataract, the result wasn’t much different than 20/20 with a pair of aphakic glasses when you took into account all of the distortion, ring scotoma, etc. Patients couldn't drive, things were magnified. I was fortunate at the time to be in a department where intraocular lenses (IOLs) were used early on. The transition from aphakic glasses to IOLs was dramatic in terms of visual improvement.

However, early problems included the trauma of the IOL and phaco to the cornea because the role of the endothelium was not clear at the time. But we worked through those issues and once we ended up learning EUROTIMES | Volume 17/18 | Issue 12/1

Jack Holladay

how to use viscoelastics and other ways to protect the cornea we began to move from lenses that were on the iris, like the Sputnik, and the Fyodorov lens, to lenses in the anterior chamber (Choyce), then in the sulcus, where there were problems with uveal contact. But by the time we got to the 1980s and we began to put them in the bag, the results were wonderful. Since then we’ve learned the importance of the capsulorhexis.

But this is not the end of the story. Today we’re talking about more improvements, such as correcting higher order aberrations (HOAs) in the cornea, and providing lenses that truly accommodate. I expect that within the next five to seven years we will reach that Holy Grail of having lenses that provide wonderful vision at all distances and correct most HOAs. Fine tuning. Predicting the Effective Lens Position (ELP) of the IOL is one of the remaining problems. Are we ever going to get to the point where we know where the lens will be exactly in the eye before surgery? There is always going to be some variability in that, because the anatomy of the eye is very complicated. Our ability to refract a patient is plus/minus a quarter. So once you get down to a quarter of a dioptre, additional improvements won’t make much of a difference to the patient. However, improving those other HOAs, coma, trefoil and spherical aberration, will make a difference. We will be able to improve

“The past 40 years in ophthalmology have seen a remarkable evolution in everything we do. When I started in the mid-1970s we were doing intracapsular cataract extraction and giving people aphakic glasses” quality of vision in patients who already see a pretty good 20/20, getting closer to 20/10. We will be able to make adjustments intraoperatively. The Calhoun light adjustable lens already allows adjustments using UV. There are other ways to do this coming along. Companies are making femtosecond lasers that will adjust the index of refraction within the lens that will also be able to correct aberrations.

Problems with multifocals. The multifocal IOLs have given us an interim solution for providing distance and near vision, but with a compromise in contrast and night-time dysphotopsias. This has been a good step along the way. But I think as we go forward we will see the use of multifocals drop off, as truly accommodative lenses become available. Then we won't have the problems with night-time dysphotopsias that doctors and patients fear with multifocal lenses.

Future of LASIK. In ophthalmology we often see a pattern of an initial wave of excitement in the short term when positive results are announced, when a lot of people jump on the wagon, until the long-term results come in, and people begin to jump off. However, with laser refractive surgery we can now look back 20 years and see the benefits in terms of producing good spectacle-free vision, without seeing any large-scale problems, provided we avoid the patient with forme fruste keratoconus. The

benefits of the laser continue to be refined in terms of optical performance. I think we will continue to see improvement in terms of providing optimal vision. Wavefront still has some delivery issues, but we are almost there. I expect to see significant improvement within the next few years to achieve 20/10 to 20/12 visual acuity in almost everyone with improvement in contrast sensitivity, so top gun pilots are not the only ones with “super vision”.

Evidence and clinical experience.

Ophthalmology is becoming more evidence based, which is clearly a good thing. We’ve always wanted to have science as the reason for why we did things. The shift to what we call evidence based makes that more concrete, in terms of proving that the treatment modalities we use really are best for the patient. However, I would also say oftentimes clinical opinion is quicker, and predicts what evidence-based approaches will show. For example, back in the 1980s the US FDA had an advisory council that looked at 17,000 articles published on cataract surgery, and concluded that there was no study to show that it was beneficial.

Sometimes the criteria for a clinical trial become so stringent and the theoretical basis for doing a double blind, randomised, age-matched, sex-matched clinical trial that accounts for every possible variable becomes so onerous that it doesn't get done. The studies become so costly and so long that the information becomes outdated by the time it is available. There has to be some balance.

There is an important role for approaches such as the EUREQUO registries.

Avoiding the hype and propaganda. There is a certain amount of propaganda one encounters on the conference trail. I advise young ophthalmologists to retain a healthy scepticism. It is essential at conferences to get to know people you feel have been honest and forthright, who give their financial disclosures, who you respect and have a proven track record of honesty.

Listen to them, they provide long-term opinions. It is also important to keep up with the peer-reviewed journals. These tend to lag behind maybe a year, but that is a good thing. If you are within a year of the latest technology, you will do well.

contact

Peter Barry – peterbarryfrcs@theeyeclinic.ie

Special Focus

Cataract & refractive

Endophthalmitis

Intracameral antibiotics becoming standard practice among European cataract surgeons

by Roibeard O’hEineachain in Milan

A

wareness of the ESCRS Endophthalmitis Study has led to the adoption of the prophylactic use of intracameral antibiotics in cataract surgery by about three-fourths of centres participating in a recent survey reported by Peter Barry FRCS, at the XXX Congress of the ESCRS. “Our survey showed that the majority of those who use intracameral antibiotics use cefuroxime and that only a small proportion would not use it under any circumstance, even if it was commercially available, said Dr Barry, Dublin, Ireland, Dr Barry and his associates conducted their survey to determine how widely European ophthalmologists have adopted the prophylactic use of intracameral antibiotics in cataract surgery in the six years since the publication of the ESCRS Endophthalmitis Study (Barry et al, J Cat Refract Surg 2006; 32:407-410).

The survey’s respondents included 193 cataract surgeons from 31 European countries, and were mainly surgeons on the ESCRS database. Of those surveyed 43 per cent were based in hospitals, 39 per cent were in private practice and the remainder were in

university or government institutions.

Dr Barry noted that the ESCRS Endophthalmitis Study was a randomised controlled trial involving 1,600 patients undergoing cataract surgery. It showed that the rate of endophthalmitis among those receiving intracameral cefuroxime was only 0.05 per cent compared to 0.35 per cent among those who did not receive the antibiotic. “This was a surprise because this was, in a way, the antithesis of a clinical trial. What it actually demonstrated was the safety and efficacy of a drug that did not exist in commercial form. It’s probably the first time in the history of medicine that such a paradox has been achieved,” Dr Barry said.

As a result, everyone subsequently adopting the use of the agent did so on a “kitchen pharmacy” basis that would not be likely to gain approval by regulatory bodies in either Europe or the US, he added.

Uptake high in Europe Dr Barry noted that 91 per cent of the survey’s respondents were aware of the ESCRS Endophthalmitis Study and its results, and 74 per cent said they always or usually use intracameral antibiotics for cataract surgery.

t State-of-the-Ar

Of those who used intracameral antibiotics, 82 per cent used cefuroxime, and 18 per cent used other agents, including intracameral vancomycin, moxifloxacin and gentamicin.

“I was quite surprised by the uptake of cefuroxime across Europe. If we had carried this survey out 10 years ago the use of intracameral cefuroxime would have been quite uncommon, and I think that there is still an apprehension using it because no commercial preparation is available,” Dr Barry said.

Among those who said that they rarely or never use intracameral antibiotics in their cataract procedures, 52 per cent said it was because they felt that there was no need to do so, and 26 per cent cited the lack of a protocol in their country or their clinic for their use. Another 16 per cent said they were concerned about the possibility of adverse events, while10 per cent cited lack of a commercially prepared product. An additional six per cent said that they were worried about contamination risks.

Single-dose In their response to the question of whether they would use a commercial single-dose preparation of cefuroxime if one became available, 73 per cent said they would, 14 per cent said they would not and 13 per cent said they might use it on occasion. Dr Barry noted that 12 of the 27 respondents who would not use a commercial preparation were already using intracameral cefuroxime and were satisfied with the results, and saw no need to switch to a commercial preparation.

Conversely, the 73 per cent who said they would use it if it was commercially available included respondents who were not using

TM Coating Biofilm New engineered nefits to enable Be g in d n ta ts u IOLS. provides o on of Premium ti c je In ve ti c fe safe and ef

e as small as • enables an incision siz subMICS 1.5 mm • no additive transfer • no lens scratches • no splitting cartridges drophobic IOLs • for hydrophilic and hy

EUROTIMES | Volume 17/18 | Issue 12/1

it already. Therefore, only eight per cent of the 193 surgeons interviewed would not use intracameral cefuroxime, whether or not it was commercially available.

Dr Barry noted that the fears some cataract surgeons have expressed about the possibility of adverse events when using in-house preparation methods are not without grounds. There have been reports of mistakes in preparation of intracameral cefuroxime leading to disastrous outcomes in cataract patients. For example, at one hospital a contaminated multiple-dose preparation of cefuroxime resulted in eight cases of fusarium endophthalmitis.

“That is pretty frightening. If you didn't use any intracameral antibiotics you would have to do a hell of a lot of cataract operations before you got that many cases of endophthalmitis,” Dr Barry said.

At another hospital, an incorrect dilution procedure led to a number of cataract patients receiving intracameral cefuroxime at a concentration 50 to 100 times higher than it should have been, and eight eyes were blinded as a result. “There are serious potential issues and that is the fundamental cause for concern with intracameral cefuroxime. If you used an unlicensed product in the United States and you had serious adverse events, your practice would be finished,” Dr Barry said.

However, help may soon be at hand.

During the discussion portion of the session, Per Montan MD, Sweden, noted that if all goes according to plan, the drug manufacturer Thea, will be launching a single-dose preparation of cefuroxime called Aprokam, specifically designed for intracameral administration.

5

Special Focus

Cataract & refractive

IMPROVING PRESBYOPIA

Stable vision gains come without compromises of other techniques

by Cheryl Guttman Krader in Milan

I

Courtesy of Daniel S Durrie MD

mplantation of a small aperture cornea inlay (KAMRA, AcuFocus) into a femtosecond laser-created lamellar pocket provides emmetropic presbyopes with near and intermediate vision improvements that are remaining stable through lengthening follow-up, reported Daniel S Durrie MD, at the XXX Congress of the ESCRS. Dr Durrie is an investigator in the prospective, international study evaluating “Pocket Emmetropia KAMRA” (PEK), a presbyopia-correcting procedure for emmetropic patients in which the small aperture corneal inlay is placed in the non-dominant eye. He reported results from follow-up to two years in the study that enrolled 507 patients at 24 sites in the US, Europe and Asia.

The PEK study enrolled patients who were naturallyoccurring presbyopic emmetropes with a spherical equivalent between -0.75 and +0.5 D and no history of refractive surgery. Other inclusion criteria required patients to have near UCVA that was worse than 20/40 and better than 20/100 along with BCDVA of 20/20 or better in both eyes.

All patients received the most recent version of the small aperture inlay, which is five microns thick with 8,400

Don’t Miss Eye on Technology, see page 30 EUROTIMES | Volume 17/18 | Issue 12/1

contact

6

Daniel S Durrie – ddurrie@durrievision.com

“

The smoother surface obtained using the newer generation lasers with the tighter spot/line separation provides better optics that explains the better vision results Daniel S Durrie MD

random holes and measuring 3.8mm in diameter with a 1.6mm central aperture. Depth of the pocket for inlay placement was ~200 microns, and all of the procedures were done prior to the availability of technology for intraoperative centration guidance (AcuTarget, SMI). The inlay was positioned based on marking the first Purkinje reflex on the epithelium preoperatively.

Mean near UCVA in the inlay eye was about 20/63 at baseline, improved by an average of 3.2 lines to about 20/32 (J2) at one month and remained unchanged over time.

Intermediate vision in the inlay eye was also improved at one month by an average of about 1.5 lines, and the benefit remained stable throughout follow-up, with mean intermediate vision being about 20/25 at 24 months.

The procedure resulted in a slight hyperopic shift in mean MRSE (~+0.2 D), and mean distance UCVA in the inlay eye decreased slightly. However, mean distance UCVA remained 20/20 in the inlay eyes at 24 months and was stable in binocular testing at 20/16 throughout follow-up.

Mean BCVA was also unchanged throughout follow-up and was 20/20 or better in all inlay eyes and 20/16 binocularly at 24 months.

“Additionally, the gains in near and intermediate vision are stable, with data from some investigators showing the improvements are maintained during follow-up extending to at least four years. This long-term efficacy is a nice advantage of PEK compared with other options for presbyopia correction and may be explained by the inlay’s mechanism.

By increasing depth of focus, the inlay can compensate for some of the age-related worsening of near vision, at least for some time,” said Dr Durrie, professor of ophthalmology, University of Kansas Medical Centre, Kansas City, and president, Durrie Vision, Overland Park, KS. Data for contrast sensitivity testing was available from follow-up at 12 months for 479 eyes and the results showed preservation of function under both mesopic and photopic conditions.

“PEK is a straightforward and simple procedure that is accessible to most refractive surgeons using equipment they already have. And for patients, PEK is a unique presbyopiacorrecting procedure that improves near and intermediate vision occur without compromising distance vision, contrast sensitivity or stereopsis,” he commented.

Dr Durrie noted that with its large patient population and some diversity in patient characteristics and equipment used, the PEK study allowed for subgroup analyses to investigate factors predicting outcomes. With eyes stratified by preoperative refractive error, results showed that those with slight myopia, in the range of -0.5 to -0.75 D, had the best results for near as well as for distance vision.

Differences also emerged comparing groups of eyes having pocket creation done using different femtosecond lasers. Three platforms were used across the study sites –

the IntraLase FS60 (Abbott Medical Optics), iFS (Abbott Medical Optics), and Femto LDV (Ziemer). Vision results were best in eyes where the pocket was made with one of the more advanced lasers that uses a tighter spot/line separation, either the iFS or Femto LDV, and there was also a benefit for faster vision recovery. The outcomes analyses indicated that the optimal spot/line setting was 6x6 or less. Among eyes operated on with lasers using this setting, mean near UCVA improved from 20/63 at baseline to 20/25 at 12 months and mean distance UCVA was unchanged from the baseline level of 20/20, Dr Durrie reported.

“The smoother surface obtained using the newer generation lasers with the tighter spot/line separation provides better optics that explains the better vision results.

This technology also results in less of a wound healing response, which accounts for the faster rehabilitation,” he said.

Pocket vs. flap A drawback of placing the small aperture corneal inlay into a lamellar pocket instead of underneath a flap is that the pocket procedure does not allow for simultaneous laser vision correction of refractive error. The patients that qualify for the pocket procedure fall into three groups. Plano presbyopes like the patients included in this study, pseudophakic patients that are close to plano and post LASIK and PRK patients who are now developing presbyopia. There are several advantages of using a pocket for inlay placement, said Dr Durrie.

“Cutting of a pocket involves less energy delivery to the cornea, severs fewer corneal nerves, and better maintains corneal strength since there is less extensive corneal fibre dissection. In addition, there is reduced chance for causing topographic changes using the pocket technique, and it also enables more accurate inlay centration by allowing better visualisation of the surface marking of the first Purkinje image,” he explained.

7

Special Focus

Cataract & refractive

Objective evaluation of the lens density in 3D

FINDING CASES

Recording methods used for reporting endophthalmitis don’t always work as designed

by Roibeard O’hEineachain in Milan

A

n analysis of the methods used for reporting endophthalmitis after cataract surgery in a UK teaching hospital indicate that consulting the records of the Microbiology Department can be the most efficient approach, said Miss Aabgina Shafi, Department of Ophthalmology, Bradford Royal Infirmary, Bradford, UK. “Endophthalmitis remains a devastating complication of cataract surgery. It can happen in outbreaks, making early recognition of an increasing trend in incidence of utmost importance,” Miss Shafi said at the XXX Congress of the ESCRS .

Ms Shafi and her associates compared the different systems of data entry used at the Bradford Royal Infirmary to find the most failsafe method of identifying endophthalmitis cases occurring after cataract surgery. They analysed the hospital’s records from a five-year period, from January 2007 to January 2012.

Overall, from all the data sources available at their centre, they found 25 cases of endophthalmitis. Nine were bleb-related, and six occurred after phacoemulsification procedures, one of which was carried out in Pakistan.

There were also four endogenous cases, three cases that occurred following intravitreal injection of triamcinolone acetonide, one which occurred following pars plana vitrectomy and one that was a result of trauma.

“Out of 11,535 cataract surgeries performed over five years, there were five cases of endophthalmitis. That gives us an incidence of 0.04 per cent,” Miss Shafi said.

Data collecting software disappoints Miss Shafi noted that the

Medisoft software they used for the general recording of procedures gave particularly poor results. In fact, it only identified two cases, despite the fact that it logged nearly every cataract case performed, she said “I still hold that Medisoft would be the most practical method. It is available at the click of a finger. However, it is dependent on us actually inputting the data. Therefore the recommendation in our department is to log on every patient who has presumed endophthalmitis. We can always remove cases later if the diagnosis changes,” Miss Shafi added.

EUROTIMES | Volume 17/18 | Issue 12/1

“

Out of 11,535 cataract surgeries performed over five years, there were five cases of endophthalmitis.

That gives us an incidence of 0.04 per cent”

OCULUS Pentacam® HR The indispensable tool for anterior segment analysis

Aabgina Shafi Critical incident reporting, which should have identified all cases according to the NHS policies, was even less effective and did not identify a single endophthalmitis case for the whole of the period under study.

A review of the coding logs yielded a sample of 98 cases. Excluding the mis-codes reduced the sample to 68 cases and crossreferencing the sample with intervention codes yielded 21 cases, including some repeats, she noted.

The missed cases included two cases of endogenous endophthalmitis, one case that had received intravitreal triamcinolone acetonide, and one case that occurred following phacoemulsification.

The information provided by the Microbiology Department identified 18 of 21 endophthalmitis cases. Those missed included one post-phacoemulsification cases, one trauma case and one case that occurred following phacotrabeculectomy.

The pharmacy records of vancomycin usage identified 15 of 25 endophthalmitis cases. The missed cases included three that occurred following phacoemulsification and one that followed pars plana vitrectomy “Consulting the microbiology records would be my preference because it gives us the least number of case notes to look at.

Over the five years it really missed only one phaco-related endophthalmitis case and that was because during that year we sent some of our cases to an outside laboratory,” Miss Shafi added.

contact Aabgina Shafi – aabginashafi@gmail.com

•

3D Cataract Analysis & PNS

•

NEW! Iris Camera and automatic HWTW

•

NEW! Indices Report

•

Anterior & posterior topography & elevation maps

•

Support for decision making regarding premium IOL, toric IOL and aspheric IOL

•

Belin/Ambrosio Display for early Keratoconus detection – NEW! Now for hyperopes too!

•

NEW! Cataract pre-op display for corneal optical quality assessment

Visit us at ESCRS Winter Meeting in Warsaw

www.oculus.de

Special Focus

Cataract & refractive

contact

Tobias H Neuhann – dr.neuhann@email.de

LIGHT ADJUSTABLE LENS

Refractive results equal corneal laser surgery at 24 months; near vision improved

by Howard Larkin in Milan

A

t 24 months, patients implanted with the intraocular Light Adjustable Lens (Calhoun Vision, Pasadena, California, US) not only achieved vision outcomes equivalent to those seen with laser refractive surgery, they also showed significantly better near vision than patients implanted with conventional monofocal IOLs, Tobias H Neuhann MD, Munich, Germany, told the XXX Congress of the ESCRS. Excellent results were obtained even in eyes with keratoconus, previous corneal refractive surgery or posterior pole or mature cataracts that rendered A-scan or IOL Master measurements unreliable.

“Difficult eyes showed the same good results as virgin eyes,” Dr Neuhann said.

He noted that both sphere and cylinder corrections after cataract surgery or clear lens exchange with the implanted LAL were similar to those seen in custom laser refractive surgery, and they remained stable and safe throughout the follow-up period. Good near vision in LAL patients was an unexpected positive side effect, which Dr Neuhann plans to investigate further.

Fine-tuning after surgery Dr Neuhann reported results from 65 eyes, including 41 “virgin” or uncomplicated eyes with no previous refractive surgery, and 24 complicated eyes. These included 13 post-LASIK eyes of which nine were myopic treatments and three hyperopic treatments with uncorrected visual acuity of 20/20-plus, and one myopic treatment plus a complete vitrectomy; two eyes with keratoconus with uncorrected visual acuity of 20/20 and 20/40; and nine eyes with no reliable IOL Master axis measurement, including two with mature cataracts and seven with posterior pole cataracts. Mean patient age was 63 years ranging from 48 to 83.

All eyes were implanted with the Calhoun LAL, an aspheric, three-piece silicone IOL with a 6.0mm optic. The lens is constructed of ultraviolet-sensitive silicone polymers that allow spherical and toric adjustment of about 2.0 D as well as correction of aberrations using the UV light delivery device. Once the desired refraction is achieved, the correction is locked in. This makes it possible to fine-tune postoperative refraction based on patients’ specific requirements making the LAL the perfect choice for patients who have had laser vision correction or corneal cross-linking, Dr Neuhann noted. In this series corrections were made two weeks after surgery.

