Volume 16_Issue 10 by EUROTIMES

VOLUME 16

ISSUE 10

OCTOBER 2011

micro-incision

implantation

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MICROIMPLANTATION CATARACT SUITE

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ESCRS

EUROTIMES

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october 2011 Volume 16 | Issue 10 This month... Special Focus: Cataract

Cover Story: Is femtosecond laser-assisted cataract surgery the way forward?

Study shows favourable results for bilateral surgery of cataracts

Survey of French ophthalmologists provides valuable insights

Simple procedure can rescue capsulorhexis tear-out

Studies compare toric IOLs and LRIs for astigmatism patients

Greater precision with new technology, according to studies

Variety of tools can reduce risk of complications for small pupils during surgery

Cataract & Refractive 18 Combined technique could provide new refractive surgery option 19 New method unveiled for adjusting the power of an IOL in situ 20

Survey shows growing acceptance of IOLs among US refractive surgeons

Cornea 22 Emergency corneal transplants could be prevented with collagen cross-linking 23 Metallic ring may prevent vascularisation of corneal grafts

Glaucoma 24 Researchers move closer to development of genetic screening for glaucoma 25 Safety concerns with treatment of perfusion pressure

Retina 26 Surgical intervention after choroidal detachment can help restore vision 27 Retrospective study shows risks of anti-VEGF agents 28 Microneedles target drug delivery

Ocular 31 32

Follow-up study on MRSA epidemic Study looks at how blind people can see by ear

News 34 ESASO Fellowship programme attracts global interest 35 Emanuel Rosen pays tribute to David Apple MD 36 Ophthalmology resident talks about his daily challenges 37

EBO looks to higher subspecialty training at a European level

38 Preview of 16th ESCRS Winter Meeting in Prague

Features 39 Practice Development

46 EU Matters

42 Book Review

47 Industry News

43 JCRS Highlights

48 Calendar

44 Eye on Travel

Cover image: Manual capsulorhexis (bottom) versus laser capsulotomy (top) with OptiMedica’s CatalysTM Precision Laser System. (Image courtesy of OptiMedica.)

With this month’s issue... vienna 2011 REPORT from 2nd eucornea congress & xxix congress of the escrs

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

Seamus Sweeney Gearóid Tuohy

Circulation Manager Angela Morrissey

Colour and Print Times Printers

Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin

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

Contributors Devon Schuyler Eisele Stefanie Petrou-Binder Maryalicia Post

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

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

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

EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 16 | Issue 10

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

NEW CATARACT TECHNOLOGY

In many surgical procedures the energy of the hand is replaced with other types of energy

by Boris Malyugin MD, PhD

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND

his month’s issue of EuroTimes is devoted to cataract surgery and features a number of very interesting articles on the subject. In particular, our Cover Story discusses how femtosecond laser-assisted cataract surgery (FLCS) has the potential to make cataract surgery more precise and repeatable. As surgeons, we devote a significant part of our professional lives trying to increase precision and control, improve efficiency and safety to the best of our ability. All this is done not only through the process of learning and training, but also by adopting and implementing the latest technological achievements into our routine clinical practice.

Exciting opportunities That is why if one asks a group of surgeons: “Do you want to have the new cataract technology that allows you have better results and happier patients?”, I think everybody will say “yes” unanimously. That is why many of us are extremely enthusiastic about FLCS. Although at this particular time we do not have enough clear and statistically significant evidence of its superiority over the existing ultrasonic technology, there is no doubt that FLCS will offer us very exciting opportunities in the future. Some ophthalmologists may not be in a hurry to jump into FLCS immediately but will prefer to observe how the procedure evolves. Of course there are some other concerns regarding the added cost and issues with the speed of the procedure and smooth patient flow, to name just a few of the issues that need to be addressed. No doubt all of these issues will be resolved with the progress of the technology and also with the discussion among ophthalmologists about how to implement the procedure safely and effectively. We know that in different fields of medicine, machines can be more efficient than the human body and in many surgical procedures EUROTIMES | Volume 16 | Issue 10

Roberto Bellucci ITALY the energy of the hand is replaced with other types of energy. History teaches us a lot and drawing the parallels between femto-phaco and US-phaco we can see how dramatically the latter technology changed after its initiation by Charles Kelman in the early ‘70s.

Raising standards

This example makes us believe that implementation of FLCS into clinical practice in the near future will not be a step towards “robotic” cataract surgery, but rather will raise our cataract surgery standard to the new higher level of safety and clinical results. Of course only time will show whether this is correct. I hope this issue of EuroTimes and our Cover Story will contribute to the debate and I would welcome any comments or observations from my colleagues about the future of FLCS.

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

BORIS MALYUGIN Boris Malyugin is professor of ophthalmology, Cataract & Implant Surgery Department, and chief, S Fyodorov Eye Microsurgery Complex, Moscow, Russia.

Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

CATARACT

exciting NEW TECHNOLOGIES

Femtosecond laser-assisted cataract surgery has the potential to make procedure more precise and repeatable by Howard Larkin

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The potential of this technology is to raise cataract surgery to a consistently higher level with greater safety Douglas Koch MD

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The attraction for both the surgeon and the patient in terms of quality and safety (mainly reproducibility and repeatability of the main surgical steps) are so high that it will be used despite the possibility that the initial cost will be higher Jose Guell MD

EUROTIMES | Volume 16 | Issue 10

n 1967, Charles Kelman MD performed the first phacoemulsification procedure on a non-sighted eye. It ended badly, with purulent endophthalmitis and a phthisical globe. Dr Kelman famously persevered. Still, it took more than 20 years for phaco to overtake extracapsular cataract extraction as the dominant procedure. As phaco technology continually advanced, the clinical benefits clearly outweighed its cost. But there’s plenty of room for improvement. Accurately predicting postoperative effective lens position, and minimising induced astigmatism, lens dislocation, capsular rupture, endothelial cell loss, and infection all remain issues. Visual outcomes are far less predictable than laser refractive surgery, with only about half of cataract patients achieving 20/40 uncorrected. Resolving these issues is critical for presbyopia-correcting, toric and other premium intraocular lenses to work as advertised. More significantly, it could also improve safety and visual outcomes for all cataract patients. Femtosecond laser-assisted cataract surgery (FLCS) has the potential to resolve these issues, many researchers say. They believe that automating key surgical steps, including making corneal incisions, opening the capsule, and softening the lens nucleus, will make cataract surgery more precise and repeatable. “Even skilled surgeons can have inconsistent operative experience depending on the cascading effects of each surgical step. The goal is to improve every step,” Zoltan Nagy MD of Semmelweiss University, Budapest, Hungary told the 2011 annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS). Early tests have shown that femtosecond lasers can greatly increase the precision of corneal incisions and capsular openings, and reduce the phaco energy required for extracting nuclei.

“The potential of this technology is to raise cataract surgery to a consistently higher level with greater safety,” said Douglas Koch MD of Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, US, and former editor of the Journal of Cataract and Refractive Surgery (JCRS). Because it will reduce variation, it will also facilitate research into how tissues respond to surgery, he added. However, as of mid-summer, statistically significant differences in visual acuity outcomes had not yet been reported. Neither had reductions in postoperative infections or incidence of radial tears or vitreous loss. While femtosecond cataract surgery is much more advanced than phaco was at the outset, real questions remain about how much surgical precision can reduce refractive outcome variations given the role of factors such as capsular contraction and metabolic issues over time. And then there’s the cost. At a projected price of $400,000 to $550,000 each, the imaging-guided femtosecond lasers needed for cataract surgery are a level of magnitude more expensive than phaco machines. Governments aren’t likely to pay, so femtosecond lasers for cataracts may make economic sense only for the highest volume practices serving privatepaying patients, according to analysis by Kevin M Miller MD of the University of California – Los Angeles, US, which he presented at the 2011 International Conference on Femtosecond Lasers in Ophthalmology in June. Nevertheless, many observers expect femtosecond technology will eventually spread just as phaco did – and for the same reasons. “The attraction for both the surgeon and the patient in terms of quality and safety (mainly reproducibility and repeatability of the main surgical steps) are so high that it will be used despite the possibility that the initial cost will be higher. Once the set of surgeons using the technology is full

and this ideally should rely on the results, the cost will diminish. This is how the market works for everything,” said ESCRS president Jose Guell MD. Below is a brief review of the current state of femtosecond-assisted cataract surgery, and its prospects for improving outcomes.

Corneal incisions The importance of well-constructed corneal incisions has become increasingly evident in recent years, Samuel Masket MD of the University of California, Los Angeles, told the ASCRS annual meeting. “While it used to be considered just a portal of entry to do our intraocular manoeuvres, there are far more important aspects of the incision. Ensuring hermetic sealing to prevent infection and limiting surgically induced astigmatism are two. With regard to both we have come to realise that square and small are better.” Dr Masket noted that reported intraocular infection rates are higher with clear corneal incisions than scleral tunnel incisions. He believes the difference is not that scleral tissue is inherently more likely to seal, but that surgeons have more difficulty constructing a square entry through the clear cornea. IOP is one factor. Surgeons also tend to vary their angle of approach depending on the ergonomics of the situation. Dr Masket’s 2004 study of femtosecond laser-assisted side-port incisions in a pressure-regulated eye demonstrated that square incisions were more stable and less likely to leak. Similarly, an unpublished study of 75 eyes by Roger F Steinert MD, University of California, Irvine, California, US, and Dr Nagy for LenSx found that 17 of 18 eyes with manual Langerman incisions and 13 of 15 eyes with dimpledown manual incisions required stromal hydration to seal. By contrast, zero of 42 eyes with a two-plane femtosecond-assisted incision required hydration.

Anterior capsulotomy Dr Steinert pointed out that an femtosecond-assisted capsular opening technically is not a “rhexis,” which refers to a tear, but a true cut. Across many tests of several platforms, capsulotomies have proven predictable to within a small fraction of a millimetre in size and can be much more precisely centred than manual procedures. This could lead to better visual outcomes by reducing the guesswork involved in predicting effective lens position, and reducing the chances of lens dislocation. Research presented to ASCRS by Dr Steinert confirms that femtosecond technology has the potential to reduce variability in effective lens position. A study he conducted with Dr Nagy comparing femtosecond capsulotomies to manual capsulorhexes found the variation in both lens position and the ratio of anterior chamber depth to axial length was significantly lower in the femtosecond group. Dr Nagy pointed out that these eyes also showed lower levels of lens tilt and coma, as well as improved contrast sensitivity across a broad range of modulation transfer function frequencies. However, this did not translate into a statistically significant improvement in subjectively measured best-corrected or uncorrected visual acuity. Nonetheless, Jonathan Talamo MD of Harvard University, Boston, US, expects that this reduced clinical variation will open up new avenues of clinical investigation by eliminating background “noise” associated with variable manual outcomes. For example, intraoperative OCT allows surgeons to see where the centre of the capsular bag is and how it lines up with the pupil. “That opens up a whole new way to centre the capsulorhexis,” he noted. John Vukich MD of the University of Wisconsin, Madison, US, pointed out that the reproducibility of femtosecond capsulotomies has already enhanced the understanding of how the capsule stretches. In a test of reproducibility, conducted with OptiMedica’s Catalys™ Precision Laser System, buttons extracted from incisions targeting 4.6mm measured within 27 microns (µm) of that size. The capsulotomies contracted with time; however, at one month the diameter of the capsulotomy created with the laser deviated about 100um with a tight standard deviation, whereas the diameter of the capsulorhexis created manually deviated well over half a millimetre with a large standard deviation. EUROTIMES | Volume 16 | Issue 10

LRI immediately post-op 40°

Courtesy of William Culbertson MD

Femtosecond lasers “allow us to make square incisions. The only question that remains is what are the best incision configurations?” Dr Masket asked. However, Dr Steinert cautioned that creating a self-sealing corneal incision with femtosecond lasers “is not a slam dunk. …We learned this in corneal transplants. We all sat around drawing all sorts of interesting incisions. It turns out it is not so easy to dissect them after the femtosecond laser makes the cut. Because the cornea is lamellar it will create false channels pretty easily, so there is a limit to what you can get away with. I am looking forward to experimenting with it clinically to find out what really works.”

Peripheral corneal relaxing incisions made with the OptiMedica Catalys laser at 40 degrees inclination to the corneal surface and at 80 per cent depth shown without staining (left), with fluorescein stain (middle) and on corneal OCT (right)

Dr Vukich suggested that the geometry of the zonules relative to the capsulotomy size and shape is responsible. The zonules will have a different resting tension and the action of the ciliary body will transfer force at a different angle. Measuring and understanding the dynamics of these relationships will be crucial as surgeons try to replicate the action of a young eye with accommodating lenses, Dr Vukich said, adding that it is not as simple as just effective lens position.

Astigmatism correction

Beyond improving visual outcomes, corneal relaxing incisions may be important economically for the advancement of femtosecond cataract surgery. Because many public health programmes do not cover astigmatism correction, it opens the door to using – and charging extra for – femtosecond technology in cataract cases that otherwise are subject to strict limits that will not support the cost of the technology. The precision and greater patient comfort may well justify the extra charge. “It has already been demonstrated that we can correct some corneal astigmatism without breaking the anterior surface of the cornea,” Dr Koch noted. This could greatly reduce dry-eye and foreign body sensations that are thought to result mostly from injuries to the corneal epithelium, he said. In a test of sub-Bowman’s femtosecond laser-assisted relaxing incisions, one patient saw post-implant astigmatism drop from 1.75 D to 0.5 D, resulting in much better uncorrected vision and a much

happier patient, William Culbertson MD of the University of Miami, Florida, US, told the ASCRS. He noted, however, that current femtosecond technology requires that surgeons accurately determine and mark the axis, arc, length and depth of any relaxing incision before surgery. Dr Culbertson also pointed out that relaxing incisions of any type rely upon an empirical nomogram, which typically take into account patient age, the amount of cylinder to be corrected and the axis of correction (horizontal or vertical). Those developed for manual incisions may not be useful for femtosecond incisions, though the consistency of femtosecond incisions should contribute to developing morereliable adjustment factors (see image above). In particular, the gape of a manual incision is greater due to the splitting of the epithelium and Bowman’s layer. The potential ingrowth of epithelial cells as well as fibroblasts and other inflammatory responses that affect the final outcome of manual incisions may not be present in femtosecond-assisted cuts, especially cuts made under Bowman’s membrane, entirely within the stroma. Femtosecond cuts also leave behind collagen bridges in the cornea that must be separated with a spatula to obtain maximum effect, Dr Culbertson noted. However, such bridges may be turned to advantage by making femtosecond corneal relaxing incisions titratable, Dr Koch said. “We don’t have enough understanding of individual corneal biomechanics to know how much gape or correction we will get from a specific incisional shape in any

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Femtosecond lasers allow us to make square incisions. The only question that remains is what are the best incision configurations? Samuel Masket MD

“

Because the cornea is lamellar it will create false channels pretty easily, so there is a limit to what you can get away with. I am looking forward to experimenting with it clinically to find out what really works. Roger F Steinert MD

Cover Story

CATARACT

The technology has the potential to eliminate the need for divide and conquer, or ultrasound-sparing but difficult manual steps such as chopping or phaco flips

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given cornea. Eric Donnenfeld has already shown the potential benefits of being able to incrementally open an incision after surgery,” said Dr Koch, who noted that theoretically this could allow adjustments even several years postoperatively.

