Volume 16_Issue 6 by EUROTIMES

VOLUME 16 ISSUE 6 JUNE 2011

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ESCRS

EUROTIMES

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JUNE 2011 Volume 16 | Issue 6 This month... Special Focus Glaucoma 4

Cover Story: Research can help to find improved treatments for patients

Cataract surgery and glaucoma patients

Prostaglandins and SLT?

Study highlights valuable information on disease progression

Cataract & Refractive

New device offers a promising new alternative for presbyopia correction

Refractive enhancement after IOL implantation can be effective, study shows

Shallow anterior chambers and cataract surgery

Vertical gas breakthrough a rare complication of refractive surgery

Bilateral cataract surgery infection

Good results shown with new lens for astigmatic cataract patients

Lessons can be learned from keratitis outbreak in Japanese clinic

Cornea 23

New treatment solution for blepharitis

Assessment risk for keratoconus

Retina

Myopic eyes and retinal disorders

Retinal detachment surgery options

News 34

ESCRS supporting Oxfam project in Uganda

AMD and Retina Congress preview

EUREQUO showcases the enabling power of technology

Features 40

Bio-Ophthalmology

Book Review

Industry News

44, 45, 47 Journal Watch

40 editorial staff

ESCRS

EUROTIMES

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

Practice Development

EU Matters

JCRS Highlights

Eye on Travel

Calendar

CORRECTION Research conducted by Prof Thomas Kohnen and colleagues at Goethe University, Frankfurt am Main, Germany on nanosecond pulses for tissue separation was mistakenly attributed to Dr Theo Seiler, in our Refractive Laser Cover Story, Volume 16 issue 3, EuroTimes. Where errors occur it is the policy of EuroTimes to correct them.

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

Cover Image: Blue light tonometry is used to measure intraocular (eye) pressure. Elevated eye pressure is a risk factor for glaucoma. Credit: National Eye Institute, National Institutes of Health

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.

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

GUEST EDITORIAL

Medical Editors

Volume 16 | Issue 6

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

ESCRS GLAUCOMA DAY

Vienna programme reflects unprecedented interest in glaucoma surgery

by Keith Barton

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

lthough a glaucoma day has been an integral part of ASCRS congresses for some years, there has not been an ESCRS equivalent until now. Over the last few years, the success of the ASCRS Glaucoma Day and an increasing interest in glaucoma at ESCRS congresses has made the formation of an ESCRS Glaucoma Day an obvious step forward. It is timely that the first ESCRS Glaucoma Day will take place this year in Vienna on Friday September 16, 2011 during a time when there has been unprecedented interest in glaucoma surgery and for that reason the flavour of the day will be almost exclusively surgical, with one notable exception, the Dimmer Lecture by Prof Wolfgang Drexler. The programme has been developed by the European Glaucoma Society (EGS). We have tried to provide a balance across the surgical spectrum from traditional procedures to those that are newer. In that respect we hope that the programme will represent the spectrum of glaucoma practice in Europe which is perhaps more varied than that in the US. The programme will commence with preoperative preparation and decision-making by Dr Susanna Duch (Spain) and Prof Thierry Zeyen (Belgium). The first main session, chaired by Prof Roger Hitchings (UK) and Dr Anton Hommer (Austria) will discuss laser procedures and some of the newer devices, including trabeculoplasty, iridoplasty, pigment dispersion, as well as glaucoma, the implications of glaucoma as a comorbidity when performing laser refractive surgery. After a break for coffee, the session on aqueous shunts and trabeculectomy will be chaired by Francisco Goni (Spain) and myself. In this session, we will discuss five-year data of the tube versus trabeculectomy (TVT) study that was recently presented at the American Glaucoma Society. This session will also discuss potential enhancements to trabeculectomy such as the Express implant and the use of anti-VEGF antibody therapy to enhance filtration surgery. The first session after lunch will be chaired by Tarek Shaarawy (Switzerland) and Nitin Anand (UK) and will cover deep sclerectomy, canal procedures and trabectome. EUROTIMES | Volume 16 | Issue 6

The highlight of the day will be the only non-surgical talk. As we are in Vienna, the named lecture will be the Dimmer Lecture, to honour the ophthalmologist of that name (1855-1926) who practised in Vienna. The Dimmer lecturer, Prof Wolfgang Drexler, is well-known for his astonishing high-technology presentations that bring the complex science of optical coherence tomography to a level that the ophthalmologist can readily understand. Arguably, of all the recent developments in imaging, OCT has the greatest potential in the long-term detection of structural progression in glaucoma. The meeting will conclude with a final session on combined procedures, angle-closure glaucoma and cyclophotocoagulation. Although this is only the first ESCRS Glaucoma Day, it is our hope that the day will prove interactive with plenty of lively discussion and cover all of the areas of glaucoma surgery that might interest ESCRS delegates.

KEITH BARTON Keith Barton MD, FRCP, FRCS, is programme co-chairperson with Anton Hommer, Vienna, for the ESCRS Glaucoma Day, Friday September 16, 2011.

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Joseph Colin FRANCE Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA 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 Rudy Nuijts THE NETHERLANDS Thomas Neuhann GERMANY Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

GLAUCOMA

Glaucoma in focus

Growing understanding of disease processes offers hope of better treatments by Roibeard O’hEineachain

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Health purchasers will see this as an impetus to change the way things are being done, with more and more patients being moved out of hospitals into clinics

Keith Barton MD, FRCP, FRCS Moorfields Eye Hospital, London, UK

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In published literature, there is little difference in the diagnostic precision between instruments, but in general the OCTs tend to do slightly better than HRT and GDx

David Garway-Heath MD Moorfields Eye Hospital, London, UK

EUROTIMES | Volume 16 | Issue 6

laucoma is a disease whose aetiology remains unknown, whose pathophysiology is poorly understood and whose diagnosis is often uncertain until it has progressed to the point that changes are occurring in patients’ vision. Yet research continues to shed light on the mysterious condition and bring hope of improved treatments and better outcomes for patients. According to the World Health Organization (WHO), glaucoma is the leading cause of preventable irreversible blindness worldwide. Roughly 70 million of the world’s population are affected by glaucoma, and according to most epidemiological studies, 50 per cent are undiagnosed. Population studies indicate that around 10 per cent of patients diagnosed with glaucoma will go blind bilaterally and 20 per cent will go blind unilaterally after 20 years. The ageing of the European population makes the need for improved diagnosis and treatment for glaucoma all the more urgent, Keith Barton MD, FRCP, FRCS, Moorfields Eye Hospital, London, UK, told EuroTimes in an interview. The prevalence of glaucoma is roughly one per cent among people aged 40 years, four per cent among people aged 80 years. According to current projections, one third of the European population will be over 65 years old by the year 2050, and around 10 per cent will be over 80 years old, he said, adding: “These are the people who are going to be getting glaucoma and countries with relatively few hospitals are going to be overwhelmed by people. Health purchasers will see this as an impetus to change the way things are being done, with more and more patients being moved out of hospitals into clinics. However, we may find in the end that while it is laudable to bring care into the community in this way, in order to be efficient and less expensive, to have satellite clinics dealing with high volumes

of patients networked with local hospitals using a central database,” he added.