“

With this lens we have opened a completely new, exciting and sophisticated area for customising premium IOLs for patients’ needs in modern refractive cataract surgery Tobias H Neuhann MD

EUROTIMES | Volume 17/18 | Issue 12/1

Postoperatively, mean spherical equivalent fell to -0.37 D, ranging from -2.25 to 1.25 from a preoperative mean of 1.75 D ranging from -22.0 to 4.63. Mean sphere fell to -0.23 +/0.79 D from -1.41 +/- 4.51D preoperatively.

Mean cylinder also dropped to -0.28 +/- 0.37 D from -0.67 +/- 0.48 D after surgery. All eyes had low astigmatism, or 2.0 D or less preoperative said Dr Neuhann. He suggested that the LAL is especially good for treating low-dioptre astigmatism because they can be very difficult to measure precisely preoperatively.

“You can implant a -1.0 toric lens, but the reading you get preoperatively may be 1.0 but post-op it is 1.5. With the light adjustable lens, the patient tells you this astigmatism plus the axis and therefore the low-dioptre correction is so nice.”

Refractions were remeasured at three, six, 12, 18, 24 months, with some reaching 36 months as well. Mean spherical equivalent ranged between a low of -0.86 D at six months and a high of -0.25 D at 18 months, Dr Neuhann said. “This is a little fluctuation but we all have that. It depends on the dry eye and the history of refraction.”

At 24 months, 94 per cent of eyes were within ±0.5 D of the target refraction and all were within 1.0 D, Dr Neuhann said. Visual outcomes were also excellent, with all eyes achieving 20/30 or better uncorrected, 82 per cent 20/25 or better, 54 per cent 20/20 or better and nine per cent 20/16.

These outcomes are similar to what he sees with custom corneal laser surgery, Dr Neuhann added.

Near-vision bonus An unexpected but welcome outcome was significantly better uncorrected near vision for LAL patients compared with conventional monofocal patients, Dr Neuhann noted. All 65 LAL-implanted eyes achieved J8 or better uncorrected compared with just 10 per cent of monofocal eyes. Nearly two-thirds of LAL eyes read J6 or better compared with two per cent of monofocal eyes, and one-third of LAL eyes read J4 compared with none for monofocal IOLs. Some 16 per cent of LAL eyes read J3. Other early users of the LAL have also observed the effect.

Dr Neuhann is uncertain why the LAL-implanted eyes did so well with uncorrected vision in what is still essentially a monofocal lens. “This is amazing and it was not intended. To this day we don’t know why.”

He noted, however, that after the second lock-in a significant amount of coma of about 1.2 microns can be measured, (see Figures 1a and b) producing post-op aberrations similar to those seen with Oculentis (Berlin, Germany) Mplus multifocal implants. The Mplus is an asymmetric bifocal design with an add on only one side of the lens instead of 360 degrees. “It is very close when you compare it to the Oculentis. Probably the induced coma and higher order aberrations make the patients read much better,” Dr Neuhann said (see Figures 1a and b).

Asked if the coma were induced between the time that the lens corrections were made and the time that they were locked in, Dr Neuhann responded that he did not know as

Courtesy of Tobias H Neuhann MD

8

Figure 1a: 3rd and 4th order aberration preoperative – internal coma 0.12µm

Figure 1b: 3rd and 4th order aberration postoperative – internal coma 1.13µm

the measurements were only made preoperatively and after the corrections were locked in.

“We don’t know what we induced or when we induced it. But since I can measure the internal wavefront aberrations and the corneal aberrations we shall see.

Can we use this effect and enhance this effect? Time and scientific work will tell us.

"With this lens we have opened a completely new, exiting and sophisticated area for customising premium IOLs for patients' needs in modern refractive cataract surgery. "

Special Focus

Cataract & refractive

IMPERFECT ‘PERFECT’ VISION

Dysphotopsias leading cause of post-cataract dissatisfaction, even with excellent acuity

by Howard Larkin in Chicago

Beyond annoying The problem isn’t new. Dr Olson recalled a patient he saw as a resident before the days of intraocular lenses (IOLs). The patient had achieved 20/20 vision with aphakic spectacles, but suffered a raft of day-to-day visual problems including disabling glare. Finally she asked Dr Olson if he had saved her cataracts – and could they be put back.

“The realisation that it was that severe showed me that intraocular lenses were going to be a godsend for us as they have been.”

But even today, patients have similar complaints after surgery. To give an impression of how disabling glare and light-scatter can be, Dr Olson noted that light hitting a dirty windshield can completely obliterate vision in an instant, and had in fact recently caused him to drive off the road.

Existing studies suggest the link between dysphotopsias and dissatisfaction may be strong. In a study Dr Olson and colleagues EUROTIMES | Volume 17/18 | Issue 12/1

“

The realisation that it was that severe showed me that intraocular lenses were going to be a godsend for us as they have been Randall J Olson MD

What did correlate with satisfaction were the NEI-VFQ, with an r value of -0.47 (p<0.001), and even more strongly the dysphotopsia survey, with r value -0.58 (p<0.001).

“This supports our previous research,” Dr Olson said.

But there was a surprise – dysphotopsias was the only thing that correlated with NEIVFQ. “This tells us that dysphotopsia is not just an annoyance, it is a dysfunction in overall visual capability,” Dr Olson said.

Further analysis showed the correlation was because of dysphotopsia. “I think this takes the question to another level, that indeed for these patients it actually has an impact on their real function.”

published in the Canadian Journal of Ophthalmology, a survey of cataract patients found dysphotopsias to be much more strongly correlated with dissatisfaction, at an r value of 0.6017 (p<0.0001), than best Biggest problems Among the most corrected visual acuity, which was only common disabling effects were problems marginally correlated at 0.2593 (p=0.040). with bright lights, with 21 per cent of But this study was not looking specifically patients ranking it five or higher on a scale at the link between dysphotopsias and dissatisfaction, Dr Olson noted. There were also many confounding pathologies in the sample that clouded the results.

To isolate the contribution of dysphotopsias to satisfaction, Dr Olson conducted a new survey including only patients with no pathologies including PCO or dry eye, uncomplicated surgery, excellent corrected vision and no complaints in the medical record at least one year after implantation of an AcrySof single piece IOL. Out of 2,953 patients operated, just 82 met all the inclusion criteria.

The patients were evaluated for refractive error, logMAR visual acuity, mesopic logMAR acuity, mesopic 10 per cent acuity and mesopic 10 per cent contrast logMAR with glare. Glare was tested by placing two halogen bulbs beside the 10 per cent chart, CO simulating oncoming headlights. Stray PHA SLT light was tested with the Oculus C-Quant, YAG the NEI-VFQ was administered to assess • Combi SLT & Nd:YAG functional vision. A survey of the presence • Combi KTP & Nd:YAG SLIT S P of dysphotopsias and a satisfaction survey LAM • bright and coaxial aiming beam were also given.

N KTP • adapters for Haag-Streit AT IO Y Uncorrected visual acuity did not N OINVG E R M A N IN …

ER MADE correlate with either satisfaction or LAS disability as measured by the NEI-VFQ, Dr Olson reported. Neither did any visual Your local distributor: function study correlate with satisfaction or A.R.C. Laser GmbH  +49 (0) 911 217 79 -0 disability. The C-Quant results did correlate Bessemerstraße 14 (0)local 911 217 79 99  +49 Your distributor: with mesopic 10 per cent contrast acuity, D-90411 Nürnberg info@arclaser.de www.arclaser.de A.R.C. Laser GmbH Germany +49 (0) 911 217 79 -0 This year you can expect a brand new range of lasers and ophthalmic but not with visual function or satisfaction Bessemerstraße 14 +49 (0) 911 217 79 99  www.arclaser.de products from A.R.C. Laser. Watch out for the stars.

D-90411 Nürnberg info@arclaser.de questionnaire results.

The year of SLT & Nd:YAG

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

2

0/20 uncorrected is the standard for cataract surgery outcomes today. Yet even when it’s achieved, many patients aren’t satisfied, and may even suffer significant loss of visual function, 2012 Binkhorst Medal recipient Randall J Olson MD told the annual ASCRS symposium opening session.

So what drives dissatisfaction in this “20/20 unhappy” group? Dysphotopsias, including glare, shadows and doubling of vision, according to recent research presented by Dr Olson, who is CEO of the John A Moran Eye Centre and chair of the Department of Ophthalmology at the University of Utah, Salt Lake City, US. Not only were dysphotopsias found to be statistically related to patient dissatisfaction while uncorrected visual acuity was not, dysphotopsias also correlated with loss of patient function as measured by the National Eye Institute Visual Function Questionnaire, or NEI-VFQ. But the extent and causes of post-cataract dysphotopsias are not well understood, Dr Olson said in his Binkhorst Lecture, “Where are we on the Road to Optical Perfection?”

With patients increasingly demanding refractive precision, “it’s time to figure out the causes, address the concerns and come up with new products.”

of 1-10, with 10 as debilitating. Temporal darkness was reported by 20 per cent with four listing it at eight or more.

Peripheral light causing a central flash was noted by 40 per cent, with eight rating a five or greater. Dr Olson emphasised that these patients had never complained and had good measured visual acuity.

“We’ve got patients out there with this condition who have never complained about it. This was surprising. We thought we had done away with it by treating the edge of the lens.”

Dr Olson said the results do not mean uncorrected vision and glare are not issues, they just didn’t show up in this sample, which had no acuity or PCO issues.

Emerging technologies may help eliminate postoperative dysphotopsia and refractive errors, Dr Olson said.

Higher order aberrations and cylinder errors appear to be major culprits. These may be reduced through better biometry and improved formulae for calculating effective lens position, and intraoperative aberrometry to detect and correct errors during surgery. Better lens design also could help, as could dialing in results after surgery with light-adjustable lenses or manipulating lenses in situ with femtosecond lasers.

“Hopefully, the era of the 20/20 unhappy patient may soon be a thing of the past.”

Germany

www.arclaser.de

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

contact

Randall Olson – randallj.olson@hsc.utah.edu

9

10

Special Focus

Cataract & refractive

POST-LASIK ECTASIA

Surgical management of post-LASIK ectasia effective for majority of patients

by Dermot McGrath in Paris

W

For reFractive and cataract Surgery reaching a new level in corneal tomography Patented Dual Scheimpflug system provides highly accurate pachymetry and ray-tracing, even when the measurement is decentred. the only true solution Placido and Scheimpflug for highly accurate pachymetry, elevation and curvature data – in all eyes.

iris-based eye motion compensation Have confidence in your follow-up measurements with realignment of maps in 3-D.

one platform, one solution.

We simplify the daily workflow in your clinic with an all-in-one solution, from refractive to cataract surgery.

Only the GALILEI G4 unites Placido and Dual Scheimpflug technologies in one measurement. With the GALILEI G4, you get highly precise measurements for posterior and anterior curvature, pachymetry, Total Corneal Power, Total Corneal Wavefront and the anterior segment of your patient’s eye. The new GALILEI G4, for first-class clinical results. The GALILEI G4 is a modular platform, which can be upgraded according to your needs. Learn more on galilei.ziemergroup.com.

EuroTimes_dez2012_GALILEI_G4_ad_120x300.indd EUROTIMES | Volume 17/18 | Issue 12/1

1

26.10.12 13:37

hile still one of the most feared complications of refractive surgery, postLASIK ectasia can be successfully managed with a combination of therapeutic strategies to preserve patients’ quality of vision and delay and arrest the progression of the underlying pathology, according to Dominique Pietrini MD. “There are two main components in treating post-LASIK ectasia – first, visual rehabilitation which is usually achieved with corneal ring implants and/or topography-guided PRK, and then collagen crosslinking with riboflavin (CXL) to treat the underlying condition. Using these techniques, we can achieve a gain of up to three lines of uncorrected visual acuity, and a significant reduction in corneal astigmatism and higher order aberrations,” Dr Pietrini told delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting.

Dr Pietrini, in private practice at the Clinique de la Vision, Paris, said that the incidence of post-LASIK ectasia remains rare, with a frequency of between 0.008 per cent and 0.66 per cent reported in the scientific literature.

“While this works out at about one case of ectasia for every 5,000 LASIK procedures, it is still very much a feared complication because of its potentially devastating impact on a patient’s quality of vision,” he said.

Dr Pietrini’s study included 54 eyes of post-LASIK ectasia patients with a followup ranging from six months to four years.

“We proposed surgical treatment for 36 of those patients comprising either corneal rings and/or CXL or surface ablation PRK or CXL. The average patient age was 36 years and the initial LASIK surgery was carried out between 1999 and 2011. The mean time between the original LASIK procedure and the secondary intervention was three years. Interestingly, a microkeratome was used in 69 per cent of the ectasia cases and femtosecond laser in 30 per cent, so the femtosecond has not entirely eradicated the problem,” he said.

Dr Pietrini noted that the average spherical equivalent went from -2.96 D preoperatively to -1.49 D postoperatively.

Subjective cylinder was also significantly reduced from a mean of -3.36 D preoperatively to -1.58 D after surgery.

“

We proposed surgical treatment for 36 of those patients comprising either corneal rings and/ or CXL or surface ablation PRK or CXL Dominique Pietrini MD

Both uncorrected and best-corrected visual acuity also improved significantly after surgical treatment.

Dr Pietrini said that forme fruste keratoconus was apparent in 10 cases based on preoperative topography maps, and insufficient residual stromal bed thickness was found in four cases. No identifiable aetiology was found in two patients who presented a perfectly normal preoperative topography, he said.

Intacs (Addition Technology) intracorneal rings were implanted using femtosecond laser in three eyes, while 28 eyes were fitted with Keraring (Mediphacos). Ten of the latter patients were also treated with associated CXL. Three patients were treated by topographyguided PRK. The option not to operate with either corneal rings or CXL was taken for 18 out of 54 patients, said Dr Pietrini.

“These cases concerned those patients in whom the best corrected visual acuity was maintained, who tolerated the use of soft or hard contact lenses, and in whom the pathology was stable with an absence of progression of the disease,” he said.

Dr Pietrini advised close monitoring of all post-LASIK ectasia patients.

“Close topographic surveillance is indispensable for these patients as we need to keep an eye on the potential evolution of the condition, which is sometimes late onset in cases of pellucid marginal degeneration, and of course after the secondary treatment,” he said.

contact Dominique Pietrini – dpietrini@club.fr

E

E R IP FR EA SH ES 3 Y ER N E B AI EM R M RT FO

ESCRS

12

Update

Cornea

AMSTERDAM 2013

4 EUCORNEA CONGRESS TH

4-5 OCTOBER 2013 Abstract Submission

Deadline: 22 March 2013

www.eucornea.org

EUROTIMES | Volume 17/18 | Issue 12/1

DRY EYE SYNDROME

Role of mucins explored in dry eye syndrome

by Dermot McGrath in Milan

U

nderstanding and classifying the gene expression levels of certain ocular surface mucins that play a major role in maintaining ocular surface health may one day help to diagnose patients with dry eye more accurately than current methods, according to David J Galarreta MD, PhD. “Mucins perform an essential role in the tear film-epithelium unit and are responsible for key functions in the regulation of a healthy ocular surface. As well as their antimicrobial function, mucins are also implicated in cellular signalling, cellular adhesion and may function as osmo-sensors as well,” Dr Galarreta told delegates attending the 3rd EuCornea Congress.

Dr Galarreta, University of Valladolid, Spain, said that several studies have shown that dry eye syndrome leads to an alteration in the expression of certain ocular mucins. This paves the way to using specific mucin levels as a diagnostic marker for dry eye syndrome.

“This will not only increase the accuracy of classifying patients correctly, but also significantly aid in clinical trials for the development of therapeutic agents for this prevalent ocular disease. Our job now is to define which targets are the best ones to try to modulate with drugs in order to benefit our patients,” he said.

Discussing the background to the burgeoning interest in researching ocular mucins, Dr Galarreta said that traditional concept of the tear film as being comprised of three layers, lipid, aqueous and mucous, has evolved considerably in recent years. “We are now also talking a lot about hydromucinic gel, which is a complex structure, secreted from goblet cells or mucus-secreting cells of glands and present at the apical surfaces of the epithelia. Mucins are usually classified into two main groups: secreted mucins which can be gel forming or soluble, or membrane-bound mucins,” explained Dr Galarreta.

Comprising both soluble and membrane-bound molecules, ocular surface mucins are highly glycosylated proteins which help to structure the tear film by binding both to each other and to the aqueous component of the tear film.

In helping to stabilise the tear film, mucins play a key role in maintaining ocular surface health. In a normal eye, the concentration of ocular surface mucins is highest near the surface of the globe, and it gradually decreases as the tear/air interface is approached.

Focusing on the classification of mucins, Dr Galarreta said that different types of mucin perform different functions in the ocular surface. Secreted mucins are essentially clearing molecules with the ability to clear allergens, pathogens and debris from the ocular surface. They are also excellent lubricating agents with a high ability to retain water due to their highly hydrophilic character.

Soluble mucins, such as MUC7, are produced mainly by the lacrimal gland and comprise the smallest mucin molecules in the tear film.

“MUC7 in particular has an additional antimicrobial activity, and its expression is reduced in contact lens wearers,

what could be one of the causes of a higher incidence in microbial keratitis in these patients” he said.

Gel-forming mucins, such as MUC2, MUC19 and MUC5AC, are secreted mainly by the goblet cells of the conjunctiva. "Gel-forming mucins are dissolved in the tear film, but are larger and more interactive with other mucin molecules than soluble ones," he said.

Membrane-associated mucins, such as MUC1, MUC4 and MUC16, are even longer molecules that have an intracellular extension that anchors them to epithelial cells.

In the ocular surface epithelia, these mucins play a key role in protecting the ocular surface, providing boundary lubrication and preventing adhesion of facing cell surfaces.

They may also function as osmo-sensors, although more research is needed to confirm this particular hypothesis.

“The idea is that mucins can sense the osmolarity of the extracellular environment through their extracellular domain and then signal through the intracellular domain to the cell and actually change the condition of the cell,” he said.

Turning to the scientific literature, Dr Galarreta noted some previous studies have shown altered mucin levels in patients with Sjögren’s syndrome. In patients with Sjögren’s syndrome, the inflammation of tear-secreting glands combined with changes in the composition of the tear film reduces tear production and results in chronic dry eye.

One study showed that the mucin MUC5AC transcripts in the conjunctival epithelium of patients with dry eye syndrome associated with Sjögren’s syndrome were significantly lower than those in normal individuals.

Another study showed significant variations in conjunctival mucin mRNA expression in contact lens wearers.

Compelling evidence has also come from a prospective study carried out at the University of Valladolid and published last year in the journal of Investigative Ophthalmology & Visual Science (Vol. 52, No.11, pp.

8363-8369). That study set out to evaluate mRNA levels of the ocular mucins MUC1, MUC2, MUC4, MUC5AC, and MUC7 in conjunctival impression cytology samples from patients with moderate to severe dry eye syndrome and compared them with a population of healthy subjects. It also investigated the use of the levels of these mucin genes as biomarkers of dry eye syndrome and subsequently as a potential diagnostic test for dry eye syndrome.

Expressions of MUC1, MUC2, MUC4, and MUC5AC were significantly lower in conjunctival epithelium of patients with dry eye syndrome compared with that in normal subjects. These results were replicated in the external control subject and patient groups. MUC1 expression levels demonstrated the greatest sensitivity (83 per cent) and specificity (87.5 per cent) among all genes tested. “The data strongly suggest that the expression levels of MUC1 may be used as a diagnostic test in dry eye syndrome for investigational and selective clinical trials,” the study authors concluded.

contact

David J Galarreta – david@ioba.med.uva.es

contact

Jose L Güell – guell@imo.es

Update

Cornea

PTERYGIA

Anti-angiogenic therapy supported by scientific rationale, but not by trial results

by Cheryl Guttman Krader in Milan

A

lthough VEGF inhibition appears to be an attractive therapeutic target for preventing pterygium recurrence, randomised controlled trials investigating anti-VEGF treatment have produced disappointing results, said José L Güell MD. Speaking at the 3rd EuCornea Congress during a symposium on cornea neovascularisation, Dr Güell noted that recurrent pterygia tend to have a more exuberant fibrovascular growth response than primary lesions and are much more difficult to handle surgically. Therefore, various strategies have been suggested for use at the time of pterygia excision or postoperatively as a means to prevent lesion recurrence. These modalities include anti-mitotic agents (5-fluorouracil or mitomycin-C), corticosteroids and betairradiation.

However, when used alone or in combination, none of these approaches has proven to be completely effective and each is accompanied by safety concerns. Therefore, the search for alternatives continues.

Interest in anti-VEGF therapy relates to evidence that angiogenesis plays a role in pterygium development and growth. In addition, researchers analysing pterygium tissue found elevated expression of a variety of proangiogenic factors along with decreased expression of various angiogenic inhibitors.

“We know that pterygium is a proliferative invasive conjunctival lesion characterised by chronic inflammation and angiogenesis with resultant connective tissue remodelling.

Among the chemical mediators stimulating angiogenesis, VEGF appears to be the most important. Therefore, it was postulated some years ago that suppressing neovascularisation with anti-VEGF therapy might prevent pterygium recurrence or retard its progression,” said Dr Güell, professor of ophthalmology, Universidad Autonoma de Barcelona, and director, cornea and refractive surgery unit, Instituto de Microcirugia Ocular de Barcelona, Spain.