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Nuclearfractis Femtosecond technology also has the potential to reduce the amount of phaco energy needed to liquefy and remove some cataractous lenses, Dr Nagy said. The technology has the potential to eliminate the need for divide and conquer, or ultrasound-sparing but difficult manual steps such as chopping or phaco flips. In a study comparing 48 eyes treated with femtosecond fragmentation to 26 eyes with manual techniques only with grade 2 to 2.5 cataracts, the femtosecond group showed a 51 per cent reduction in phaco power and a 43 per cent reduction in phaco time, Dr Nagy reported. An alternate method in which the nucleus is liquefied using a circular technique allowed lens extraction without any phaco, chopping or other manipulation beyond irrigation and aspiration in most cases, he added. “We observe a 40 per cent reduction in cumulative dispersed energy, so it is a pretty substantial decrease in ultrasonic energy,” said Dr Vukich of his experience. While he is still in the process of gathering data, Dr Vukich suggested that most clinicians would accept the reduction in ultrasound as good on the face of it because it is associated with clear corneas immediately after surgery, and less endothelial cell loss over time. Economics “Using a laser to scribe a capsulotomy is more expensive than a bent needle, and the costs associated with it are unavoidable and a consequence of the higher technology involved. The reality is it becomes a value proposition. Is the value of the improvement worth the extra cost? That is the great unknown,” Dr Vukich said. But he suggests that surgeons ask themselves this: If femtosecond technology were free, would you use it for routine cataract surgery? “I’ve asked audiences and virtually every hand goes up. Conceptually it is already something surgeons relate to.” While femtosecond technology adds a step and increases surgery time today, Dr Talamo believes this will diminish. “Once it becomes second nature and part of the

A procedure that is already very good is going to get even better. You can either run away or you can embrace it and welcome it. It is going to happen Jonathan Talamo MD

“

Is the value of the improvement worth the extra cost? That is the great unknown John Vukich MD

operating room and clinic workflow, things are going to be streamlined. It adds a step to the process, but net-net it will probably even out.” Still, the expense will limit diffusion at least initially. “With its present construct, this is really only accessible to surgery centres with economies of scale,” Dr Talamo said. That means at least 1,000 surgeries a year for each machine. “This is going to force some consolidation in cataract surgery,” Dr Talamo predicted. He recommends moving toward a higher-volume model that can accommodate the transition. “A procedure that is already very good is going to get even better. You can either run away or you can embrace it and welcome it. It is going to happen,” Dr Talamo said.

contacts Zoltan Nagy - nz@szem1.sote.hu Douglas Koch - dkoch@bcm.edu Kevin M Miller - kmiller@ucla.edu Jose Guell - guell@imo.es Samuel Masket - avcmasket@aol.com Roger Steinert - steinert@uci.edu Jonathan Talamo - jtalamo@lasikofboston.com John Vukich - javukich@gmail.com William Culbertson - wculbertson@med.miami.edu

Don’t miss Eye on Travel, see page 44 EUROTIMES | Volume 16 | Issue 10

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EUROTIMES | Volume 16 | Issue 10

ame-day bilateral cataract surgery is just as safe and effective as conventional cataract surgery done on separate dates, and costs less, according to a study published by Spain’s national health and consumer ministry, and the Canary Islands’ regional health service. (Informes de Evaluación de Tecnologías Sanitarias SESCS Núm. 2006/05.) Advocates suggest that the study, which is the first of its kind financed, overseen and published by independent government agencies, is a milestone in advancing bilateral cataract surgery. In a randomised, prospective, multicentre trial involving 804 patients, no significant differences in peri-operative or postoperative complication rates, or visual or healthrelated quality of life outcomes were observed one year after surgery. However, costs in the simultaneous bilateral group were about €460, or 23 per cent, less per patient than in the conventional group. As a result, the bilateral approach yielded a significantly lower cost per added quality-adjusted life year gained, a standard measure of healthcare cost utility. The bilateral group also reported better visual and daily living function one month after surgery, though the conventional group reported similar results soon after the second eye was operated. “The conclusions of the study are very clear in favour of bilateral surgery of cataracts, not only in terms of security and effectiveness, but also in terms of economic costs to the public service (also affects the patient's and family economy - transportation, medicines, absenteeism from work ...),” said David Pérez Silguero MD, Las Palmas, Gran Canaria, Spain. Dr Silguero was one of four Canary Islands surgeons who initiated the study and asked for government involvement in collecting and analysing the results.(The other three people involved in the study were M Perez Silguero, Goas de Ussel, Henriquez de la Fe. And the director and coordinator of the work was Pedro Serrano.) The Canary Islands study adds to a growing body of evidence that bilateral cataract surgery can be safe when properly executed by experienced surgeons, said Steve A Arshinoff MD, Toronto, Canada, president of the International Society of Bilateral Cataract Surgeons (iSBCS). “Like most things in medicine we have to look at bilateral cataract surgery based on medical benefit and not be concerned about cost. But if the outcomes are the same and the risk is negligible, you should do it.” By Dr Arshinoff’s reading of the literature, as well as the combined experience of the 40 active members of his society, the risk of bilateral endophthalmitis is, if anything, lower among bilateral surgeons – about one in 100 million, according to his calculations of the actual rates of endophthalmitis reported by society members, which are about one in 17,000. He believes the risk of other processrelated complications, like toxic anterior segment syndrome (TASS) or corneal edema, are also lower. But he emphasises that high surgical skill and meticulous adherence to protocols to prevent cross-contamination, including separate sterilisation for instrument sets and use of irrigants and

other intraocular products from different production lots, are necessary to maintain this exceptional safety record. Indeed, the Canary Islands study questions how broadly bilateral surgery can be done. “To warrant generalisation of these results caution should be considered on adequate selection of patients and expert surgeons, as well as implementation of evidence-based surgical protocols independently at every eye,” the report concludes. “We don’t believe the practice can be generalised, for a series of strict requisites have to be met up with,” Dr Silguero said. More research will need to be done for bilateral surgery to gain wide acceptance, said Jose Guell MD, ESCRS president. “Surprisingly, it is much more common on the private side than the public side. One attraction is it diminishes cost and your patient feels much happier after surgery, especially if it is a refractive lensectomy.” But he still feels more comfortable with a unilateral approach, particularly for safety.

Cutting waiting lists However, the growing need for cataract surgery along with greater confidence in the safety of a bilateral approach could drive the practice. That’s why it started in the Canary Islands, Dr Silguero said. “From approximately 12 years the waiting list for cataract surgery was so high that the public hospitals weren’t able to cope with so many patients, and it was decided to arrange with private hospitals to perform the excess of cataract surgeries.” Dr Silguero and three other surgeons began performing and studying bilateral surgeries. Results were good, so they adopted it as their routine approach. In 2004, 60 per cent of cataract surgeries on the Gran Canary Island were bilateral, and about 35 per cent throughout the province, he noted. This success prompted the four surgeons to push for an official study. “Realising that over 20,000 bilateral surgeries through several years and no direct complications exist from doing the bilateral way, we decided to put into action a serious study on this theme.” Dr Arshinoff said that acceptance of bilateral surgery is growing. 10 per cent of ESCRS members reported doing same-day bilateral care in the 2009 annual survey by David Leaming MD. More than two-thirds of surgeons in Finland do so, and about one-quarter of surgeons in Sweden and Serbia do. Bilateral surgery is even making inroads in the US, where five per cent said they occasionally do bilateral refractive lens exchange, and two per cent said they usually do, according to Dr Leaming’s 2010 survey of American Society of Cataract and Refractive Surgery members. Dr Arshinoff believes that the economics of bilateral surgery will eventually be compelling. “Eye care already soaks up a huge portion of healthcare expenditures. At some point, health programmes will insist on it.”

contacts Steve Arshinoff - ifix2is@sympatico.ca David Perez Silguero - dpsilguero@gmail.com Jose Guell - guell@imo.es

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FRENCH PRACTICE TRENDS

Annual survey provides valuable snapshot of French cataract and refractive trends

by Dermot McGrath in Paris

growing preference for intracameral antibiotic use in cataract surgery, a marked trend towards higher-volume cataract surgery to cater for an increasingly older population, and a dramatic increase in the use of multifocal and toric IOLs are among some of the more interesting findings of the latest survey of French ophthalmologists conducted by Richard Gold MD. In the 14th of his annual surveys of French practices in ophthalmic surgery, Dr Gold, in private practice in Le Raincy, France, collected 991 responses to an anonymous questionnaire sent to almost 5,000 French ophthalmologists. The response rate of 20.06 per cent was identical to last year’s survey, noted Dr Gold. As well as providing valuable insights into trends and developments in clinical practice, Dr Gold’s questionnaire serves as

a useful barometer of the current well-being of French ophthalmology in general. The proportion of French ophthalmologists with a low volume of cataract surgery continues to decline, with six per cent performing fewer than 100 cataract surgeries per year, down from 22 per cent in 1998 and 10 per cent in 2007. The proportion performing between 100 and 199 procedures annually has also decreased in recent years to just below 20 per cent in 2010 compared to a high of 33 per cent in 2001. The most striking trend has been the proportion of surgeons performing higher-volume cataract surgery: 26 per cent of respondents perform between 300 and 499 surgeries per year compared to 17 per cent in 2000, while those treating between 500 and 999 patients per year has increased from just eight per cent in 2000 to 22 per cent in the 2010 survey. As elsewhere in the world, the size of

Eye Chat with Oliver Findl

“

Capsule Tears

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

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Oliver Findl

Boris Malyugin

the incisions used by French ophthalmic surgeons for cataract surgery has continued to decrease in recent years. Over three per cent of respondents now use an incision smaller than 1.8mm, while the number of those using an incision size between 1.8mm and 2.2mm has rocketed from 15 per cent in 2008 to more than 31 per cent in 2010. The majority (45 per cent) prefer an incision size between 2.2mm and 2.8mm. French surgeons also continue to prefer temporal incisions (36 per cent), followed by oblique (25 per cent) and 12 o’clock (24 per cent). The use of injectors for cataract surgery has now been almost universally adopted (97 per cent), said Dr Gold, while in terms of OVD use, DuoVisc continues to be by far the most popular viscoelastic in France, used by 58 per cent of respondents, followed by Visthesia (11 per cent) and DiscoVisc (nine per cent). The trend towards ambulatory cataract surgery continues in France, as elsewhere in the industrialised world, with 87 per cent of surgeons now performing treatments on an outpatient basis compared to less than 40 per cent in 2000. In terms of anaesthesia, the trend towards greater use of topical anaesthesia continues apace, with 66 per cent of respondents using topical anaesthesia plus intracameral lidocaine compared to 45 per cent in 2005 and less than 10 per cent in 2000. The use of peribulbar anaesthesia, once the anaesthesia of preference for French ophthalmologists, continues to decline, down from 75 per cent in 2000 to 20 per cent in the most recent survey. The most widely used IOLs in France remain foldable acrylics, with hydrophobic acrylics (73 per cent) gaining in popularity in recent years at the expense of hydrophilic models (51 per cent). The years of Dr Gold’s survey also charts the steady decline of silicon implants, down from 64 per cent in 2000 to just three per cent in 2010. The growing trend towards a merging of cataract and refractive surgery is also reflected in the outcomes of Dr Gold’s survey, with multifocal implants taking a significant leap forward in 2010 and are now being used by 44 per cent of respondents compared to 29 per cent the previous year. Toric IOLs have also made their presence felt on the French

Richard Gold - rg@ophtalmo.net

market and are now used by 36 per cent of respondents in 2010 compared to 13 per cent in 2008.

Intracameral prophylaxis catching on Dr Gold noted that the

use of intracameral injection of antibiotics in cataract surgery has shown a dramatic increase in recent years, with more than 30 per cent of respondents now routinely using intracameral antibiotics compared to just six per cent in 2006. Turning to refractive surgery trends, the breakdown of ametropias treated by French surgeons remains largely unchanged in recent years: 99 per cent treat myopia, 95 per cent treat astigmatism and 84 per cent treat hyperopia. Presbyopic treatments continue to gain in popularity, up to 45 per cent in 2010 compared to 25 per cent in 2005 and less than seven per cent in 2000. The latest survey also underlined the continuing French preference for PRK over LASIK in the treatment of myopia, with 90 per cent opting for PRK with Mitomycin-C compared to 76 per cent for LASIK. An increasing proportion of French surgeons now use refractive surgery for the treatment of presbyopia, although such procedures continue to be more widely practised than they were in 1998 when the surveys began. PresbyLASIK is the treatment of choice for 30 per cent of respondents, compared to 23 per cent for presbyopic lens exchange. In terms of topography, the Orbscan continues to be the most popular choice on the French market (46 per cent), although the last two years have witnessed a significant increase in the use of Pentacam from 11 per cent in 2009 to 29 per cent in 2010. The competitive landscape of the excimer laser market is also reflected in Dr Gold’s survey. The Bausch + Lomb Technolas (26 per cent), Wavelight Allegretto (25 per cent) and Zeiss-Meditec (22 per cent) are now the most popular lasers, with Nidek continuing to fall out of favour (30 per cent in 2005 compared to 15 per cent in 2010). Not surprisingly, femtosecond lasers are now the preferred method of flap creation at the expense of mechanical microkeratomes. As well as practice trends, Dr Gold’s survey also takes an interesting snapshot of the current health and morale of the ophthalmic profession in France. One worrying trend is the continued ‘greying’ of the ranks of French ophthalmologists: less than one per cent of respondents to the survey were under 35 years of age (compared to 11 per cent in 2000), 39 per cent were aged between 45 and 54 and 46 per cent between 55 and 64 years.

General eU

Special Focus

cataract

Capsulorhexis

Simple strategy can rescue tear-out cases by Dermot McGrath in Geneva

simple yet highly effective technique can be employed by surgeons to rescue most cases of capsulorhexis tear-out even when the tear has gone out into the zonules, according to Brian Little MD. “This is a subject very close to my heart. In constructing the capsulorhexis, it is essential to control the course of the capsule tear. This technique has probably saved me from more trouble than anything else and it is really very simple once you understand how to do it and it really does work,” Dr Little told delegates attending the joint meeting of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO). Defining a capsulorhexis tear-out as a tear that begins moving peripherally or in a radial fashion, Dr Little, Moorfields Eye Hospital NHS Trust, in London, England, said that it could happen to the most experienced surgeon. “Most of us like to think of a tear-out as a spontaneous event which we have no responsibility for and which just happens, but the reality is that it happens for reasons related to vector forces. The critical point is to recognise when it is happening and to stop immediately when the tear starts to move in a radial or peripheral fashion,” he said. Dr Little said that surgeons should be particularly attentive when performing capsulorhexis on larger pupils. “We should be particularly careful with larger pupils, because in my experience this is the commonest risk factor of a tear-out. We are magnetically drawn to the pupil margin once we start the capsulorhexis. The discipline required to produce a rhexis of the correct size in a well dilated pupil is enormous because if the rhexis is correctly sized it will be between 4.0mm and 5.00mm and it looks very small on a large pupil,” he said. Once progression of the tear has been stopped, an ophthalmic viscosurgical device (OVD) should be added to the eye if required in order to maximise the anterior chamber depth and flatten the anterior lens surface, said Dr Little. Steps can then be

Don’t miss Book Review, page 42 EUROTIMES | Volume 16 | Issue 10

“

This technique has probably saved me from more trouble than anything else and it is really very simple once you understand how to do it and it really does work Brian Little MD

taken to salvage the situation and retrieve the capsulorhexis. To rescue the capsulorhexis, the tear must be re-directed centrally and back to the desired circumferential path, explained Dr Little. “The best and most efficient way of achieving this is to unfold the anterior capsule flap and lay it flat against the lens cortex. Using forceps, the trick is then to hold the flap near the root of the tear and pull it back circumferentially in the direction from where it came, applying the force in the plane of the capsule, to put it under tension,” he said. If necessary, a second corneal paracentesis incision can be made at the position that allows the optimum angle of approach for applying traction, said Dr Little, adding that a needle cystotome is not recommended for this manoeuvre due to the risk of tearing the capsule with the needle. “Don’t be afraid to make another incision. You can’t do this manoeuvre with a needle – you have to do it with forceps as only forceps enable you to have fine control over the direction of the tear. Grab it as near to the root of the tear as possible and pull it backwards and then centrally and you will have retrieved the situation. Technically this is not difficult, you simply have to recognise when it is happening and have the discipline to stop early and perform the retrieval,” he said.

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contacts

Special Focus

cataract

Richard Awdeh - rawadeh@med.miami.edu Eric Donnenfeld - eddoph@aol.com Paolo Cecchini - paolo.cecchini@libero.it Timothy Peters - tpeters@globalv.com Masayuki Ouchi - mouchi@skyblue.ocn.ne.jp Eriko Fukuyama - eriko@ss.iij4u.or.jp

Study results

Lenses more stable, but relaxing incisions work and technology may improve them by Howard Larkin in San Diego

oric intraocular lenses are generally more stable and predictable, and may reduce residual astigmatism more in cataract patients with regular astigmatism than do limbal relaxing incisions (LRIs), according to several prospective studies presented at the 2011 annual meeting of the American Society of Cataract and Refractive Surgery. However, LRIs are also effective, and may be more suitable in some cases. Femtosecond laser technology also holds promise for increasing the accuracy and predictability of LRIs and possibly making them titratable after surgery, several presenters said. “The ability to create a digital arcuate incision to treat cylinder in a customisable and adjustable fashion will be a significant advance,” said Eric D Donnenfeld MD, New York University, New York City, US. Sub-Bowman’s incisions may also be possible, reducing the chances of loss of corneal sensation or dry eye due to LRIs, noted Richard M Awdeh MD, University of Miami, Florida, US. He believes that femtosecond laser technology will help integrate refractive surgery into cataract surgery. However, more research will be needed to determine how effective it will be.

Toric outcomes In three prospective studies comparing the AcrySof TORIC (Alcon, Fort Worth, US) lens with LRIs, the lenses consistently reduced astigmatism while the LRI results were more variable. Mean post-op refractive cylinder was not statistically different between toric and LRI groups in a contralateral eye study of 20 patients conducted by Eriko Fukuyama MD, Fukuoka, Japan. She randomly implanted one eye of patients with 1.0 D or more of regular astigmatism in both eyes with an aspheric monofocal toric lens and implanted the other with a conventional aspheric monofocal lens with LRI. Dr Fukuyama used her own nomogram, which takes into account with- or against-the-rule astigmatism, as well as patient age. She emphasised the

“

It is important to have a firm understanding of the characteristics and to utilise each technique for better visual outcomes Femtosecond cataract surgery with arcuate incisions for astigmatism management

Eriko Fukuyama MD importance of physicians developing and measuring outcomes of their own LRI nomograms for best results. All lenses were inserted through a 2.4mm incision, on the steepest axis for the toric IOLs and the flattest for LRIs. “Both toric IOLs and LRIs are effective surgery techniques to reduce pre-existing astigmatism at the time of cataract surgery. It is important to have a firm understanding of the characteristics and to utilise each technique for better visual outcomes,” Dr Fukuyama said. For example, she noted that LRIs can be used to treat asymmetric astigmatism, but toric lenses cannot. Paolo Cecchini MD, University Eye Clinic of Trieste, Italy, and colleagues conducted a similar prospective study with 35 patients receiving AcrySof Toric IOLs and 33 AcrySof IQ IOLs plus LRIs. Preoperative cylinder ranged from 1.0 D to 2.5 D of regular astigmatism. Uncorrected distance visual acuity was significantly better in the toric group one day, 30 days and 180 days after surgery, ending at 6.92 Snellen for toric vs 5.76 for LRI at six months. LRI eyes saw a significant reduction in corneal keratometry and topography compared with the toric group, but higher postoperative residual refractive astigmatism, ending at 1.28 D compared with just 0.64 D for the toric group. The LRI group also trended toward higher refractive astigmatism at each post-op interval. “The toric IOL seems to work in a better way,” Dr Cecchini said. N Timothy Peters MD, Portsmouth,

Don’t miss 16th ESCRS Winter Meeting preview, see page 38 EUROTIMES | Volume 16 | Issue 10

Courtesy of Eric D Donnenfeld MD

New Hampshire, US, compared secondand third-order corneal aberrations in patients with toric IOLs vs. LRIs in his prospective contralateral eye study, which involved 70 patients operated by three surgeons. At three months, corrected and uncorrected visual acuity was significantly better for the toric group among the 60 patients examined. Changes in all second order and three of four and third order corneal aberrations were also higher in the LRI group, though the differences were not significant. Dr Peters believes the higher order aberration differences will eventually reach significance in the LRI group, and is planning on a six-month follow up. Masayuki Ouchi MD, PhD, Kyoto Prefecture University of Medicine, Japan, used both approaches to treat patients with 2.5 D or more astigmatism. Until earlier this year, toric lenses available in Japan were limited to 2.0 D correction at the cornea, he explained. In 27 eyes in 23 patients, he reduced mean preoperative corneal astigmatism from 3.60 to 1.85, and subjective cylinder from 4.02 to 0.97. He cautioned against overcorrecting with LRIs over toric IOLs. “It compounds the problem. Make sure to undercorrect.”