Diagnosis by structure and function The technologies used for

diagnosing glaucoma are in general designed to detect either structural changes in the optic nerve or functional changes in terms of a reduced visual field. However, there are numerous factors that limit the confidence with which glaucoma specialists can determine either of those findings in early disease. The structural tests range from the ‘gold standard’ stereo optic disc photograph to the more objective technologies that are quickly gaining acceptance in the glaucoma specialist’s diagnostic armamentarium. Those technologies include the Heidelberg Retinal Tomograph (HRT, Heidelberg engineering) which is a scanning laser ophthalmoscope and the GDx Nerve Fiber Analyzer (Carl Zeiss Meditec), which is a scanning laser polarimeter. There are also optical coherence tomographers such as the Stratus OCT (Carl Zeiss Meditec) which is fast becoming obsolete, and the more modern spectral-domain OCTs (Carl Zeiss Meditec, Optovue, Heidelberg Engineering, Topcon). All of the devices are designed to provide objective measurements of the optic nerve and/or the peripapillary region and all have accompanying software for comparing their measurements with normative databases. “In published literature, there is little difference in the diagnostic precision between instruments, but in general the OCTs tend to do slightly better than HRT and GDx. However, good quality images can be obtained in a very high proportion of unselected individuals with the HRT, but in fewer white Europeans with the GDxVCC. There are few data in this respect for the GDxECC or OCTs,” said David GarwayHeath MD, Moorfields Eye Hospital. The HRT has the longest pedigree and,

therefore, there are more publications concerning the ability of the HRT to identify and quantify progression. The HRT may identify elements of progression relating to the retinal nerve fibre layer (RNFL) and optic disc architecture (such as lamina cribrosa position). There are reports demonstrating the application of GDx and OCT for measuring RNFL loss over time in glaucoma, he added. Standard automated perimetry (SAP) is currently the gold standard for visual field testing. Several new types of perimetry have become available over the past decade that are designed to detect visual field changes more sensitively, such as short wave automated perimetry and frequency doubling technology. There are also now devices available which measure the functionality of the optic nerve through the use of visually evoked potentials. There is, however, little or no good quality evidence that these technologies perform any better than SAP. A new functional test currently under development, called the Moorfields Motion Displacement Test (MDT), which can be performed with a laptop computer, has been shown to perform better than other vision function tests and the HRT a pilot case detection study for glaucoma (Artes et al, ARVO e-abstract 4080).

Matching structure to function

There is a clear correspondence between structure and function across the spectrum of glaucoma. However, in many of the larger studies that have charted glaucoma progression over several years, structural changes have occurred before detectable visual field changes and vice versa, with only a small overlap where both structure and function change together. This apparent discrepancy may result from measurement artefacts from the relatively short follow-up of the studies compared to the sometimes decades-long disease process of glaucoma, Dr Garway-Heath told EuroTimes. Numerous factors can weaken the

IOP a moving target

Currently, all treatments for glaucoma are aimed at reducing IOP. The results of several large studies indicate that reducing IOP in patients with ocular hypertension and glaucoma significantly reduced the risk of glaucomatous changes to the optic nerve or changes in the visual field. The studies have also shifted the goalposts with regard to the level of IOP reduction that physicians should aim for. For example, in the Ocular Hypertension Treatment Study (OHTS) the patients in the medication group had received therapy adequate to reduce IOP to 25 mmHg or lower and by at least 20 per cent from baseline. However, the results of the Advanced Glaucoma Intervention Study (AGIS) indicate that an IOP below 18.0 mmHg is a more effective target. Moreover, the results of the Early Manifest Glaucoma Trial (EMGT) indicated that the risk of disease progression could be reduced by 10 per cent for every 1.0 mmHg of IOP reduction. Accurate measuring and monitoring of IOP is therefore essential for titrating therapy and assessing treatment efficacy. However, current approaches to IOP measurement and monitoring may fall short of the standard necessary to determine a patient’s true level of IOP control, Robert N Weinreb MD, told EuroTimes in an interview. “Clinical management at the current time consists of a single measurement of intraocular pressure in the office which EUROTIMES | Volume 16 | Issue 6

Visual field test result

Visual field predicted from GDx image

Concordance map

Courtesy of David Garway-Heath MD

association between structure and function in the short term, including factors that are unrelated or indirectly related to neuronal loss in the optic nerve head, he said. “Factors other than retinal ganglion cell number can cause changes in both structure and function. For example, visual field tests can be confounded by media opacity from cataract, retinal pathology, and subject inattention during the test. Similarly, retinal nerve fibre layer measurements may contain non-axonal tissue, such as glial tissue and blood vessels, and neuroretinal rim measurements in the optic nerve head, in addition to containing non-axonal components, may be affected by glaucomatous changes to the lamina cribrosa,” he added. Retinal anatomy needs to be considered when relating structure and function measurements. Although an average map relating visual field test locations to optic nerve head sectors (Garway-Heath et al, Ophthalmology. 2000:107(10):1809-15) performs well, individuals may vary from each other in the precise retina/optic nerve head correspondence. A new technique to predict visual function from structure measurements, RNFL thickness (RNFLT) measurements from GDxVCC, has shown good results diagnose glaucoma (Zhu et al, IOVS 2010). “The technique may enable structure and function measurements to be used together more effectively in the clinical routine, both to diagnose glaucoma and monitor its progression, something that it difficult at present. The same technique can be used to assess structure/function concordance (Zhu et al Arch Ophthalmol 2011, in press), which can highlight to clinicians good (concordant) and poor (discordant) data,” he said.

The structure/function concordance map shows regions of good concordance (small squares) and highlights regions of discordance (large squares). In this example, the GDx nerve fibre layer thickness measurements predict better visual function than that seen in the actual visual field (large green squares)

means that the vast majority of the time the level of IOP is not known. We have demonstrated in several studies that peak IOP occurs outside of office hours in at least two thirds of healthy patients and glaucoma patients,” said Dr Weinreb, University of California, San Diego, La Jolla, California. As a result, the peak IOP of many patients with glaucoma would go undetected, and could only be ascertained with 24-hour monitoring. To that end there are now several technologies under development such as contact lens-based and implantable devices, and self-tonometry devices are already available in clinical investigations. “The prospect of 24-hour monitoring gives us the opportunity to personalise IOP measurement,” he said. Dr Weinreb noted that variations among glaucoma patients in terms of their 24-hour IOP patterns could have very important clinical implications. The different pharmacologic agents and surgical procedures used for controlling IOP in glaucoma patients have different effects on 24-hour pressure, he said. He pointed out that while the prostaglandin analogues and carbonic anhydrase inhibitors are effective in controlling IOP at day and night, the beta-blockers and alpha agonists are only effective during the day. He added that 24-hour monitoring could reveal important clues regarding what aspects of IOP are more important in the glaucoma disease process. “At the current time we don’t fully understand the relationship between IOP and the progression to glaucoma. By being able to have a broader understanding of IOP throughout the 24 hour day we should be able to ascertain which IOP parameters are

most relevant and are the ones that are most important to treat, whether it is the peak IOP, mean IOP, the area under the curve, the degree of variation, or all of them,” Dr Weinreb said. Research in recent years has revealed additional risk factors for glaucomatous disease, he noted. They include ocular perfusion pressure, which is calculated by subtracting IOP from systemic blood pressure, and intracranial pressure, which is derived from cerebral spinal fluid pressure measured through lumbar punctures. These findings may help explain why the condition progresses in some patients despite good IOP control, Dr Weinreb added. “There appears to be a pressure dependent component in some patients and a pressure independent component in some patients. That is one of the reasons why the concept of neuroprotection, a treatment independent of IOP, to reduce glaucoma progression is so interesting,” he said.

Trabeculectomy a less predictable option The introduction

of prostaglandin analogues appears to have greatly reduced the need for surgery, however, for various reasons IOP remains elevated despite maximal therapy and when this occurs surgery becomes the chief option. The current surgery of choice is trabeculectomy, a procedure that, with a few modifications, is over a century old. It is the standard surgical treatment for open-angle glaucoma because most glaucoma surgeons find it is the most reliable means of bringing IOP down to target levels. However, the technique is not without its drawbacks. Because of its invasive nature it can

“

The prospect of 24-hour monitoring gives us the opportunity to personalise IOP measurement Robert N Weinreb MD

“

I am relatively certain in the near future that we won’t be looking beyond IOP we will be looking behind IOP...