“Based on published reports describing use of topical or subconjunctival bevacizumab (Avastin, Genentech), anti-VEGF treatment appears to be safe. However, in controlled studies, any favourable effect of the antiVEGF therapy for limiting conjunctival neovascularisation in impending pterygia EUROTIMES | Volume 17/18 | Issue 12/1

was incomplete and temporary. Furthermore, the data show no advantage of treatment with bevacizumab for lessening symptoms of irritation, recurrence rate, or the thickness and size of recurrent lesions.”

Aside from his own personal experience, in reviewing the literature through the period ending July 2012, Dr Güell identified 12 articles reporting on the use of local antiVEGF therapy with bevacizumab (Avastin, Genentech) as treatment for primary pterygium or to treat or prevent recurrence.

The first five papers published on this topic were single case reports or small case series including no more than five eyes, and the treatment outcomes were mixed.

Subsequently, five randomised, controlled clinical trials evaluating local bevacizumab were published along with two larger interventional series.

The randomised controlled studies included between 30 and 80 eyes.

Bevacizumab was applied topically twice daily for one week in one study of patients with impending recurrent pterygium. The other studies investigated subconjunctival bevacizumab in doses ranging from 1.25 to 3.75mg for the treatment of impending recurrent pterygium, primary pterygium treatment or to prevent recurrence after primary pterygium excision. However, none of the randomised controlled studies demonstrated any conclusive evidence of a significant benefit of bevacizumab.

“Favourable results were reported in two other papers, but both were uncontrolled studies and in one that investigated subconjunctival bevacizumab for advanced primary pterygium, patients received multiple injections,” Dr Güell said.

Why the failure? Dr Güell reviewed several possible reasons that might account for the lack of efficacy of anti-VEGF therapy in pterygium management and noted that the full explanation might be multifactorial.

One factor to consider is that even though angiogenesis plays an important pathophysiologic role in pterygium development and progression, VEGF inhibition by itself may be insufficient to stop neovascularisation in a milieu containing other proangiogenic growth factors and cytokines.

“Perhaps future research might find that the combination of an anti-VEGF agent

with angiogenic inhibitors targeting other stimulators might be effective,” he said.

The fact that vascularisation in pterygia is a mixture of old and new vessels might also explain the lack of a better response to anti-VEGF therapy, recognising that mature vessels are less sensitive to the antiangiogenic activity of VEGF inhibition. In addition, because the aetiology of recurrent pterygia is multifactorial, treatment aimed at only the vascular component may be ineffective. Furthermore, there may be unrecognised differences in the pathogenesis of primary and recurrent pterygia, Dr Güell said.

There is an obvious difference in response to anti-VEGF therapy for macular disease and pterygium. Dr Güell suggested this might be related to differences in the histopathological characteristics of retinochoroidal neovascularisation. In addition, the anti-VEGF agent has a much longer half-life at the target site when it is injected into the vitreous than when it is applied topically or subconjunctivally where the drug is cleared into the systemic circulation via absorption through the conjunctival vessels, he said.

“Increasing the dose of locally applied bevacizumab could improve its bioavailability at the target site when used to treat pterygia, but would also increase the risk of side effects,” Dr Güell added.

“

Among the chemical mediators stimulating angiogenesis, VEGF appears to be the most important José L Güell MD

Based on the positive experience using anti-VEGF therapy in treating neovascular macular disease and considering the multifactorial aetiology of pterygia, Dr Güell suggested that future studies might evaluate combination approaches using an anti-VEGF agent together with antiinflammatory corticosteroid therapy. He also reminded ophthalmologists that while the role of anti-VEGF treatment in pterygia management requires further study, available evidence supports VEGF inhibition for controlling corneal neovascularisation in other clinical situations.

“Anti-VEGF therapy has been shown to be an excellent strategy in controlling corneal neovascularisation associated with lipid degeneration, infectious keratitis, after penetrating keratoplasty to prevent graft rejection, and perhaps in the treatment of some superficial carcinomas,” Dr Güell said.

Ophthalmic Women Leaders leadership

I

advancement

I

community

Ophthalmic Women Leaders (OWL) is the preeminent nonprofit organization for the professional development and advancement of women in the eye care industry.

Consider OWL membership OWL offers members many career enhancing benefits including webinars, mentoring/coaching programs, networking opportunities, special events, and more. For details and to become a member, visit www.owlsite.org.

13

contact

14

Update

glaucoma

LENS EXTRACTION

Cataract extraction effective in treatment of primary angle-closure glaucoma

Courtesy of Augusto Azuara-Blanco MD, PhD

by Roibeard O’hEineachain in Copenhagen

C

ataract extraction alone is enough to resolve angle closure and reduce IOP to optimum levels in many eyes with primary angle-closure glaucoma (PACG), and clear lens extraction may also be a justifiable option in select cases, said Augusto AzuaraBlanco MD, PhD,University of Aberdeen, Aberdeen, Scotland.

“At the moment, laser peripheral iridotomy plus medication is the primary treatment that we use. But perhaps in some patients lens extraction may have a role, or perhaps we should only consider lens extraction in those patients in whom laser iridotomy does not open the angle, as is the case in at least a quarter of patients,” Prof Azuara-Blanco told the 10th European Glaucoma Society Congress.

The growth of the lens with age is the most important factor in the pathogenesis of angle-closure glaucoma, he noted. That is why the condition occurs much more commonly in older people, he added.

There are additional ocular factors that may predispose some patients to the disease. They include the position of the ciliary process, the thickness of the peripheral iris, and the level of insertion of the iris and the anatomy of the anterior part EUROTIMES | Volume 17/18 | Issue 12/1

of the lens. But it is the increased volume of the lens that ultimately precipitates angle-closure in the majority of cases, Prof Azuara-Blanco said.

“With increased lens volume there is a shallowing of the anterior chamber and an increase in the relative pupillary block and this can result in angle-closure in eyes that are predisposed,” he added.

For angle closure and cataract

Prof Azuara-Blanco noted that a fairly strong argument can be made in favour of cataract extraction as a first line treatment in eyes with angle-closure and cataract.

However, the evidence in favour of that approach is mainly restricted to numerous case-series studies, the first of which was published in 1988 (Greve E L. Int Ophthalmol 1988. 12157–162.162).

The case-series studies have consistently shown that lens extraction is associated with a good reduction in IOP and a reduction in the number of medications required to control IOP. However, a Cochrane review, which did not include case-series studies, concluded that there was no reliable evidence (ie, from randomised controlled trials) in favour of the procedure for that indication.

On the other hand, the results of two randomised studies published more recently indicate that cataract surgery can achieve IOP control similar to that achieved by combined phaco-trabeculectomy (Tham et al Arch Ophthalmol. 2010;128(3):303-311).

Both studies were carried out at the same centre in Hong Kong. The first study involved 72 angle-closure glaucoma patients with cataract whose IOP was well controlled with medication. They were randomised to undergo phacoemulsification alone or with trabeculectomy. At a follow-up of two years, there was no significant difference in terms of IOP between those who underwent phacoemulsification alone and those who underwent phaco-trabeculectomy.

The phaco-trabeculectomy group needed fewer medications but also had more complications.

In the second study, which involved 51 patients with poorly controlled IOP, angle-closure glaucoma and cataract, those who underwent phaco-trabeculectomy had significantly lower IOP than those who underwent phaco alone, at a followup of two years. As in the other study, the phaco-trabeculectomy group also required fewer medications and also had more complications.

“At the moment, laser peripheral iridotomy plus medication is the primary treatment that we use” Prof Azuara-Blanco said that he currently offers the procedure to patients either as a primary intervention or after laser iridotomy has been unsuccessful. He added that in eyes with poorly controlled IOP and in those with severe glaucomatous damage he combines phacoemulsification with trabeculectomy plus mitomycin C in order to bring the pressure under control as much as possible as soon as possible.

Performing phacoemulsification in an eye with angle-closure glaucoma entails several important considerations. For example, such eyes tend to have shallower anterior chambers, which necessitates the use of non-dispersive viscoelastic to allow more

Augusto Azuara-Blanco – aazblanco@aol.com

“

If there is a clear lens I start with laser iridotomy and I consider phaco only in those patients with glaucomatous damage in whom the angle remains closed after laser iridotomy and intraocular pressure is not well controlled

Augusto Azuara-Blanco MD, PhD room for manoeuvring. In addition, there will also be an increased risk of iris prolapse, because the iris in such eyes is closer to the cornea, he noted.

Moreover, if the patient has had previous acute attacks of angle-closure there may be a compromised endothelium and weakened zonules. Pupil dilatation may also be poor especially if the eye has undergone previous iridotomy.

He added that there have been studies suggesting that peripheral synecholysis can enhance the IOP-lowering effect of cataract extraction. The procedure may be performed with a cohesive viscoelastic or with a spatula using a gonioscopic lens.

Clear lens extraction Lens extraction in eyes with angle-closure glaucoma but without cataract is more controversial because it can mean removing a healthy lens from an eye with good vision.

“I do follow the EGS guidelines. If there is a clear lens I start with laser iridotomy and I consider phaco only in those patients with glaucomatous damage in whom the angle remains closed after laser iridotomy and intraocular pressure is not well controlled,” he explained.

To provide a clearer picture of the longer term effects of cataract extraction on angle closure glaucoma, Prof Azuara-Blanco and several other investigators are conducting a multicentre, randomised controlled study which will follow a cohort of patients with angle closure glaucoma but without cataract who have undergone either primary lens extraction or laser peripheral iridotomy.

Called the EAGLE study, it has completed its recruitment phase and now includes 419 patients. The study involves collaboration between 23 sites in the UK, seven in Asia and one in Australia, he noted (see: https://viis.abdn.ac.uk/hsru/eagle).

“The results of this study will leave us in a much better position to be able to answer the question of whether clear lens extraction in primary angle-closure glaucoma patients can be justified,” Prof Azuara-Blanco added.

contact

Philippe Denis – Philippe.denis@chu-lyon.fr

Update

glaucoma

IRIDOPLASTY

Technique opens angle and removes synechiae in eyes with refractory angle-closure

Courtesy of Philippe Denis MD

by Roibeard O’hEineachain in Copenhagen

L

aser peripheral iridoplasty is a useful option in the treatment of eyes with acute angle closure or angle-closure glaucoma where laser peripheral iridotomy has been unsuccessful, said Philippe Denis MD, CHU Lyons, Lyons, France at the 10th European Glaucoma Society Congress.

“We know that iridotomy is not always effective and we know that it tends to be ineffective in eyes where angle closure is not associated with pupillary block,” Dr Denis said.

Pupillary block is the most common and best-known underlying mechanism for primary angle-closure glaucoma (PACG), he noted. Pupillary block occurs when contact between the iris and the lens creates aqueous flow resistance. That, in turn, causes the iris to bow so that its periphery presses against the cornea and closes the angle, he explained.

Laser peripheral iridotomy can eliminate pupillary block in the majority of cases of angle closure, Dr Denis continued. By equalising the pressure between the anterior and posterior chambers, the procedure allows the peripheral anterior chamber to deepen, he said. In eyes that have angle closure, and where pupillary block is the sole cause, laser iridotomy will generally result in an opening and widening of the angle, he added.

However, laser iridotomy tends to be less successful in eyes where pupillary EUROTIMES | Volume 17/18 | Issue 12/1

Uveal effusion syndrome (lymphoma)

block is not the sole cause of angle closure, he noted. The conditions that can cause the unresponsive types of angle closure include plateau iris, anterior rotation of the ciliary mechanism, increased iris thickness, peripheral synechiae, and phacomorphic angle closure, where the cataractous lens itself presses against periphery of the iris.

Another cause of angle closure is uveal effusion syndrome, such as may result from lymphoma or central retinal vein occlusion.

Dr Denis noted that in some populations of Eastern Asia, iridotomy has a high failure rate in the treatment of angle-closure glaucoma. For example, one study showed that in China nearly 20 per cent of eyes have residual posterior anterior synechiae after undergoing iridotomy. In another

Iridoplasty: The procedure consists of placing contraction burns (long duration, low power, and large spot size) in the extreme iris periphery to contract the iris stroma between the site of the burn and the angle, physically pulling open the angle

study of Chinese patients, the dark prone provocation test remained positive in 60 per cent of eyes that had undergone iridotomy.

The iridoplasty option

For those eyes where iridotomy is not successful, iridoplasty is gaining some acceptance as the next option, Dr Denis said. Moreover, in eyes at a high risk of failure to achieve angle patency through iridotomy, there may be some justification for the use of iridoplasty as the first line of therapy, either alone or in combination with iridotomy, he added.

“Considering that a mixed mechanism can be associated with angle closure in the same patient, it makes sense to combine laser iridoplasty and iridotomy to achieve the efficacy of the combined procedures,” Dr Denis said.

There are fairly few published reports showing the efficacy of iridoplasty as a primary treatment for angle-closure glaucoma, Dr Denis noted. However, in one notable study, involving 10 patients with phacomorphic glaucoma, iridoplasty reduced IOP by a mean of about a third within 30 minutes, and by over half within two hours. The treatment also eliminated pain associated with the condition completely in eight patients within two hours (Tham et al Eye (Lond) 2005;19 (7):778-83).

In another study involving 156 patients with PACG, laser iridotomy achieved approximately the same amount of IOP reduction as did a combination of iridotomy and iridoplasty, at one year’s follow-up.

However, the combined treatment group resulted in a greater reduction in peripheral synechiae (Sun et al, Am J Ophthalmol 2010;150:68-73).

How and when to perform iridoplasty Dr Denis noted that

iridotomy is the first line of treatment in eyes of European patients with primary open-angle angle-closure glaucoma.

However, patients who undergo iridotomy require close observation to insure the treatment has been successful, he said.

“

We know that iridotomy is not always effective and we know that it tends to be ineffective in eyes where angle closure is not associated with pupillary block Philippe Denis MD

“If the angle widens dramatically after iridotomy, then it is the pupillary block form of angle closure and therefore no further treatment is necessary. However, if it is still narrow with at positional closure or the patient has a positive response to darkroom provocative test, it is a multimechanism form. Iridoplasty may be the treatment of choice in such cases.

The aim of laser iridoplasty is to create small burns on the periphery of the iris that will cause it to contract and pull away from the angle, Dr Denis said. The procedure requires the use of an Argon laser at a very low energy setting of 200 milliwatts with a large spot size of 150 to 200 microns for a duration of 0.5 seconds.

It is best to use between 20 to 24 spots for each session. Some eyes require more than one iridoplasty treatment, he added.

Iridoplasty may also be indicated as a primary treatment in eyes with plateau iris configuration and in eyes where iridotomy is not possible because of ocular inflammation, corneal oedema or flat anterior chamber.

Other potential indications include cases where the angle remains appositionally closed despite a patent iridotomy and in cases medically unbreakable attacks of angle-closure glaucoma. Less common indications include phacomorphic angleclosure glaucoma, and nanophthalmos, he added.

Anterior segment of an eye with iris plateau in which iridoplasty has been partially performed. Note that the treated angle (on the right – see arrows) is wide open, whereas the untreated angle (on the left – see arrows) remains narrow

15

contact

16

Update

glaucoma

GUIDELINES FOR DIAGNOSIS

Rigid definitions of glaucoma based on specific features are a pitfall in diagnosing the condition

by Roibeard O’hEineachain in Copenhagen

D

espite the availability of treatments which can delay or prevent the progression of glaucomatous optic neuropathy, patients still go blind from the disease because of inaccurate diagnoses and incorrect treatment, said George Spaeth MD, at the 10th European Glaucoma Society Congress.

“An accurate diagnosis is important, but it is not achieved by extensive testing; it is achieved from accurate testing with minimal bias,” said Dr Spaeth, Wills Eye Institute, Philadelphia, Pennsylvania, US. He noted that of the patients referred to him, almost half of them have been overtreated, about a quarter of them have been under-treated, others are inappropriately treated and only a very small percentage appear to be getting correct treatment.

There are a range of factors that can lead to misdiagnoses and incorrect treatment, he said. Such factors include drawing conclusions from indirect evidence, failure to perform appropriate examinations and unconscious bias.

Tonometry is an example of an indirect measurement that can lead to false-positive and false-negative diagnoses of glaucoma, he noted. Some ophthalmologists continue to regard IOPs in excess of 20.0 mmHg and 24.0 mmHg as diagnostic of the disease.

Conversely, some will fail to make the diagnosis of glaucoma in patients with loss of vision because their IOP is in the lower ranges.

Failure to look at the optic disc or evaluate it properly also gives rise to a high proportion of misdiagnoses, Dr Spaeth said.

He cited a study conducted in the US that

Excellence in Education Diploma Examination 2013

Deadline for Applications 31 January 2013

www.ebo-online.org Don’t Miss Resident’s Diary, see page 39 EUROTIMES | Volume 17/18 | Issue 12/1

An accurate diagnosis is important, but it is not achieved by extensive testing; it is achieved from accurate testing with minimal bias George Spaeth MD

showed that there was mention of the optic disc in only half of the glaucoma patients’ charts surveyed.

As an example of a false negative diagnosis based on IOP, Dr Spaeth described the case of a man referred to him by his ophthalmologist because he complained of failing vision. The patient was in general good health and his pressure was low, at 13.0 mmHg. However, one look at the patient’s optic disc was enough for an unequivocal diagnosis of glaucoma, Dr Spaeth said.

“Had his ophthalmologist looked at the disc without paying attention to pressure, he would have seen this much earlier.

As to where he is on the glaucomatous neuropathy scale, he is way down in the disabled area already. He is in serious trouble,” he added.

Cup/disc ratios can be misleading

EBO 2013 will take place in Le Palais des Congrès, Paris, France 10-11 May, 2013

For all further information log on to

“

Seal of

Achievement

Another common mistake is to use large cup/disc ratios as being diagnostic of glaucoma at initial examination. However, it is only when cup/disc ratios are about 0.8 or 0.9 at initial presentation that they have any diagnostic value at all, Dr Spaeth said. Otherwise, it is only when the ratio increases over time that it becomes indicative of glaucomatous optic neuropathy, he added.

Similarly, a large optic disc size may mislead the physician to believe that glaucoma is present, Dr Spaeth said.

He described the case of a 63-year-old engineer who was in good health, had no symptoms and was in doubt over his

George Spaeth – gspaeth@willseye.org

ophthalmologist’s recommendation for surgery. When Dr Spaeth looked at his optic discs he saw that while they were very large, they were symmetrical and lacking in pathological features. “He has no visual field loss, he does not have glaucoma, he just has huge disks. Regarding his level of disability, he is way up in the normal patients range,” Dr Spaeth said.

Another case he cited was that of a 64-year-old beautician who was very unhappy because the drops she was receiving for glaucoma were making her eyes uncomfortable. She came to Dr Spaeth for a second opinion. Her IOP was 26.0 mmHg in one eye and 22.0 mmHg in the other eye, he noted. However, although her optic discs had some asymmetry of size and cupping, the cupping was greatest in the eye with the lowest pressure. “Not only does she not need surgery but she probably doesn't need any treatment at all,” he added.

Unconscious bias Another factor that can lead to the inaccurate diagnosis of glaucoma is a failure to eliminate unconscious bias. Research has shown that trained observers are three times more likely to say a disc photograph was abnormal if they were previously shown an abnormal field testing results and told they belonged to the same patient than if they were shown a normal field. Similarly, research has also shown that trained observers are three times more likely to say a disc has changed for the worse if they believe that the second photograph was taken after the first. “That biases you, because you know that glaucoma tends to get worse. So if you want to compare photographs without bias, don’t tell the person making the judgment which one is first which is second. You have to look at them masked. Knowing ancillary information leads to biased interpretations,” he said.

Rigid definitions of glaucoma based on specific features are another pitfall in diagnosing the condition, Dr Spaeth noted.

He added that the digital information provided by technology such as OCT and HRT provide a deconstructive approach to diagnosis, but do not provide qualitative information. As a result, the confident interpretation of their measurements is generally only possible in about half of cases.

“We can deconstruct the glaucomatous optic nerve into its individual components or we can look at a nerve and say, what does that nerve look like? We have marginalised that information, we have forgotten that it can be valid,” he added.

17th ESCRS Winter Meeting in conjunction with the Polish Society of Cataract and Refractive Surgery

Warsaw, Poland

15 – 17 February 2013

PROGRAMME OVERVIEW FRIDAY 15 FEBRUARY

SATURDAY 16 FEBRUARY

SUNDAY 17 FEBRUARY

08.00

09.00 FREE PAPERS

10.00

FREE PAPERS REFRACTIVE COURSE Part 2

YOUNG OPHTHALMOLOGISTS PROGRAMME

11.00

CATARACT COURSE

SYMPOSIUM

FREE PAPERS

FREE PAPERS

Organised by the PSCRS

Part 2

FREE PAPERS

12.00

13.00

BASIC OPTICS COURSE

SYMPOSIUM

Measuring success in cataract surgery

CORNEA COURSE

CORNEA DAY In conjunction with EuCornea

SYMPOSIUM

Capsular complications: first aid kit prevention, detection, solution

14.00

15.00

LIVE SURGERY Organised by the PSCRS

CATARACT COURSE

16.00

Part 1

REFRACTIVE COURSE Part 1

17.00

SYMPOSIUM Strategies for treating keratoconus

SYMPOSIUM

18.00

Cataract with other disorders: combined or sequential surgery?