Improving LRIs Drs Donnenfeld and Awdeh reported success using femtosecond lasers to cut arcuate incisions. In 14 eyes, 10 with natural astigmatism and four postcataract extraction, Dr Awdeh succeeded in reducing mean refractive cylinder from 3.66 pre-op to 1.52 post-op using an OCT-

guided IntraLase device. Uncorrected distance vision improved from 0.84 logMAR, or about 20/100, to 0.25 logMAR, or about 20/35 (p=0.002). At 36 months, one patient lost one line of best corrected vision and another two lines, though that patient had developed a cataract. Two patients gained one line and the rest were even. In an uncontrolled study comparing 15 manual LRIs to his first 20 FS-assisted LRIs, Dr Donnenfeld found that the laser reduced astigmatism 75 per cent on average compared with 66 per cent for the FS laser. While this isn’t much, and the study has no statistical significance, he believes femtosecond technology will improve astigmatism management. He pointed out that only about 25 per cent of surgeons attempt LRIs. “A lot of people are uncomfortable with the technology of hand-held instruments.” He believes that femtosecond laser technology will eliminate uneven incisions that make outcomes unpredictable and may induce higher order aberrations. And because the laser leaves adhesions, the incision could be left partially closed and later opened at the slit lamp based on postoperative refraction. “Removing inconsistencies in the procedure will improve the accuracy and understanding of all corneal incisions,” he said. He looks forward to controlled tests of the hypothesis.

Special Focus

cataract The solution for demanding cases…

FEMTOSECOND LASER

Study suggests new technology induces less macular thickening by Roibeard O h’Eineachain in Istanbul

emtosecond laser-assisted cataract surgery (FLCS) appears to be significantly less traumatic to the macula than conventional cataract surgery, according to the results of a comparative study presented at the 15th ESCRS Winter Meeting. “Our results suggest that femtosecond laser cataract surgery may carry a reduced risk of macular oedema compared with conventional phacoemulsification surgery,” said Zoltan Nagy MD, Semmelweis University, Budapest, Hungary, the study’s principal investigator. Dr Nagy noted that the results of several studies indicate that FLCS allows greater precision and safety in the creation of an anterior capsulorhexis than is possible with conventional techniques that employ a forceps or other instrumentation. The new technology also reduces significantly the amount of phaco time and phaco power needed to emulsify a lens. “Reduction in ultrasound use, which has been associated with reduced postoperative complications, such as corneal oedema, endothelial cell loss, and corneal burn, may also potentially lower the incidence of postoperative macular oedema,” Dr Nagy said.

Reduced retinal thickening In Dr Nagy’s prospective case-control study, 20 patients underwent conventional ultrasound phacoemulsification, and 20 patients underwent femtosecond-assisted cataract procedures. The study’s primary outcomes were OCT retinal thickness in the central macula, the inner macular ring and the outer macular ring, and total macular volume. The study’s secondary outcomes were changes in retinal thickness at one week and one month postoperatively with respect to preoperative retinal thickness values, and effective phaco time and lens density. In the femtosecond laser-assisted procedures Dr Nagy and his associates used a LensX femtosecond laser using the system’s integrated real-time OCT three-dimensional real-time video imaging to perform the capsulorhexis, the incision and lens photolysis. Following fragmentation by the femtosecond laser, EUROTIMES | Volume 16 | Issue 10

“This technology may be particularly advantageous for those who are at more risk for developing postoperative cystoid macular oedema, such as patients with uveitis or diabetic retinopathy” they were able in most cases to remove the lens with a fraction of the phaco power usually required. Dr Nagy noted that, after adjusting for age and preoperative thickness, a multivariable modelling of the effect of surgery on postoperative macular thickness showed significantly lower macular thickness in the inner retinal ring in the femtosecond group (p=0.002). In the control group, the inner macular ring was thicker than that of the femtosecond group by 21.68 um at one week and by 17.56 um at one month, which was only marginally significant, he said. However, there were no significant differences between the thickness of the central and outer macula adjusted for age and preoperative thickness, Dr Nagy noted. Dr Nagy pointed out that the differences between the macular thickness values of the two groups, although statistically significant, were not clinically significant. He nonetheless maintained that FLCS could make cataract procedures safer in certain groups of patients. “This technology may be particularly advantageous for those who are at more risk for developing postoperative cystoid macular oedema, such as patients with uveitis or diabetic retinopathy.”

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Special Focus

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Cataract Update

Small pupils need not represent big problems in cataract surgery by Dermot McGrath in Geneva

hile poor or non-dilating small pupils have always presented a challenging situation for cataract surgery, surgeons now have a variety of tools and techniques available to stretch the pupil and ease visualisation during phacoemulsification and reduce the risk of complications, according to Larry Benjamin FRCS(Ed), FRCOphth. “There are a variety of approaches including sphincter cutting, pupil stretching, iris hooks, expansion devices and so forth, and most of them work very well. The important point is to find a safe and effective method that you are comfortable with that will enlarge the pupil and will lead to more successful surgery,” he told a session of the joint meeting of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO). Dr Benjamin, an ophthalmologist in the Department of Ophthalmology at Stoke Mandeville Hospital, in Aylesbury, UK noted that strategies for pupil enlargement greatly depend on surgeon skill and preferences, as well as on the intraoperative situation. “Some surgeons will tell you that they will be happy to operate on different size pupils and I think that the definition of a small pupil depends on your own personal experience and on the outcome you want.

If you are implanting an aspheric or a multifocal lens, then you must consider what size the capsulorhexis needs to be and also what size the pupil should be for safe surgery and an optimal outcome,” he said. One approach is to proceed with the surgery without touching the pupil if the surgeon’s experience and judgment suggest that there is no need to mechanically enlarge the pupil. “If you think that the pupil is big enough for that particular surgery, then the best option might be to leave it alone. Some more experienced surgeons are happy to tackle pupils in the range of 4.0mm and rarely encounter complications,” he said. Another approach to small pupil management is to use a sharp instrument such as intraocular scissors to cut the iris sphincter. “Once you have made the cuts, the pupil can then be expanded using viscoelastic. Using this approach and expanding the pupil by 1.0mm allows the surgeon to achieve about one-third extra surface area to work in, so it is a useful technique,” he said. While the cutting method is more controlled than mechanical stretching, the use of a large instrument in the eye may result in corneal endothelial damage and permanent damage of the iris sphincter. Mechanically stretching the pupil is another option for small pupil management, said Dr Benjamin. In this approach,

a pair of hooks is introduced through two incisions in the cornea and used to mechanically stretch the iris. The hooks engage the iris sphincter and are pulled in opposite directions, resulting in one or more tears of the sphincter, which leads to an enlargement of the pupil aperture. An advantage of this technique is that it requires no special instruments and can be used in conjunction with a high viscosity viscoelastic to further enlarge the aperture. The downside of this approach is that it also results in permanent damage to the iris sphincter and may damage the blood/aqueous barrier and cause more postoperative inflammation. Iris hooks also offer a safe and controlled means of enlarging the pupil, said Dr Benjamin. “One of the most important aspects of iris hooks is the angle of the wound through which to place them. I tend to make these wounds limbal and very parallel to the iris and they work very well and give a very gentle stretch of the pupil. If you pull hard enough, you will tear the sphincter just as with stretching instruments. However, if you pull gently you can manipulate the pupil to a size where the sphincter is actually still working and give you access,” he said. Dr Benjamin urged particular caution when removing the iris hooks at the end of the surgery. “This step should not be overlooked. Removing the hooks properly is important; the manoeuvre to remove them is to first of all loosen them and then disengage them from the edge of the pupil. If you do not disengage them properly, you may pull pigment off the back of the iris and it takes a lot longer to flush the pigment out than it does to remove the hook properly in the first place,” he said. Another advantage of the iris hooks is that they can be used to simultaneously stabilise a zonular defect by

Larry Benjamin - larry.benjamin@btopenworld.com

“

While the device does give you quite good access, the pupil is still quite mobile and its use involves quite a lot of manipulation of the iris and the wound itself

Larry Benjamin FRCS(Ed), FRCOphth

inserting them to support the edge of the capsulorhexis. For surgeons who prefer not to use iris hooks, Dr Benjamin said that another possible solution is to use a device such as the Perfect Pupil (Becton Dickinson Ophthalmic Surgical), a sterile, disposable and flexible polyurethane ring with an integrated arm designed for insertion and removal through a small incision. “While the device does give you quite good access, the pupil is still quite mobile and its use involves quite a lot of manipulation of the iris and the wound itself,” he said. Dr Benjamin also noted the growing popularity of another device, the Malyugin Ring (MicroSurgical Technology), a squareshaped temporary implant with four circular loops that hold the iris at equidistant points. “This is a clever device and it works well. It gives you nice exposure and room to work but again the pupil is quite mobile and there can be complications associated with inserting and removing a device like this,” he said.

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new laser thermal keratoplasty approach to central corneal reshaping that combines intrastromal collagen shrinkage and collagen cross-linking (CXL) may provide an alternative to corneal ablative techniques for the treatment of both myopia and hyperopia, said John Kanellopoulos MD, Athens, Greece, at the 15th Winter Meeting of the ESCRS. “This epithelium-sparing corneal reshaping and stabilising technique represents a novel and minimally invasive approach in refractive manipulation of the cornea without tissue removal,” Dr Kanellopoulos said. The technique involves the utilisation of a cooled sapphire applanation disc and a continuous wave infra-red laser to create three concentric ring-like areas of intrastromal shrinkage, followed by CXL using 0.1 per cent riboflavin solution and 10mw/cm2 UV irradiation to stabilise the resulting change in corneal refraction, he explained. “Depending on the placement of these predetermined rings you can get considerable corneal flattening with no epithelial defect, and that is the big difference between this and other thermal procedures,” he said. In order to leave the epithelium intact following the corneal cross-linking procedure, the technique uses benzalkonium chloride, 0.1 per cent riboflavin sodium phosphate drops. The formulation appears to loosen the hemidesmosome links between the corneal epithelial cells and allow large riboflavin molecules to sink into the corneal stroma and allow cross-linking. He noted that in a laboratory study in which he performed the procedure in 12 cadaver corneas pre- and postoperative evaluation with placido disc topography, Pentacam tomography showed significant uniform cornea flattening of 4.0 D to 8.0 D in a round central zone 5.0mm in diameter. He added that he has also recently carried out the procedure in a keratoconus patient who was awaiting a keratoplasty procedure. He noted that Bowman’s membrane and the epithelium of the patient’s eye remained intact. Moreover the shrinkage effect was undiminished at one year’s follow-up. “Our small clinical study showed a significant refractive change immediately post-delivery that was consistent in all the

“

Depending on the placement of these predetermined rings you can get considerable corneal flattening with no epithelial defect, and that is the big difference between this and other thermal procedures John Kanellopoulos MD

cases, and the procedure did not induce significant astigmatism or higher order aberrations,” he said. Dr Kanellopoulos noted that further investigations of the technique have shown that the refractive effect titrated from hyperopic to myopic corrections, depending on the depth of the collagen shrinkage. That is, more deeply placed rings produce a steepening effect while those placed closer to the surface have a flattening effect. Furthermore, numbers of rings and diameters have a direct linear refractive effect for the same, he said. There have been several thermal keratoplasty techniques introduced in the past, he noted. Some, like laser thermal keratoplasty and conductive keratoplasty have produced good initial refractive results in hyperopic patients, but have been prone to regression over time. More recently Avedro Keraflex MTK, a contact procedure that directs microwave thermal energy onto the anterior cornea, has been shown to immediately induce a circular epithelial defect, he said. In contrast, Dr Kanellopoulos said that the collagen shrinkage treatment did not affect the corneal epithelium. The absence of thermal effect on the corneal epithelium may also reserve the nerve plexus. Moreover, the laser used enabled easy avoidance of endothelial damage by constraining collagen shrinking to the 50 per cent depth of the cornea, he added.

contact

John Kanellopoulos - ajkmd@mac.com

Update

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index shaping

New technology may make possible fine-tuning lenses after implantation by Howard Larkin in San Diego

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emtosecond lasers and a new generation of customisable intraocular lenses may hold the solution to the dreaded “refractive surprise”. They could make it possible to correct the power, asphericity and toric axis of lenses after they have been implanted. “Almost all cataract surgeries result in a considerable amount of residual refractive error. We have developed a new method for in vivo fine-tuning of the IOL’s optical properties to achieve perfect vision,” said Josef F Bille PhD, who is professor of physics and on the clinical teaching staff at Heidelberg University, Germany. The adjustment is accomplished by a process known as refractive index shaping, or RIS, Dr Bille told the Innovators Symposium at the annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS). Rather than cutting or changing the external shape of the lens, RIS uses femtosecond laser energy to selectively change the refractive index of a layer of material approximately 50 microns thick within the IOL. Infrared energy absorbed by electrons in the material cause its chemical bonds to restructure. The resulting layer of higher refractive index material forms a lens within the lower refractive index IOL material. Its optical properties are determined by both the three dimensional shape and refractive index of the higher index layer, which can be precisely controlled with the femtosecond laser. Dr Bille presented the results of a 1mm diameter lens that was incorporated into a button of hydrophobic acrylic IOL material. Its initial power was 1.6 D. A process known as phase wrapping can be used to increase its power at a given lens thickness. By dividing the surface of the lens into five concentric diffractive zones, its power can be multiplied by five times. The advantage of phase wrapping is that it allows several dioptres of adjustment within a very thin lens, Dr Bille said. In a 6.0mm optic, phase wrapping allows up to 5.0 D correction within a single 50 micron lens layer. Four layers could create up to 20 D correction, Dr Bille said. The shape of the higher index lens layers can also be adjusted to compensate for other optical aberrations, Dr Bille noted. A toric lens can be achieved by tightening the diffractive zones along one axis. Similarly,

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asphericity can be adjusted by changing the relative heights and profiles of the refractive zones. The lens adjustments were made using a commercial two-photon 500 mW femtosecond laser from Heidelberg Engineering with an acousto-optic modulator allowing it to treat 10 million spots per second. Dr Bille estimates the total treatment time in vivo would be about 20 seconds. A patent is pending on the technique, which was developed on behalf of Aaren Scientific, Ontario, California, US, for whom Dr Bille is a consultant. Dr Bille also consults with Heidelberg Engineering. “Refractive index shaping can be used to adjust the power of an IOL in situ,” Dr Bille said. “The method could be used to create a customised IOL.”

Carl Zeiss Meditec AG Goeschwitzer Str. 51–52 07745 Jena Germany www.meditec.zeiss.com/iol www.meditec.zeiss.com/contacts

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To register visit: www.escrs.org/dublin2011

EUROTIMES | Volume 16 | Issue 10

S laser vision correction volume jumped to an estimated 960,000 procedures in 2010, up 27 per cent from 2009 but still well short of the estimated 1,066,000 procedures in 2005, according to analysis of the 2010 survey of American Society of Cataract and Refractive Surgery (ASCRS) members. Growth was particularly strong in surface procedures. LASIK accounted for an estimated 680,000 procedures, while PRK and other surface ablations totalled 280,000, almost double the 127,000 estimated for 2005. The 15th annual ASCRS survey by Richard J Duffey MD, Mobile, Alabama, and David V Leaming MD, Palm Springs, California also showed a growing acceptance of intraocular lenses among US refractive surgeons. Asked what procedure they recommended for a 30-year-old -10 dioptre myope, 44 per cent of ASCRS respondents opted for a phakic IOL in 2010, up from 23 per cent in 2005. For a 45-year-old +3 hyperope, 24 per cent opted for refractive lens exchange while 61 per cent would do so for a +5 hyperope. The results reflect growing awareness of the limits of laser surgery as well as the safety of modern lenticular approaches, Dr Duffey said. The extrapolated laser volume figures from the 2010 ASCRS survey are at odds with other data that suggested a rise of one to two per cent, Dr Duffey noted. These include procedure card sales reported by Abbott Medical Optic’s VISX, which was the laser most often used by 74 per cent of ASCRS respondents in 2010, and results from major commercial chains. However, the ASCRS numbers are roughly consistent with procedures monitored by SurgiVision DataLink software reported by Guy M Kezirian MD, Scottsdale, Arizona. However, his data suggested an uneven recovery, with many centres showing sharp increases in 2010 while others “fell completely off the map.” Daniel Durrie MD, Kansas City, Missouri, was the co-author of this presentation. The 2010 ASCRS survey response rate was similar to previous years at about 12 per cent, though it was only the second year the survey was conducted entirely online.