Clive Peckar MSc, FRCS, FRCOphth

contacts

Cover Story

Courtesy of Clive Peckar

GLAUCOMA

Gonioscopic photograph showing polyamide implants in Schlemm’s Canal 10 years following ‘Bleb-Free Schlemm’s Canal Surgery’: IOP reduction from 40-15 mmHg, without medication

induce a high rate of cataract progression, flat anterior chambers leaking blebs and hypotony maculopathy and endophthalmitis rates up to 1.0 per cent. There are several alternative penetrating techniques available to surgeons which appear to result in similar reductions of IOP with fewer complications. For example, in the Tube vs. trabeculectomy study, the trabeculectomy group had significantly lower mean IOPs than the tube group during the first three months, but there was no difference afterwards. In addition, surgery with the Baerveldt tube resulted in a significantly lower failure rate than trabeculectomy (3.9 per cent vs. 13.5 per cent). Furthermore, significantly more patients in the trabeculectomy group (57 per cent) experienced postoperative complications than those in the tube group (34 per cent) during the first year of followup (p = 0.001). In order to reduce the risk of hypotony, tubes can be constricted, with an absorbable or releasable suture or fitted with a minimum pressure controlling valve, as in the Ahmed valve. In addition, non-penetrating techniques such as deepsclerectomy, reduce the risk of hypotony

by draining aqueous via a Descemet’s membrane which separates the anterior chamber from the sclerectomy flap. “It should be remembered, however, that trabeculectomy, tubes, valves and deepsclerectomy all work in the same way. They are all “bleb-dependent surgery” utilising a bleb, or fistula, which leaks under the conjunctiva draining aqueous away from the sub-conjunctival space, via the subconjunctival blood vessels. This makes them susceptible to bleb failure, from fibrosis, or you run the risk of bleb leakage, and possible endophthalmitis, following the use of anti-metabolites”, said Clive Peckar MSc, FRCS, FRCOphth, Warrington, UK. For that reason, some ophthalmologists favour “bleb-independent Schlemm’s canal surgery” designed to restore the natural outflow of aqueous, he told EuroTimes in an interview. Back in the 1990s Prof Robert Stegmann developed viscocanalostomy, a technique that involved the baring of Descemet’s membrane, to create a bypass of the diseased trabecular meshwork, into an intra-scleral lake, and direct drainage into a distended Schlemm’s canal, utilising high viscosity sodium hyaluronate. Whilst this technique did reduce complications,

Keith Barton - keith2barton@gmail.com David F Garway-Heath - david.garway-heath @moorfields.nhs.uk Robert N Weinreb - rweinreb@ucsd.edu Ananth C Viswanathan - a.viswanathan@ucl.ac.uk Clive Peckar - www.PeckarEyeClinic.co.uk

“The future of glaucoma treatment may take an entirely new direction as genome-wide association studies continue to make progress towards discovering the ultimate cause of disease” especially hypotony, it was criticised for not dropping the IOP as low as trabeculectomy. More recently, Prof Stegmann and his associates, have introduced a variation of this technique in which a microcatheter is used to open Schlemm’s canal for the full 360 degrees, and a suture, or stent, drawn thought the canal, to hold the canal open. In a study 157 eyes underwent the canaloplasty procedure mean IOP of 15.2 mmHg with patients using a mean of 0.8 medications compared to a mean IOP of 23.8 mmHg on a mean of 1.8 medications (Lewis et al, JCataract Refract Surg. 2011;37(4):682-90). The FDA approved the use of iScience catheter for canaloplasty procedures in 2008. However one of the criticisms the FDA voiced against the studies conducted using the technique is the lack of a control group. Proponents of the technique maintain that the benefits of the technique and its safety advantages over trabeculectomy are so obvious as to render a prospective study virtually unethical. However, recruitment is now under way for two large FDA studies, one sponsored by iScience, to provide such a comparison. The UK National Institute for Health and Clinical Excellence regards canaloplasty as a research procedure that should be used in the context of research or formal prospective data collection. The future of glaucoma treatment may take an entirely new direction as genomewide association studies continue to make progress towards discovering the ultimate

cause of disease. The studies involve the comparison of the entire genome of large populations of glaucoma patients with large populations of individuals without the disease and identifying slight variations from the normal gene sequence called single nucleotide tide polymorphisms in the gene sequence occurring more frequently in the disease population, said Ananth Viswanathan MD, PhD, Moorfields Eye Hospital/UCL Institute of Ophthalmology, London, UK, at the 9th European Glaucoma Society Congress. The studies so far suggest that glaucoma’s hereditary factors involve a complex interaction of a number of genes. An Australian group has found associations between variations in optic disc size and variations in the ATOH7 gene, which appears to play a key role in retinal ganglion cell formation (Macgregor et al, Hum. Mol. Genet. 2010; 19 (13): 2716-2724), said Dr Viswanathan, who is the principal investigator for glaucoma for the Wellcome Trust Case-Control Consortium (WTCCC) a research group conducting genome-wide association studies. “I am relatively certain in the near future that we won’t be looking beyond IOP we will be looking behind IOP because a number of groups are looking at the genetic basis of intraocular pressure and I think in the near future we will see some very interesting publications to do with how IOP is determined genetically,” he added.

PRAGUE 2012 16 ESCRS WINTER MEETING TH

3-5 February 2012

Hilton Hotel, Prague, Czech Republic

European Society of Cataract & Refractive Surgeons EUROTIMES | Volume 16 | Issue 6

www.escrs.org

HERE’S A DISCOVERY

Introducing DUOTRAV® Solution containing POLYQUAD® preservative. Provide your patients the powerful efficacy1-3 you want, with none of the BAK* they can do without. The first and only PG/BB fixed combination without BAK*, containing POLYQUAD® preservative *Benzalkonium chloride DuoTrav® 40 micrograms/ml + 5 mg/ml eye drops solution (travoprost and timolol maleate). Prescribing Information (Refer to full Summary of Product Characteristics (SmPC) before prescribing). Presentation: Plastic bottle containing 2.5ml eye drops. Each 1 ml contains 40 micrograms of travoprost, 5 mg of timolol (as maleate). Indication(s): Decrease of intraocular pressure (IOP) in adult patients with openangle glaucoma or ocular hypertension who are insufficiently responsive to topical betablockers or prostaglandin analogues. Posology and method of administration: Adults: including the elderly population: One drop once daily, morning or evening. Administer at same time each day. Children and adolescents: Not recommended. Use in hepatic and renal impairment: No dose adjustment necessary. Nasolacrimal occlusion after administration is recommended. If more than one ophthalmic medicinal product is being used administer at least 5 minutes apart. Instruct patients to remove contact lenses prior to use and wait 15 minutes after instillation before reinsertion. Contra-indications: Hypersensitivity to the active substances or any of the excipients. Bronchial asthma or severe chronic obstructive pulmonary disease. Sinus bradycardia, second or third degree atrioventricular block, overt cardiac failure or cardiogenic shock. Severe allergic rhinitis, bronchial hyper reactivity; corneal dystrophies, hypersensitivity to other beta-blockers. Warnings and precautions: Systemic effects: Cardiovascular and pulmonary adverse reactions as seen with systemic betablockers may occur. Cardiac failure should be adequately controlled before beginning therapy with timolol. Patients with a history of severe cardiac disease should be watched for signs of cardiac failure and have pulse rates checked. Respiratory and cardiac reactions, including death due to bronchospasm in patients with asthma and, rarely, death in association with cardiac failure, have been reported with timolol maleate. Betablockers should be administered with caution in patients subject to spontaneous hypoglycaemia or to diabetic (especially labile diabetes) patients as Beta-blockers may mask the signs and symptoms of acute hypoglycaemia. They may also mask signs of hyperthyroidism, and cause worsening of Prinzmetal angina, severe peripheral and central circulatory disorders and hypotension. Women who are pregnant or attempting to become pregnant should avoid direct exposure to the product. Anaphylactic reactions: While taking beta-blockers, patients with a history of atopy or severe anaphylactic reaction to a variety of allergens may be unresponsive to usual doses of adrenaline used in treatment. Concomitant Therapy: Effect on IOP or known effects of systemic beta-blockade may be potentiated when DuoTrav® is given to patients already taking oral beta-blockers. Use of two local beta-blockers or local prostaglandins is not recommended. Ocular effects: Travoprost may gradually change the eye colour. Unilateral treatment can result in permanent heterochromia. Change in eye colour occurs slowly. Predominantly seen in patients with mixed coloured irides and may increase brown iris pigmentation. Travoprost may cause periorbital and/or eyelid skin darkening. Travoprost may gradually change eyelashes (length, thickness, pigmentation and/or number of lashes). Use with caution in aphakic and pseudophakic patients with a torn posterior lens capsule or anterior chamber lenses, or in patients with known risk factors for cystoid