19.00

Welcome Reception Friday 15 February 19.00 Forteca, 12 Zakroczymska Street, Warszawa EUROTIMES

™

SATELLITE EDUCATION PROGRAMME

Satellite Education Programme Saturday 16 February

Lunchtime 13.00 – 14.00

Evening 18.00

How do new technologies help to improve outcomes in cataract and refractive surgery

Advanced technologies for cataract surgery

Moderator: G. Grabner AUSTRIA

Moderator: D. Holland GERMANY

New innovations in cataract and refractive surgery

SPONSORED BY: SPONSORED BY:

Register online: www.escrs.org/satellites

SPONSORED BY:

Introducing Alcon innovations in cataract and refractive surgery – 3D video symposium SPONSORED BY:

17th ESCRS Winter Meeting

Warsaw, Poland

15 – 17 February 2013

SYMPOSIA

BASIC OPTICS COURSE

FRIDAY 15 FEBRUARY

SATURDAY 16 FEBRUARY

FRIDAY 15 FEBRUARY

17.00 – 18.30

16.30 – 18.00

08.30 – 15.40

CATARACT WITH OTHER DISORDERS: COMBINED OR SEQUENTIAL SURGERY?

STRATEGIES FOR TREATING KERATOCONUS

Chairpersons: I. Pallikaris

Chairpersons:

PART I: VISUAL OPTICS

Chairpersons:

17.00

S. Morselli ITALY W. Omulecki POLAND

16.40

C. Roberts USA Biomechanics of keratoconus

08.50

S. Marcos SPAIN Aberrations of the optical system

16.50

Discussion

09.15

E. Mrukwa-Kominek POLAND A sequential approach is clearly superior

17.00

T. Seiler SWITZERLAND Cross-linking to arrest progression of keratoconus

A. Glasser USA Optics of crystalline lens and accommodative response

09.35

Discussion

17.10

J. Colin FRANCE Combined treatments for keratoconus

T. Van den Berg THE NETHERLANDS Straylight: Importance of different domains of the point-spread function

17.20

Discussion

09.55

M.J. Tassignon IOL optics

17.30

T. Neuhann GERMANY Cataract surgery in the keratoconic eye

10.15

J. Rozema BELGIUM Epidemiology of the optical parameters of the eye

17.40

J. Izdebska POLAND Deep anterior lamellar keratoplasy vs penetrating keratoplasty

10.35

W. Haigis GERMANY IOL power calculation

10.55

Discussion

CATARACT AND GLAUCOMA:

CATARACT SURGERY IN ENDOTHELIAL DISEASE:

DEALING WITH THE LENS IN VITRECTOMY:

17.50

Discussion

G. Richard GERMANY The lens is in the way and should be removed

18.00

End of session

B. Parolini ITALY The lens should be left in place as a physiological barrier

SUNDAY 17 FEBRUARY

Discussion

CAPSULAR COMPLICATIONS – FIRST AID KIT: PREVENTION, DETECTION, SOLUTION

End of session

Moderators: I. Pallikaris

Chairpersons:

MEASURING SUCCESS IN CATARACT SURGERY Chairpersons:

P. Barry

IRELAND,

Moderator:

J. Szaflik

U. Stenevi

SWEDEN

13.00

R. Applegate

USA

R. Applegate USA Retinal image quality

11.20

I. Pallikaris GREECE Presbyoptics

11.40

S. Plainis GREECE State of the art assessment of visual acuity and contrast sensitivity

12.10

P. Artal SPAIN Visual function assessment using adaptive optics

12.30

H. Ginis GREECE Modelling visual function

12.50

Discussion

13.00

Break

11.30

O. Findl AUSTRIA Beyond the posterior capsule

11.40

X. Corretger SPAIN Avoiding capsular-related complications in difficult cases

11.50

Discussion

Moderators: A. Pallikaris

12.00

14.00

B. Frueh SWITZERLAND Monofocal IOL and glasses is still the gold standard

P. Rosen UK Recognising when disaster strikes

12.10

B. Malyugin RUSSIA IOLs, capsular tension rings and segments

A. Pallikaris GREECE Confocal microscopy, from research to clinical practice

14.20

Discussion

12.20

Discussion

J. Rozema BELGIUM Scheimpflug imaging, from research to clinical practice

M. Lundström SWEDEN 20/20 and still unhappy

12.30

14.40

B. Malyugin RUSSIA OCT imaging, from research to clinical practice

I. Dooley IRELAND Modern technology can predict post-op unhappiness and help avoid it

R. Packard UK Essentials of performing an anterior vitrectomy

12.40

P. Barry IRELAND When to refer to a vitreoretinal surgeon

15.00

O. Stachs GERMANY Very high frequency ultrasound imaging, from research to clinical practice

Discussion

12.50

Discussion

15.25

Discussion

End of session

13.00

End of session

15.40

End of Session

POLAND

Uncorrected visual acuity is the only yardstick Yes D. Spalton UK No K. Pesudovs AUSTRALIA Discussion

12.30

G. Cleary UK D. Kook GERMANY S. Manning IRELAND M. Morral SPAIN T. Rudolph SWEDEN

GREECE,

11.00

Organised by the Young Opthalmologists Committee

11.30 – 13.00

BELGIUM

PART II. VISUAL BEHAVIOUR (VISUAL FUNCTION)

11.30 – 13.00

SATURDAY 16 FEBRUARY

12.00

GREECE

F. Van de Velde BELGIUM Light propagation in the eye

Discussion

11.30

I. Pallikaris

08.30

J. Hjortdal DENMARK Cataract extraction alone is often sufficient

18.30

BELGIUM,

BELGIUM

G. Kymionis GREECE Natural course of keratoconus

B. Cochener FRANCE Combined endothelial keratoplasty and cataract surgery is the way to go

18.00

Moderators: M.J. Tassignon

M.J. Tassignon

16.30

T. Zarnowski POLAND Why combined glaucoma surgery is the procedure of choice

17.30

I. Grabska-Liberek POLAND R. Nuijts THE NETHERLANDS

GREECE,

R. Bellucci ITALY Monofocal IOLs should be obsolete

PART III. IMAGING THE HUMAN EYE GREECE,

B. Malyugin

RUSSIA

CATARACT SURGERY DIDACTIC COURSE

REFRACTIVE SURGERY DIDACTIC COURSE

CORNEA DIDACTIC COURSE

FRIDAY 15 FEBRUARY

FRIDAY 15 FEBRUARY

SATURDAY 16 FEBRUARY

14.30 – 17.00

15.00 – 17.00

Chairpersons: R. Packard UK, P. Rosen UK W. Omulecki POLAND, A. Crnej

Moderators: R. Bellucci SLOVENIA

PART 1 14.30 T. Kohnen GERMANY Teaching the teachers of cataract surgery 14.45 P. Ursell UK Learning how to learn cataract surgery 15.00 THE ERGONOMICS OF CATARACT SURGERY P. Rosen UK 15.20 BIOMETRY W. Haigis

08.00 – 16.00 SWITZERLAND

PART 1 15.00 D. Siganos GREECE Patient selection and preoperative preparation 15.15 G. Kymionis GREECE Lasers in refractive surgery 15.30 C. Roberts USA Corneal topography and IOL power calculation 15.55 R. Bellucci ITALY LASIK: surgical technique

16.35 D. Epstein SWITZERLAND Results of corneal refractive surgery

SPAIN

15.55 THE CAPSULE L. Benjamin UK, A. Crnej

D. Epstein

16.15 T. Seiler SWITZERLAND Surface Ablation Techniques (SATs): surgical technique

GERMANY

15.40 INCISIONS L. De Benito-Llopis

ITALY,

SLOVENIA

16.25 Z. Biro HUNGARY Viscoelastics 16.45 Discussion 17.00 End of session

Chairpersons: R. Packard UK, P. Rosen UK W. Omulecki POLAND, A. Crnej

PART 2 08.00 21ST CENTURY PHACO DYNAMICS R. Packard UK 08.30 COMPLICATIONS AND COMPLEX CASES: ADVANCED PHACO TECHNIQUES B. Malyugin RUSSIA, W. Omulecki POLAND, R. Packard UK, V. Pfeifer SLOVENIA, P. Rosen UK, P. Stodulka CZECH REPUBLIC 10.15 Break 10.30 FEMTOSECOND LASERS AND CATARACT SURGERY J. Szaflik POLAND

12.30 End of session

08.20 M.J. Tassignon BELGIUM Pathological responses of the cornea 08.30 J. Merayo SPAIN Laboratory testing for ocular surface diseases 08.50 B. Frueh SWITZERLAND Infectious keratitis

08.00 – 12.35

09.50 M. Morral SPAIN Non-infectious keratitis

AUSTRIA,

C. Roberts

USA

08.10 J. Krumeich GERMANY Overview of microkeratomes

10.50 F. Kruse GERMANY Dry-eye and ocular surface disease

11.30 Discussion

09.00 A. Marinho PORTUGAL Overview of phakic IOLs

SURGICAL CORNEA Moderators: J. Krumeich GERMANY, R. Nuijts THE NETHERLANDS

09.20 O. Findl UK Multifocal IOLs

12.40 J. Krumeich GERMANY Penetrating keratoplasty: preoperative consideration technique, postoperative management and complications

AUSTRIA

09.50 R. Applegate USA Quality of vision evaluation

13.00 R. Bellucci ITALY Anterior lamellar keratoplasty procedures: up to date

10.50 V. Katsanevaki GREECE Non-optical complications of LASIK and corneal surgery

T. Kohnen

12.05 L. de Benito-Llopis SPAIN Customised ablational procedures

13.40 J. Colin FRANCE Corneal cross-linking: intracorneal ring segments in ectatic disorders

Moderators: G. Grabner GERMANY

11.30 V. Katsanevaki GREECE Optical complications of refractive surgery 11.45 R. Nuijts THE NETHERLANDS Complications of phakic IOLs

13.20 R. Nuijts THE NETHERLANDS Management of postkeratopathy astigmatism

14.00 Break

11.15 Break GREECE,

FRANCE

10.30 TBC Ectasia disorders and degenerations

11.50 Break

Moderators: V. Katsanevaki

J. Colin

10.10 E. Çoşkunseven TURKEY Corneal dystrophies

08.40 E. Rosen UK Refractive lens exchange

09.30 G. Grabner Presbyopia

ITALY,

11.10 G. Grabner AUSTRIA Immunological disorders of the cornea

08.30 J. Colin FRANCE Intrastromal corneal implants

10.30 J. Güell SPAIN Refractive reoperations and enhancements

12.20 Discussion

08.05 G. Kymionis GREECE Basic science: anatomy, physiology and biomechanics

Moderators: M. Busin

11.10 PRESBYOPIA CORRECTION WITH INTRAOCULAR LENSES O. Findl AUSTRIA

12.05 M. Amon AUSTRIA Supplementary lenses

GREECE

SATURDAY 16 FEBRUARY

10.10 C. Roberts USA Biomechanics of the cornea

11.50 M. Filipec CZECH REPUBLIC Post-operative ametropia correction: laser refractive surgery

G. Kymionis

09.30 Break

10.50 INTRAOCULAR LENS DESIGN D. Spalton UK

11.30 TORIC INTRAOCULAR LENSES AND LIMBAL RELAXING INCISIONS B. Frueh SWITZERLAND

FRANCE,

17.00 End of session

08.00 T. Kohnen GERMANY Incisional and coagulative corneal procedures: principles, technique and results SLOVENIA

Moderators: B. Cochener

09.10 B. Cochener FRANCE Corneal and anterior segment evaluation techniques

PART 2

08.00 – 12.30

CLINICAL CORNEA

16.55 Discussion

Moderators: G. Grabner

SATURDAY 16 FEBRUARY

08.00 J. Güell SPAIN Introduction

AUSTRIA,

J. Güell

SPAIN

14.20 J. Güell SPAIN Conjunctival surgery 14.40 J. Güell SPAIN Amniotic membrane 15.00 M. Busin ITALY Endothelial transplantation: up to date

12.20 Discussion

15.20 G. Grabner AUSTRIA Limbal transplantation and keratoprosthesis

12.35 End of Session

15.40 Discussion 16.00 End of session

ANNUAL CORNEA DAY

YOUNG OPHTHALMOLOGISTS PROGRAMME

(ORGANISED BY ESCRS AND EUCORNEA)

FRIDAY 15 FEBRUARY

FRIDAY 15 FEBRUARY

09.00 – 12.00

SUNDAY 17 FEBRUARY

09.30 – 16.30

Moderators:

09.00 – 11.00

Chairperson: J. Güell

SPAIN,

R. Nuijts

THE NETHERLANDS

Topics will include: –

Management of corneal complications after refractive surgery

–

Tips and pitfalls in corneal graft surgery: DALK, DSEK, PK

–

Ocular surface disease: what worked and what did not

–

Corneal potpourri (miscellaneous cases, including corneal inflammation, degeneration, infections etc)

The Cornea Day Programme will comprise expert keynote lectures and case presentations on the topics listed above.

For further details, go to www.escrs.org or www.eucornea.org

O. Findl AUSTRIA S. Morselli ITALY

LEARNING FROM THE LEARNERS: INTERACTIVE SESSION ON CATARACT SURGERY FOR TRAINEES 09.00

L. Benjamin UK Before you hit the operating room: preparing for your first cataract surgery Discussion

09.15

Learning from the learners: one of my first operations Video cases presented by young ophthalmologists

POLISH SOCIETY OF CATARACT AND REFRACTIVE SURGERY SYMPOSIUM

Chairpersons: – – –

– – –

Discussion 10.30

Break

10.45

P. Ursell UK How to teach cataract surgery Discussion

11.00

Learning from the learners: tackling more risky cases Video cases presented by young ophthalmologists

–

– – –

Discussion

SURGICAL SKILLS TRAINING COURSE

11.45

Roundtable: summary

–

12.00

End of session

– –

COST PER COURSE: €100

FRIDAY 15 FEBRUARY

SATURDAY 16 FEBRUARY

09.00 – 10.30

LASIK

14.00 – 16.00

11.00 – 12.30

LASIK

15.30 – 16.30

Artisan Phakic IOL

Organiser:

17.00 – 18.30

Intraocular Suturing Techniques

08.30 – 10.30

Basic Phacoemulsification

11.00 – 13.00

Basic Phacoemulsification

14.00 – 16.00

INTACS

16.30 – 18.15

Basic Suturing Techniques

ITALY

SATURDAY 16 FEBRUARY 09.00 – 10.00

Artisan Phakic IOL

14.00 – 15.30

PRK, LASEK & Epi-LASIK

16.00 – 17.30

PRK, LASEK & Epi-LASIK

18.00 – 20.00

KeraRings

08.00 – 09.45

Basic Suturing Techniques

10.15 – 11.45

Bimanual Micro-Incision Phaco

12.15 – 13.45

Bimanual Micro-Incision Phaco

14.45 – 16.15

Phaco: Management of Complications

16.45 – 18.15

Phaco: Management of Complications

18.30 – 20.00

Ferrara Rings

SUNDAY 17 FEBRUARY 09.00 – 10.30

LASIK

11.00 – 12.30

LASIK

08.00 – 10.00

Basic Phacoemulsification

10.30 – 12.30

Basic Phacoemulsification

Controversies in congenital cataract surgery Surgical techniques in pediatric cataract Assessment of anatomical and functional status of pseudophakic eye in children operated due to congenital cataract Lens surgery in presbyopic correction Functional results of toric IOL implantation in cataract patients Comparison of visual function and patient satisfaction after bilateral cataract surgery with diffractive IOL implantation and monofocal implantation in monovision procedure Assessment of visual function in patients with bilateral diffractive IOL Tecnis ZMB00 implantation Additional intraocular lens implantation in pseudophakic patients Femtosecond laser in cataract surgery Simultaneous endothelial keratoplasty and femtosecond laser-assisted cataract surgery Methods of keratoconus prevention: own experiences Fast cross-linking in treatment of keratoconus Is uncorrected visual acuity the main yardstick in measuring success in cataract surgery?

LIVE SURGERY ORGANISED BY THE POLISH SOCIETY OF CATARACT AND REFRACTIVE SURGERY

Course Director: R. Bellucci

P. Jurowski POLAND W. Omulecki POLAND

J. Szaflik

POLAND

Transmitted from the Department of Ophthalmology, Medical University of Warsaw.

17th ESCRS Winter Meeting in conjunction with the Polish Society of Cataract and Refractive Surgery

FOR FURTHER INFORMATION PLEASE VISIT: WWW.ESCRS.ORG

21

Update

retina

AMD TREATMENTS

Kreissig Lecture highlights need for AMD treatments to move beyond “palliative” capability

by Dermot McGrath in Milan

A

nti-VEGF therapy has revolutionised the therapeutic approach to neovascular agerelated macular degeneration (AMD) and has opened up potentially exciting avenues for future treatment of the disease, according to Gisele Soubrane MD, PhD, FEBO, FARVO who delivered the annual Kreissig Lecture at the 12th EURETINA Congress.

Prof Soubrane, professor of ophthalmology at Hotel Dieu, University Paris Centre Descartes, noted that while important breakthroughs have been made in recent years, the proliferation of recent clinical trials do not provide answers to all the questions physicians face in daily practice. “While immense progress has been made in recent years, there is still a long way to go in our research. Current treatments are not able to cure AMD and remain palliative in nature. Despite the fact that many of our patients recover some vision, this is only the case in one-third of the treated eyes, and one in every six patients still progress to legal blindness,” she said.

Prof Soubrane stressed the importance of finding adapted and appropriate treatment for a disease that will place an increasing burden on national healthcare services in the coming years. “Forty million people worldwide have AMD of whom 17 million have advanced atrophic or exudative AMD. These numbers are expected to double by 2020,” she said.

While upcoming treatments may restrain or even destroy the choroidal neovascularisation underlying the development of AMD, Prof Soubrane said that none of them are foreseen to preclude the occurrence of the neovascularisation in the first place. “A number of key problems remain to be solved. We need to work out the optimal routes of drug or cell delivery and ensure adequate concentration in the target tissue while also sparing the neighbouring tissue,” she said.

With the proliferation of potential treatments now under development targeting different aspects of the pathogenetic cascade chain, Prof Soubrane said that the hope is that these compounds, either alone or in association, may one day lead to an algorithm for personalised treatment. “We still need a better understanding of the pathophysiology EUROTIMES | Volume 17/18 | Issue 12/1

“

While immense progress has been made in recent years, there is still a long way to go in our research

Gisele Soubrane MD, PhD, FEBO, FARVO of AMD which would lead to earlier intervention to block the cellular and molecular disturbances resulting in the development of CNV in order to tailor new therapeutics,” she said.

Among the latest anti-VEGF therapies hoping to compete with ranibizumab, Prof Soubrane noted that both ESBA1008 (Alcon) and AGN150998 (Allergan) are currently undergoing clinical trials to assess their safety and efficacy.

Another compound, pazopanib (GSK), has just completed phase 2b trials and could eventually pave the way for a topical treatment for AMD, said Prof Soubrane.

Another interesting approach is the use of integrin antagonists such as Volociximab (Ophthotech) and ALG-1001 (Allegro) that are designed to inhibit endothelial cell proliferation by multiple pathways, said Prof Soubrane.

Recent results of the anti-plateletderived growth factor aptamer Fovista (Ophthotech) have also shown considerable promise as an anti-angiogenic treatment when administered in combination with ranibizumab, said Prof Soubane.

While much of the research in AMD focuses on new treatments for the disease, Prof Soubrane stressed the importance of learning more about possible predictors of the pathology and which patients might be better responders to current treatment regimens, she said.

contact Gisele Soubrane – soubraneg@gmail.com

The Kreissig Award was established in 2003 in recognition of the immense contribution of Prof Ingrid Kreissig to ophthalmic training and research, particularly in the field of retina.

22

Update

RETINA

OXYGEN SENSITIVE SWITCH

New therapies in diabetic retinopathy and AMD

by Gearoid Tuohy in Dublin

A

gene therapy approach using an oxygen sensitive “on/off” switch may produce new therapies in diabetic retinopathy and agerelated macular degeneration (AMD), report US researchers.

Several research groups worldwide have focused significant efforts into fine-tuning the mechanics of how and when to turn genes on and off for maximal therapeutic benefit. New studies from a US research team, based at the Centre for Complex Systems and Brain Sciences at Florida Atlantic University, report the construction of a novel gene promoter regulated by oxygen concentration (IOVS; DOI:10.1167/ iovs.10-6835). The promoter, which may be incorporated upstream of a therapeutic gene, could ultimately be used in the treatment of hypoxia-related retinal disorders, including diabetic retinopathy and AMD. Gene therapy has become an attractive therapeutic approach to dealing with retinal disorders, not least of all due to the retina’s relatively immune privilege status, its surgical access and the presence of the blood-brain barrier, minimising any “leakage” of delivered genes and their vectors. Recent human and animal clinical successes have boosted the field over the last three years and in recent months the first gene therapy approval was announced by the European Medicines Agency following the development of a product aimed at delivering a functional lipoprotein lipase gene to treat lipoprotein lipase deficiency (LPLD).