Appeal to younger patients Other studies reported at the 2011 ASCRS annual meeting showed an ongoing shift toward younger patients for LASIK. The average age of 225,128 patients TLC centres treated dropped steadily from about 39 in 2000 to about 35 in 2009, while the percentage of male patients grew from about 42 per cent to about 46 per cent. “Patients are getting younger but they are still mostly over age 30,” said Louis Probst MD, medical director for TLC Vision US outlets in Chicago; Madison, Wisconsin; and Greenville, South Carolina, US. Dr Kezirian documented a similar age trend among nearly 180,000 eyes tracked by the SurgiVision software products he helped develop. From 2005 to 2010, patients under age 40 rose from 57 per cent to 70 per cent. The data also show a persistent bimodal distribution in patient age with a trough in the 36- to 46-year-old range – possibly due to issues with presbyopia, he speculated. Throughout the six years studied, though, the younger peak rose and the older peak declined.

“

Surgeons have had a couple of bad years, but I think the future for refractive surgery is very bright

Guy M Kezirian MD These findings suggest that while the “baby boom” generation is ageing out of the LASIK market, younger patients are increasingly welcoming the procedure, Dr Kezirian said. “Surgeons have had a couple of bad years, but I think the future for refractive surgery is very bright. Understanding the demographic shifts will help surgeons develop marketing messages and techniques, including social media, to recruit new generations of patients.” 2010 ASCRS survey data also show an ongoing concern for safety, particularly avoiding postLASIK ectasia, Dr Duffey said. Nearly half reported having one or more documented case of post-LASIK ectasia in their career. 2005 was a watershed year, with new ectasia cases basically stable since then, he said. The proportion of surgeons aiming for 100 micron flaps rose from 35 per cent in 2009 to 43 per cent, while those looking for 120 to 130 microns fell from 53 per cent in 2009 to 47 per cent. Those looking for a minimum residual stromal bed of 300 microns rose to 42 per cent from 31 per cent in 2009 and eight per cent in 2004. Conversely, those satisfied with 250 microns fell from 75 per cent in 2004 to 38 per cent in 2010. On the other hand, 51 per cent of surgeons were OK operating on patients with central corneal thickness of 480 microns or less. Femtosecond lasers for flaps remained stable in 2010 at about 53 per cent after growing from about 21 per cent in 2007 to 55 per cent in 2009, Dr Duffey reported. Similarly, 55 per cent of surgeons used wavefront-guided custom ablations more than 75 per cent of the time in 2010. Dr Probst also reported a shift in technique over time and a corresponding improvement in visual outcomes. In 2004, the majority of TLC patients were treated with custom ablations, and in 2006 more than half were treated with IntraLase instead of mechanical microkeratomes. Today almost all receive custom ablations and IntraLase. The proportion of TLC patients treated for 3.0 dioptres or less of myopia also grew from 32.7 per cent in 2000 to 36.7 per cent in 2009. In his personal practice, 92.5 per cent achieved 20/20 or better uncorrected distance visual acuity in 2009, up from 74.6 per cent in 2000. Only 0.25 per cent lost two lines of vision in 2009, down from 1.14 per cent in 2000, and enhancement rates are now below three per cent.

contacts Richard Duffey - richardduffey@gmail.com Louis Probst - leprobst@gmail.com Guy Kezirian - Guy1000@SurgiVision.net

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Update

CORNEA

CORNEAL MELTING

Case studies show collagen cross-linking can salvage eyes from corneal melting

by Roibeard O’hEineachain in Istanbul

See the benefits!  Reduced Congress Fees  Journal of Cataract & Refractive Surgery  EuroTimes  Members’ Area on www.escrs.org  Membership Certificate  Voting Rights

To find out more, visit www.escrs.org EUROTIMES | Volume 16 | Issue 10

Courtesy of Nashwan Al-Sabai MD, FEBO

C ESCRS Membership

ollagen cross-linking (CXL) can halt the progression of corneal melting and in that way prevent the need for emergency corneal transplants, according to Nashwan Al-Sabai MD, FEBO, Antwerp University Hospital, Antwerp, Belgium. “Collagen cross-linking appears to be an effective way to treat corneal melting. The combination of increased resistance to enzymatic degradation through crosslinking and the antimicrobial effect of the UVA light combine to preserve the integrity of the cornea,” he told the 15th Winter Meeting of the ESCRS. Dr Al-Sabai presented the case reports of two patients in whom CXL rapidly stabilised corneas that were in an advanced state of corneal melting and were in danger of imminent perforation. The first case was a 70-year-old woman referred for severe ulcerative keratitis that had persisted for more than a month (see figure above). An initial culture of the corneal ulcer revealed a pseudomonas aeruginosa infection. However, despite hospitalisation and intensive treatment with fortified antibiotic,Tobramycin and Vancomycin, corneal melting developed, especially in the inferior part of the cornea; exacerbation of the ulceration was by the subconjunctival injection of corticosteroids. The second case was a 65-year-old man referred for corneal melting. The patient had undergone a second corneal transplantation in the affected eye two years previously. The running suture had cheesewired through the tissue at the graft/ host junction leading to melting that was resistant to antibiotics or steroids. Dr Al-Sabai performed CXL on both eyes to avoid a likely corneal perforation. He used the standard parameters for the procedure, which are the application of riboflavin 0.1 per cent in dextran 20 per cent, followed by UVA irradiation at a wavelength of 365 nm, at a rate of three mW/cm2 for 30 minutes. In both cases corneal melting stopped and the lesion became scarred over and there was no corneal perforation. Several previous studies have demonstrated a similar efficacy of CXL as a treatment for corneal melting, Dr Al-Sabai said. They include a case series in which the treatment was effective in three out of

Corneal melting and imminent corneal perforation

four cases of corneal melting due to various causes (Schnitzler et al, Klin Monatsbl Augenheilkd 2000;217(3):190-193). In another study, cross-linking was successful in the treatment of five cases of therapyresistant infectious ulcerations with corneal melting (Iseli et al, Cornea 2008; 27:590594). In addition, in a study presented by Karim M. et al at the Corneal crosslinking Conference in Dresden, Germany in 2008, eight cases of infectious keratitis that underwent the treatment all had an arrest of corneal melting with complete epithelialisation. Moreover, there were no complications, no perforation, and none required an emergency keratoplasty, Dr Al-Sabai said. Dr Al-Sabai noted that there are several different mechanisms of action whereby CXL halts the progression of corneal melting. He noted that research has shown that CXL may increase corneal tissue’s resistance to enzymatic degradation. Furthermore, both ultraviolet light and oxygen radicals such as are created by the procedure have anti-microbial properties, he said. “The ultraviolet light and oxygen radicals have a destabilising effect on the cell membrane and also destroy the DNA and RNA of the bacteria. So it is a combination effect against the bacteria and their destructive enzymes that helps protect the cornea,” he added.

contact Nashwan Al-Sabai - Nashwan.Al-Sabai@uza.be

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Update

CORNEA

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EUROTIMES | Volume 16 | Issue 10

PKP + ISCR LE 28 months post-op xeroderma pigmentosum BCVA 0.8

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Courtesy of Jörg H Krumeich MD

metallic intrastromal corneal ring can prevent vascularisation of corneal grafts and may help prevent immune reactions and may enhance the effect of anti-VEGF agents in keratoplasty patients at high risk of graft rejection, said Jörg H Krumeich MD, Bochum, Germany at the 15th ESCRS Winter Meeting. The intrastromal corneal ring is designed to be sutured into the wound of an eye receiving a corneal graft, he said. The ring has a thickness of 150µm and an inner diameter ranging from 7.03mm to 8.04mm and is composed of an alloy of titanium, cobalt, chrome and molybdenum, he noted. Facial surgeons have used the same material and have also noted its seeming antivascularisation properties, he said. Dr Krumeich described two cases which were at high risk for graft failure but whose corneas remained clear when the graft was combined with the intrastromal corneal ring. The first case was a 24-year-old man with xeroderma pigmentosum. His visual acuity was limited to light perception in both eyes due to complete corneal vascularisation. Several University Clinics had refused to perform a keratoplasty procedure in the patient because they said there would be absolutely no chance that the graft would remain avascular and clear for long enough to justify the procedure, Dr Krumeich said. In May 2007, Dr Krumeich performed a 7.0mm keratoplasty procedure on the patient, with the intrastromal corneal ring sutured into the wound. The patient achieved a visual acuity of 0.8 for 31 months, and the transplanted tissue remained avascular until a tumour on the ocular surface, a common feature of xeroderma pigmentosum, began to grow over the cornea. By 39 months visual acuity had fallen to 0.2, although there was still no vascularisation of the graft tissue. The second patient Dr Krumeich described in his presentation was a keratoplasty patient who had two previous graft rejections. The patient underwent a third keratoplasty procedure, but this time with the intrastromal corneal ring. The patient also received two intraparenchymal corneal injections of 1.0mg bevacizumab (Avastin, Genentech) at the time of the transplant and at six and nine months postoperatively. Dr Krumeich noted that throughout the follow-up period the blood vessels were

10 months post-op, 2. intracorneal Avastin injection BCVA 0.3

apparently blocked from growing into the grafted tissue. Moreover, as the months progressed veins present previously in the host cornea tissue receded, until by the most recent follow-up, at 10 months postoperative, both the host and donor cornea tissue were almost completely free of blood vessels. At that point the patient’s visual acuity in that eye was 0.3. Dr Krumeich said that the anti-vascular effect of the ring noted in these cases – and in other cases as well as in comparative trials - may result from an interruption of the immune cascade by the device’s metallic components. “One thing we can conclude for sure is that a metallic ring composed of cobalt chrome, titanium and molybdenum can help reduce the vascularisation of corneal grafts. The next step should be that we test it systematically so that we can come to some conclusion about which cases are most likely to benefit from it the most,” Dr Krumeich concluded.

contact Jörg H Krumeich - jk@krumeich.de

*Technolas Perfect Vision data on file Some of the products and/or specific features as well as the procedures featured in this document may not be approved in your country and thus may not be available there. Design and specifications are subject to change without prior notice as a result of ongoing technical development. SUPRACOR is NOT approved for use in the US. SUPRACOR is not approved in all countries. Please contact our regional representative regarding individual availability in your respective market. The trademarks (™ and ®) and logos used in this document are the property of Technolas Perfect Vision GmbH or the respective owner. Design by kbcomunicacion. Ref. TPV-068/09-2011 ©2011 Technolas Perfect Vision GmbH. All rights reserved.

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Update

Glaucoma

GENETIC SCREENING

Researchers shed light on genetic risk factors for glaucoma

by Dermot McGrath in Paris

esearchers are moving ever closer to the goal of developing a genetic screening test to identify individuals who are at high risk for developing glaucoma or for progressing once diagnosed with the disease, according to a study presented at the World Glaucoma Congress. “A lot of progress has been made in recent years and I think that we will have in the not-too-distant future a gene screening panel that can be used to identify individuals at risk for glaucoma with sufficient sensitivity and specificity, and also to identify the prognostic and diagnostic features of the disease,” said Janey L Wiggs MD, PhD. Dr Wiggs, associate professor of ophthalmology at Harvard Medical School and Massachusetts Eye and Ear Infirmary, said that a major goal of gene discovery and human genetics is to be able to take

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EUROTIMES | Volume 16 | Issue 10

genetic information and translate it into the clinic to improve the care of patients. “The general areas where gene discovery can help in the clinic are in pre-symptomatic population screening, in establishing a genetic or molecular diagnosis, in determining a prognosis of the disease, developing therapeutic responses and also ultimately developing novel gene-based therapeutics and devising a plan for personalised medicine,” she said. For glaucoma, the goal is to use genetic risk factors to identify individuals who are at high risk for developing glaucoma or for progressing once diagnosed with glaucoma, said Dr Wiggs. “We also would like to be able to use genetic testing to be able to establish a molecular diagnosis for individuals with glaucoma that is both diagnostic and prognostic and ultimately we could use these tests to establish a

Ph. +39 06 35.49.71.14 • info@jaka.it - www.jaka.it

therapeutic response and then using genes or information about the function of the genes to develop gene-based or neuroprotective therapies,” she said. Focusing on recent progress in molecular diagnostic techniques, Dr Wiggs said that currently physicians can establish a molecular diagnosis by testing for mutations in genes known to cause dominant and recessive forms of inherited glaucoma. “Most of these cause early-onset forms of glaucoma, and even though these are rare diseases, testing for gene mutations in families that carry these mutations can provide valuable diagnostic and in some cases prognostic information,” she said. Current tests have identified genes causing dominant and recessive forms of glaucoma, said Dr Wiggs, including two that cause congenital glaucoma (CYP1B1/LTBP2), and the Myocilin gene that causes primarily early onset open angle glaucoma (OAG). Four genes have also been identified as causing anterior segment dysgenesis or Axenfeld Rieger type syndromes (PITX2, FOXC1, LMX1B, PAX6), and one gene optineurin, which causes a rare form of familial normal tension glaucoma. To highlight the utility of the testing, Dr Wiggs cited the example of a 25-yearold male patient who had a history of glaucoma as a baby and who came to her clinic and requested screening to see whether or not he was at risk for having children affected with the disease. The screening identified two mutations in the CYP1B1 gene that cause a congenital autosomal recessive form of glaucoma, said Dr Wiggs. “Not only were we able to identify two genetic mutations but we were also able to identify his sister as a carrier which meant that we could provide genetic counselling for both him and his sister based on their mutation status and the mutation status of their spouses,” she said. In terms of screening populations at risk using genetic factors, Dr Wiggs said that recent genome-wide association studies have identified several genes implicated in the development of primary open angle glaucoma (POAG). “Of the genes identified in four important studies in the past year, the

Janey L Wiggs - janey_wiggs@meei.harvard.edu

“

Ultimately we need to be able to study gene-gene and gene-environment interactions because this is where we will be able to increase our specificity and sensitivity of these screening tests Janey L Wiggs MD, PhD

CDKN2BAS gene is the one that is common in three of these four studies. This is a gene that participates in the regulation of the TGF beta signaling pathway, which appears to play a role in optic nerve disease in glaucoma. This is a very important candidate gene for glaucoma and it is very interesting in terms of its overall function,” she said. While much progress has been made, Dr Wiggs emphasised that further research and studies are needed before a sufficiently sensitive and specific screening test can be developed for a disease as complex as POAG. “We need to identify more genes that contribute to POAG and other common forms of glaucoma such as exfoliation glaucoma. This will hopefully come from the new genomic approaches that are now used for genetic analysis, including whole genome association studies and new technologies that will allow for whole genome sequencing,” she said. Researchers also need to understand better the role of the genes in the disease process, said Dr Wiggs. “We need to be able to correlate specific genes and mutations with specific clinical features of the disease, which will require the careful collection of clinical data on patients who have genetic information. We would also like to be able to correlate specific genes with treatment responses. The field of pharmacogenomics is really just beginning but should prove to be very useful once we have more genes to work with. Ultimately we need to be able to study gene-gene and gene-environment interactions because this is where we will be able to increase our specificity and sensitivity of these screening tests,” she concluded.