Date of preparation: April 2011.

macular oedema, or predisposing risk factors for iritis/uveitis. Contains Propylene Gycol may cause skin irritation. Contains polyoxyethylene hydrogenated castor oil 40 which may cause skin reactions. Interactions: No interaction studies performed. Potential for additive effects resulting in hypotension and/or marked bradycardia when eye drops with timolol are administered concomitantly with oral calcium channel blockers, guanethidine or beta-blockers, antiarrhythmics, digitalis glycosides or parasympathomimetics. The hypertensive reaction to sudden withdrawal of clonidine can be potentiated when taking betablockers. Betablockers may increase the hypoglycaemic effect of antidiabetic products and can mask the signs and symptoms of hypoglycaemia. Women of Childbearing Potential: Do not use unless adequate contraceptive measures are in place. Fertility: No data are available. Pregnancy: Do not use unless clearly necessary. Lactation: Not recommended. Effects on ability to drive and use machines: May blur vision. The patient should wait until vision is clear before driving or using machines. Undesirable effects: Very common: ocular discomfort, ocular hyperaemia. Common: nervousness, dizziness, headache, punctate keratitis, anterior chamber inflammation, eye pain, photophobia, eye swelling, conjunctival haemorrhage, visual acuity reduced, visual disturbance, vision blurred, dry eye, eye pruritus, conjunctivitis, lacrimation increased, erythema of eyelid, blepharitis, asthenopia, growth of eyelashes, heart rate irregular, heart rate decreased, blood pressure increased, blood pressure decreased, bronchospasm, urticaria, skin hyperpigmentation (periocular), pain in extremity. Serious: cerebrovascular accident, macular oedema, cardiac failure, uveitis, cerebral ischaemia, myasthenia gravis, cardiac arrest, respiratory failure. Prescribers should consult the SmPC in relation to other side effects. Overdose: Topical overdose with travoprost not likely to occur or be associated with toxicity. Most common symptoms of systemic timolol overdose are bradycardia, hypotension, bronchospasm and heart failure. Symptomatic and supportive treatment. Timolol does not dialyse readily. Legal Category: POM. Package Quantities and Basic NHS and GMS price(s): Costs: Cartons containing 1 x 2.5ml (£12.55, €18.38), 3 x 2.5ml (£35.70, €52.38), 6 x 2.5ml not marketed. MA Number(s): EU/1/06/338/001-003. Further information available from: Alcon Laboratories (UK) Limited, Pentagon Park, Boundary Way, Hemel Hempstead, Hertfordshire. HP2 7UD. Telephone: 01442 341234. Date of preparation: March 2011 (V6). Adverse events should be reported. Reporting forms and information can be found at www.yellowcard.gov.uk. Adverse events should also be reported to Alcon Laboratories (UK) Ltd. Tel.: 01442 341234. Email: gb.adr@alconlabs.com References: 1. Kitazawa Y for the travoprost 0.004%/timolol 0.5% BAK-free study group. Submitted for publication. 2. Barnebey HS, Orengo-Nania S et al. Am J Ophthalmol 2005; 140: 1-7. 3. Hughes BA, Bacharach J et al. J Glaucoma 2005; 14: 392-399.

DUO:EUR:04/11:HC

contacts

Update

Glaucoma

combining procedures

European Glaucoma Society discusses new studies on range of issues

Greater myopic shift after phacotrabeculectomy In

by Roibeard O’hEineachain in Madrid

ataract surgery can widen the iridocorneal angle, reduce IOP, and improve the visual field in glaucoma patients. Combining the procedure with trabeculectomy will lower IOP still further but will make the visual outcome of the surgery less predictable, according to studies presented at the 9th European Glaucoma Society Congress. In one of the studies, which involved a series of 35 eyes of 35 consecutive cataract patients, the iridocorneal angle was significantly increased and IOP significantly lowered after cataract surgery, said Alain Bron MD, Service d’Ophtalmologie, CHU Dijon, Dijon, France. “It has been shown in different studies that in some patients you can get a decrease in IOP while in other patients you can’t. However, nowadays we think that after a regular cataract extraction you may expect a decrease of 1mm or 2mm of mercury which is sustained over time,” he added. The patients in the prospective study had a mean age of 72 years. They included 11 patients with primary open-angle glaucoma (POAG), two with angle-closure glaucoma (ACG) and one with ocular hypertension. All underwent a coaxial MICS procedure and implantation of an intraocular lens in the capsular bag. At one month’s follow-up, OCT imaging (Visante®, Carl Zeiss Meditec) showed that the nasal angle had increased by a mean of 52 per cent compared to preoperative values, and that the nasal angle opening distances at 500 microns and 750 microns from the angle had increased by means of 75 per cent and 73 per cent, respectively. Similarly, the temporal angle had increased by a mean of 46 per cent and the nasal angle opening distances at 500 microns and 750 microns from the angle had increased by 70 per cent and 91 per cent, respectively. In addition, the mean IOP fell from a preoperative value of 16.7 mmHg to 14.0 mmHg, (p=0.001). Dr Bron noted that mean IOP remained at that level at six months’ follow-up. However, there was no statistically significant correlation between the amount the angle was opened and the postoperative reduction in IOP. EUROTIMES | Volume 16 | Issue 6

Mean

95% Confidence Interval of the Difference Upper Lower

MS-MSp

-1.63±3.65

-2.68

-0.583

0.03

MD-MDp

1.63±3.65

0.590

2.68

0.03

LV-LVp

0.723±10.90

-2.41

3.85

0.645

sLV-sLVp

0.138±1.31

-0.240

0.516

0.465

MS: mean sensitivity; MD: mean deviation; LV: loss variance; SLV: standard loss variance; p: post surgery

Average MD before and after cataract surgery for each of the 59 points explored, the Octopus TOP G1 visual field

Dr Bron noted that the increased opening of the iridocorneal angle is a result of the increase in anterior chamber depth that follows cataract extraction. In this study, the anterior chamber depth increased from 2.62mm to 3.66mm after cataract removal. There was a statistically significant correlation between the change in anterior chamber depth and axial length, but not between the change in anterior chamber depth and age or preoperative spherical equivalent, he said. “Cataract extraction leads to important changes of anterior segment configuration evaluated with anterior segment. In our series, all measured parameters showed an opening of the iridocorneal angle with wide variation among patients,” Dr Bron concluded.