A key challenge arising in many of the human and animal trials to date is to design a system that controls the level and

timing of gene expression. One ideal way to achieve such control is to use perturbations arising from the pathology itself to trigger the “cure”. In a number of ocular disorders oxygen sensitivity is critical to pathogenesis and a reduction in O2 levels may serve as a trigger of pathology, for example in diabetic retinopathy and AMD. The Florida Atlantic University based team, led by Prof Janet Blanks, used such knowledge to harness the environmental trigger to drive the expression of an AAV (adeno-associated virus) delivered transgene in retinal Müller cells. The genebased technology uses a regulatory domain that incorporates multiple hypoxia (oxygensensing) responsive elements (HREs) known to bind the transcription factor HIF-1, a key component of the oxygen-dependent sensing system. Under hypoxic conditions HIF-1 dimerizes with HIF-1 beta and translocates to the nucleus activating gene transcription of target genes. Combining the HREs with a Müller cell specific promoter – the human glial fibrillary acidic protein (GFAP) sequence – facilitates the expression of the transgene under hypoxic conditions within a specific cell type.

In experimental models the US research team delivered AAV vectors intra-vitreally containing the HRE-GFAP sequence upstream of a green fluorescent protein (GFP) marker. For cell-based work the team used primary cultures of Müller cells that were transfected to show a lack of gene (GFP) expression under normoxic conditions but high levels of expression under hypoxic conditions.

However, in testing the system under in vivo conditions the oxygen-induced retinopathy (OIR) model was employed

Read EuroTimes on the move!

A key challenge arising in many of the human and animal trials to date is to design a system that controls the level and timing of gene expression where post-natal experimental models are exposed to high levels of oxygen between day seven and 12 and then returned to normal air for five days.

During the five-day regression phase retinal cells produce several HIF-1 mediated pro-angiogenic factors leading to neovascularisation by day 17. Expression of HIF-1 in the day-17 hypoxic retina is 31 times greater than the normoxic retina. The engineered promoter remained silent under aerobic conditions however, induction of hypoxia induced a 12-fold (in primary Müller cells) and a 16-fold increase (in human Müller cell lines) in gene promoter activity indicating the effect of oxygen depletion on gene expression.

Intravitreal injection of the engineered promoter at post-natal day-seven produced high levels of GFP expression only in retinal Müller cells at day-17 but was absent in retinas exposed to room air only.

In essence the in vivo studies confirmed for the researchers that gene expression was silenced in normoxic conditions, induced under hypoxic conditions and only expressed in the specific cells receiving the regulated promoter.

By tethering the expression of the therapeutic to the cell type in which oxygen levels become depleted, “delivery” of the treatment may be triggered hopefully long before the macroscopic symptoms become apparent to either patient or clinician.

Several research groups are active in using oxygen sensitive regulators upstream of a range of beneficial “products”, such as growth factors, including bFGF and VEGF, antioxidant components, anti-angiogenic factors including angiostatin and proapoptotic transcripts such as Bax (Bcl2 associated X protein). All such systems have been designed to exploit the biology of the HREs that bind the transcription factor HIF-1.

In conclusion to the study (published in IOVS; DOI:10.1167/iovs.10-6835) the authors commented that, “our hypoxiaregulated, retinal glial cell-specific vector is likely to be applicable to a range of diseases”, including AMD where the technology may be used to induce a range of neurotrophic factors once hypoxic conditions are detected. The authors additionally proposed that, “activation of the promoter by the oxidative/ inflammatory environment contributing to geographic atrophy in dry AMD would provide an efficient means to deliver neurotrophic therapy only to the pathologic regions of the retina”.

The technology could be applied to a number of retinal gene therapy approaches using a variety of gene products such as pro-survival kinases, antioxidant enzymes and secreted factors to block angiogenesis or promote neuroprotection. Establishing proofof-principle for inherited photoreceptor degenerations, diabetic retinopathy and glaucoma are expected to represent key applications for this platform approach.

Retinopathy and Diet

In EuroTimes Volume 17 Issue 11, November 2012, we printed an incorrect image with the article, Retinopathy and Diet. The correct image and caption are featured below.

Our new mobile website is designed for tablets and smartphones and includes content from the print edition of the magazine.

Visit the new EuroTimes mobile website at

http://m.eurotimes.org EUROTIMES | Volume 17/18 | Issue 12/1

Retina after 34 years of Type I diabetes

Update

retina

RETINOPATHY

Population-based study produces surprising data on prevalence and risk factors

by Cheryl Guttman Krader in Milan

T

he majority of cases of retinopathy found in a recent population-based Icelandic study occurred in persons who do not have diabetes. The Icelandic study also showed a hitherto unreported association between retinopathy in non-diabetic patients and high levels of microalbuminuria, reported Fridbert Jonasson MD, at the 12th EURETINA Congress.

Icelandic researchers investigated retinopathy prevalence and risk factors using data from 4,994 persons aged 67 years and older who participated in the Age, Gene/Environment Susceptibility Reykjavik (AGES-R) Study. The survey found that 516 (10.3 per cent) participants had diabetes based on a definition of an HbA1c level ≥6.5 per cent.

Based on a modified ETDRS protocol for rating fundus photographs, retinopathy was identified in 138 (27 per cent) diabetic patients and 476 (10.7 per cent) of those without diabetes. Of note, most eyes with retinopathy did not present with severe changes. The most common features were blot retinal haemorrhages and microaneurysm.

Among the 138 cases of retinopathy in the diabetic cohort, there were five persons who had proliferative diabetic retinopathy and five who had clinically significant macular oedema. Among the 476 non-diabetics with retinopathy, there were only five eyes with macular oedema.

“Although the prevalence of retinopathy is about 2.5-fold higher among the diabetics than in the non-diabetic cohort, it is noteworthy that three-fourths of cases of retinopathy in this random population sample occurred among persons without diabetes,” said Dr Jonasson, professor of ophthalmology, University of Iceland, Reykjavik.

Multivariate analyses were conducted to identify risk factors for retinopathy. The variables investigated included age, sex, systolic blood pressure, hypertension, HbA1c level, and microalbuminuria. Duration of diabetes and use of glucoselowering medication (insulin and oral hypoglycaemics) were also included in the statistical models for diabetic persons.

“

More data are needed to understand the underlying pathophysiology of retinopathy in patients who are not diabetic and to establish an evidence basis for directing their clinical care Fridbert Jonasson MD

In univariate analyses, systolic blood pressure, duration of disease, and level of HbA1c were significantly associated with retinopathy among the diabetics. However, when treatments for diabetes were added into the multivariable model, disease duration dropped out, and independent predictors of diabetic retinopathy were HbA1c level (odds ratio = 1.35 for each percentage point), systolic blood pressure (odds ratio = 1.16 for each 10 mmHg), insulin use (odds ratio = 3.51) and use of oral hypoglycaemic agents (odds ratio = 1.93).

Independent risk factors for retinopathy in the nondiabetic cohort were microalbuminuria (odds ratio = 1.77) and increasing age (odds ratio = 1.30 for every 10 years).

“To our knowledge, this association between retinopathy and microalbuminuria in non-diabetics is a novel finding.

We believe they may both be a marker of systemic microvascular dysfunction, and we have recently identified an associated genetic variant,” Dr Jonasson said.

He noted that when he sees patients with retinopathy in clinical practice, his routine has been to refer them for evaluation by a diabetologist. While this approach may be called into question by the study’s findings, developing recommendations on patient management are pending further investigation.

“More data are needed to understand the underlying pathophysiology of retinopathy in patients who are not diabetic and to establish an evidence basis for directing their clinical care,” he said.

Dr Jonasson added that patients with low-grade retinopathy are also unlikely to present to the ophthalmologist with vision complaints, but that initiation of screening programmes to identify non-diabetics with retinopathy are not warranted.

Further details on this study may be found in a published report [Diabetologica 2012;55:671-80].

3RD EURETINA

WINTER MEETING

ROME ‘Innovation in Management of Retinal Disease’

EUROTIMES | Volume 17/18 | Issue 12/1

23

Courtesy of Fridbert Jonasson MD

contact

Fridbert Jonasson – fridbert@landspitali.is

1-2 FEBRUARY 2013

Rome Cavalieri Waldorf Astoria Hotel

Register online www.euretina.org

am ur 13th EURETINA Congress

26â&#x20AC;&#x201C;29 September 2013 abstract submission deadline: 1 march 2013

www.euretina.org

25

Update

PAEDIATRIC OPHTHALMOLOGY

meet

JIA And UVEITIS

Risk factors for development of complications and treatment options

by Leigh Spielberg in Milan

EUROTIMES | Volume 17/18 | Issue 12/1

Courtesy of Joke de Boer MD

K

nowing which patients are at highest risk of developing juvenile idiopathic arthritis (JIA)associated uveitis, and which of those are greatest risk for severe disease is essential for optimal management of these hard to treat patients, according to Joke de Boer MD, a uveitis specialist at the Donders Institute of Ophthalmology in Utrecht, the Netherlands.

This can be a tricky disease to diagnose, she reminded a Joint Session of the 2nd WCPOS and 12th EURETINA Congress.

“Remember, JIA-associated uveitis is an anterior segment disease, so if you see chorioretinal lesions, you should consider another diagnosis,” she said.

Which patients are at risk of developing uveitis? She emphasised the importance of three risk factors. First, female gender, with a ratio of three to one female to male patients. Second, ANA positivity, since 90 per cent of patients with JIA who are ANA positive go on to develop uveitis. The third factor is oligoarthritis subtype of JIA, since 79 per cent of all patients with JIAassociated uveitis have the oligoarthritis subtype of JIA, she noted.

However, these risk factors are distinct from those that predict a poor prognosis.

Here, the focus is on those patients with a short interval between arthritis and uveitis; patients who present with severe uveitis at the first examination; patients who present with uveitis, as opposed to arthritis, as the initial manifestation of JIA, and patients who develop posterior synechiae.

More controversial is whether males with JIA-associated uveitis, and patients with a young age at onset, are at greater risk for severe disease. Dr de Boer highlighted the fact that there are several studies with conflicting results on these two risk factors.

However, multivariate analysis suggests that male gender and development of uveitis prior to arthritis are independent prognostic factors for poor outcome.

But why do patients with JIA-associated uveitis go blind? Dr de Boer highlighted the three main causes of blindness: glaucoma (50 per cent), cyclitic membranes (33 per cent); and cystoid macular oedema (25 per cent). Significantly, this progression to glaucoma is nearly four times as common in JIA-associated uveitis than in nonJIA-uveitis. The practical implication of

Uveitis associated with JIA with poor visual outcome

this statistic is that IOP must always be measured in children with JIA-associated uveitis, despite the challenges presented by the difficulty of IOP measurement in this young population.

The next topic was a sobering account of the difficulty in preventing blindness in this condition. Dr de Boer referred to a study published by Cassidy in 1977 in which 15 per cent of eyes went blind, and then to another study by Kalinina-Ayuso, published in 2010, in which again 15 per cent of all eyes were blind. At first glance, this seems like a total lack of progress over 33 years. However, those patients analysed in Kalinina-Ayuso’s long-term study included a significant proportion of patients who were never treated with biological agents, which have since become the standard of care in refractory cases. Future studies, reporting only on patients during the biologicals era will likely show a lower percentage of blind eyes.

Dr de Boer closed her presentation with a short summary of the treatment of the disease. The main take-home messages on this topic were that methotrexate is still a mainstay in the treatment of the disease, and that longer inactivity during long-term treatment with methotrexate is independently protective against a relapse of uveitis.

“Every year of inactivity under methotrexate treatment decreases the hazard of a new relapse by 93 per cent,” she said.

contact

At the heart of EVA is a revolutionary fluid control system called VacuFlow VTi using Valve Timing intelligence technology. It just effortlessly delivers the precise flow and fast vacuum required by you, the surgeon.

Put simply, EVA VacuFlow VTi technology puts you in absolute control, all of the time.

www.evabydorc.com

Joke de Boer – jboer@umcutrecht.nl 109-..._ADV_Meet_EVA_tbv_Eurotimes_120x300.indd 1

31-10-12 09:13

Update

PAEDIATRIC OPHTHALMOLOGY

STICKLER SYNDROME

Prophylactic treatment may do more harm than good

by Roibeard O’hEineachain in Milan

P

rophylactic treatment of Stickler syndrome with laser or cryotherapy has yet to demonstrate any benefit in clinical trials and may actually be harmful in the long term, said G W Aylward FRCS, FRCOphth, MD, at a joint WCPOS/ EURETINA symposium at the 2nd World Congress of Paediatric Ophthalmology and Strabismus.

“For every case you can show me that has benefited from laser or cryotherapy prophylaxis, I can show you a case that has been harmed by it,” said Dr Aylward, Moorfields Eye Hospital, London, UK. He noted that there are very good reasons for desiring an effective prophylaxis against retinal detachment in eyes with Stickler syndrome. Patients with the condition are at a high risk of giant retinal tears. In addition, their rate of successful retinal re-attachment tends to

be only around 80 per cent, compared to around 90 per cent among patients without Stickler syndrome. (Abeysiri et al, Graefes Arch Clin Exp Ophthalmol 2007; 245: 1633-1666.)

However, there is little evidence from studies conducted to date that prophylactic laser or cryotherapy has any protective effect, he pointed out. Moreover, there are reports in the literature that have implicated prophylactic therapy in the pathogenesis of retinal detachment.

“When you apply cryotherapy or laser, what you are doing is creating a new abnormality in the chorio-vitreo-retinal relationships, and that may not be an apparent problem until much later in life,” he noted.

In eyes that have undergone prophylactic laser or cryotherapy for indications other than Stickler syndrome there is a phenomenon in which a posterior vitreous

• brilliant view • single hand operation • wide range of accessories

SLIT PS LAM

KTP LAS

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

• 5 magnification levels

A.R.C. Laser certifies that the product complies to 21 CFR 1040.10 and 1040.11 EN 13485/ 2003 - 93/42 EWG

Its a PCL5 year

CO

PHA

SLT YAG N AT IO Y N OINVG E R M A N IN …

ER ADE M

Your local distributor:

Laser GmbH merstraße 14 11 Nürnberg ny

A.R.C. Laser GmbH Bessemerstraße 14 D-90411 Nürnberg Germany  +49 (0) 911 217 79 -0 +49 (0) 911 217 79 99  www.arclaser.de info@arclaser.de www.arclaser.de

 +49 (0) 911 217 79 -0  +49 (0) 911 217 79 99 info@arclaser.de Your local distributor: www.arclaser.de This year you can expect a brand new range of lasers and ophthalmic products from A.R.C. Laser. Watch out for the stars.

2012-03_EUROTIMES_120x120.indd EUROTIMES | Volume 17/18 2| Issue 12/1

04.06.2012 14:31:40

“

It would be great if we could prevent their retinal detachments, but I don’t think that we have enough evidence now that prophylaxis works

G W Aylward FRCS, FRCOphth, MD detachment occurring 40 or so years later can lead to tears along the edge of the treated area, Dr Aylward said.

“It may be that your treatment hasn't actually prevented the detachment, but has in fact caused it. The trouble is that, because it will be 40 years later, you will have retired by then and so you will never know, he added.

Prophylactic therapy also carries the risk of retinal complications occurring in the shorter term, Dr Aylward said. He described the case of a seven-year-old girl with Stickler syndrome who presented with a giant retinal tear in one eye and who underwent prophylactic laser in the other eye. Ten days postoperatively, she presented with a retinal tear on the edge of the laser treatment, such that the prophylactically treated eye is now the one with worse vision.

Selection bias Some of the early investigators into the prophylaxis of retinal detachment in Stickler syndrome patients went so far as to perform scleral buckling. However, most have abandoned that practice in favour of less extreme treatments like cryotherapy and laser treatment, Dr Aylward continued.

A study investigating the prophylactic use of 360° cryotherapy in the fellow eyes of patients with giant retinal tears – including some Stickler syndrome patients – indicated that the treatment provided a clinically significant and statistically significant benefit compared to no treatment in historical controls (Wollensberger, Ophthalmol 2003; 110: 1175-7).

That is, among the fellow eyes that underwent cryotherapy, two per cent had

contact

26

G W Aylward – bill.aylward@moorfields.nhs.uk

retinal tears without retinal detachment, six per cent had retinal detachment and two per cent had giant retinal tears. By comparison, among the fellow eyes of historical controls, 60 per cent had retinal tears, 18 per cent had retinal detachments and 17 per cent had giant retinal tears.

However, it is in the nature of such trials that a selection bias for the historical controls can be difficult to rule out, Dr Aylward said.

A more recently published study yielded similar results. The retrospective study involved 204 Stickler syndrome patients who underwent 360 degree cryotherapy.

After a follow-up of one to 27 years, the rate of retinal detachment was only eight per cent among the treated eyes, compared to 73 per cent among the eyes that weren’t treated (Ang et al, Ophthalmol 2008; 115: 164-168).

On the basis of these results, the study’s authors concluded that cryotherapy significantly reduces the likelihood of retinal detachment in patients with type 1 Stickler syndrome. However, a closer scrutiny of the details of the study reveals a strong selection bias regarding the controls, Dr Aylward said.

For example, the average age of the patients receiving cryotherapy was 21 years, compared to 49 years among the controls, he pointed out. The longer a Stickler syndrome patient lives, the greater will be their likelihood of having a retinal detachment, he noted. Therefore, the control population was inherently at increased risk of retinal detachment, he said.

Furthermore, the location of the study in a Stickler syndrome clinic that advocates prophylactic therapy in itself creates a selection bias, Dr Aylward argued further.

“This gives the authors an enormous problem, because if you're treating most Stickler patients, where do you get the control group from? They are the patients who come into the department unexpectedly, most likely because of retinal detachment. So I'm afraid that the reason the incidence of retinal detachment is so high is because of the way the treatment and control groups were selected,” he said.

Dr Aylward noted that he was not alone in his criticism of the study. In fact, all of the retinal consultants at Moorfields Eye Hospital wrote a letter to the journal, Ophthalmology, to express their rejection of the conclusions of the study’s authors.

“We know that Stickler’s syndrome patients have a higher risk for retinal detachment, but that doesn’t equate with the idea that we can modify that risk. It would be great if we could prevent their retinal detachments, but I don't think that we have enough evidence now that prophylaxis works,” he concluded.

27

Update

PAEDIATRIC OPHTHALMOLOGY

local training

Novel approach to ophthalmology fellowship training in Vietnam could prove useful model

by Leigh Spielberg in Milan

T

“

he yearly incidence of paediatric ophthalmic disease in Vietnam is estimated to include nearly 1,000 cases of congenital cataract, 600 babies born with glaucoma and 100 new cases of retinoblastoma. Moreover, with a single neonatal intensive care unit with more than 150 beds, retinopathy of prematurity is also a serious issue in that country, James Elder MD, Royal Children’s Hospital, Melbourne Australia, told a session of the “My World, My Way” Symposium, during the Second World Congress on Paediatric Ophthalmology and Strabismus (WCPOS).

The current resources, both financial and human, are insufficient to deal with the magnitude of the problem. Few ophthalmologists are trained to treat children. Quality screening programmes and postoperative care have not been organised. For congenital cataract, barriers to good outcomes include late presentation, absence of contact lens services and difficulty obtaining aphakic spectacles.

Sight for All

It is in this context that Sight For All, a non-profit organisation, committed to reducing preventable blindness in the Asia-Pacific region, decided to experiment. Its approach was to start a “reverse fellowship” in which the trainers would travel to the trainees. This is the opposite of the traditional fellowship arrangement, in which the fellow travels to the trainer’s institution to obtain his or her education. This first reverse fellowship was held in the capital city of Hanoi.

“The advantage of a reverse fellowship is that the fellows remain in a familiar environment. They avoid having to go abroad for a year or more, so costs are kept under control and family life is not interrupted. There is no language barrier between fellows and patients and the training can be tailored to the local situation,” said Dr Elder.

On the other hand, the logistics of a reverse fellowship are tricky. A 12-month fellowship must be condensed into 12 oneweek visits, leading to interrupted, episodic contact with various different teachers. This makes teaching complex surgical procedures a particularly difficult task, said Dr Elder.

And in this situation, the trainer is outside his or her own familiar environment.

EUROTIMES | Volume 17/18 | Issue 12/1

The advantage of a reverse fellowship is that the fellows remain in a familiar environment. They avoid having to go abroad for a year or more, so costs are kept under control and family life is not interrupted. There is no language barrier between fellows and patients and the training can be tailored to the local situation James Elder MD

“The most precious resource in this type of situation is time,” he said.

Financial and logistical support are crucial, Dr Elder emphasised. He acknowledged the leading role played by chairman of Sight for All Dr James Muecke.

Dr Muecke, an ophthalmologist, made two planning visits to Vietnam prior to the start of the training sessions.