Update

Glaucoma

Objective evaluation of the lens density in 3D

PERFUSION PRESSURE

Further research needed to unlock perfusion pressure secrets in glaucoma by Dermot McGrath in Paris

hile there is growing evidence of the role of low ocular perfusion pressure in the development and progression of open-angle glaucoma (OAG), there are still too many unanswered questions to justify its inclusion as a standard part of glaucoma management regimens, said Fotis Topouzis MD. “In theory, ocular perfusion pressure could be incorporated in glaucoma management by checking or treating perfusion pressure. However, based on the current state of knowledge we are not there yet. We have a limited understanding of the complexity of ocular perfusion pressure and its interaction with potential risk factors for glaucoma,” he told delegates attending the World Glaucoma Congress. Dr Topouzis, associate professor of ophthalmology, Aristotle University of Thessaloniki, Greece, said that recent studies have described the potential effects of low ocular perfusion pressure in the development and progression of glaucoma and shown that prevalence rates decrease progressively with increased diastolic perfusion pressure. Based on current glaucoma management guidelines, Dr Topouzis said that treating the ocular perfusion pressure is not a straightforward matter. “We can treat perfusion pressure either by increasing blood pressure or by lowering IOP. However, there is no evidence to date that increasing perfusion pressure by increasing blood pressure would be of benefit in glaucoma patients,” he said. Safety concerns should also be to the fore of any discussion involving treatment of perfusion pressure, added Dr Topouzis. “The role of blood pressure in glaucoma remains controversial and there are serious cardiovascular safety concerns to be borne in mind. Studies have shown a doubling of mortality for every 20 mmHg increase in systolic blood pressure or 10 mmHg increase in diastolic blood pressure. In addition, we should consider that 66 per cent of hypertensive patients are not being controlled to target blood pressure levels,” he said. Dr Topouzis said that the prevalence of white coat hypertension – up to 30 per cent in the general population and more common in the elderly – could lead to overtreatment of hypertension. “Furthermore, in extreme dippers very low blood pressure could potentially lead to end-organ damage EUROTIMES | Volume 16 | Issue 10

including the optic nerve. In these patients, adjustment of antihypertensive treatment by the cardiologist may be justified, but there is no evidence of potential benefit to glaucoma.” Turning to IOP, Dr Topouzis said that the difference in a new treatment scenario would be that lowering IOP would also aim to achieve a target perfusion pressure, involving a re-evaluation of the target IOP beyond the established algorithm. “We need to bear in mind that perfusion pressure is a tricky variable. Of the two players in ocular perfusion pressure, we do not know for sure who is really playing the game: IOP alone, blood pressure alone or, more likely a combination of both? In the combination scenario, we need to ask what is the weight of each variable? Is it the same for the whole IOP spectrum?” he asked. Dr Topouzis noted that the EgnaNeumarkt study found no association between low diastolic perfusion pressure and increased glaucoma prevalence in normal tension glaucoma. Furthermore, the Rotterdam study found that low diastolic blood pressure actually decreased the risk for individuals with low-tension glaucoma, which makes the data difficult to interpret. In the Early Manifest Glaucoma Trial (EMGT) subgroup analyses with regards to IOP, systolic blood pressure less than 60 mmHg was associated with progression in patients with baseline IOP less than 21 mmHg, while in patients with higher baseline IOP, systolic perfusion pressure less than 125 mmHg was associated with progression, but not systolic BP less than 160 mmHg. Furthermore, while perfusion pressure involves blood pressure level, it does not take account of blood pressure status, meaning normal, hypertension, treated hypertension, lowered blood pressure secondary to antihypertensive treatment, and high blood pressure despite antihypertensive treatment. In the Rotterdam Study, low diastolic perfusion pressure was associated with glaucoma prevalence only in subjects under antihypertensive treatment. “With this in mind, we think it might be a good idea to introduce perfusion pressure status into the equation, taking account of the use of antihypertensive treatment, rather than the traditional method of using only perfusion pressure level,” he concluded.

contact

Fotis Topouzis – ftopouzis@otenet.gr

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Update

retina

Gisbert Richard – augenklinik@uke.uni-hamburg.de

CHOROIDAL DETACHMENT

Even severe cases of complication can benefit from treatment by Roibeard O’hEineachain in London

ven in very severe cases of choroidal detachment, with or without retinal detachment, a surgical intervention can sometimes provide a useful restoration of vision, said Gisbert Richard MD at the EuroLam symposium of the 11th EURETINA Congress. “Choroidal detachment and delayed suprachoroidal haemorrhage are rare complications after ocular surgery that may lead to severe visual deterioration or blindness. Surgical intervention is indicated in patients with high-grade and progradient choroidal detachment,” said Dr Richard, University Medical Center HamburgEppendorf, Hamburg, Germany. He noted that choroidal detachment is a detachment of the uvea from the sclera and usually there is a sudden effusion of serous humour but no blood into the suprachoroidal space. Suprachoroidal haemorrhage, on the other hand, is an accumulation of sanguineous fluid into

EUROTIMES | Volume 16 | Issue 10

suprachoroidal space. Both complications originate from the same pathophysiological process, Dr Richard said. “We know from animal experiments that stretching the choroid may lead to serous effusion into the suprachoroidal space and to traction on the vessels, especially at the base of the ciliary body and then to a massive effusion of blood from ciliary vessels,” he noted. Glaucoma surgery carries the highest risk for the complication, particularly when Molteno filtration devices are used. The rate of choroidal detachment can reach six per cent, or when the patient is aphakic and the rate can be as high as 10 per cent. Around 10 per cent of patients with choroidal detachment will also have retinal detachments. In aphakic patients, vitreous prolapse into anterior chamber and kissing choroids are fairly common. The systemic risk factors for the choroidal detachment include advanced age, arterial

hypertension and diabetes.The ocular risk factors are aphakia, pseudophakia after glaucoma operations, and retrobulbar block anaesthesia. Prophylaxis includes strict control of arterial hypertension and the intraocular pressure, using such means as hyperosmotic drugs and prolonged oculopression, with the aim of keeping blood pressure and intraocular pressure as close to normal throughout any ocular surgery. In addition, special care should be taken with anterior segment surgery in myopic, hyperopic or aphakic patients. Dr Richard noted that choroidal detachment can sometimes be delayed for several days postoperatively. A patient’s presenting symptoms in such cases include a sudden loss of vision accompanied by pain and occasionally also vomiting and nausea. Examination will typically reveal a flattening of the anterior chamber. Surgeons are often too quick to declare some of the more complicated cases as hopeless, Dr Richard said. He said that in his own series of 16 eyes of 16 patients with choroidal detachments, 10 of whom also had retinal detachments, simple draining and/ or vitreoretinal surgery resulted in complete re-attachment of the choroid and retina in 13 patients and re-attachment of the macula attached in 15 patients at three months’ follow-up. The study involved nine men and seven women with an average age of 71 years. They had undergone an average of 1.9 eye operations before their choroidal detachments occurred. In addition, six had small retinal detachments and four had bullous retinal detachments. He noted that five patients were myopic, four were hyperopic and 10 were pseudophakic or aphakic. Their intraocular pressures covered a broad range, eight had pressures of 8.0 mmHg or below, six had pressures ranging from 11.0 mmHg to 22.0 mmHg, and two had pressures above 22.0 mmHg. The patients underwent a total of 10 drainage procedures, two of which were re-operations, and nine vitreoretinal procedures, one of which was a re-operation. Dr Richard and his associates performed the drainage procedures seven to 10 days after the choroidal detachments occurred. It involved setting up an infusion in the anterior chamber to deepen it and raise the intraocular pressure, puncturing the

Acute choroidal detachment after glaucoma surgery

Courtesy of Gisbert Richard MD

Choroidal detachment complicated by retinal detachment

choroidal detachment at its highest point, around 2.5mm from the limbus, and then using gentle irrigation allowing the yellow liquid to flow out of the suprachoroidal space, he said. A vitreoretinal approach is the best option in eyes with concomitant retinal detachment, vitreous haemorrhage or dislocated lens in choroidal detachment, Dr Richard said. “Although the pars plana approach is difficult, it has several advantages. First, it enables the anatomic reconstruction of the intraocular structures affected. It also allows the removal of pathologic vitreous components and haemorrhages and vitreous tractions,” he added. Dr Richard described a complex case involving a choroidal detachment patient who also had a cataract requiring extraction. Following the cataract procedure and drainage of the suprachoroidal space, he removed all the vitreous and performed a retinotomy which also cut into the choroid. He then performed a silicone oil infusion and after the slow re-attachment of the retina and the choroid he carried out a laser treatment. He noted that in his series of patients there was residual choroidal detachment in nine patients who underwent drainage procedures and in four who underwent a vitreoretinal procedure. He said that small peripheral choroidal detachments usually regress within a few days after surgery but require strict control because of the risk of retinal complications. He added that an almost complete reattachment of the retina usually occurs intraoperatively. “Reconstruction of the choroidal and retinal anatomy usually results in rapid and lasting functional improvement,” Dr Richard concluded.

Update

retina

ANTI-VEGF DRUGS

Retrospective claims analysis explores relative risks of various anti-VEGF agents by Cheryl Guttman Krader in Fort Lauderdale

esults of a Medicare (US public healthcare) claimsbased study show differences in risks of ocular and systemic adverse events between bevacizumab (Avastin, Genentech) and ranibizumab (Lucentis, Genentech) when these antiVEGF medications are administered by intravitreal injection to treat neovascular age-related macular degeneration (AMD). However, the risks of these complications are low with either drug, reported Emily Gower, PhD, associate professor of ophthalmology Johns Hopkins University, Baltimore, MD, in a late-breaking abstract presented at the annual meeting of the Association for Research in Vision and Ophthalmology. The retrospective study identified Medicare beneficiaries who had at least one treatment claim for neovascular AMD between 2005 and 2009. Data on complications were identified from inpatient and outpatient claims, and cases were censored if the ability to identify specific claims was lost or if they received an intravitreal steroid injection. The researchers conducted two separate analyses. The first was based on a “pure cohort” of almost 78,000 patients who were identified as initiating treatment with ranibizumab or bevacizumab in 2008-9 based on the specific drug codes for the two anti-VEGF agents. The second analysis used an expanded “any cohort” comprised of about 180,000 patients that included persons initiating treatment as early as July, 2006 and those presumed to have received intravitreal bevacizumab or ranibizumab based on unclassified drug or biologic codes plus charge data. Comparisons of safety risks were made using Cox proportional hazard models with adjustment for differences between treatment groups in baseline co-morbidities, demographics and socioeconomic status. Results of the adjusted analysis for the pure cohort showed bevacizumab was associated with statistically significant increased risks of intraocular inflammation, cataract surgery, hemorrhagic stroke, and all-cause mortality compared with ranibizumab, but a significantly lower risk for being newly diagnosed with ocular hypertension/

EUROTIMES | Volume 16 | Issue 10

“

These findings are based on a very large population of patients that allows us to look at rare events Emily Gower, PhD

glaucoma. In the ‘any’ cohort, the between-treatment differences remained statistically significant only for the two ocular adverse events. There were no statistically significant differences between groups in either the ‘pure’ or ‘any’ cohort for the rates of other adverse events investigated, which included myocardial infarction, ischemic stroke, and endophthalmitis, reported Dr Gower. “These findings are based on a very large population of patients that allows us to look at rare events. Putting this strength into context considering the mortality rates seen in our study, a clinical trial of 40,000 patients would be needed to see a statistically significant difference between groups. We have also done our best to adjust for socioeconomic factors given the data accessible to us,” she commented. “However, this retrospective claims analysis has several limitations, including the potential for misclassification of drug treatment and for residual and unmeasured confounding given the absence of data on body mass index, smoking status, and severity of the baseline co-morbidities we considered. Therefore, our study cannot establish causality of events based on treatment and should not be used as the definitive opinion on relative risk. Rather the results should be viewed as hypothesis generating and may be used to guide further research to elucidate whether the differences we’ve identified are real,” she added.

contact Emily Gower – egower1@jhmi.edu

Update

retina

Microneedles

Suprachoroidal injections may allow long-lasting treatment for retinal disease by Howard Larkin in San Diego

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EUROTIMES | Volume 16 | Issue 10

icroneedles, which at less than 1mm are about as long as the bevel tip of a 30-gauge conventional needle, have successfully injected microbeads, microbubbles and suspensions into the suprachoroidal space in rabbit eyes. The technology holds promise for reducing the frequency of injections for treating retinal disease while also limiting the exposure of the lens and other anterior structures to potentially harmful compounds such as corticosteroids, Henry F Edelhauser PhD, Atlanta, US, told the Innovators symposium of the American Society of Cataract and Refractive Surgery annual meeting. In animal tests, various substances, including a commercially available ocular corticosteroid suspension, have been shown to persist much longer and at much higher concentration in the suprachoroidal space and retina than similar doses delivered by intravitreal injection. At the same time, concentrations in the lens, cornea, iris and ciliary body are much lower than in intravitreal injections, presumably lowering the risk of cataracts or other complications. Experimental drug delivery systems, including microparticles and microbubbles that can be activated to release compounds by ultrasound after injection, have also been shown to last at high concentrations in the suprachoroidal space for periods of 70 days or more, said Dr Edelhauser. He is developing the technology with colleagues at Emory University and the Georgia Institute of Technology in Atlanta and has applied for patents on the process. “The suprachoroidal injection targets chorioretinal tissues much better than intravitreal injections, and sustained delivery can be achieved with proper formulation design. As we look to the future we will find this is a wonderful way to keep drugs in the suprachoroidal space and possibly deliver them for up to three to six months or more,” Dr Edelhauser said.

Rapid diffusion Dr Edelhauser showed the rapidity with which microneedle injections diffuse by injecting India ink into a rabbit eye. Within a few seconds it was visible throughout the globe. Dissection showed the ink particles were retained completely within the space between the choroid and the sclera, suggesting that the

suprachoroidal space may contain injected materials near the retina longer than has been observed in the vitreous. To determine whether a formulation injected into the suprachoroidal space could potentially provide drug delivery for weeks or months, Dr Edelhauser injected a range of fluorescent microbeads, measuring 20 and 500 nanometres, and one and 10 micrometres. Flourophotometry readings showed the concentration of the beads retained in the choroid/retinal tissues over time. Fluorescence in the suprachoroidal space of the smallest 20 nm particle tested increased out to about 20 days, and then began to decline. Larger particles showed stronger fluorescence at the outset and it persisted longer than with the smallest particles. Fluorescence of the one micron particles was initially about two orders of magnitude higher than the 20 nm beads and remained flat out to 70 days. 10 micron particles were readily visible into the suprachoroidal space of animals sacrificed 60 days after injection, with no migration outside the space observed. The results suggest that sustained delivery via microparticles is viable, Dr Edelhauser said. Dr Edelhauser also tested the performance of injected suspensions. He injected a 2mg dose of triamcinolone acetonide (Triesence, Alcon, Fort Worth, US) in 100 microlitres volume into rabbit eyes in vivo, with half receiving suprachoroidal and half intravitreal injections. After one week, both groups retained about 1,600 micrograms. However, 63 per cent was in the vitreous and more than 10 per cent in the lens and anterior in the intravitreal group, whereas 77 per cent remained in the choroid and negligible amounts reached the lens and anterior in the suprachoroidal group. At two months 635 micrograms of triamcinolone remained in the suprachoroidal eyes, or about six times the 107 micrograms that remained in the intravitreal eyes. As at one week, more than 70 per cent of the compound remained in the choroid and less than one per cent in the lens in the suprachoroidal injected eyes, while 60 per cent remained in the vitreous and 5.3 per cent in the lens in the intravitreal eyes.

contact

Henry Edelhauser - ophthfe@emory.edu

n a l i M

XXX Congress OF THE ESCRS 8-12 September

2012

31 October 2011 bmission Deadline: Course Su 15 March 2012 Submission ct ra st b A : e lin ad e D

for Preliminary Programme visit

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PRAGUE 2012 16 ESCRS WINTER MEETING TH

In conjunction with the Czech Society of Cataract and Refractive Surgery

3-5 February

Hilton Prague Hotel

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EUROPEAN SOCIETY OF CATARACT & REFRACTIVE SURGEONS

Update

Ocular

Corneal Transplant

MRSA EPIDEMIC

Follow-up study suggests stabilisation of rising infection rates by Cheryl Guttman Krader in Fort Lauderdale

esults of a follow-up study investigating trends in the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections and antibiotic sensitivity patterns may be considered potentially positive news. In an initial study published in 2006 [Trans Am Ophthalmol Soc 2006;104:322345] Preston H Blomquist MD, assistant professor of ophthalmology, University of Texas Southwestern Medical Centre, Dallas, analysed data on MRSA infections presenting to Parkland Health and Hospital Systems, the Dallas County, Texas public healthcare system, between 2000 and 2004. The results showed community-acquiredMRSA (CA-MRSA) infections of the eye and orbit became increasingly prevalent over the five years. The infections were almost always managed initially with empirical antibiotic therapy, but half the time, the medication chosen provided inadequate coverage against the causative pathogen. At the annual meeting of the Association for Research in Vision and Ophthalmology (ARVO), Dr Blomquist and colleagues reported an update based on data collected between 2005 and 2009. The analyses in this more recent time period showed slowing of the previously described rapid increase in CA-MRSA infection and more judicious physician selection of initially prescribed antibiotics. Compared with the previous five years, antibiotic sensitivity patterns for MRSA remained unchanged. Matthew Kruger MD, ophthalmology resident, University of Texas Southwestern Medical Centre, Dallas, collaborated with Dr Blomquist in his research. He told EuroTimes, “The number of total MRSA infections and those involving the eye and orbit rose almost exponentially during the five years of the previous study. The annual incidence was more variable in the present analysis, but overall the data indicate some stabilisation in the rate. “The recent data plus the finding that MRSA antibiotic resistance did not increase are reassuring. However, cautious interpretation is needed because it can’t be determined from our study whether the slowing incidence is a real phenomenon or because physicians are culturing less. The message to ophthalmologists is to remain cognizant that MRSA is a common and formidable pathogen,” he said.

EUROTIMES | Volume 16 | Issue 10

“

The message to ophthalmologists is to remain cognizant that MRSA is a common and formidable pathogen

For Ultra-thin Lamellar Grafts

Matthew Kruger, MD Cases of MRSA infection were identified through review of the institution’s Microbiology MRSA database, and additional details on ocular infections were obtained through chart review. Between 2005 and 2009, a total of 7,073 culturepositive MRSA infections were recorded. CA-MRSA was considered the pathogen in about 80 per cent of the cases. There was a low incidence of MRSA infections involving the eye or orbit (n = 55, 0.78 per cent). As in the earlier series, preseptal cellulitis and/ or lid abscess followed by conjunctivitis were the most common ophthalmic MRSA infections. Rates of corneal ulcers, orbital cellulitis and endophthalmitis were stable during the two study periods. As in the earlier study, almost all patients received initial empiric treatment. However, 80 per cent of the antimicrobial agents prescribed between 2005 and 2009 had adequate activity against MRSA. “In the earlier study, empiric antibiotic treatment was often with penicillins and cephalosporins that provide suboptimal coverage for MRSA, whereas trimethoprim/ sulfamethoxazole was most commonly prescribed between 2005 and 2009. We believe this change indicates that physicians have become more aware of the importance of MRSA as a pathogen in eye and orbit infections and more educated about what antibiotics are appropriate for empirical treatment when Staphylococcal infection is suspected,” Dr Kruger said.