Better visual fields after cataract surgery Another study presented at the

congress showed significant improvements in some visual field parameters following cataract surgery in patients with co-existing cataract and glaucoma. The study involved 49 patients (35 patients with glaucoma, seven patients with ocular hypertension and six normal subjects) who underwent cataract extraction and IOL implantation. All patients underwent visual field examinations with a TOP-G1 Octopus perimeter one month before and one month after the surgery. All had previous perimetric experience, said Jesus FraileMaya MD, Hospital Clinico San Carlos, Madrid, Spain. The researchers found that the patients’ visual fields had significant improvements in mean sensibility and mean deviation but not in loss variance. That is, the mean sensibility improved from 19.58 to 21.21 and the mean deviation improved from 6.47 to 4.83, but the change in loss

Alain Bron - alain.bron@chu-dijon.fr Jesus Fraile-Maya - jbenitez.hcsc@salud.madrid.org Isabelle Orignac - isabelle.orignac@chu-nantes.fr

variance, from 18.12 to 17.39 was not statistically insignificant, Dr Fraile-Maya said.

Courtesy of Jesus Fraile-Maya MD

another study presented at the Madrid congress, glaucoma patients who underwent phacotrabeculectomy had a significantly higher amount of unintended postoperative refractive error than those who underwent phacoemulsification alone, said Isabelle Orignac MD, CHU Nantes, Nantes, France. In the retrospective study 15 eyes underwent phacoemulsification and 17 eyes underwent phacotrabeculectomy. In this group, 35 per cent had POAG, 41 per cent had ACG, and 24 per cent had secondary glaucoma from pseudoexfoliation or pigment dispersion. All phacotrabeculectomies were twosite procedures with 3.2mm clear corneal incision for the cataract surgery and IOL implantation (AR 40, AMO) and limbalbased incision for the trabeculectomy procedures, using an anti fibrotic agent (5FU or mitomycin C) with peribulbar anaesthesia. Dr Orignac and her associates performed all biometry measurements with theIOLMaster (Zeiss). In the phacotrabeculectomy group, the postoperative refractive error varied from its predicted value by a mean of -0.99 D at one week and -0.61 D at one month. By comparison, in the phacoemulsification group the postoperative refraction varied from its predicted value by a mean of only +0.05 D at one week and +0.12 D at one month. Furthermore, all of the eyes in the phacoemulsification alone group were within 0.5 D of predicted refraction compared to only 35 per cent in the combined procedure group. Dr Orignac noted that phacotrabeculectomy was effective in reducing IOP, which fell from a preoperative mean of 24.5 mmHg to a mean of 9.3 mmHg at eight days postoperative and 13.7 mmHg at one month. There was no correlation between the decrease of IOP and the axial length or refractive error in phacotrabeculectomy group. “In common with reports in the literature, patients undergoing phacotrabeculectomy in our study were more likely to have a postoperative myopic shift and the refractive outcome was a little less predictable,” Dr Orignac added.

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o prostaglandins affect the outcomes of SLT? Contrary to traditional teaching that prostaglandins work by increasing uveoscleral outflow recent research strongly suggests they also increase aqueous outflow through the trabecular meshwork, said Mark Latina MD, Boston, US, who invented SLT. As a result, they do not complement and potentially interfere with SLT, he added. At the 2010 ASCRS Glaucoma Day, Dr Latina debated the question with Brian Francis MD, Los Angeles, US, who argued there is no conclusive evidence for interference. Despite their disparate readings of the literature and even their own research, both recommend aqueous inflow inhibitors and other medications over prostaglandins as the first choice for adjunct therapy after SLT. Dr Francis acknowledged that research by Dr Latina and Jorge Alvarado MD, San Francisco, US, suggests that prostaglandins and lasers have similar effects. Notably, a 2010 study by Dr Alvarado, (AJO in press) found that medium from SLTtreated trabecular meshwork cells and prostaglandins both increased the permeability of cultured Schlemm’s canal cells, apparently by opening up junctures between the cells, while inflow controlling compounds including timolol and brimonidine did not. Nonetheless, Dr Francis remains unconvinced that the two are mutually exclusive. “I could not find any clinical studies that supported the idea that prostaglandins adversely affect SLT outcomes.” He cited a recent retrospective study of 120 eyes comparing the influence of various classes of glaucoma medications on the success of SLT that found no statistical difference among them (Matrow et al. AJ Glaucoma 2010). “The only thing they found was a predictor of SLT success was preoperative IOP. They concluded that topical medications do not adversely or favourably affect SLT,” Dr Francis noted. Similarly, a study of 123 patients treated with 180 degree SLT, 74 of whom received prostaglandins afterward, found no differences at six months among those who received no meds, prostaglandins

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Prostaglandins

20.04.11 15:51:31

only, or combinations of prostaglandins and non-prostaglandins (Singh D et al. Eye 2009). Dr Francis’ own study of patients undergoing repeat SLT generated similar results, with no differences in SLT success found between those treated afterward with prostaglandins and non-prostaglandins. He also pointed out there are no prospective studies examining the relationships between prostaglandins and SLT success. Dr Latina found the lab evidence more compelling and suggested there is plenty of support in the clinical literature for overlap. Several prospective studies have found that 360-degree SLT is the functional equivalent of latanoprost (McIlraith I et al. J Glaucoma. 2006; 15: 124-230. Katz et al and the SLT/MED study group. Presented at AAO. November 2006). His own research has found that patients treated with prostaglandins prior to SLT are only about half as likely to respond to SLT as those treated with aqueous suppressants. “Our concern was that SLT and prostaglandins may share a common pathway and the effect of SLT may be masked by prostaglandins. And likewise, SLT may be affected by the prostaglandin cascade,” Dr Latina said. He cited research by Shin et al showing that prostaglandins do affect conventional outflow in normal eyes as further evidence of a common pathway. He also cited a study by Dr Alvarado that patients removed from prostaglandins before SLT saw pressures rise, but saw little or no further reduction when prostaglandins were reintroduced after SLT. The Singh retrospective study never stopped prostaglandins, so its impact is unknown, he pointed out. “We should use complementary mechanisms. My choice is to use inflow medicines first and prostaglandins last,” Dr Latina concluded. Dr Francis concurred. “I still use prostaglandins with SLT, but given the choice I would favour aqueous suppressants as a combination therapy with this outflow procedure.”

contacts Mark Latina - mark.latina2@verizon.net Brian Francis -bfrancis@doheny.org

contact

Anders Heijl - Anders.Heijl@med.lu.se

Update

Glaucoma

GLAUCOMA MANAGEMENT

Groundbreaking trial effected paradigm shift in disease control by Dermot McGrath in Paris

EUROTIMES | Volume 16 | Issue 6

to think that any progression was a reason for stepping up treatment, while we now use rate of progression to assess whether the patient is risking disability of loss of quality of life during his or her remaining lifetime.” Another of the intriguing findings of the EMGT results was the light it shed on possible predictors of the disease, said Dr Heijl. “It is true that most of the significant risk factors such as age, bilateral disease and exfoliation syndrome, were known or at least suspected before. It came as a surprise, however, that exfoliation syndrome was a strong risk factor independent of IOP. Most of us had probably believed that the higher risk of worsening in exfoliation glaucoma was due to higher IOP levels, not that exfoliation in itself more than doubled the risk independently of IOP,” he said. A follow-up of patients screened to recruit for EMGT also discovered that exfoliation