Rewarding work The effort is definitely worthwhile. The range and rarity of the pathology that Dr Elder saw on a single day is staggering. “On my first day in the clinic, we diagnosed cryptophthalmos, ablepharon, Rieger’s syndrome, FEVR, bilateral retinoblastoma and endogenous endophthalmitis.

“The work is incredibly rewarding,” he said, citing positive reactions from both patients and fellows-in-training.

And more challenges await. Sight for All is currently planning future reverse fellowships in Bangladesh, Laos and Cambodia.

contact James Elder – james.elder@rch.org.au ad-EUR-1-2 hoch-1202v2-pva RZ.indd 1

29.02.12 13:43

GLOBAL OPHTHALMOLOGY

ORBIS AND TELEMEDICINE

Expanded capabilities of Cyber-Sight tele-health system bolster partner physician education and overall programme quality

by Cheryl Guttman Krader in Milan

W

hile its DC-10 airplane may be the most recognised icon of ORBIS, the Flying Eye Hospital represents just a fraction of how the humanitarian organisation is acting on its mission to preserve and restore sight by strengthening the capacity of local partners to prevent and treat blindness, said Daniel E Neely MD. Speaking at the 2nd World Congress of Paediatric Ophthalmology and Strabismus, Dr Neely discussed Cyber-Sight, the ORBIS telemedicine and tele-education programme. He provided a review of its basic mechanics, current capabilities, and information on programme updates.

“There is a lot that goes on beneath the surface of the programme weeks that take place when the Flying Eye Hospital is onsite, and Cyber-Sight is a prime example of that,” said Dr Neely, professor of ophthalmology, Indiana University School of Medicine, Indianapolis, and ORBIS senior medical advisor to Cyber-Sight.

“Cyber-Sight is an extremely effective and inexpensive way to educate physicians in developing countries, and it establishes an extended presence that allows for continuing education and patient care.

Now, new Cyber-Sight capabilities designed to enhance patient selection, case documentation, and outcomes monitoring represent an exciting expansion of the telemedicine programme.”

Cyber-Sight E-Consultation was initially developed to provide remote strabismusoriented consultation, but “partners” in developing countries can submit questions about patients with any condition. Since inception of the programme, consultations have covered a broad spectrum of issues in general and subspecialty ophthalmology, including: cataract, cornea/external disease, glaucoma, neuro-ophthalmology, oculoplastics, ophthalmic genetics, paediatric cataract and retina, vitreoretinal disease, retinoblastoma and uveitis.

Cyber-Sight E-Consultation users comprise both physicians who have taken advantage of the system to continue information exchange following a Flying Eye Hospital visit and those who have initiated a consultation after finding the site online.

In requesting a consultation, users are asked initially to provide some basic

EUROTIMES | Volume 17/18 | Issue 12/1

ORBIS Cyber-Sight telemedicine programme gives the organisation an “extended presence”, the ability to provide education and patient care even when The Flying Hospital has moved on to a new location

information and to prioritise the need for a reply as normal, high, or urgent (within 24 hours). The system has a full strabismus template as well as blank templates for other ophthalmic subspecialties and allows for uploading of photos along with additional supporting information, including diagnostic images, pathology slides, scanned notes and even short videos.

“It usually doesn’t take a lot of information for a mentor to give an opinion about the case. Photographs and other supplemental images are nice, but not critical. Rather, in my opinion, the two most important elements that partners should complete when filling out the consultation request are their presumed diagnosis and tentative plan,” said Dr Neely.

“With that information, the mentor can develop an understanding of the partner’s background and skill set and tailor the response appropriately. It’s of no benefit to make suggestions that the partner is unable to accomplish or carry out.”

A submitted consultation is immediately

“There is a lot that goes on beneath the surface of the programme weeks that take place when the Flying Eye Hospital is onsite, and Cyber-Sight is a prime example of that” processed by the ORBIS server and triaged out to a subspecialist teaching mentor who is immediately notified of the consultation request via email. The email will contain the basic information and priority, but details are accessible only by secure log-in.

Sometimes the mentor may feel confident answering a question right away, but depending on the clarity and depth of the information provided, further communication may be needed.

contact

Update

Courtesy of Daniel E Neely MD

28

Daniel E Neely – deneely@iupui.edu

“There have been about 8,000 E-consultations submitted over the last eight years since Cyber-Sight began. However, those cases represent 35,000 exchanges back and forth between partners and mentors, and it is this discussion of the findings, diagnostic and therapeutic options that is important in the teaching process,” noted Dr Neely.

Entering the EMR era While CyberSight has traditionally functioned as an educational exchange process, its expanded capabilities relate specifically to care of patients seen during a Flying Eye Hospital visit. New additions include a pre-screening form, which has already been implemented, along with a programme record that includes forms for a screening exam, operative report, medical/laser treatment, discharge report and surgical case review.

Beta-testing of the programme record elements began at the end of August, 2012.

Dr Neely explained that access to prescreening patient information allows ORBIS physicians to select appropriate cases for the programme week. Not only does that enhance the educational value for the local physicians by ensuring their experience will involve good cases, but it limits the need to turn away people who come from rural areas hoping to receive care.

“The pre-screening has been very valuable for helping to make the most productive use of limited time during a Flying Eye Hospital visit, and it minimises our disappointed patients who are not selected, especially if they have travelled some distance to the programme site,” Dr Neely said.

With the new features in the programme record, Cyber-Sight will function like a primitive electronic medical record. Its advantages include eliminating the need for transporting hard-copy charts for use on the screening day, providing immediate access to operative reports, and facilitating distribution of discharge reports to the family and local physicians.

Information collected in the surgical case review is expected to provide value for partners, their patients and ORBIS itself. The surgical case review form was developed to be completed by the ORBIS staff ophthalmologist who returns about six to eight weeks after a Flying Eye Hospital visit to examine as many patient participants as possible. Online access to the data through the Cyber-Sight system will enable subsequent patient monitoring through mentor consultation, should it be needed, and also enhances the ability to perform internal analysis, which is vital for quality assurance of patient medical and surgical care provided either on the Flying Eye Hospital or in the local hospital of the partner physicians in developing countries.

Amsterdam

2013

5 -9 O C TOB E R 20 13

XXXI congress of the escrs Abstract Submission Deadline: 15 March 2013

WWW.ESCRS.ORG

contact

30 News

EYE on TECHNOLOGY

NEW TECHNOLOGY FOR AMD

The cataract surgeon’s solution to a retinal problem

by Soosan Jacob, MS, FRCS, DNB

T

wo mirror telescopic implantable lenses now available allow surgeons to provide improved vision in both phakic and pseudophakic patients with dry or wet AMD. Dr Isaac Lipshitz from Israel designed the first intra-ocular telescopic device in the form of the Implantable Miniaturized Telescope based on the principles of a Galilean telescope containing a concave and a convex lens with air compartments in between. Though it does enlarge the image up to 2.2 to 2.7 times the normal size, surgical disadvantages include the need for a large incision, more difficult implantation, greater possibility for endothelial cell loss and a long and complex patient rehabilitation process.

Dr Lipshitz then designed a miror telescopic IOL – the Lipshitz Macular Implant (LMI, OptoLight, Israel) based on magnification provided by intra-ocular mirrors (Figure 1).

“It makes possible optical treatment for both dry and wet ARMD, scar stage as well as other similar macular lesions using reflective optics. We do not cure the disease or even stop its progress, we only enable the patient to function better with the disease.

Treatment requires a long commitment, coordinated with a retinal specialist. Patient selection process is very important and complex. We should remember that the patients that suffer from these dreadful diseases are never completely happy and satisfied. Nevertheless, it can give encouraging results in patients who are highly motivated to read and improve visual capabilities and who know the risks and potential benefits,” says Dr Lipshitz.

The first prototype of the LMI was introduced in 2005. Now two models are available. The phakic implant (LMI) has an optic size of 5.5 x 6.5mm and an overall length of 13.5mm. A routine phacoemulsification is followed by implanting the IOL in the bag through an extended clear corneal incision of about 6mm or through a separate scleral tunnel incision.

The pseudophakic implant (OriLens – OptoLight, Israel) is implanted as a piggyback lens over the existing IOL of the patient (Figures 2A, B). This offers the advantages of the mirror reflective optics even in long-standing pseudophakic patients

EUROTIMES | Volume 17/18 | Issue 12/1

Figure 1: Illustration demonstrating the optical mechanism of the mirror reflective technology. Central light rays are magnified by the mirrors whereas the peripheral rays pass unchanged.

Magnification of central rays is possible through the internal reflection occurring between the mirrors within the LMI/OriLens

Figure 2A: Image shows a pseudophakic mirror telescopic IOL (OriLens) implanted in a piggy back manner over a regular in-thebag IOL. The implant is well centred over the optics of the IOL and the mirror reflective elements can be seen

Figure 2B: Image shows ultrasound bio microscopic image of the same eye. In-the-bag IOL as well as the sulcus placed OriLens are seen

Figure 3: A computer-generated image as seen by an eye with Mirror Telescopic Technology is shown.

The central image is enlarged up to 2.5 times whereas the periphery remains unaltered

without having to perform complicated IOL explantation procedures. The OriLens may also be implanted in phakic patients after first performing a cataract surgery, implanting a regular IOL according to the patient's biometry and then placing it as a piggyback lens in the sulcus. It has an oblong optic of 5.00 x 6.00mm, an overall length of 13.5mm and central thickness of 1.25mm. It can also be explanted easily.

"The ageing baby boomers need immediate help, which right now can only be achieved by an implanted telescopic optical solution. This requires no additional equipment or investment. By using the

new intraocular mirror telescope, cataract surgeons can now improve vision of AMD patients and treat both dry and wet type AMD. It is in fact the cataract surgeon’s solution to a retinal problem!” noted Dr Lipshitz.

The surgery can be performed by any cataract surgeon. Follow-up is carried out in conjunction with the retinal surgeon.

A close watch is kept for formation of synechiae or IOP spikes, which if they occur, are treated accordingly. The IOL is made from biocompatible material and it magnifies only the image on the central retina. It may preserve at least part of the

Soosan Jacob – dr_soosanj@hotmail.com

peripheral vision, thus bilateral surgery is possible (Figure 3).

If needed, it is also safe and easy to remove the OriLens leaving behind the in-the-bag IOL thus reverting the patient back to normal pseudophakic status.

It is complementary to other medical treatments which can also be carried out simultaneously, he explained.

Potential candidates for this lens need to be tested preoperatively with an external telescope of x 2.5 magnification using ETDRS charts. OptoLight has also developed a special computer-based testing program for pre- and postoperative visual testing. Patients with a preoperative visual acuity ranging from 20/60 to 20/800 and showing improvement in visual acuity for distance and/or near when tested with a x 2.5 magnification external telescope are suitable candidates.

“The system has two visual fields – central and peripheral, each of which can be modified for distance or for near and modified relative to each other by changes such as colour, contrast, focal distance etc. The pupil size is also important as the peripheral vision is pupil dependent. A pupil between 2.5 to 4.0mm diameter gives a good peripheral and a good magnified central image. Hence, the pupil size has to be controlled postoperatively for optimal performance,” says Dr Lipshitz.

It is important that there should be no tilt, which can affect the functioning of the implant. The pupil should not be eccentric and should overlie the central mirror. If required, a pupilloplasty may be performed in such cases to centralise the pupil, and also in rigid, non-dilating, miotic pupils to enlarge the pupil. Fundus evaluation, laser treatment as well as other treatments such as anti-VEGF remain possible after implantation of this implant.

Dr Lipshitz chose reflective optics technology because it does not depend on the index of refraction of the medium and can achieve high magnification in a small volume/thickness. It can be used in combination with diffractive and/or refractive optical elements and can be partly hidden under the iris.

Prof Amar Agarwal who implanted the first LMI and the first OriLens commented, “The cataract surgeon is often faced with co-morbid pathologies because of an increasingly ageing population. Implanting a normal IOL in such patients would not lead to a great improvement in central vision.

The other big advantage of the OriLens is that it does not require any complicated power calculations or require an inventory of different powers to be maintained as it is a standard implant which fits all patients. It is therefore implanted over the in-the-bag IOL which is the one selected according to biometry.”

31

News

ESASO

a step forward

The 12th AMD and Retina Congress covered the whole spectrum of retinopathy

T

he 12th AMD and Retina Congress in Prague, Czech Republic took a significant step forward, demonstrating how international collaboration and exchange among ophthalmologists can facilitate therapeutic advancements.

More than 1,000 delegates from 45 countries attended the meeting which featured 23 plenary presentations, 20 case studies and six meet-the-expert-sessions.

Panel discussions and a poster exhibition were also included in the programme.

The first session was chaired by Prof Anat Loewenstein from the Tel Aviv Medical Center and Prof Frank Holz from the University of Bonn. They reviewed therapeutic approaches to the treatment of retinal vein occlusion (RVO) and the evidence for intravitreal aflibercept which has the potential to offer new treatment options for patients with RVO. A second session focused on surgical treatment of macular diseases and was chaired by Prof Anselm Kampik from the Ludwig Maximillians University in Munich and Prof Michael Georgopoulos from the Medical University of Vienna and the Vienna Medical Hospital. During this session, the Faculty discussed the role of surgical treatments in the management of patients with diabetic macular edema (DME). An additional focus was on the challenges and impact of cataract surgery in patients with AMD and diabetic retinopathy.

“Expanding the role of anti-VEGF therapy in ocular disease: examining the evidence,” was the title of the session led

by Prof Leonidas Zografos, chairman at the Faculty of Biology and Medicine of the University of Lausanne and Prof Gabriel Coscas from the Créteil University Eye Clinic at the University of Paris XII. The session covered a controversial issue: the role of anti-VEGF therapy in the field of ocular tumours.

With 366 million people worldwide predicted to have diabetes by 2030, the treatment of diabetic retinopathy is a key clinical challenge, and was the subject of the session chaired by Prof Paul Mitchell from the University of Sydney and Dr Susan B Bressler from the Johns Hopkins University School of Medicine in Baltimore. Leading retina specialists discussed a new system EUROTIMES | Volume 17/18 | Issue 12/1

for the classification of DME. This system facilitates innovative treatment paradigms that minimise the risk of moderate visual loss, including the approval of the antiVEGF agent ranibizumab. In a roundtable discussion a faculty of experts addressed a variety of topics on the management of DME, ranging from the role of widefield angiography and OCT, to systemic management.

Neovascular AMD A further session discussed the management of neovascular AMD; Prof Ursula Schmidt-Erfurth from the University of Vienna, and Prof Marco Zarbin from the New Jersey Medical School in Newark NJ, US, chaired this session and 12 specialists presented various interactive clinical cases including recalcitrant vascularised PED, and the treatment of PCV in the anti-VEGF era.

In the final session, two scientists from the Oakland University in Royal Oak, MI, US, Prof Antonio Capone Jr, clinical professor of biomedical sciences and Dr George Williams, chair of the Department of Ophthalmology highlighted the disorders of the vitreomacular interface. This session also explored whether pharmacological vitreolysis has the potential to induce total posterior vitreous detachment without the need for surgery.

As well as an exciting Scientific Programme, the humanitarian award, XOVA, was an integral part of the congress.

XOVA is an award programme led by international eye care specialists and sponsored by Novartis Pharma and Alcon.

XOVA provides funding (in the form of a grant) to non-profit initiatives that are expected to have a significant impact on unmet needs in ophthalmology.

Last but not least 13 graduates were awarded with their Diplome Specialist Superior (DiSSO) for passing ESASO’s five module programme successfully this year.

Two will start consecutively their ESASO Fellowships in Vienna, Austria and the US. * All sessions can be viewed at eCongress on the ESASO website at: www.esaso.org and in the ESASO electronic newsletter eFOCUS.

contact

ESASO Programme 2013

More information at www.esaso.org

Oculoplastic & Orbital Surgery

Valletta

21 – 25 January 2013

Surgical Retina

Lugano

04 – 08 February 2013

Cataract

Moscow

20 – 25 May 2013

Medical Retina

Lugano

03 – 07 June 2013

Surgical Retina

Lugano

10 – 14 June 2013

Glaucoma

Lugano

09 – 13 September 2013

Retina

Ankara

September 2013

Cornea

Lugano

September 2013

Cataract

Dubai

October 2013

ESASO c/o Università della Svizzera italiana (USI) Via Giuseppe Buffi 13 6904 Lugano, Switzerland Tel. +41 (0)58 666 4629 Fax +41 (0)58 666 4619 Email info@esaso.org

www.esaso.org

Gabriella Skala – Gabriella.Skala@esaso.org 08_1209_09 ESASO_Anz_EUT_120x300_RZ.indd 1

28.10.2012 16:20:35 Uhr

32

News

YOU CAN HAVE...

3 FREE YEARS OF ESCRS MEMBERSHIP. VASTLY REDUCED CONGRESS FEES. CONVERSATION. UNLIMITED HOURS OF VIDEO PRESENTATIONS ON ESCRS ON DEMAND. MENTORING. RESEARCH TOOLS. FREE ACCESS TO EXPERT OPINION ON THE EYECHAT PODCAST. FULL CONGRESS PROGRAMME INFORMATION. OPPORTUNITIES TO OBSERVE CLINICAL PRACTICE IN INSPIRING SETTINGS. JOIN COMPELLING DISCUSSIONS WITH PEERS ON FACEBOOK.DEVELOP YOUR KNOWLEDGE AT ANY TIME WITH ILEARN INTERACTIVE EDUCATION...

YOUNG OPHTHALMOLOGISTS

can get all of this and more.

Join today and enjoy these benefits www.escrs.org/youngophthalmologist

EUROTIMES | Volume 17/18 | Issue 12/1

YOUNG OPHTHALMOLOGISTS

OBSERVership

40 grants of €1,000 are available for trainees and residents

U

nder the ESCRS Observership Programme, young ophthalmologists are given the opportunity to travel outside of their own country and experience clinical practice in a hospital or university setting.

The programme is now in its second year and the feedback from both trainers and trainees has been very positive.

"I would advise my young colleagues to apply for these grants as soon as possible," said Oliver Findl MD, MBA, chairman of the Young Ophthalmologists’ Forum.

“The Observership Programme is for young ophthalmologists who are starting their surgical training or already in surgical training,” said Dr Findl. "While the young ophthalmologists taking part in the programme will not be able to carry out surgery, they will get the opportunity to see senior ophthalmologists working. It will also be interesting for them to see how an ophthalmological department is run,” he said.

One of the trainees who took part in the programme said her experience had been very rewarding.

Anna Lysenko, a young ophthalmologist from the Ukraine was given a grant for an Observership in the Ophthalmology Department of Goethe University Clinic, Frankfurt am Main, Germany, from July 30 until August 10, 2012.

“I observed clinical and surgical cases in the Department of Cataract and Refractive surgery and also in the Paediatric Ophthalmology Unit of Goethe University Clinic,” she said. “In the operating room, I had the opportunity to observe different approaches to cataract and refractive surgery with Prof Thomas Kohnen, as well as surgery of the cornea and anterior segment and also vitreoretinal and strabismus surgery. Then in the clinic I observed and studied the different approaches to diagnostics and treatment of such patients," she said.

Dr Lysenko said she was very grateful to Prof Kohnen, Prof Frank Koch, Dr Jens Buhren, Dr Burkhard von Jagow, Dr Fritz Hengerer and Dr Melanie Bödemann who were her mentors during the Observership.

"I also gained valuable experience working with Dr von Jagow and Dr Bödemann in the Paediatric Ophthalmology Department," she said. "I

Dr Anna Lysenko (right) pictured during her Observership, with Dr Melanie Bödemann

will apply this knowledge into everyday practice in my department."

Dr Lysenko said her Observership was a unique learning experience. “It will have a positive impact on my personal knowledge and practice in the field of cataract and refractive surgery. I strongly feel that the programme’s training will facilitate both my short- and long-term career aspirations," she said.

Dr Lysenko said she would like to offer special thanks to the ESCRS for the opportunity to visit one of the best clinics in Europe.

"This is a great opportunity for ophthalmologists like myself, working in small Ukrainian cities, who don’t have the opportunity to visit European meetings or congresses of ophthalmologists, to observe different surgical and management training," she said.

Dr Buhren said: “It was a pleasure to have Anna as an observer in our department and we wish her all the very best for her future career. * To apply for an Observership visit: http://www.escrs.org/Youngophthalmologist

contacts Anna Lysenko – b_lysenko@rambler.ru Jens Buhren – Buehren@em.uni-frankfurt.de Oliver Findl – oliver@findl.at

33

News

ORBIS & Oxfam

ESCRS CHARITIES

HPMC 2%

Fundraising initiatives have helped to deliver real change to communities

S

ESCRS is contributing funds to an ORBIS project to establish a Paediatric Eye Care Unit in Gondar University Hospital in Northern Ethiopia. The contribution is helping to fund the training of Dr Mulusew Asferaw and Dr Asamere Tsegaw in the subspecialties of paediatrics and retina.

The ESCRS funded both doctors to attend the XXX Congress of the ESCRS in Milan in September 2012 and Dr Yared Assefa, the head of the Ophthalmology Department, also attended the congress.