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Update

Ocular

Mel Goodale - mgoodale@uwo.ca Gordon Dutton - duttongn@gmail.com Daniel Kish - daniel.kish@worldaccessfortheblind.org

SEEING BY EAR

Canadian study maps brains of blind echolocators

ike bats and dolphins, some blind people are able to navigate their environment with echolocation – without exclusive reliance on a cane or assistance. The first successful brain imaging study of blind echolocators appeared in a recent issue of the journal PLoS ONE. Echolocation is the ability to detect the location, size, density and arrangement of objects after emitting a sound (in humans, this is often from a clicking sound made with the mouth) and interpreting the resulting echoes. Only a small number of blind people are known to practise echolocation to an advanced degree, and most people, including ophthalmologists, are not aware of this as a possible tool blind people could learn and use, according to Mel Goodale PhD, professor of psychology and director of the Centre for Brain and Mind at the University of Western Ontario, who was senior author of the study. The first challenge was to find a way for the volunteers in the study to listen to the echoes from their own clicking sounds and identify a variety of objects within the confines of the MRI system. Any movements of the mouth would disrupt the brain scan, and, besides, there was nothing to echolocate within the small bore of the brain scanner. The solution was to develop a passive listening system to use with fMRI. Before

Eye Chat

the scans were performed, study subjects were taken to a variety of locations where they made clicking noises and identified objects. The clicks and returning echoes were recorded via small microphones placed in their ears. Later, when subjects were inside the fMRI machine, the clicks and echoes were played back in a random order through headphones. Scans were performed while two sighted and two unsighted people listened to the recordings, and were asked to identify what the echoes described. The study showed that while the echolocators listened and deciphered echoes, the part of the brain that was most active was the visual cortex, with the most activity being in the calcarine cortex. In the sighted subjects, there was no increased activity in this region. It is not known why that part of the brain was recruited for the activity. It’s possible it was recruited for echolocation activity simply because it wasn’t being used for visual activities – in other words, it was unused brain space and available. Alternatively, as the visual brain maps the external world, it is handling the auditory mapping data instead in these blind subjects. The visual cortex helps with spatio-topic representation of the world in sighted

“

with Oliver Findl

Monovision

Oliver Findl and Graham Barrett discuss Monovision Surgery, a safe and effective procedure that does not compromise stereoacuity.

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Podcasts are also available on iTunes EUROTIMES | Volume 16 | Issue 10

Oliver Findl

Graham Barrett

Courtesy of Mel Goodale PhD

by Pippa Wysong in Toronto

ESCRS

Image shows a scan of Daniel’s brain showing echo-related activity in his visual cortex. (Note that there is no activation to echoes in the brain of an age-matched control subject)

people. It may play some sort of analogous role with these particular blind people. In other words, it helps provide a type of map. “Until we do more experiments with blind echolocators we won’t know exactly what the visual cortex is offering,” Dr Goodale said. Additional neural organisation was noted in one of the blind subjects. When echoes were of objects that had been to the right of the individual “the echoes returning from those activated the visual cortex in the opposite hemisphere and things that were on the left activate the right side,” he said. This suggests there may be spatial interpretation – at least with this one person, he said. The two echolocators in this study are able to get around by using their echolocation skills alone, they can even ride bicycles and go for hikes, Dr Goodale said. One well-known echolocator is Daniel Kish, president, World Access for the Blind, California, US, who taught himself to ‘see’ the world through echolocation as a young child. When he was 13 months of age he suffered from retinoblastoma and had to have both of his eyes removed. Now, he is a researcher in echolocation and teaches the skill to other blind people. He was one of the subjects in Dr Goodale’s study, and has been to Scotland and other places around the world giving seminars and workshops about echolocation. Mr Kish notes that work such as Dr Goodale’s is important because to date, “hard science has been conspicuously lacking in this area. Our approach to blind rehab is one of the very few actually seeking scientific investigation. With hard science comes credibility,” he told EuroTimes in an email interview. “To date there has been a lot of scepticism that blind people can truly perceive the

world around them by echolocation. As this is such a remarkable and empowering skill, it is important to dispel such disbelief by scientific, rather than just behavioural, validation of this remarkable attribute,” said Gordon Dutton MD, a paediatric ophthalmologist and professor of vision science at Glasgow Caledonian University in Scotland. He was not part of the study group, but feels the study is important. He has worked with echolocators. According to Dr Dutton, the results of Dr Goodale’s study are remarkable but not surprising. “The visual brain has been redeployed to accept and analyse auditory data as a surrogate for visual information, to analyse it as if it were vision, and to interpret it accordingly, in the areas of the brain which serve both image analysis and motion detection.” “I have been an ophthalmologist for over 30 years. I first learned about echolocation only about three years ago and was amazed when I saw what blind people with this skill can achieve,” he said. “I have seen a number of blind children move freely through the environment that they do not see, and it has long been evident that they are interpreting a range of perceptions to accomplish this.” He suggests that if young children are doing things that may appear unconventional, but helps them navigate within their surroundings, parents should let them continue. Like Mr Kish did, they may be coming up with another way to ‘see’ the world. n Echolocation in action www.youtube.com/watch?v=uobuBc2GO0o n Teenage echolocator www.youtube.com/watch?v=YBv79LKfMt4

Call for Submissions Open August 1 – September 26, 2011 ASCRS Symposium on Cataract, IOL and Refractive Surgery

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News

Esaso

FELLOWSHIP

Students selected who want to practise cutting edge ophthalmology, research and teaching

by Stanley Chang

stablished in September 2008, the ESASO Foundation has its offices on the Lugano Campus of Università della Svizzera Italiana. Its mission is to support and contribute to all initiatives launched within the European School of Advanced Studies in Ophthalmology and carried out in Europe and the rest of the world. ESASO has created an academic curriculum consisting of taught specialisation modules, leading to the degree of Diplome Specialist Superior in Ophthalmology (DiSSO), and runs a Fellowship scheme for eye specialists. The advanced training programme may be undertaken through admission to a one-year Fellowship focused on one specific sector of ophthalmology. The Fellow’s advanced training shall be conducted within one of the high specialist teaching hospitals or university centres that have entered a partnership agreement with ESASO and agreed on a training programme on an ophthalmological specialist branch. This is how ESASO pursues its long-term objective of academic excellence, consistently with its international vision of the best training for ophthalmologists. ESASO awards Fellowships on an annual basis. Recipients are MSO graduates. Priority is given to those who earned top marks calculated on the basis of the overall grades obtained in the examinations of each taught module and of the ESASO evaluation. Each Fellowship runs for 12 months. The amount of the grant is determined year by year, based on actual revenues. The grant will be paid out in two instalments, half within the first six months and the balance of 50 per cent on completion of the Fellowship. The ESASO Fellowship is an advanced specialist training programme in which the recipient can acquire a thorough, in-depth understanding of the specific subject and, accordingly, proficiency in the exercise of the clinical-surgical profession. It is expected that Fellows will reach a level of competence enabling them to practise autonomously in the ultra-advanced sector of their expertise. ESASO plans its Fellowship curricula in accordance with its accredited Departments of Ophthalmology. The Fellowship programme is agreed

ES_19-11 ESASO_Anz_120x300_Students_RZ.indd EUROTIMES | Volume 16 | Issue 10

5.9.2011 10:22:16 Uhr

“

Our main aim is to create a group of really well-trained sub-specialists in each sub-specialty of ophthalmology.... Stanley Chang

between the Scientific Committee of ESASO and each head of Department of Ophthalmology. In each accredited department, the Fellowship programme director appoints a number of tutors and places them in charge of teaching the single Fellows the subject of their respective field of competence. Each Fellow is to be issued with a ‘student book’ in which to record systematically all progress made during clinical practice and research, in compliance with the selected Fellowship’s schedule. Our main aim is to create a group of really well-trained sub-specialists in each sub-specialty of ophthalmology and we have had a lot of support from the best people in these sub-specialties who come and spend time lecturing and helping in the practical sessions in Lugano and the other ESASO centres. The programme selects the people who want to be the best and return to their home countries or proceed international careers and practise cutting-edge ophthalmology. The Fellows are encouraged to do clinical research and teaching. We originally felt ESASO would be a European project but it appears that ESASO has become a global project to develop this model for the world. n

For further details visit our website at: http://www.esaso.ch/

Stanley Chang is director of the ESASO Fellowship Programme

contacts Gabriella Skala – gabriella.skala@esaso.org Stanley Chang – gn2211@mail.cumc.columbia.edu

News

OBITUARY

DAVID APPLE MD,1941-2011

Emanuel Rosen pays tribute to the late David Apple, a great pioneer of ophthalmology

avid Apple combined a superb intellect with an encyclopaedic knowledge of ophthalmology and ophthalmic pathology, a combination of talents that found an outlet in the practise of cataract surgery at the right time in its evolution. He utilised a vivid imagination with an enquiring mind into the pathological processes that followed from the introduction by Ridley of the placement of an artificial replacement for the cataractous crystalline lens. Clinicians involved in cataract and lens implant surgery battled against the destructive inflammatory processes that threatened to destroy the viability of lens implantation. David attracted talented research fellows to his laboratory many of whom have gone onto personally distinguished careers thanks to his education and guidance in their assistance in solving the many problems caused by entrepreneurial lens implant designs based on an inadequate knowledge of pathophysiologal processes in the eye. David and his ‘Apple Korps’ team were responsible for the discovery of the reasons for the poor clinical outcome of some anterior chamber IOLs, sulcusbased posterior chamber IOLs and pupil supported IOLs. The consequence was the firm establishment of the sequestration of IOLs in the capsular bag to avoid the UGH syndrome. His demonstrations of ocular pathology were seen through the diligent dissection of enucleated implanted eyes and the Apple-Miyake demonstrations of lens implantation anatomy. Amongst many other honours David received the Life Achievement Honour Award by the American Academy of Ophthalmology. He was elected to the ASCRS Ophthalmology Hall of Fame and delivered the ASCRS Innovator's (Kelman) Lecture and the Binkhorst Lecture. Among his highest academic honours was his election to the German Academy of Research in the Natural Sciences. David produced the huge textbook on the pathophysiology of lens implantation and subsequently spent several years as Sir Harold Ridley’s official biographer producing his epic book; Sir Harold Ridley and his Fight for Sight. Ridley changed the world so that we may better see it. For the benefit of all ophthalmic practitioners David’s book was in a format that also EUROTIMES | Volume 16 | Issue 10

12th EURETINA Congress 6-9 September 2012

David Apple

“David Apple combined a superb intellect with an encyclopaedic knowledge of ophthalmology and ophthalmic pathology” allowed the general public to perceive the genius and contribution of Sir Harold in rejuvenating the sight of millions of patients. It was fitting indeed that the combined genius of Ridley and Apple combined to make the invention of lens implantation a brilliant and safe reality. I know that David was proud to participate in what he termed “the golden age of ophthalmology and the visual sciences” despite the resistance he met from vested interests from some surgeons and ophthalmic companies through his pathological revelations. David was a most assiduous and enthusiastic supporter of the ESCRS and each year he made many unique contributions to our understanding of the pathophysiology of lens implantation. He was awarded the Ridley Gold Medal at the XVII ESCRS Congress, Vienna, Austria, in September 1999. David is survived by his wife Ann, his most enthusiastic companion and supporter, one stepson, one stepdaughter and two stepgrandchildren.

for further information visit: www.euretina.org

Abstract Submission Deadline:

15 March 2012

News

young ophthalmologists

BIG STRESS

Ophthalmology resident learns to deal with younger patient by Leigh Spielberg MD

icture it: you’ve just spent three years of your life focused on what you’ve considered to be pretty difficult challenges. You’ve written about retinal imaging, combination therapy for AMD and radiation retinopathy. You’ve presented at a dozen conferences, finished your pre-residency research fellowships, and landed an ophthalmology training position. You passed your Kanski exam, completed your medical retina and neuroophthalmology rotations, and have generally felt pretty good about what you can do. Yet none of it matters at all as you’re standing there in front of a visual acuity reader, trying to figure out whether a fiveyear-old girl can see the third line of race cars and bunnies with her left eye. You’ve done everything to make her comfortable to make sure that moments like these would go smoothly. Your desk is littered with little Smurf figurines and sticker rewards. You removed your white lab coat before she came into the examination room and you spoke to her in cartoonish kiddie voices when she entered. You feigned an intense interest in the sparkly pink princess images on her t-shirt, and you pretended to ignore her parents to

focus on her, but all to no avail. She now only acknowledges your existence with the classic head-turn-and-arm-across-the-eyes-“I’m not here, leave me alone”-pose. You start to sweat, ever so slightly. Your mind starts racing: “Amblyopia? Congenital abnormality? Cortical blindness?” Unlikely. “Or is she simply embarrassed by all the attention and caving under pressure?” Yes. But what to do? You realise you weren’t prepared for this. The first month of paediatric ophthalmology is like a trip to the Land of No & I Don’t Know, since that is what you’ll be spending a lot of time hearing and saying. “Shall we take a look to see what we can see today?” “No!” “Do you want eye drops?” “No!” “Is there any chance at all that I’m going to get you to cooperate?” “NO!” And the answer to your own question: “Now what?” is, of course, “I don’t know.”

True COMICS

Suspecting a possible refraction abnormality, you manage to administer cyclopentolate, all the while dreading the possibility that a similar scene will unfold during retinoscopy half an hour later. You reflect. Listening to a crying child’s heart and lungs is a skill that really can be learned with some practice & patience. Suturing the chin of a hysterical child in the emergency room is no problem at all, as long as you have a big restraining blanket and a little help from the nurses. But properly examining a crying child’s eyes really is impossible. It seems it just can’t be done.

Learning to wiggle So, you make sure that you’re prepared to either prevent those situations (Smurfs! Goofy voices!) or solve them when they occur. Barnyard noises and alien clicks become a standard part of the repertoire to hold and maintain the attention and curiosity of a child. I’ve always been able to wiggle my ears, but it wasn’t until my paediatrics rotation that I learned to wiggle them independently of one another, so that while examining the optic disc of one eye, I could tell the patient to look at my ear (“Which one?” “The one that’s wiggling!”) without having to say “right” or “left,” which young children don’t understand anyway. Further, finding ways to maintain your own attention and curiosity during each of nearly 1000 examinations, and throughout the whole rotation, is also part of the game. Maybe this is now a bit easier for me because my wife is pregnant, so I have a little extra focus on all things “kids.” But still, helping choose birth announcement cards boosts neither your retinoscopy skills nor your confidence.

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Clearly, the potential rewards of paediatric ophthalmology are huge. Removing congenital cataracts, preventing amblyopia and correcting strabismus have an enormous and positive impact – not only in the long path of young patients’ lives but also in their parents’. Even the simple reassurance to parents that their young child’s vision is and will remain fine in the foreseeable future is of incalculable benefit. And getting the paediatric examination right, the first time, is the first step. Enough daydreaming. The five-year-old girl has now returned to the exam room and, with her huge pupils and blurry vision, she’s now sitting so close to Mommy that they could practically be one. Retinoscopy! It seems impossible the first 95 times you do it. Those little lines crisscrossing the pupil, scissoring left and right in astigmatic eyes, disappearing in high myopia and hypermetropia. But this one is going well. She seems to be interested in the retinoscope and the moving line of light, along with the clicky noises you’re making behind the scope. She’s slightly hypermetropic, totally normal at this age. You breathe a mental sigh of relief. And then, around what must be about the 100th attempt, your results finally correlate with those of your supervisors’. Victory! Leigh Spielberg is an ophthalmology resident at the Rotterdam Eye Hospital in the Netherlands. In this column he reflects on learning ophthalmology and daily life in the clinic.

News

european board of oPhthalmology

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FOCUS ON TRAINING

General Assembly approves proposal to set up committees to focus on ophthalmic subspecialties

The Surgeon’s Edge

by Dermot McGrath

hen he took up his official duties as president of the European Board of Ophthalmology (EBO) in December 2010, Wagih Aclimandos FRCS, FRCOphth set his sights on getting the EBO more involved in the accreditation of higher subspecialty training at a European level. “I think there is a definite demand for this across Europe,” Prof Aclimandos said at the time. Less than a year later, the EBO has taken the first steps to achieving that particular goal. The EBO General Assembly held in Slovenia in June this year voted overwhelmingly to approve Prof Aclimandos’ proposal to set up a number of new specialty subcommittees of the Executive Board. These subcommittees will be focused on specific ophthalmic subspecialties such as cornea, glaucoma, uveitis, retina and so forth, and will be comprised of acknowledged experts in these fields who will carry out specific roles as designated by the EBO Executive Board. “It is a very positive move and I am delighted that the EBO Executive Board has recognised the growing importance of ophthalmic subspecialties and the need for the EBO to play an enhanced role in subspecialty training and accreditation,” said Prof Aclimandos. Prof Aclimandos said that the initial goal is to establish subcommittees in the principal ocular subspecialties such as cornea, vitreoretinal, oculoplasty, uveitis and glaucoma, and then perhaps expand into other areas at a later stage. With this in mind, Prof Aclimandos said that he has taken the first step of writing to some of the relevant subspecialty societies such as EURETINA, EVER, EuCornea, etc, to inform them of the initiative and to solicit their support. “It is vital to explain our mission and for these existing organisations and societies to understand that we are not trying to compete with them – our goal is not to set up yet more societies in these particular domains. We are simply asking them to propose some names of individuals whom they think might be interested in serving on the EBO subcommittees. We want to make these subcommittees as representative as possible and have people from as many different participating countries as possible. We are trying to build support and be as open and inclusive as possible and avoid any suggestion that we are trying to set up more societies, which is absolutely not the case,” he said.