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“The study addressed – and still addresses – fundamental issues and, therefore, gave results that are of importance for glaucoma care,” believes Dr Heijl. “The EMGT results provide a stronger foundation for glaucoma care than we had before. We are on firmer ground. Critics can no longer come and say that glaucoma care should have low priority because we do not know whether treatment makes a difference – at least unless the intraocular pressure is very high,” he said. Dr Heijl believes that one of the principal benefits to emerge from the EMGT is that patients, physicians and nurses now know for sure that the pressure-lowering treatment that has been used for almost 100 years actually works. Furthermore, the trial confirmed that the treatment effects are significant, with a risk reduction of more than 10 per cent per mmHg and that further IOP reduction is meaningful if the IOP levels are within the statistically normal range. The study has also helped clinicians to devise treatment strategies for those patients at greatest risk. “I believe that EMGT results are a particularly important help in clinical situations where low-risk and easy medical treatment no longer is enough, but where we have to recommend more effective treatment associated with side effects and risks, particularly surgery or repeat surgery,” he said. In terms of glaucoma progression, EMGT demonstrated that rates of disease progression vary tremendously among patients, whether treated or untreated, and also showed that most glaucoma patients progress if followed for long enough, even if IOP levels are normal, said Dr Heijl. The significance of this can be gauged from the fact that the latest glaucoma guidelines issued by the European Glaucoma Society (EGS) recommended that assessing the rate of progression should be part of routine glaucoma care, and that visual field testing should be performed much more frequently during the first few years after diagnosis. “The rate of progression has become an important parameter and a key factor in being able to provide individualised glaucoma care,” Dr Heijl said. “The EMGT results are also behind the paradigm shift regarding glaucoma progression and treatment that we are seeing now. We used ESCRS

lmost a decade after the initial results of the Early Manifest Glaucoma Trial (EMGT) were first published, this groundbreaking study continues to yield valuable information on the progression and management of glaucoma. The EMGT was the first large, controlled, randomised clinical trial to evaluate the effect of lowering the intraocular pressure on the progression of newly detected, open-angle glaucoma (OAG). EMGT was initiated at the Department of Ophthalmology, Malmö University Hospital, the University of Lund. Later the Dept of Ophthalmology in Helsingborg, Sweden joined and the Dept of Preventive Medicine at Stony Brook University, New York became the data centre. EMGT compared glaucoma progression in patients initially randomised to treatment versus an untreated control group of patients with newly detected OAG and allowed quantification of the effect of immediate IOP-lowering treatment on progression during the followup period. Now widely acknowledged as one of the pivotal glaucoma trials of recent times, Anders Heijl MD, PhD, chairman of the Department of Ophthalmology at Malmö University Hospital, Sweden, and study director of the trial, told EuroTimes that the EMGT might never have taken place were it not for the determination of a committed group of researchers. “Any young and ambitious researcher or group of clinicians/scientists should not let sceptical remarks discourage them. When we planned EMGT, most fellow researchers said that such a study would be impossible: we would never be able to recruit, patients would not accept, ethics committees would not approve and funding would be impossible. We spent considerable time in the 1980s to prepare for EMGT. We started a randomised study on ocular hypertension, which did not show any significant differences between treatment arms after about 8 years, and we developed perimetric methods in order to be able to detect progression very early,” he said. Despite resistance from some quarters, persistence finally paid off and the EMGT trial was launched. To this day, it continues to yield important data and lessons for the management of glaucoma patients.

combined with ocular hypertension carries a large risk of manifest glaucoma. Nine years after the screening more than half of such patients had developed field loss, which was more than twice as often as ocular hypertensives without exfoliation syndrome, noted Dr Heijl. New predictors of glaucoma such as perfusion pressure and a positive cardiovascular history were not initially identified in the study, but emerged when the patients had been followed for another few years. “That to us indicates that those factors probably are less important than the stronger factors that came out right away, particularly IOP, exfoliation and age,” said Dr Heijl. While the EMGT has already made a major contribution to understanding and treating glaucoma, Dr Heijl believes that the study has not yet exhausted its potential to add new insights to the current evidence base. “We are still following the patient cohort and plan to continue follow-up as long as possible. The key issues here are impairment, blindness and quality of life. A very important question is whether delaying treatment until progression occurred in patients randomised to the untreated control arm will have an associated ‘cost’ – will there be more impairment, blindness and impact on quality of life during the patients’ life time in the initially untreated group?” he asked.

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Update

CATARACT & REFRACTIVE

Multifocal Ablation

Second-generation presbyopic LASIK offers promising outcomes

Courtesy of Cyres Mehta MD

by Dermot McGrath in Crete

PresbyMax with an add of +2.50 D

ultifocal ablation profiles generated with the PresbyMax (Schwind eyetech-solutions) system yield safe and predictable outcomes in selected patients and offer a promising new surgical alternative for the correction of presbyopia, according to Cyres Mehta MD. “While this is not the so-called ‘Holy Grail’ for presbyopia that we have been waiting for, PresbyMax is nevertheless a definite step forward from first-generation presbyopic laser techniques. This is the first systematic and scientifically based approach for the correction of presbyopia with an excimer laser and is an excellent option for the compensation of initial and intermediate presbyopia in patients with spherical equivalent between + 4.00 D and 4.00 D,” Dr Mehta told delegates attending the Aegean Cornea X meeting. Dr Mehta emphasised, however, that PresbyMax is not a ‘silver bullet’ solution for all presbyopic patients and should not be oversold in terms of the results that patients could expect to achieve with such technology. “It is essential to manage patients’ expectations with this technology. In our clinic, patients are specifically informed that their distance vision is likely to be slightly compromised and will recover in about two months. In higher dioptric powers they need to accept the compromise of good near vision for a slightly hazy distance vision. Patients may also require EUROTIMES | Volume 16 | Issue 6

sunglasses for distance vision in bright light conditions especially for driving. However, patients will see better for near vision in a bright light setting. Finally, we warn them that it takes time for the brain to adapt to the new set-up, so the patient should be prepared to give two to four weeks for the adaptation process,” he said. Reviewing the evolution of PresbyMax, Dr Mehta noted that Schwind developed the innovative software in cooperation with Vissum Eye Institute in Alicante, Spain, under the direction of Dr Jorge Alió and colleagues at the University of Alicante. “The advance with PresbyMax is that it is now possible to treat emmetropic, myopic, hyperopic and astigmatic patients whose accommodative response is limited. The technique can be used with PRK, transepithelial PRK, LASIK or LASEK,” he said. Noting the limitations of the technique, Dr Mehta said that PresbyMax did nothing to slow down or halt the progress of presbyopia or to restore accommodation. However, the benefits of the procedure far outweighed these drawbacks, he said. “The technique has a lot of advantages. It reduces dependency on reading glasses, it provides controlled pseudoaccommodation and it can be prescribed for preventing latent presbyopic symptoms. Furthermore, it delays the need for reading glasses while the presbyopia progresses, it can be repeated if necessary to take account of the evolution in refraction over time and

it offers an external, minimally-invasive form of refractive surgery,” he said. Based on his clinical experience now of more than 100 PresbyMax patients, Dr Mehta said that some general trends could be observed in terms of expected outcomes in the first six months after treatment. “There is a similarity in the postoperative progress of all refractive types after PresbyMax, although the adaptation differs from patient to patient. The patient typically experiences excellent near vision on the first postoperative day. However, the near vision slightly decreases from day one up until the third postoperative month and then stabilises. The distance vision is usually not very good for the first month, although this usually improves from 20/32 to 20/25 up until about six months and then stabilises,” he said. Presenting the results in more detail, Keiki Mehta MD said 114 patients – 62 myopes, 28 hyperopes and 24 emmetropes – underwent PresbyMax at the Mehta International Eye Institute in Mumbai, India. Exclusion criteria included patients with abnormal corneal topography with signs of keratoconus, any gross corneal irregularity for any reason including fine scars, dry eye syndrome, and patients with ectopic pupils. Patients whose livelihood necessitated excellent vision for specific tasks such as drivers or pilots, professional photographers and so forth, were also excluded.