“It is still very early days but a lot of progress has been made in putting the proper structures in place to develop a fully functional paediatric eye care service at Gondar Referral Hospital in order to serve the eye care needs of the local population,” Allan Thompson of ORBIS told EuroTimes.

Oxfam WASH Programme ESCRS is also supporting the Oxfam WASH programme in Uganda. As part of this public health project in the Kitgum and Lamwo districts, Oxfam has continued to strengthen the services provided by local government and build the self-reliance of households who returned to their villages after the two-decade conflict ended.

Oxfam is working with district staff, subcounty staff and communities to consolidate all the achievements of the last four years, since communities are starting returning to their villages of origin. These achievements EUROTIMES | Volume 17/18 | Issue 12/1

Corneal hydration that lets you stay focused on the surgery • In clinical trials, physicians reported significantly greater optical clarity with CORNEA PROTECT®

than with BSS (median grade 1.0 vs 2.0, p=0.03)1 • Just 1 drop provides corneal hydration for up to 20 minutes • No statistically significant difference between CORNEA PROTECT® and BSS in fluorescein staining

scores 1 hour after surgery1

The ORBIS/Oxfam booth at XXX Congress of the ESCRS in Milan 2012

are being built into an overall CommunityBased Water Resource Management system that complies with the national operation and maintenance policy and will enable the government and people to take responsibility for their own water and sanitation needs and performance in the future.

Oxfam Ireland's chief executive Jim Clarken said: "The generosity of ESCRS members and the ESCRS Board has delivered real change to the communities of Kitgum and Lamwo. By supporting Oxfam and our partners in the Water, Sanitation and Hygiene Promotion (WASH) project, ESCRS has provided effective and sustainable water sources as part of a major investment in public health," he said.

Continued support

ESCRS president Peter Barry said that while a lot of good work already had been done, it was important that the society continued its commitment to ORBIS and Oxfam.

“Charitable initiatives are very important for the society and our support of ORBIS and Oxfam has been very rewarding,” said Dr Barry. “I am delighted to confirm that this support will continue for the next two years.”

There will be further opportunities to donate when delegates register for the 17th ESCRS Winter Meeting in Warsaw in February 2013 and the XXXI ESCRS Congress in Amsterdam, or by donating directly through the ESCRS website at: www.escrs.org/charitable-donations.

Median Application Frequency of CORNEA PROTECT® vs BSS (Balanced Saline Solution) During Cataract Surgery (n=101)1 10

BSS

9

10

8 7 6 5 4 3 2 1 0

CORNEA PROTECT®

1

Reference: 1. Chen Y-A, Hirnschall N and Findl O. Corneal wetting with a viscous eye lubricant to maintain optical clarity during cataract surgery. Submitted to J Cataract Refract Surg under review.

CORNEA PROTECT® is a registered trademark of Croma-Pharma GmbH.

Croma-Pharma GmbH • www.croma.at

ad cornea protect 120x300 ENG 1112v1 gpf eurotimes.indd 1

0123

ACP002Ab

Paediatric Eye Care Unit

For cataract and other ophthalmic surgeries

Median Application Frequency

ince the beginning of 2011 the ESCRS has donated a total of €66,400 to ORBIS and Oxfam. In addition to donations from the society, this amount has been raised through donations from delegates at the annual meetings in 2011 and 2012.

“I would like to thank delegates and members for their generosity in helping us to raise this figure and I hope that they will continue to donate generously at our future meetings,” said ESCRS president Peter Barry.

All the funds donated are being divided equally between ORBIS and Oxfam for the specific charitable initiatives selected by ESCRS. At the XXX Congress in Milan, representatives from ORBIS and Oxfam shared a booth to create awareness of their initiatives.

20.12.11 16:10

34

Feature

OUT & ABOUT

DISCOVER WARSAW

Chopin’s city of music and palaces

Poster man Meanwhile, the National Gallery’s Poster Museum, at the Summer Palace in Wilanów, is holding a retrospective of a versatile artist whose journey echoes that of many 20th-century Poles. Fleeing the Nazis, Stefan Norblin, his wife and child left Poland in 1939, passing through Iraq and India before emigrating to the US where he died in 1952. His and his wife’s remains were only recently repatriated to Poland where they were given a state funeral on the day this exhibition opened. The No 180 bus takes about an hour to reach Wilanów from the Old Town via the Royal Route. (Remember to validate your ticket when boarding.)

Muzeum Plakatu w Wilanowie, ul St Kostki Potockiego 10/16, Mon 12-4, Wed 12-8, Tue, Thur-Sun 10-4, www.mnw.art.pl.

Telephone: + 48 22 842 48 48.

Canvassing Europe Recently re-opened after re-organisation, Warsaw’s century-old National Museum is facing a brighter future after an unhappy history which saw it looted during World War II. Though many of its treasures have never been returned, its three main galleries still display a rich collection. In the gallery of European Painting, you will find works by Botticelli, Cranach the Elder, Rembrandt, Tintoretto and Vuillard, while the gallery of Polish Painting features works by luminaries of the Młoda Polska (Young Poland) school, including Wyspiański, Mehoffer, and Jan Matejko’s massive Battle of Grunwald, depicting the 1410 high point in Polish military history.

Muzeum Narodowe w Warszawie, al Jerozolimskie 3, Tue-Sun 10-6, Thur 10-9. www.mnw.art.pl. Telephone: +48 22 621 10 31.

Good vibrations Ever since it opened in 2010, the Copernicus Science Centre, on the banks of the Vistula, has been enormously popular, with adults as well as the children who swarm over its hundreds of interactive exhibits. Its first temporary exhibition explores the physics of sound, encouraging us to find music in ice-cream sticks, egg-slicers and even our own bodies.

If you’ve ever wanted to sing like a robot, you can try here.

Wszystko Gra, Centrum Nauki Kopernik, ul Wybrzeże Kościuszkowskie 20, Tue-Fri 9-6, Sat and Sun 10-5, www.kopernik.org.pl.

Telephone: +48 22 596 41 00.

Source: National Archives, Washington

Labour and love If you only visit one place in Warsaw, it should be the Royal Palace, where a temporary exhibition in the Kubicki Arcades documents the widespread use of forced labour in German-occupied Europe during World War II. After witnessing these workers’ grim stories of appalling conditions, it lifts the heart to explore the rest of the splendid palace, product of a labour of love. Though it was blown up by the Nazis in September 1944, local people smuggled away fragments from the rubble, enabling their heroic reconstruction of the palace in the 1970s and 1980s.

Arkady Kubickiego, Zamek Królewski, pl Zamkowy 4, Tue-Sat 10-4, Sun 11-4. www.zamek-krolewski.pl. Telephone: + 48 22 355 51 70.

Liberated forced labourers registering to go home

EUROTIMES | Volume 17/18 | Issue 12/1

Solid light Los Angeles recently made a big fuss of its new museum devoted to those ultimate 20th-century artefacts – neon signs. But Warsaw narrowly beat them to it, opening its Neon Museum in May of 2012. Since welcoming 10,000 visitors on its first night, the museum has been busily expanding its collection of neon signs from Poland’s cold war era to include more modern items such as light sculptures. A visit makes a good focus for exploring the arty, fast-changing right-bank district of Praga, home to Warsaw’s edgiest clubs, bars and galleries.

Neon Muzeum, Budynek 55, Soho Factory, ul Minska 25, Tue-Sat 12-6, Sun 12-4, www.neonmuzeum.org. Telephone: +48 516 608 881.

Credit: ©NCS/ J. Kosnik

by Renata Rubnikowicz

National Stadium at night

Royal patron Warsaw has no shortage of palaces. Łazienki Palace, the summer residence of the last king of Poland, Stanisław August, includes the Myślewicki Palace, an old orangery and several pavilions, all set in extensive gardens. At its centre is the 17th-century Pałac na Wyspie, the Palace on the Isle, where you can get a better idea of the king’s life and times through an exhibition of the paintings of Marcello Bacciarelli, who was not only his favourite painter but helped his patron choose the palace’s superb collection.

Muzeum Łazienki Królewski, ul Agrykoli 1, Mon 11-4, Tue, Wed, Sun 9-4, Thur-Sat 9-6, www.lazienki-krolewskie.pl. Telephone: +48 22 50 60 024.

Chopin’s city The Łazienki Gardens have a statue to Chopin, but you can find the composer and his music everywhere in Warsaw. Concerts of his music take place almost daily. Of the many sites connected with his life, the best place to start is at the Chopin Museum in the Ostrogski Palace.

But even out and about in the city it’s easy to hear his music. A legacy of the bicentenary of his birth in 2010 are the benches that play excerpts of his works – including one outside the Kościół św. Kryża, the baroque Church of the Holy Cross on ul Krakowskie Przedmieście 3, where there is an urn containing his heart.

Muzeum Fryderyka Chopina, Pałac Ostrogskich, ul Okólnik 1/ul Tamka 41,

Chopin bench

Tue-Sun 11-8, www.chopin.museum.pl (for all Chopin in Warsaw links). Telephone:+ 48 22 44 16 251. For a guide to the location of the Chopin benches, visit: www.chopin. um.warszawa.pl

From rock to football Opening in time for Euro 2012, Poland’s new 55,000-seater National Stadium – gleaming red and white on the right bank of the Vistula – has not restricted itself to hosting sporting events. Fans of Madonna and Coldplay have already seen their idols here, while Depeche Mode are due in July 2013.

But anyone can take a tour to touch the turf trodden by so many international football stars.

Stadion Narodowy, buy tickets at tour reception entrance: al Zieleniecka, ticket office Tue-Sun 9.30-6, tours for individuals at 10am, noon, 2pm, 4pm, and 6pm.

Forever amber From the earliest times, Poland has been on the amber trade route, crossed by merchants bringing the solidified ancient resin from the Baltic to the Mediterranean and farther south and east.

“Amber Beyond the Baltic” is an exhibition that explores its wider distribution and showcases the exceptional relationship Polish craftsmen have with it. See it before you part with your money at a gift shop.

Bursztyn nie tylko nad Bałtykiem, PAN Muzeum Ziemi, al Na Skarpie 20-26, Mon-Fri 9-4, Sun 10-4, www.mz-pan.pl.

Telephone: + 44 22 621 76 24.

Stalin’s sore thumb A legacy of the former Soviet administration, Warsaw’s once-hated Palace of Culture is now admired in an ironic fashion by young Poles. Most locals still agree that the best view of the city is from its observation deck on the 30th floor – mainly because that’s the only place in Warsaw from which you cannot see the 237m-high Stalinist skyscraper.

Taras Widokowy XXX, Pałac Kultury i Nauki, pl Defilad 1, daily 9-6, www.pkin.pl.

Telephone: +48 22 656 76 00.

35

Review

JCRS HIGHLIGHTS

Journal of Cataract and Refractive Surgery

Measuring retinal image quality in a model eye

Learning to do femtosecond LASIK

What is the ideal configuration for a realistic reproduction of the pseudophakic retinal image quality in a model eye?

Researchers in the US have introduced a new adaptive optics IOL metrology system comprising a model eye, wavefront sensor, deformable mirror, and an image-capturing device that acquires through-focus images of a letter chart with 3.0mm and 5.0mm pupil diameters. They noted that to simulate pseudophakic retinal image quality on an optical bench, it is critical to reproduce real-life conditions. Corneal lower-order aberrations and higher order aberrations are present in all eyes to a varying degree and have a significant impact on pseudophakic through-focus visual performance.

Furthermore, corneal aberrations interact with the aberrations of the IOL to yield the complete ocular aberrations, which increase with pupil size. The researchers used the new system to induce corneal astigmatism and higher-order aberrations in previously measured pseudophakic presbyopic eyes. A single-optic accommodating IOL (Crystalens HD (HD500), an apodised (ReSTOR +3.0 D SN6AD1) and fullaperture (Tecnis ZM900) diffractive multifocal IOL, and a monofocal IOL (AcrySof SN60AT) were evaluated. Image quality was quantified using the correlationcoefficient image-quality metric. The singleoptic accommodating IOL and monofocal IOL performed similarly. However, with a 3.0mm pupil, the former had better intermediate (1.50 D) image quality. The multifocal IOLs had bimodal through-focus image quality trends. Corneal astigmatism reduced through-focus image quality and depth of focus with all IOLs. However, the multifocal IOLs had the most severe decline in depth of focus. Ocular spherical aberration had the strongest impact on image quality when typical pseudophakic corneal HOAs were present.

Femtosecond lasers are now used by more than 50 per cent of LASIK surgeons in the US. It appears that the introduction of femtosecond laser systems for flap creation may improve the learning curve for newly trained surgeons because many of the more visually threatening flap complications, such as free caps, irregular flaps, buttonholes, decentred flaps and epithelial defects, occur much less frequently. British researchers looked at the learning curve of the first 200 consecutive myopic LASIK procedures using the Visumax femtosecond laser and the MEL 80 excimer laser by an expert surgeon (11,637 previous microkeratome LASIK procedures) and a fellowship-trained surgeon (observed 1057, performed 155 supervised LASIK procedures) following a standardised surgical technique. They observed no statistically significant differences in outcome measures between surgeons. Preoperatively, the mean SE was −4.00 D ± 1.83 (SD) and −3.97 ± 1.98 D and the mean cylinder was 0.81 ± 0.67 D and 0.79 ± 0.66 D for the expert surgeon and fellowship-trained surgeon, respectively.

Postoperatively, the SE was ±0.50 D in 79 per cent and 74 per cent, uncorrected distance visual acuity was 20/20 or better in 96 per cent and 96 per cent, and one line of CDVA was lost in 3.5 per cent and 1.5 per cent for the expert surgeon and fellowshiptrained surgeon, respectively. Contrast sensitivity increased or was unchanged.

n

n

D Reinstein et al., JCRS, “Transitioning from mechanical microkeratome to femtosecond laser flap creation: Visual outcomes of an experienced and a novice LASIK surgeon,” Volume 38, Issue 10, 1788-1795.

L Zheleznyak et al., JCRS, “Impact of corneal aberrations on through-focus image quality of presbyopia-correcting intraocular lenses using an adaptive optics bench system,” Volume 38, Issue 10, 1724-1733.

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

Don’t miss Ophthalmologica Highlights, see page 43 EUROTIMES | Volume 17/18 | Issue 12/1

36

Feature

EU MATTERS

EXPERIENCE COUNTS

Ophthalmologists hired permanently should receive credit for service performed under previous fixed-term contracts

by Paul McGinn

T

he salary scale for ophthalmologists newly hired as permanent public servants should reflect at least some of the length of service they have already accrued under any fixed-term state contracts, under a new ruling from the European Union’s highest court.

In its decision, handed down in late October, the Court of Justice found that the same EU laws that prohibit discrimination against fixed-term workers continue to protect those same workers from discrimination once they are hired permanently.

Under EU law adopted in 1999, “fixed-term workers shall not be treated in a less favourable manner than comparable permanent workers solely because they have a fixed-term contract or relation unless different treatment is justified on objective grounds.”

The case arose after the Italian National Competition Authority hired, on a permanent basis, five employees

From the Archive Wavefront rated in ‘top five’ innovations in last five years

W

avefront analysis will lead to an improved understanding of the optics of the human eye and provide the foundation for developing therapeutic devices and procedures in the future, according to a US ophthalmologist.

Daniel S Durrie MD said wavefront sensing is one of the top five advances in ophthalmology during the last 25 years in his Barraquer lecture during the annual meeting of the American Academy of Ophthalmology.

“Through its application in guiding customised ablation, it has brought us into an era focusing on quality of vision, but advanced vision testing with wavefront analysis is relevant to many other technologies.

“It has been my privilege to be part of the start of this new wave and I look forward to where it will take us in the future,” Dr Durrie said. * From EuroTimes, Volume 7, Issue 12, December 2002 EUROTIMES | Volume 17/18 | Issue 12/1

In determining the pay scale for those employees, the authority refused to take into account any of the periods of service previously completed by those employees under the fixed-term contracts. previously employed by the authority under fixed-term contracts. In determining the pay scale for those employees, the authority refused to take into account any of the periods of service previously completed by those employees under the fixed-term contracts. The employees consequently contested that refusal in the Regional Administrative Court in Rome.

The Regional Administrative Court dismissed the employees’ case on the basis of an Italian national law that prohibits the state from crediting any length of service accrued as a fixed-term state employee in setting the pay scale for that employee if later hired as a permanent civil servant.

The Competition Authority employees appealed the Administrative Court’s decision to Italy’s Council of State, arguing that the national law was illegal under EU law because the law unfairly discriminated against them. At the core of their appeal was their argument that the duties they performed under fixed-term contracts were exactly the same as those they performed as permanent employees. As such, they argued that they should be credited with the length of service accrued as fixed-term workers in the setting of their level of civil servant pay.

The Council of State rejected the employees’ argument on the basis that by refusing to give credit for length of service under a fixed contract, the law was properly attempting to avoid so-called “reverse discrimination” against permanent civil servants who had been recruited on a permanent basis following a general competition.

Despite its findings, the Council of State referred the case to the European Court of Justice in Luxembourg because another Italian court, hearing a separate case, had found that the length of service accrued must be acknowledged when converting a fixed-term employment contract into a permanent one.

In its judgment, the Court of Justice found that the EU legal principle of non-discrimination provides that fixedterm workers must not be treated in a less favourable manner than comparable permanent workers solely because they work on a fixed-term basis, unless different treatment is

Don’t miss Calendar of events, see page 44

justified on objective grounds. The fact that the Competition Authority employees had acquired the status of permanent workers did not exclude the possibility of relying on that principle.

Having made that general finding, the Court of Justice said that it was not for it but rather for national courts to apply such a principle when determining if employees working under fixed-term contracts were in a situation comparable to that of career civil servants employed on a permanent basis. The Court of Justice stated that national courts should take account of the nature of the duties performed by those employees under fixed-term employment contracts and the quality of the experience which they thereby acquired in determining whether they were, in fact, working in a situation comparable to that of career civil servants.

On that basis, if the national court found that the nature and experience of the fixed-term work were the same as the nature and experience of the permanent work, a public authority could not discriminate against the fixed term worker by failing, in setting the appropriate civil servant pay scale, to acknowledge the duties already performed and experience already gained.

The Court of Justice also found, that as a general principle, just because fixed-term workers had not passed the general competition for obtaining a post in the public sector did not, of itself constitute objective grounds for discriminating against them.

The Court of Justice ruled that to be objective, such a ground for discriminating against the fixed-term workers can only be “justified by the existence of precise and specific factors, characterising the employment condition to which it relates, in the particular context in which it occurs and on the basis of objective and transparent criteria in order to ensure that unequal treatment in fact meets a genuine need, is appropriate for achieving the objective pursued and is necessary for that purpose.”

The Court of Justice noted that even were there to be an objective ground for discrimination against fixed-term workers, the discrimination must be proportionate to the objective. In this case, the refusal to take account of any of the length of service accrued under the fixed-term contracts in determining the civil servant pay scale was not proportionate to the objective and so was illegal. The court held that Italy “cannot, in any event, justify disproportionate national legislation such as that at issue in the main proceedings which completely and in all circumstances prohibits all periods of service completed by workers under fixed-term employment contracts being taken into account in order to determine the length of service of those workers upon their recruitment on a permanent basis and, thus, their level of remuneration.”

To allow the temporary nature of an employment relationship to justify a difference in treatment as between fixed-term workers and permanent workers would render the objectives of EU law “meaningless” and would be tantamount to perpetuating a situation that is disadvantageous to fixed-term workers, the court held.

For more information about the case, Rosanna Valenza and Others v Autorità Garante della Concorrenza e del Mercato, see the European Court of Justice website at www.curia.eu.

Technicians & Nurses Program ¡ April 20â&#x20AC;&#x201C;22, 2013

Attend the only meeting dedicated to the precise needs of the anterior segment specialist aligned with the most established practice management program for comprehensive ophthalmology and subspecialties.

Register Today www.ascrs.org or www.asoa.org Follow @ASCRStweets on Twitter. #ASCRSASOA2013

38

Feature

industry news

Recent developments in the vision care industry

Precise and clean cutting

Geuder Uno Colorline 20G, 23G and 25G

Geuder says that the one-use instrument product line Uno Colorline offers additional instruments in 20G, 23G and 25G. The instruments available are new one-use vitrectomy scissors for highly precise and clean cutting, a trocar chandelier set (25G) for bright and uniform illumination and high-quality one-use laser probes for various laser consoles. Also available are: a perfected Uno Colorline trocar system and an extended assortment of vitrectomy forceps that now also includes tips in the Tano design.