“It is a very positive move and I am delighted that the EBO Executive Board has recognised the growing importance of ophthalmic subspecialties...” EUROTIMES | Volume 16 | Issue 10

Disposable Ophthalmic Products While the designation of tasks and responsibilities for the speciality subcommittees has not been fully thrashed out, Prof Aclimandos said that there is nevertheless broad agreement on the type of functions that the subcommittees might be expected to carry out. “The EBO Board has formulated an initial list of possible roles for each of those subcommittees. First of all they will be asked to review the multiple-choice questions for the EBO Diploma exams held in Paris every year. To date, we have relied on the expertise of the Executive Board and a network of colleagues to review the questions. Having a subcommittee means that we can look at those questions more professionally and review them on an ongoing basis because science changes and knowledge progresses,” he said. To illustrate the point, Prof Aclimandos cited the example of age-related macular degeneration (AMD). “Things have changed very rapidly indeed in this field, for example, with anti-VEGF treatments and other innovations, so we need to make sure that some experts in that particular field can look at the questions and be entirely happy that the content is up-to-date. We would envisage having anything between eight and 10 experts in a particular field serving on each subcommittee,” he said. Another possible role for the subcommittees will be to work hand-in-hand with the American Academy of Ophthalmology to co-edit a series of ophthalmology textbooks, said Prof Aclimandos. “This is the kind of enhanced cooperation with other organisations which reflects well on the EBO and which furthers the cause of ophthalmology in general,” he said. Yet another critical role for the subcommittees will be to advise on the accreditation of CME credits for particular courses and meetings. “The idea again is to have a more professional evaluation of particular courses and have a subcommittee examine it in an objective and transparent way, rather than leaving it up to one or two individuals to do it informally,” he said. Last but not least, Prof Aclimandos said that the subcommittees will be asked to look into the feasibility of setting up examinations for their own subspecialty which could be held in tandem with the EBO Diploma examination in Paris every spring. “First, the subcommittees will be asked to decide if the subspecialty exam is a good idea, secondly to define what the prerequisites for sitting that exam should be in terms of training, cases, log books, etc. Finally, the subcommittee members will help decide the format for the exam and propose questions. In each specialty there may be a need for the exam to have a different structure. It may well be the case that there is no one-size-fits-all solution in terms of the exam format and we may need to have different types of exams for different subspecialties,” he said. Prof Aclimandos said that the EBO hopes to have at least one or two subspecialty exams in place for the EBO Diploma examination in April 2012.

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For further information please contact: Organising Secretariat OIC srl Viale G. Matteotti, 7 50121 Florence, Italy Phone +39 055 50351 Fax +39 055 5001912 egs2012@oic.it

Courses, symposia, scientific papers and posters, SIGs, exhibits in a newly built venue in the heart of Copenhagen's Tivoli Garden: a great chance for all to enjoy the exchange of science, clinical pearls, updates while meeting and networking with colleagues from Europe and beyond.

www.eugs.org EUROTIMES | Volume 16 | Issue 10

n previous years Prague has hosted a number of important ophthalmological events including the European VitreoRetinal Society (EVRS) annual meeting in September 2008 and the World Congress on Controversies in Ophthalmology in March 2010. Now we are looking forward to the great honour of hosting the 16th ESCRS Winter Meeting from 3-5 February, 2012. It is an excellent opportunity to share experiences, either through videos or short papers or by simply participating in the open forum, to search for new approaches and techniques, to express doubts and contribute ideas and to discuss thoughts with international experts. As Prague is a city in the heart of Europe it is also a great occasion for meeting ophthalmologists from Western and Eastern Europe. The exciting schedule for the 16th ESCRS Winter Meeting includes basic and advanced didactic courses as well as surgical skills courses, free paper sessions and keynote lectures delivered by international specialists. The meeting will be attractive for the residents as well as for our experienced colleagues not just from Czech Republic but worldwide. Participants will have the advantage of discussing unresolved issues with leading world experts in the field of cataract and refractive surgery. The congress aims to deliver the best answers currently available and provide the clinician with reliable, up-to-date scientific solutions, based on the best existing evidence. Over the years, Czech ophthalmology has undergone an enormous expansion in clinical trials and basic research as well as in cutting-edge technology. The greatest leaps forward have taken place in cataract and refractive surgery, lamellar keratoplasty, presbyopia and advances in IOLs, in the field of dry eye. The growing challenges of treatment possibilities are being explored and have contributed to the need to debate many controversial issues, which come up in clinical situations every day. Jan Evangelista Purkinje (1787-1869) is known to all ophthalmologists for Purkinje's cells. He had wide-ranging interests and an exceptional capacity for innovative thinking. Purkinje was a Czech nationalist and had a major influence on Czech cultural life in the middle of the 19th century. He was a friend of the famous German poet

Johann Wolfgang von Goethe, who wrote about Purkinje: “And should you fail to understand, let Purkyně give you a hand!”. Purkinje published a Czech translation of Friedrich Schiller's poems, and translated works of William Shakespeare into Czech. Jan Vanýsek (1910 - 1995)) was a professor of ophthalmology at the Medical Faculty of Masaryk University (formerly Medical UJEP in Brno). From 1955 to 1970, he was head of the Department of Ophthalmology Faculty of Medicine and between 1957-1960 he was dean of the Faculty. He was also a long-time chairman of the Czechoslovak Medical Society JE Purkyně in Prague. In 1969 he was elected rector of the university, but for political reasons he was not confirmed by the Ministry of Education of Czechoslovakia and had to retire from the university. Prof Václav Vejdovský (1896 -1977) was for many years head of the Olomouc Clinic. He was one of the founding members of the Czechoslovak Ophthalmological Society and for many years its vice-chairman. From 1967-1970 he was the chairman of the society. He also represented Czechoslovakia in the committee of the European Ophthalmological Society. There are many other great Czech ophthalmologists that I could mention but you can find out more about them when you visit us next February. We look forward very much to the 16th ESCRS Winter Meeting and hope it will help us to build on the successes of other winter meetings in recent years. Pavel Studeny is a member of the ESCRS Board.

contact

Finola Bromle – finola.bromley@fil.com

Feature

PRACTICE DEVELOPMENT

PARTNERING FOR INNOVATION

Teaming with industry may help profession overcome cost of advancing technology by Howard Larkin

“

We get a lot of benefit out of partnering with a large group of surgeons versus employing five or six or seven

Tim Clover, CEO of Optegra and uncertain end market makes it harder to finance product development and clinical trials, and lack of coordination among surgeons in the field impedes outcomes research. “It is really an unsatisfactory model for product launch.” Mr Clover believes these issues can be resolved by surgeons partnering with industry. “Our model is to develop a specialist hospital that brings together 20 surgeons so you can justify the investment, and create better outcomes for patients.” Bringing surgeons together in large partnerships will also spur innovation by facilitating organised research, he adds. At Optegra, surgeons maintain their independent and academic practices, but collaborate through a variety of mechanisms, Mr Clover notes. These include advisory boards that evaluate new technologies, and organised networks that support product development and clinical trials. Outcomes are also tracked to improve quality and provide feedback to device and drug manufacturers. The firm also funds research efforts directly through a not-for-

visit our new look website for indian doctors

profit arm. Surgeons are encouraged to conduct their own trials and research. Currently 80 consultant-level surgeons partner with the firm’s five eye hospitals in the UK. Contracts with the UK National Health Service make up about 25 per cent of volume, private insurance another 10 per cent and the rest private fee-forservice. The five hospitals Optegra recently acquired from Augentis in Germany will be similarly structured. Mr Clover believes that providing the most advanced equipment and research support helps attract the most talented and experienced surgeons. Their broad expertise and leadership, in turn, give the organisation a clinical and market advantage. “We get a lot of benefit out of partnering with a large group of surgeons versus employing five or six or seven. There is a greater richness of experience. It is a combination of equipment and better surgeons that we believe deliver better outcomes.”

A comprehensive approach Rather than focusing on refractive surgery, as many other ophthalmic chains have, Optegra offers a complete range of services. Mr Clover gives two reasons. First, he believes the refractive surgery market is moving toward maturity, with volume fairly stable. On the other hand, the ageing population makes other services, particularly cataract surgery but also age-related macular degeneration (AMD) and glaucoma, major growth markets in the longer term. “We do not assume an exit, so we can make an investment for 10 to 15 years. The technology has advanced around presbyopia

EUROTIMES

ESCRS

ne downside of the rapid advance in ophthalmic technology is that the cost outstrips the ability of many smaller clinics to pay. Just ask Tim Clover, CEO of Optegra, a chain of 10 eye hospitals in the UK and Germany. According to Mr Clover, a complete suite of equipment to diagnose and treat cataracts and glaucoma and to perform retinal, corneal, refractive and oculoplastic procedures can cost more than €2.3m. “If you have a department with three or four surgeons, it is simply not possible to justify the investment in six different types of laser,” Mr Clover says. Likewise for OCT, HRT and other high-tech diagnostic devices. Drawing on his experience and expertise, Mr Clover will address such dilemmas as part of his keynote lecture, “Driving Innovation in Ophthalmology” at the EuroTimes Practice Development Workshop and Masterclass, which takes place at the Four Seasons Hotel in Dublin, Ireland on November 12 and 13 this year. In his lecture, Mr Clover will focus on the forces shaping the speciality as well as some practical issues in organising groups of ophthalmologists into partnerships. As a result, many patients have no access to the advanced treatment and diagnostic equipment that might improve surgical outcomes or prevent eye problems through early detection. The small scale and limited financial resources of many ophthalmology practices is also frustrating for manufacturers, says Mr Clover, who is also CEO of Moonray Healthcare, Optegra’s parent and a unit of Fidelity International Limited. A fragmented

correction, which is a big medium-term opportunity, but we have the facilities and we will be positioned for the wave of cataracts.” Indeed, Moonray Healthcare, which also invests in other specialty services and development of medical devices, chose ophthalmology as a specialty that can uniquely benefit from the capital, organisational and technological support that an industry partner can provide. Glaucoma is another growth area. Mr Clover believes that large organisations structured to participate in collaborative research efforts will help advance predictive technology, including structural studies and genetic markers, that will help transform ophthalmology into a more proactive specialty. “Instead of waiting for something to develop and then treating it, we can do more prevention around glaucoma. Things like that are very exciting for ophthalmology.” Mr Clover also sees AMD as an underserved area that can benefit from new technology and systematic support for research. He also notes that the partnership model he has implemented at Optegra is well suited to both supporting such research and providing patients access to the latest developments sooner. “Some people question the role for private healthcare. It’s a given that it provides patient choice, but access is also a huge part, and third is it is a catalyst for new technology introduction. An organisation the size of the NHS tends to be conservative and slow, and adoption of new technology tends to take place years after it has been on the market. The private system has the role of being the launch platform,” Mr Clover says. In addition to presbyopia-correcting lenses and laser refractive surgery, Optegra also provides non-refractive clinical services such as selective laser trabeculoplasty and diagnostic testing not covered by public plans. Mr Clover believes strongly that better outcomes are what drive success in health services. “It’s not about comfortable chairs or nice pictures on the wall or better coffee in the waiting room. It’s about better patient care.”

India

www.eurotimesindia.org EUROTIMES | Volume 16 | Issue 10

™

Experience the Extraordinary This winter, join us for the 5th annual ASCRS Winter Update. Hosted at the Fairmont Mayakoba in Playa del Carmen, Mexico, the 2012 program continues a tradition of experiential education in an extraordinary location.

Interactive sessions with accessible faculty. Pertinent topics offering practical tips. Spectacular and convenient location. meeting was great. The casual atmosphere allowed open discussion. My family loved â&#x20AC;&#x153;theThe resort and our day trips to Xcaret to snorkel and to Coba to see Mayan ruins. â&#x20AC;? Gary J. Foster, MD, Fort Collins, Colorado

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 Clara C. Chan, MD Vincent P. de Luise, MD Lisa M. Gangi, COE W. Barry Lee, MD Richard L. Lindstrom, MD Nancey K. McCann Tina Pinke, COT, COE E. Ann Rose Jonathan B. Rubenstein, MD Thomas W. Samuelson, MD Paul Studenbordt, COE R. Doyle Stulting Jr., MD, PhD Vonda Syler, COE Maureen L. Waddle, MBA Liliana Werner, MD, PhD

Program at a Glance Thursday, February 16 • Networking & Welcome

Friday, February 17 • Managing Cataract Complications/Complicated Cases: You Make the Call • Cornea & External Disease: Practical Topics and Interactive Panel Discussion • Optional Workshop: Astigmatism Management • Optional Workshop: Herpes Simplex/Zoster Ophthalmicus • Legislative Update

Saturday, February 18 • New Technology in Anterior Segment Surgery • Cataract Surgery and Retinal Disease: Evaluation & Treatment • Optional Workshop: Implementing EHR • Optional Workshop: Dilemmas in Co-Management of Patients with Retinal Disease • Video Presentations: Complications and Challenging Cases

Sunday, February 19 • Challenging Cases for the Comprehensive Clinician • Glaucoma Management Pearls • Optional Workshop: DSEK • Optional Workshop: Glaucoma • Medicare Update

Monday, February 20 • Refractive Surgery Goes Mainstream: Pearls for the General Ophthalmologist • Faculty Roundtables & Wrap-Up

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Book review

Corn

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Feature

C o r n

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

3rd EuCornea Congress

Correcting mistakes

Doing no harm when someone already has

MILAN 6 - 7 September 2012 www.eucornea.org

EUROTIMES | Volume 16 | Issue 10

Iatrogenic illnesses and conditions are unfortunately becoming an increasing rather than decreasing problem. Various statistics are bandied about – one in three hospital admissions of patients over the age of 75 years in the US will involve medically-induced harm. That statistic sits on top of the overall rate of one mistake for every 10 patients of all ages admitted to hospital. In a climate where risk assessments and health and safety are more and more emphasised, there is increasing pressure on clinicians and institutions to address the issue of medically-induced risk. Industries such as aviation became very good at ensuring that training and retraining procedures minimised pilot error. While medicine and aviation may not be directly comparable, I think the general public would be quite shocked at the loose, “see one, do one, teach one” attitude that often still prevails in medicine. Of course, some iatrogenic harm is due to a lack of technology. For instance, while electronic medical records are becoming more and more common, paper-based notes often are not available in the middle of the night or at the weekend. At those times, when notes are not available, the admitting clinician depends on the patient’s own recollection of what medication has been prescribed, often with disastrous results. Other iatrogenic conditions, however, are due not to a lack of technology but to the introduction – and use – of new technologies. Irregular astigmatism is a good example. Ming Wang, medical director of refractive surgery at the Aier Eye Hospital System in the People’s Republic of China, has edited this volume which deals with all aspects of the aetiology and clinical approach to irregular astigmatism. As Dr Wang writes in his preface, this is essentially a new and humancreated condition. The rise of LASIK surgery in recent years has seen it go from being publicly perceived as a miracle cure, to a more skeptical view focusing on the potential risks, to now a more nuanced view as the surgery rapidly becomes more routine. This is a familiar pattern in the history of medical and surgical interventions. Dr Wang’s preface concludes with the Hippocratic injunction to “do no harm.” As he writes, as well as attempting to improve the quality of primary refractive treatment,

we also need to devote resources and effort towards developing better approaches and technologies to correct iatrogenic visual problems. Dr Wang has compiled an impressive array of international contributors, from China, the US, Australia, India, Serbia, Spain, Mexico, Canada and the UK. The book is divided into two main sections; one on the optics, aetiology and clinical presentation of the irregular cornea, and a much longer section on its management. R Dax Hawkins provides the introductory “brief history of astigmatism.” He notes that the English polymath, Thomas Young, who contributed much to the deciphering of Egyptian hieroglyphics (although JeanFrancois Champollion completed the task), was jointly the first to describe astigmatism in the human eye. The rest of this first section covers the diagnosis of irregular cornea with a practical focus. The second section deals with management of the irregular cornea. The book is lavishly illustrated and has copious tables and summary sections. Each individual chapter is relatively brief and covers a particular topic comprehensively but succinctly. Any practitioner who wishes to explore how to detect and manage irregular astigmatism will find much of interest in this volume.

books editor: Seamus Sweeney publication Irregular Astigmatism: Diagnosis and Treatment Editors Ming Wang MD, PhD published by Slack INC. If you a have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

Review

JCRS Highlights Journal of Cataract and Refractive Surgery

Microincision toric IOLs for high astigmatism With precise planning and surgical technique, coaxial MICS and toric IOL implantation can offer safe, effective, predictable and stable correction of high corneal astigmatism during cataract surgery, report German surgeons. A recent study enrolled 30 patients (40 eyes) with mean preoperative keratometric cylinder of 3.55 ± 0.73 D, with a range of 2.64 to 5.39 D. All eyes underwent routine cataract extraction using 2.2mm coaxial phaco equipment and AcrySof toric IOLs. Examinations included optical biometry, Haigis IOL calculation, topography*/ and objective and subjective refractions. The mean three-month postoperative subjective cylinder was 0.67 ± 0.32 D. The mean logMAR uncorrected distance visual acuity improved from 0.93 to 0.20 and the mean logMAR CDVA, from 0.41 to 0.09. The mean prediction error (spherical equivalent) was +0.14 ± 0.44 D. The mean IOL rotation between one week and three months was 0.23 ± 1.9 degrees clockwise. The mean surgically induced astigmatism was 0.08 ± 0.41 D. The alignment error was below 10 degrees in 97.5 per cent of cases. The mean vector change in refractive cylinder between one week and three months was 0.31 ± 0.19 D. The Alpins correction index was +1.01, indicating a slight tendency toward overcorrection. n PC Hoffmann et al., JCRS, “Results of higher power toric intraocular lens implantation”, Vol 37, No. 8, August 2011, Pages 1411-1418.