Cyres Mehta - cyresmehta@yahoo.com Keiki Mehta - drkeiki@mehtaeye.com

Dr Mehta advised simulating the effect of PresbyMax preoperatively using multifocal contact lenses. “This gives us an important indication of whether or not the patient will be a good candidate or not for PresbyMax. If they seem unsteady or unsure with the results of the simulation it might be more prudent to consider abandoning the procedure and discussing other alternatives with them,” he said. The selected optical zone should be equal or larger than 5.80mm in presbyopic myopia, equal or larger than 6.20mm in presbyopic hyperopia, and equal or larger than 6.50mm in presbyopic astigmatism dominance, noted Dr Mehta. “Make sure that the ablation map is large enough for the scotopic pupil size and it is important to do both eyes simultaneously, otherwise the binocular vision will suffer from the multifocality in only one eye, potentially causing anisometropia or aniseikonia.” Putting the results into context, Dr Mehta said that excellent visual and refractive outcomes were obtained at three months for myopes, hyperopes and emmetropes. “A total of 70 per cent of hyperopic eyes and 100 per cent of myopic eyes achieved a monocular distance uncorrected visual acuity (UCVA) of at least 6/18. A monocular near UCVA of J3 or better was achieved in 80 per cent of hyperopic and 100 per cent of myopic eyes,” he said. In terms of binocular results, uncorrected distance visual acuity at least 6/12 was seen in 80 per cent of hyperopic and 100 per cent of myopic eyes. All patients achieved a binocular UCVA of at least J-4. Two eyes that underwent hyperopic PresbyMax lost up to one line of best-corrected distance visual acuity (BCVA). No lines of BCVA were lost in the myopic or emmetropic eyes. The mean postoperative spherical equivalent was -0.26 +- 40 D with 90.6 per cent of eyes having a spherical equivalent within 0.50 D of target refraction. Looking at the subjective satisfaction outcomes, Dr Mehta said that there seemed to be a clear correlation between the magnitude of the near vision add and the patient’s satisfaction with the procedure. “The problem cropped up when we looked at topography maps with more than 1.5 D addition. The patients with 2.0 D adds were less happy due to the steep central zone build-up which impacts on their quality of vision. For some patients with more than 3.0 D add, we had to reverse the procedure in some cases, which seemed to work well. The bottom line is that we need to select our patients very carefully, and make sure that the additions don’t go any higher than 2.0 D,” he concluded.

Update

CATARACT & REFRACTIVE

OCULUS Centerfield® 2

Optimising outcomes

Refractive enhancements uncommon, but useful for improving functional results by Cheryl Guttman Krader in Paris

efractive enhancement surgery in cataract patients implanted with presbyopia-correcting IOLs is not common, but is safe and effective when it is performed, suggests a study reported by Jessica Chow MD, at the XXVIII Congress of the ESCRS. The study included eyes that underwent implantation of a presbyopia-correcting IOL at the Duke University Eye Centre, Durham, NC, between January 2006, and December 2009. Dr Terry Kim was one of the authors of the study. During that study period, the majority of patients received either the +4.0 D add version of the AcrySof ReSTOR apodised diffractive multifocal IOL (Alcon Laboratories) or the Crystalens HD accommodating IOL (Bausch + Lomb). A total of 44 eyes were identified that underwent refractive enhancement after presbyopia-correcting IOL implantation. The rate of refractive enhancement was slightly higher for recipients of the multifocal IOL (9.5 per cent) than in the accommodating IOL group (6.7 per cent). However, the between-group difference in enhancement rates was not statistically significant. Most of the enhancement procedures were performed because of patient dissatisfaction with distance UCVA and targeted reduction in astigmatism or spherical error (mostly myopic). Overall, the surgery was successful as most patients demonstrated improved uncorrected distance visual acuity. There was no significant difference in the mean postenhancement distance UCVA between the two IOL groups, although there was a trend for the post-enhancement near UCVA to be better in the multifocal IOL group versus in the accommodating IOL group. “With the advent of presbyopia-correcting IOL technology, there has been an increasing trend toward refractive cataract surgery that is accompanied by higher patient expectations for a full range of uncorrected vision and reduced spectacle dependence. There are multiple reasons for patient dissatisfaction with the outcome after implantation of a presbyopia-correcting IOL. Residual spherical and astigmatic refractive error is the most common cause for patient complaints,” said Dr Chow, chief resident, Duke University Eye Centre. The current study provides data on outcomes for implants representing the two major types of presbyopia-correcting

EUROTIMES | Volume 16 | Issue 6

IOLs used in the US. The study excluded patients who had refractive surgery prior to cataract surgery, considering the potential for decreased predictability of the IOL power calculation with that history. Patients receiving any type of refractive enhancement post-IOL implantation were included, although most of the procedures (~75 per cent) were laser vision correction (mostly PRK) performed as either a conventional ablation with the VISX S4 excimer laser or a wavefront-optimised treatment with the Wavelight Allegretto excimer laser. The remaining patients underwent incisional surgery for astigmatic correction. Patients in the Crystalens and AcrySof ReSTOR IOL groups were comparable in mean age, refractive error, axial length, and keratometry/corneal astigmatism prior to cataract surgery. The preoperative target SE was significantly more myopic in the Crystalens group than for the ReSTOR multifocal IOL recipients (-0.29 D vs. 0.08 D). After the IOL surgery, mean refractive error was significantly more myopic in the accommodating IOL group compared to the multifocal IOL patients (-0.88 D vs. 0.01 D). “The difference in preoperative refractive target between the two groups may reflect the goal of achieving ‘mini-monovision’ in the Crystalens group. However, on average, the achieved SE was >0.5 D more myopic than the target in the Crystalens patients while there was a difference of less than 0.1 D between the mean target and achieved SE in the ReSTOR eyes,” noted Dr Chow. Both the Crystalens and ReSTOR groups were left with about 1.1 D of residual cylinder after cataract surgery, and there was no major difference between groups for this endpoint. The refractive enhancements were performed five to seven months after the initial surgery for patients dissatisfied with distance vision if residual sphere and/or astigmatic error was greater than 0.5 D. After enhancement, the Crystalens patients remained significantly more myopic than the ReSTOR patients (mean SE, -0.48 D vs. 0.0 D). Astigmatic error was comparably reduced after enhancement in both the Crystalens and ReSTOR groups (mean astigmatic error, 0.50 D vs. 0.48 D). Post-enhancement, about 50 per cent of patients in both groups ended up with distance UCVA better than 20/25.

contact

Jessica Chow - jhc15@duke.edu

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Update

CATARACT & REFRACTIVE

Shallow anterior chamber

Forewarned is forearmed when performing cataract surgery in eyes with shallow anterior chambers by Roibeard O’hEineachain in Istanbul

hallow anterior chambers encountered during cataract extraction procedures can pose special challenges to surgeons, but forward planning in eyes likely to have the condition can ensure a good outcome, said Paul Rosen FRCOphth, Oxford Eye Hospital, Oxford, UK. “Among the potential problems shallow chambers may cause is a difficulty in creating the corneal incisions with the risk of perioperative iris prolapse. In addition, the capsulorhexis becomes more difficult to perform because of increased vitreous pressure causing a tendency to rip outwards, which increases the risk of posterior capsule rupture and subluxation of the lens,” Dr Rosen told the 15th ESCRS Winter Meeting. Eyes with shallow anterior chambers can be associated with endothelial complications, including the stripping of Descemet’s membrane.