“Complementary to the Uno Colorline instruments, reusable accessories for optimal surgery procedures are now also available, such as the Hattenbach instruments ‘Shark’ retaining ring, ‘Triangle’ sclera depressor, ‘Horse Shoe’ instrument and a new seam support,” said a company spokeswom n

www.geuder.de

Enhancing Vision

Ludwin Monz PhD, Carl Zeiss Meditec president and CEO

Indication for symptomatic VMA

ThromboGenics has announced that the US Food and Drug Administration (FDA) has approved JETREA® (ocriplasmin) in the US for the treatment of symptomatic VMA. Dr Patrik De Haes, CEO of ThromboGenics, said: “The FDA approval of JETREA® is a major milestone for the company. We are extremely pleased that we will be able to meet a major unmet clinical need in ophthalmology when we make JETREA®, the first pharmacological agent for symptomatic VMA, available to the many thousands of US patients who could benefit from treatment of this progressive, sight-threatening condition. We are continuing to prepare for the planned launch of JETREA® in January 2013 through our own US commercial organisation. This is the biggest step in transforming ThromboGenics into a profitable biopharmaceutical company developing and commercialising innovative ophthalmic medicines,” said Dr De Haes. n www.thrombogenics.com EUROTIMES | Volume 17/18 | Issue 12/1

Launched at the 2012 ESCRS Congress, the AT LISA tri 839 MP is the first of a new generation of refractive-diffractive trifocal intraocular lenses designed to eliminate the middle-range trough in visual acuity seen with bifocal designs, said Ludwin Monz PhD, Carl Zeiss Meditec president and CEO. The lens splits incoming light 50 per cent to distance vision, 30 per cent to near and 20 per cent intermediate, and has high light transmittance. This helps maintain contrast sensitivity and range of vision, even in poor lighting, while reducing glare, haloes and other dysphotopsias. “The optics are very advanced,” Dr Monz said.

It can be implanted through a 1.8mm incision.

Zeiss also introduced PRESBYOND Laser Blended Vision. This corneal procedure increases the depth of field in both eyes, adjusting the dominant for intermediate to long vision and the non-dominant for near to intermediate. Overlap of the two fields in the intermediate range promotes fusion of the two images, making it a more flexible and tolerable alternative to conventional monovision. Astigmatism and other aberrations can also be corrected. n www.meditec.zeiss.com/escrs

New global headquarters

HOYA Surgical Optics has opened its new global headquarters in Singapore. Thomas A Dunlap, president and CEO of HOYA Surgical Optics, said: “Our business has grown rapidly and become more globally integrated. We have had a state-of-the-art manufacturing facility in Singapore since 2003,and the integration of headquarter functions in 2011 enhanced our operational efficiency and brought us closer to customers in important emerging markets. The move to new offices in the Millenia Tower is the next phase in our ongoing growth strategy and will allow us to bring additional resources to our organisation,” he said. n www.hoyasurgopt.com

Emilio Fernandez, overall winner of the inaugural Retina Race, at the 12th EURETINA Congress in Milan

Inaugural Retina Race a great success

The Arena Civica, Parco Sempione, was the location for the inaugural Retina Race, which took place during the 12th EURETINA Congress in Milan.

The race was held in aid of ORBIS, organised by EURETINA and kindly sponsored by Alcon and Novartis.

Approximately 75 runners registered to take part and 56 ran on the day, with ophthalmologists and industry colleagues across all levels from around the world taking part. There were eight categories, split across age and gender, with runners varying in age from 23 to 63 years, so there were plenty of medals to be won.

Emilio Fernandez, a Spanish sales executive with Novartis, was the overall winner with a very impressive time of 18 minutes and 33 seconds.

Stephane Wolf, global associate brand director, Lucentis at Novartis, praised those who took part in the race and said he hoped the race would continue to grow with more ophthalmologists taking part when it is held in Hamburg, Germany to coincide with the 13th EURETINA Congress.

“We are extremely proud so many people turned up today for this charity event. It was a beautiful inaugural race, which will be held every year now and we are sure in 10 years’ time there will be thousands of runners and we are sure people will look back on this day,” said Clemens Jakobi, region Europe franchise head ophthalmics, Novartis.

Feature

RESIDENT’s DIARY

FROLIC AND FIREWORKS

It may be the season of goodwill, but for many residents it’s a time to treat – and learn from – human-induced disaster

by Leigh Spielberg

EUROTIMES | Volume 17/18 | Issue 12/1

Image by Eoin Coveney

“M

ake sure you don’t miss the professor’s yearly Christmas party,” I was warned when I started my residency. “He really likes it when everyone is there. Bring your wife along too.”

Prof van Meurs has invited all his ophthalmologists-in-training and their partners to his house for a cocktail party on the Friday before Christmas for as long as anyone can remember. It’s a formal gathering: men in shirts and ties, women in nice dresses. The youngest resident in attendance is responsible for buying a gift for the professor’s wife; the second-youngest writes the gift card and makes sure everyone signs it; the oldest resident prepares a speech and a toast. Nineteen of the 20 residents are always there; the only one left out is the youngest resident, who’s on call that evening so the rest of us can go.

The professor is by the wine table, maybe because he knows that everyone will pass by there at least a few times over the course of the evening. “Bordeaux or Burgundy?” he asks us, as though any of us residents can taste the difference. I had just spent a few weeks in South Africa, so shiraz and pinotage were the grapes on my mind, but I played along. “That depends on what years the vintages are.” He smiled. “Bordeaux is 2005 and the Burgundy, um, 2004,” he replied, looking at the bottles “I’d like some Bordeaux then, please.

I think 2005 was a good year for the region, and I’m not so sure about the 2004 Burgundies.” I know almost nothing about wine, but what I do know is that bluffing about that knowledge is an acceptable alternative to actually knowing about it.

Fortunately, we residents know more about ophthalmology than about terroir. But despite our common profession, we haven’t been invited there to talk about eyes, but rather about ourselves. After pouring me a very generous glass, he asked, “How is your family doing? A second child on the way, I hear. Great! Congratulations! Has your wife adjusted to life in Rotterdam? I hear her dermatology practice is blossoming.

What do you think of the newest group of residents? Nice people, right? How was your last vacation? South Africa, right?”

I lingered at the table for as long as the next in line for wine could tolerate.

It’s always interesting to speak with an attending outside the context of the clinic. And with our partners there, the momentary mixing of our private and professional lives makes for amusing conversations: “You too?” I hear one colleague’s wife say to another’s husband.

“I hate it when the eye surgery books have surgical pictures on the cover. Those blood-shot eyes look horrible! I always flip them over. And don’t even get me started

about the surgical videos on YouTube.”

The holiday period in the Rotterdam Eye Hospital begins during the first week of December, when the staff organises a party for all the employees’ children. The centre of attention is Saint Nicolas, Northern Europe’s gift-bearing bishop and a direct predecessor of Santa Claus. Parents buy the gifts ahead of time and give them to the saint, who distributes them to the children at the party.

Its fascinating to see the other residents,

who I otherwise only know as young physicians dependent on attendings for guidance, function independently as fully fledged parents.

Despite the merriment, Christmas week can be tricky for residents. Those of us who are doing a surgical rotation hope that our time in the operating room won’t be cut short due to attendings’ absence. Others, interested in getting away to the Alps for a family ski vacation, hope that their vacation requests were honoured. A half-dozen residents have to continue working to staff the emergency room and the inpatient ward.

Vacation requests start up to eight months in advance. Fortunately, the Dutch are both fair-minded and highly organised, so those who sacrifice now always benefit later.

Saint Nicolas and Christmas constitute a small and relaxed prelude to the very intense New Year’s Eve in the Netherlands. For one evening each year, the Dutch display an inexplicable obsession with self-ignited fireworks. Despite their legendary frugality, they spend hundreds of euros on powerful Roman candles and other explosives.

These are detonated in driveways and back yards, with predictable consequences.

The emergency room is double-staffed, and we spend the whole night examining blast-injuries. The inpatient nurses rinse gunpowder and charred paper from fornices, and senior surgeons try to close bulbs in the hope of salvaging form, if not function.

“You’ve got to do it at least once during your residency. It’s the closest you’ll get to wartime ophthalmology,” a senior resident told me during my second year. I signed myself up immediately.

“You’re working on New Year’s Eve? Voluntarily?” asked my wife. I told her about the interesting pathology and oncein-a-lifetime chance to diagnose and treat it, and suggested that she spend the evening in Belgium, where champagne corks are the only things that might end up in someone’s eye.

The disaster of the Dutch New Year’s Eve is something that is being addressed by ophthalmologists at a national level, but neither the politicians nor the public is particularly interested in banning fireworks. This is a shame, since dozens of eyes are lost every year, and the victims are overwhelmingly young children and adolescents who happen to be standing around in the wrong place at the wrong time.

Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in The Netherlands

39

2013 •

WINTER UPDATE Concepts & Controversies for the Anterior Segment Practice

February 14–18, 2013 Turnberry Isle Miami Aventura, Florida

Revitalize Your Practice.

Innovate and Strategize in a Relaxing Environment.

Join us for an open exchange of ideas and solutions to help improve your Anterior Segment Practice. Attend the educational retreat where you can participate in high-energy sessions with video cases, debates, and discussions on cataract, cornea, glaucoma, and refractive.

The value of the intimacy of the Winter Update is priceless. Superb. I will highly recommend this to my “peers.

Thank you, ASCRS and ASOA. ” Tina Pinke, COT, COE, Shelton, CT

Register Today and Book Housing

www.WinterUpdate.org

Program Chairs

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

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

Faculty Brock K. Bakewell, MD John D. Banja, PhD Rosa M. Braga-Mele, MD, MEd, FRCSC Clara C. Chan, MD Robert J. Cionni, MD Garry P. Condon, MD Vincent P. de Luise, MD Terry Kim, MD W. Barry Lee, MD Richard L. Lindstrom, MD Nick Mamalis, MD Nancey K. McCann Louis D. “Skip” Nichamin, MD Stephen A. Obstbaum, MD Robert H. Osher, MD E. Ann Rose Jonathan B. Rubenstein, MD Thomas W. Samuelson, MD R. Doyle Stulting Jr., MD, PhD

Physicians Program (subject to change) Thursday, February 14 • Networking & Welcome Reception

Friday, February 15 • Video Symposium of Challenging Cases & Complications Management During Cataract Surgery • Interactive Cornea • Optional Workshop: The Future of Healthcare Reform • Evening Non-CME Session: Management of Posterior Capsule Rupture

Saturday, February 16 • What’s New in Technology?

• Rapid F-Eye-R: You Make the Call • Optional Workshop: Astigmatism Management • Optional Workshop: Retina Case Management • Evening Session: Vitreous Challenges in Anterior Segment Surgery

Sunday, February 17 • My Top 5 Pearls • Glaucoma 2013: Better Images and New Surgeries • Optional Workshop: Cornea Conundrums • Optional Workshop: Glaucoma Case Management • Evening Session: Medicare Update

Monday, February 20 • Refractive Surgery for the Comprehensive Ophthalmologist • Ethics Interactive • Faculty Roundtables/Wrap-Up

Administrators Program Collaborative Strategy Sessions for Practice Management Challenges.

Dashboards and Benchmarking | Hot Topics | Integrated Panels

i TELL ME AND I’LL FORGET;

SHOW ME AND I MAY REMEMBER; INVOLVE ME AND I’LL

UNDER

STAND - Old Chinese Proverb

i

42



Learn and explore key aspects of modern anterior segment surgery



Prepared by ESCRS in partnership with Society opinion-leaders



Earn CME points

Nearly 30 hours of interactive, assessed and accredited eLearning 

Refractive Surgery Didactic Course



Cataract Surgery Didactic Course



Workshop on Visual Optics



Cornea Didactic Course

Gain access to all of this and more online at

http://elearning.escrs.org

EUROTIMES | Volume 17/18 | Issue 12/1

Review

Book REVIEW

Possibilities and Pitfalls

We all enjoy challenging pathology.

Challenging diseases stimulate us to read about them, and by understanding them, we’re able to more accurately diagnose and treat these problems. However, recurrences are never welcome, and pterygium is one of the classic recurring problems. They appear, get inflamed endlessly, and have the tendency to re-grow after excision.

So, a textbook dedicated entirely to pterygium is a welcome addition to the literature. Dr Hovanesian, of the Jules Stein Eye Institute in Los Angeles, California, has gathered a group of ocular surface specialists to help him write Pterygium: Techniques & Technologies for Surgical Success. Published

by Slack Incorporated, this concise book of 140 pages offers the reader an up-to-date summary of the possibilities and the pitfalls in pterygium treatment.

Pterygium, the authors inform us, is a Latin term derived from the Greek word meaning “small wing.” It has been described by physicians for thousands of years, and has always been recognised as a difficult problem.

Ambroise Paré, the 16th century surgeon to the French royal court, noted that “a pterygium is an illness that always recurs, even when you have done everything in your power to cure it.” This seems to still have an element of truth even today, despite extensive experience and precise surgical techniques. Indeed, “more than a hundred techniques for pterygium surgery have been described over the past several centuries because of concern over recurrence.”

The book begins with chapters on pterygium pathogenesis, which delves deep into the molecular mechanisms and their interaction with both genetic predisposition and environmental exposure.

Ultraviolet light, oxidative stress and chronic inflammation are covered, as are the contributions of limbal stem cell abnormalities, antiapoptotic proteins and DNA damage.

The second chapter discusses historical approaches to pterygium surgery, including bare sclera and adjunctive beta radiation techniques. However, it quickly moves on to more interesting, successful and therefore relevant surgical methods.

Chapter 3 covers pterygium excision with conjunctival autograft, including postoperative therapy and potential complications. Fortunately, “conjunctival grafts never fail, and even minor complications are extremely uncommon,” say the authors.

Adjunctive substances, including fibrin tissue adhesive, 5-fluorouracil and mitomycin-C are discussed in individual chapters. Although the use of fibrin tissue adhesive is encouraged, “considerable debate still exists as to the safest and most

effective use of antimetabolite adjuncts in the setting of pterygium surgery.”

The next two chapters cover the history of amniotic membranes in pterygium surgery and the use of amniotic membrane for conjunctival reconstruction. This chapter discusses the use of amniotic membrane not only for pterygium surgery, but also for conjunctival chalasis, fornix reconstruction, chemical burns and glaucoma surgery with conjunctival complications.

The next chapter covers the use of amniotic membrane grafts for pterygium only. This is followed by a chapter on amniotic membrane placement beneath the surrounding, healthy conjunctiva after conjunctival autograft.

Of course, a book like this requires chapters on postoperative management and complications and the management of recurrence (chapters 10 and 11, respectively). As a sort of added bonus, Dr Hovanesian has included a final chapter on the diagnosis and surgical treatment of conjunctival chalasis, which is caused by the absence of subconjunctival Tendon’s fascia that normally provides adherence of the conjunctiva to the scleral surface.

This book is primarily suitable for corneal and ocular surface disease fellows who are interested in refining their surgical skills and insight and their understanding of this challenging pathology.

Ophthalmic surgeons looking to either start treating pterygium surgically, or would like to decrease the incidence of recurrence in their patients would be advised to purchase this book. Further, ambitious residents who might want to make a good impression during their cornea rotation, as well as assisting staff interested in keeping up with what goes on under the knife, will also benefit from reading this text.

BOOKS EDITOR Leigh Spielberg PUBLICATION Pterygium: Techniques & Technologies for Surgical Success AUTHOR John A Hovanesian PUBLISHED BY Slack Incorporated If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

43

Review

OPHTHALMOLOgica

Myopic maculopathy: a review Research is continuing to shed light on the pathophysiology of myopic choiroidal neovascularisation (CNV), and new treatments are beginning to show promise, according to a review article on the current understanding of the condition. Myopic CNV may account for as much as 62 per cent of CNV occurring in patients younger than 50 years of age. The condition occurs in 5.2 per cent of eyes with an axial length longer than 26.5mm. Highly myopic eyes with lacquer cracks or patchy atrophy close to the fovea have a higher risk of developing CNV. Without treatment, two-thirds to three fourths of eyes with CNV associated with high myopia will have a final visual acuity of 20/200 or worse. Direct thermal laser photocoagulation was for a long time the only treatment available. However, whatever benefit it provides in the short term is lost in the long term through the spread of the laser scar. Recent studies suggest intravitreal anti-VEGF agents may produce a more meaningful benefit. n Silva, Ophthalmologica 2012, DOI: 10.1159/000339893

Continuing improvement in retinal structure and visual function Patients who undergo surgery for idiopathic epiretinal membrane can continue to have further anatomic recovery of disrupted inner-outer segment junctions and corresponding improvements in vision for two years postoperatively, according to the results of a retrospective study. In 17 patients who underwent transconjunctival 25-gauge surgery, the BCVA at 24 months was significantly better than it was at 12 months (p = 0.018). In addition, the number of eyes with a normal appearing IS/OS junction, assessed by spectraldomain optical coherence tomography, increased from one eye at 12 months to seven eyes at 24 months. Those seven eyes showed significantly greater postoperative improvement in BCVA than the remaining 10 eyes throughout the entire follow-up period. n

Intravitreal dexamethasone implant effective in uveitis

EYE CHAT Exclusive interviews Up to date information Problem solving

Intravitreal dexamethasone implants can bring about a great reduction in the signs and symptoms of severe noninfectious uveitis that is unresponsive to immunosuppressants and periocular corticosteroids, according to a retrospective study. In 12 patients with refractory uveitis who received the implant, best-corrected visual acuity improved from 20/80 to 20/40 and the mean retinal thickness improved from 496 to 226 µm after a mean follow-up of nine months. Adverse events included intraocular pressure elevation in three eyes, vitreous haemorrhage in one eye and subconjunctival haemorrhage in one eye.

Three patients reduced the daily systemic corticosteroid dosage after treatment n Miserocchi et al, Ophthalmologica 2012 DOI: 10.1159/000343060

Indocyanine green toxic when used for chromovitrectomy Indocyanine green (ICG) will degrade into toxic metabolites even when used at their optimum concentrations with modern endoillumination systems in chromovitrectomy procedures, however brilliant blue G (BBG) and trypan blue (TB), will remain stable, according to the results of an in-vitro study. The study's investigators simulated the illumination intensities and dye concentrations used in chromovitrectomy by irradiating vials containing standardised dilutions of the three dyes at a wavelength of 366 nm with an intensity of 14 µW/cm2 for up to 48 hours. They observed an exponential photolysis of ICG, whereas BBG and TB did not break down. n Brockmann et al, Ophthalmologica 2012, DOI: 10.1159/000341605

Viscoelastics Ophthalmic viscosurgical devices are so useful that they are sometimes called the ophthalmic surgeon’s third hand.

Dr Findl talks with Dr Zsolt Biro about the different kinds of viscoelastics, their uses, and some of the complications to watch out for.

podcast

Inoue et al, DOI: 10.1159/000341606

www.eurotimes.org

José Cunha-Vaz EDITOR OF OPHTHALMOLOGICA, The peer-reviewed journal of EURETINA EUROTIMES | Volume 17/18 | Issue 12/1

Also available on iTunes

Scan this QR code to gain access to EuroTimes podcasts

44

Reference

CaLenDar Of eVentS

Dates for your Diary

December

January

January

February

5th Amsterdam Retina Debate & Amsterdam Retina Live Surgery

4th International Course on Ophthalmic and Oculoplastic Reconstruction and Trauma Surgery

28th Congress of APAO & 71st Annual Conference of AIOS

3rd EURETINA Winter Meeting

2012

7-8 AMSTERDAM, THE NETHERLANDS www.amc.nl/retinadebate www.amc.nl/congres

2013

9-11 VIENNA, AUSTRIA

2013

17-20 HYDERABAD, INDIA

2013

1-2 ROME, ITALY www.euretina.org

www.ophthalmictrainings.com

www.apaoindia2013.org www.aios.org

February

February

April

May

17th ESCRS Winter Meeting

27th International Congress of HSIOIRS

ASCRSâ&#x20AC;˘ASOA Symposium and Congress

ARVO

www.hsioirs.org

www.ascrs.org www.asoa.org

2013

15-17 WARSAW, POLAND www.escrs.org

2013

28-3 MARCH ATHENS, GREECE

2013

2013

19-23 SAN FRANCISCO, USA

5-9 SEATTLE, WASHINGTON, USA www.arvo.org

June

June

July

July

European Society of Ophthalmology (SOE) 2013

International Meeting on Anterior segment surgery

26th APACRS Annual Meeting

5th World Glaucoma Congress

www.apacrs.org

www.worldglaucoma.org

www.soe2013.org

www.femtocongress.com

2013

2013

2013

8-11 COPENHAGEN, DENMARK

22-23 VERONA, ITALY

2013

11-14 SINGAPORE

17-20 VANCOUVER, CANADA

September

October

October

November

13th EURETINA Congress

4th EuCornea Congress

XXXI Congress of the ESCRS

AAO Annual Meeting

www.euretina.org

www.eucornea.org

www.escrs.org

www.aao.org

2013

26-29 HAMBURG, GERMANY

2013

4-5 AMSTERDAM, THE NETHERLANDS

2013

5-9 AMSTERDAM, THE NETHERLANDS

2013

16-19 NEW ORLEANS, USA

Advertising Directory: Alsanza: Page: 35; A.R.C. Laser Ag: Pages: 9, 26; ASCRS: Pages: 37, 40-41; Croma: Pages: 27, 33; D.O.R.C.: Page: 25; ESASO: Page: 31; Medicel: Page: 5; Medicontur: Page: OBC; NIDEK: Page: 21; Oculus: Page: 7; Oertli Instruments Ag: Page: IFC; OWL: Page: 13; Synergetics: Page: IBC; Ziemer: Page: 10

OPTIMIZED M U LT I FO C A L

VISION