Post LASIK dry eye

Does LASIK performed with a femtosecond laser produce less dry eye symptoms than standard LASIK using a mechanical microkeratome? A recent randomised study suggests that the answer is no. Researchers at Stanford University compared the two LASIK approaches in a fellow eye study involving 51 patients. Patients underwent wavefront-guided LASIK using a Hansatome (Bausch + Lomb) in one eye and a femtosecond laser keratome (Intralase AMO) in the fellow eye. A review of dry-eye questionnaires conducted preoperatively and one, three, six, and 12 months postoperatively revealed no statistically significant differences in self-reported dry-eye symptoms between the two groups, except during the first month. The dry-eye score was 1.3 points lower in women than in men (P=.01). Central ablation depth, flap thickness and age did not appear to significantly affect the reported dryness. EUROTIMES | Volume 16 | Issue 10

n L

Golas et al., JCRS, “Dry eye after laser in situ keratomileusis with femtosecond laser and mechanical keratome”, Vol 37, No. 8, August 2011, Pages1476-1480.

One million cataract surgeries

With a national cataract registry in place since 1992, Sweden is uniquely positioned to follow long-term trends in cataract surgery. A new review summarises data collected by the registry on more than one million cataract procedures. Between 1992 and 2009, the rate of cataract surgery rose from 4.47 to 9.00 per 1,000 inhabitants. The mean patient age increased until 1999 but has slowly decreased since then. Preoperative visual acuity has risen steadily. The distribution between the sexes was stable until 2000, after which the proportion of women slowly decreased. Registration of subjective benefit has brought new knowledge regarding indications and expectations. An improved questionnaire, Catquest-9SF has been used since 2008. The outcome register generally shows good results from the surgery. Induced astigmatism has declined over the years, which the researchers attribute to the transition from extracapsular technique to standard incision phacoemulsification and small incisions with foldable IOLs. Endophthalmitis has decreased from 0.10 per cent to below 0.040 per cent. The researchers suggest that the registry data should serve as benchmarking for further improvement. n A Behndig et al., JCRS, “One million cataract surgeries: Swedish National Cataract Register 1992–2009”, Vol 37, No. 8, August 2011, Pages 1539-1545.

Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and jcrs journal ad versario 120x300 ENG 1108v1 agh euro times.indd 1

31.08.11 09:17

Feature

eye on travel

LINGER FOR LONGER There’s more to explore in Prague after – or before – the ESCRS winter meeting by Maryalicia Post

hether you’re into art, architecture, literature or even cars, few places can rival the capital of the Czech Republic.

Time stands still in the Grand Cafe Orient

Kafka astride a headless man in Prague’s Jewish Quarter

EUROTIMES | Volume 16 | Issue 10

Check-out Czech cubism Between 1910 and 1914, Prague more than held its own in the world of cubism. Artists like Braque and Picasso defined the genre in Paris, but Czechs led the way at home in a movement which influenced furniture, textiles, graphics – and architecture. The present Czech Republic was the only country in Europe in which cubism was expressed in building design. Its first cubist building was a department store, the House of the Black Madonna, on Celetna Street in Prague’s Old Town. The restored building now houses the Museum of Czech Cubism. Two floors are devoted to Czech cubist artists such as Emil Filla and Otto Gutfreund. Open daily from 10:00 to 18:00. Closed Mondays. The Grand Cafe Orient on the building's first floor recently reopened after years of disuse. Authentic period decor makes it, in itself, a monument to cubism. Open daily from 09:00 until 22:00 and from 10:00 on Sunday. There’s a pianist from 16:00 until 19:00 Wednesday through Saturday. A sophisticated shop on the ground floor, next to the entrance to the building, sells cubiststyle chinaware, jewellery, handbags and more. www.kubista.cz/en. Learn more about Mucha If you prefer curly to cubist, you’ll enjoy the work of one of the high priests of Art Nouveau, Alfonse Mucha. Born in Brno, near Prague, it was his achievements in Paris that brought him fame. Although he is probably best known for his posters for Sarah Bernhardt, there’s more to Mucha than that. Exhibiting his paintings and notebooks, plus photographs of himself and family (including a mistress) the small but comprehensive Mucha Museum also presents a 30-minute documentary film on his life and work. The museum has a large gift shop with Art Nouveau-themed wares. Enjoy a coffee and homemade cake in the coffee rooms of the nearby Municipal House on Republic Square. This explosion of Art Nouveau design and decor incorporates murals and windows by Mucha. Many of the rooms can only be seen on a tour. Times of tours vary, but are posted on the website: www.obecnidum.cz. Mucha’s window in the St Vitus Cathedral in Prague's Castle area is another of the city's treasures.

Wonders on wheels at the National Technical Museum

Connect with Kafka

The existentialist writer Franz Kafka is one of Prague's best-known sons. Between the two World Wars, his was a despairing existentialist voice; 'Kafkaesque'- became a label for a nightmarish or surreal situation. The long-term exhibition, “the City of K Franz Kafka and Prague,” opened in 2005 in the old Herget Brickworks on the Mala Strana bank of the river not far from the castle. Its aim is “to explore the city from Kafka's point of view,” to reveal the link between the claustrophobic Prague of Kafka's youth and his work. Besides letter, manuscripts, photographs and drawings, there are 3-D installations, five audiovisual pieces - and mood music. Open daily from10:00-18:00. For more details, visit: www.kafkamuseum.cz. The installation in front of the Kafka Museum is by one of Prague's more controversial contemporary sculptors, the provocative David Cerny. Two large metal men, their bodies moving realistically, urinate into a basin shaped like the Czech Republic. The stream supposedly “writes” quotes from famous Prague residents on the surface of the water, though that’s a detail that's hard to verify. You can send a text SMS to a number displayed on the fountain and they will write your message. Another of Cerny’s works, “St Wenceslas Riding a Dead Horse,” hangs from the ceiling of the Art Nouveau Lucerna passageway connecting Vodickova and Stepanska streets. There's a statue of Kafka in the Jewish Quarter on a small plaza between a church and the Spanish Synagogue. It was unveiled in 2003, 80 years after Kafka's death. An enormous bronze by Joroslav Rona, it was

inspired by a Kafka's short story, “Depiction of a Struggle.” The bronze shows a small man astride the shoulders of a very large headless man; the smaller man is Kafka.

Magic in the motion After four years of renovation Prague's National Technical Museum reopened in February 2011 with over 50,000 items on display. Airplanes, automobiles, motorbikes and steam engines are accessed from the entrance floor; military vehicles are in the basement. The top floor is dedicated to architecture and industrial design. Permanent exhibitions include the history of transport, printing and astronomy while the section devoted to the development of the camera and of photography features a mock-up of an oldfashioned photographer's studio. The museum is in a hard to reach location near Letna Park but a taxi from the Hilton Prague gets you there in about 15 minutes. Open Tuesday through Sunday from 10:00 to 18:00 and until 20:00 on the first Thursday in the month. Closed on Mondays. For details, visit: www.ntm.cz. Taxi Tip

Even locals avoid taking a taxi from a rank or hailing one on the street in Prague. To avoid the risk of a driver who might cheat you on a fare, telephone a cab from a reputable company. Two recommended services are: AAA taxis at: +420-222-333-222 and Profi taxis at +420-261-314-151. The dispatcher requires an exact address for the pickup. Try naming a nearby shop, restaurant, or hotel.

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Feature

eu matters

learning curve

In hard economic times, ongoing review of clinical mistakes best way forward by Paul McGinn

f any ophthalmologist still doubts the value of history – or proper planning – to reduce clinical errors, she or he should consider the latest report from the UK’s Royal College of Ophthalmologists. According to the report, which was published over the summer, clinical errors, or “patient safety incidents” as they are now called, will be greatly reduced if ophthalmologists continually review their practice – and mistakes – and use such tools as clinical guidelines and preoperative checklists to reduce the risk of future mistakes. “Get the fundamentals of quality and safety care correct, such as having adequate provision of capacity for demand; focus on reducing healthcare associated infections and wrong site/implant surgery. This is critical at all periods but is vital in times of economic pressures as the subsequent costs of such failures are significant,” read the report, which was authored by Simon P Kelly FRCOphth. Mr Kelly, writing on behalf of the Quality and Safety Group of the college’s

Professional Standards Committee, stressed that future mistakes can be avoided only if we continually ask ourselves why they happened before. “The process of reviewing incidents is central to incident reporting systems,” Mr Kelly wrote. “It involves gathering information about ‘what happened’ to understand ‘why it happened.’ By definition, such learning is a reactive and reflective process. Clearly, this is an essential step prior to developing solutions to prevent errors recurring.” Statistics from the US and UK indicate that a patient safety incident occurs in as many as 10 per cent of hospital admissions. And, of course, ophthalmologists are not immune from such mistakes, either. According to the UK’s National Patient Safety Agency, doctors, nurses and other health practitioners in the NHS have recorded some six million incidents over the last decade. Of those, some 30,000, or about 0.5 per cent of all such incidents, involved an ophthalmology patient.

Rome

To help reduce the risk of clinical errors in surgery, the World Health Organization in 2009 introduced a worldwide programme called “Safe Surgery Saves Lives,” which was based on a preoperative safety checklist that included 19 steps. That landmark checklist, which is available at: www.who.int, was highlighted in this column in March of 2009. This column, in the April 2009 issue of EuroTimes, also focused on a similar presurgery checklist specifically endorsed by the American Academy of Ophthalmology. Noting that the WHO surgery checklist needed to be adapted to ophthalmology, the Royal College worked with the UK patient safety agency to develop a safety checklist designed for cataract surgery and aimed at reducing the risk of an ophthalmologist inserting an incorrectly powered IOL. The UK cataract safety checklist, like the WHO and AAO checklists, emphasises communication and cooperation between all members of the surgical and anaesthetic team to ensure not only that the correct patient gets the correct IOL but also that the team is prepared for most any eventuality during and after the cataract operation. The latest version of the cataract surgery checklist is available at: www.nrls.npsa.nhs.uk. Mr Kelly noted that only by reviewing clinical incidents can ophthalmologists and the clinics in which they practise prevent mistakes from recurring. Review of incident reports in the UK has revealed that the risk of deteriorating sight and blindness could be reduced if clinics,

2nd EURETINA Winter Meeting ‘Innovation in Management of Retinal Disease’

Rome Cavalieri Waldorf Astoria Hotel

Saturday 28 January 2012 Poster submission deadline: 15 October 2011

For more information go to www.euretina.org

EUROTIMES | Volume 16 | Issue 10

hospitals and ophthalmologists looked more closely at the manner in which they treat a number of conditions. For instance, despite the availability of effective treatment and guidelines, many patients are still going blind from glaucoma simply because of delays in follow-up appointments. Because of such delays at least 13 patients lost their sight entirely and another 31 patients suffered irretrievable sight deterioration over a four-year period. In addition, incident reports involving patients with wet age-related macular degeneration (AMD) suggest that treatment with therapies targeting vascular endothelial growth factor is often delayed, according to the Royal College report. Against that background, the college has produced a host of clinical treatment guidelines for ophthalmic practice. Those guidelines are available from the college’s website at: www.rcophth.ac.uk. The Royal College isn’t the only institution to produce guidelines that improve quality and promote safety in cataract surgery. The ESCRS Guidelines on Prevention, Investigation and Management of Post-Operative Endophthalmitis, were released in 2005 and updated in 2007. There is no doubt that many patients have avoided blindness – and ophthalmologists avoided lawsuits – because of those guidelines. Mr Kelly added that the success of any programme to reduce errors depends on individual ophthalmologists assuming a leadership role in improving quality and safety.

Feature

industry news

Recent developments in the vision care industry

SCHWIND announces record sales

Rolf Schwind

SCHWIND eye-tech-solutions say growth in the Asian market has helped to produce a record growth in sales revenue in the fiscal year 2010/2011. The company generated sales revenues of around €34m (2009/2010: €26m). This corresponds to an increase in turnover of 31 per cent and ensures the highest growth rate in its history, according to the company. “An important success factor for the pleasing business development was the expansion of the technologically leading SCHWIND AMARIS product range,“ said Rolf Schwind, SCHWIND CEO.

23g laser endoscope

Endo Optiks has announced the introduction of a triple-function 23g laser endoscope which is now for sale internationally. “Endo Optiks is very pleased to have developed, with the support of its Medical Advisory Board of Retina Specialists, the first triplefunction 23g laser endoscope,” said Steve Kohn, co-founder and CEO of Endo Optiks. “With laser light and a quality image in a 23g cannula, this novel device will fit through all standard 23g trocar systems,” he said.

One Use-Plus

Moria has extended its One Use-Plus range by introducing the 110 Large-Cut head for creation of 110-120-micron planar flaps. Moria says large-cut heads and rings create greater diameter LASIK flaps than do their standard counterparts. “The flaps are suitable for excimer treatments requiring a large ablation zone such as hyperopic LASIK, presbyLASIK and wavefront-guided treatment,” said a Moria spokeswoman.

Ready-Use syringes

The intraoperative tamponades F-Decalin and F-Octane can now be obtained from Geuder in ready-use syringes for sterile handling. “This new format considerably reduces both preparation and waiting time as the PFCLS no longer need to be drawn from a vial into a syringe,” said a Geuder spokeswoman. “Furthermore, the ergonomically formed flange of the syringe promote user-friendliness by making the injection of the PFCLS easier and safer,” she said.

EUROTIMES | Volume 16 | Issue 10

2nd world congress of paediatric ophthalmology and strabismus 7-9 september 2012 www.wcpos.org

Reference

Calendar of events Dates for your Diary

October

6-7

2011

DUBLIN, IRELAND

13th International Paediatric Ophthalmology Meeting Dublin

13-16

22-25 FL, USA

ORLANDO,

American Academy of Ophthalmology Annual Meeting www.aao.org

SEOUL, KOREA

2011 APACRS-KSCRS Annual Meeting www.apacrs.org

November

February

2011

2012

prague, czech republic

3-5

12-13

1-4

23-26

MILAN, ITALY

9-10

91st SOI National Congress www.soiweb.com

February

January 2012

13-15

Athens, Greece

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

rome, ITALY

2nd EURETINA Winter Meeting www.euretina.org

June

10th EGS Congress www.eugs.org

World Ophthalmology Congress www.woc2012.org/

23-25

rome, italy

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

2012

Nurnberg,

germany

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

17-22

16-20UAE

abu dhabi,

July

2012

14-17

2012

Copenhagen,

Denmark

22-27

berlin,

germany

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

2011

DUBLIN, IRELAND

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

16th ESCRS Winter Meeting www.escrs.org

December

March

Zurich,

Switzerland

7th International Congress of Corneal Cross-Linking www.cxl-congress.org

2012

10-11

Mainz,

Germany

16-17

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

April

2012

Frankfurt Retina Meeting www.eckardt-frankfurt.de

vienna, austria

Belgrade, Serbia

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

Miami, USA

2nd EuroLam Macula and Retina Congress www.euro-lam.org

September

MILAN, ITALY

6-7 7-9

2012

3rd EuCornea Congress www.eucornea.org

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

2012

6-9 8-12

12th EURETINA Congress www.euretina.org

XXX Congress of the ESCRS www.escrs.org

Advertising Directory: Abbott Medical Optics Page: IFC; Alcon Laboratories: Pages: 45, OBC, Angiotech Page: 37; ASCRS / Eyeworld Pages: 33, 40-41; Bausch + Lomb Page: 28; Benz Research and Development Page: 21; Carl Zeiss Meditec AG Page: 19; Croma-Pharma Page: 43; D.O.R.C International BV Page: 6; ESASO Page: 34; European Glaucoma Society Page: 38; Haag-Streit International Page: 13; Katena Products Inc Page: 8; Khairabad Eye Hospital Page: 26; Medicel AG Page: 36; moria Pages: 18, 31; NIDEK Page: 27; Oculus Optikgeraete GmbH Page: 25; Oertli Instruments AG Page: 7; OPKO Instrumentation Page: 9; Rayner Intraocular Lenses Ltd Page: IBC; S.I.TRA.C. Page: 24; Technolas Perfect Vision Page: 23; VSY Biotechnology Page: 3; Ziemer Ophthalmic Systems AG Page: 11

RAYNER IOL experts, the world over.

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Sulcoflex For when perfection is the only option

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• The opportunity of multifocality to pseudophakic monofocal patients with

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superb centration and stability • Excellent biocompatibility of Rayacryl® with the uveal tract

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Sulcoflex ® Pseudophakic Supplementary IOLs are exclusively designed in collaboration with Professor Michael Amon (Vienna, Austria). Note: Sulcoflex® Pseudophakic Supplementary IOLs are not yet approved for sale in the US and Canada. 09/11 Copyright Rayner Intraocular Lenses Limited.

Cataract Surgery Will Change in a Femtosecond.

With Alcon’s LenSx® Laser, the Possibilities Have Just Begun.

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

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