Predisposing factors for a shallow anterior chamber include high hyperopia/ short eyes. In older cataract patients there is increased risk because of the increased size and hardness of the lens, the increased risk of suprachoroidal haemorrhage, and the greater use of alpha agonists, which can induce IFIS syndrome. Another risk factor is nanophthalmos, defined as having horizontal corneal diameter less than 11.0mm and an axial length less than 20.0mm which is particularly associated with choroidal effusions.

Surgical considerations The choice of anaesthesia is an important consideration when dealing with cataract patients who are likely to have shallow anterior chambers, Dr Rosen noted. Topical anaesthesia might be inadequate in such eyes because of their unusual anatomy and the higher likelihood of complications, he added. Peribulbar

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EUROTIMES | Volume 16 | Issue 6

anaesthesia is contraindicated because it tends to increase intra-orbital pressure. Sub-tenons anaesthesia with the Honan Balloon is a better choice since it reduces vitreous pressure, he said. General anaesthesia is also an option since it provides surgeons with the option to hyperventilate the patient which reduces the pCO2 and vitreous pressure. In eyes with shallow anterior chambers, preoperative intravenous infusion of Mannitol can be given 30-60 minutes prior to surgery to reduce the intravitreal pressure. Although some have advocated vortex vein decompression in nanophthalmic patients, it is technically difficult to perform and there is little clinical evidence to support its use. The corneal incisions in such eyes should not be too peripheral in order to avoid iris prolapse. Neither should they be too corneal, which could reduce the surgeon’s manoeuvrability and the visualisation of the anterior segment. Factors that can lead to shallowing of the anterior chamber during a cataract procedure include choroidal effusion and choroidal haemorrhage. Other possible causes are aqueous misdirection, which is a condition where aqueous flows into the vitreous, and wound leak, resulting from an imbalance between inflow and outflow. Should shallowing of the anterior chamber take place during surgery, the surgeon must assess whether it will be possible to complete the procedure, based on such factors as hardness or softness of the eye, the presence of iris prolapse and the status of the capsulorhexis. When the completion of the procedure appears to be the best option, intracameral phenylephrine (six drops of 2.5 per cent phenylephrine in 1.0ml BSS) will reduce the chance of iris prolapse, and injection of a cohesive viscoelastic can help reposition iris and maintain the anterior chamber. The use of trypan blue stain is helpful in reducing the difficulty of performing the capsulorhexis and the cohesive viscoelastic can relieve tension in the capsule and reduce the risk of the rhexis from ripping tangentially outwards. Dr Rosen said he has also tried one drop of pilocarpine two per cent perioperatively because it causes ciliary body contraction and therefore reduces the tension on zonules and the capsule, without affecting pupil dilation.

contact

Paul Rosen - paul.rosen@orh.nhs.uk

Vitrectomy sometimes helps

Limited vitrectomy may be necessary in some cases when it is associated with increased posterior vitreous pressure due to aqueous misdirection. In such cases the anterior chamber will be becoming increasingly shallow and iris prolapse may occur and the eye becomes hard. It is important to exclude a suprachoroidal haemorrhage by observing if there are choroidal detachments and raised intraocular pressure cf effusion where the pressure is low. Dr Rosen recommended in such cases that the surgeon first secure the corneal wound with a suture and then carry out limited pars plana vitrectomy to decompress the posterior segment and allow completion of the phacoemulsification surgery. When performing the vitrectomy, the surgeon should use 20G or 23G instrumentation to create a single pars plana “sutureless” incision 3.5mm from limbus, using no infusion and placing the vitrectomy probe into the centre of the vitreous cavity. “Care must be taken not to come too close to the posterior capsule and risk damage which in turn can result in dislocation of the lens posteriorly,” Dr Rosen cautioned. Another complication that can occur as a result of the pars plana vitrectomy is penetration of the retina when making the pars plana incision, because of the abnormal pars plana anatomy. That can in turn lead to peripheral retinal tears and retinal detachment. Furthermore, in the longer term, a portion of the vitreous can become incarcerated into the port the procedure creates and that can also lead to retinal detachment. Dr Rosen noted that when shallow anterior chamber is a result of choroidal haemorrhage, there is an urgent need for immediate action. The signs are increasing IOP, a progressive shallowing of the anterior chamber, iris prolapse and a dull red reflex. In such cases the surgeon should close the wound. If this is not possible then one can decompress the eye with a 16G cannula inserted at the equator of the globe to allow decompression of the suprachoroidal space. With the scleral wound left unsutured, corneal wounds can then be rapidly secured with multiple sutures. If the choroidal haemorrhage re-absorbs, no further treatment is necessary. However, if the choroidal detachments are touching they can lead to a retinal detachment. The correct course of action in such eyes is to drain the blood and perform a vitrectomy as a secondary procedure. “With all these situations you need to take rapid and decisive action to achieve a good visual outcome,” Dr Rosen added.

Update

CATARACT & REFRACTIVE

Rare complication

Getting to grips with vertical gas breakthrough

Courtesy of John Chang MD

by Dermot McGrath in Crete

Figure 1: OD VGB (3mm x 3mm) between 10 and 11 o’clock, next to corneal limbus after pocket was created

lthough not a common complication of refractive femtosecond laser surgery, vertical gas breakthrough (VGB) has the potential to disrupt or postpone surgery and may result in less-thanoptimal outcomes for the patient if not tackled appropriately, according to John Chang MD. “With today’s trend towards cutting thinner flaps, we are seeing some new complications such as VGB which is caused by gas escaping anteriorly through the epithelium to the corneal surface. This can obstruct further bubbles from forming and may prevent the flap from being created,” Dr Chang, director, Guy Hugh Chan Refractive Surgery Centre, Hong Kong Sanatorium And Hospital, and clinical associate professor The Chinese University of Hong Kong and The University of Hong Kong, told delegates attending the Cornea X meeting. Dr Chang said that VGB can be broadly divided into two categories: that which

occurs under the epithelial surface, which is usually minor and allows surgery to be continued; or the more serious scenario where the gas penetrates through the epithelium and generates a large bubble. Surgery usually cannot proceed any further in the latter instance. Either way, a proactive approach by the surgeon can help to mitigate the impact of the VGB, said Dr Chang. “Immediate management is needed with these patients. Patient inconvenience is an important factor and we don’t want to leave a patient with an anisometropia if only one eye was corrected. It should also be borne in mind that patients cannot wear contact lenses for a few days after VGB occurs and must come off contact lens use for another week before repeating surgery. There is also the fact that everyone knows you ‘failed’ in the surgery and there is no guarantee that VGB won’t reoccur the next time around.” Looking at his own patient data in recent years, Dr Chang said that from October

Don’t miss Eye on Travel, see page 51 EUROTIMES | Volume 16 | Issue 6

Figure 2: Immediate cut (nasal hinge) with microkeratome resulted with smooth bed

2004 to April 2010 he experienced five cases of VGB using the IntraLase with a flap thickness of 90 microns in 3,574 procedures. With a 100-micron flap using the same system, he recorded two cases of VGB in 3,160 procedures. Looking at some of these patients in more detail, Dr Chang highlighted the case of one patient who experienced VGB in the central cornea. “In this particular case the side cut was completed but not dissected. Even if we waited for another day or even months, repeating IntraLase may cause VGB again, so we decided to re-cut the flap using a Zyoptix XP microkeratome (Bausch and Lomb) with a 140-micron flap and an inferior hinge. Importantly, the flap was cut in the same direction as the original attempt for two reasons: first, the initial hinge would stop the flap from moving and second, a cut from any other direction may result in flap movement and possible flap shredding,” he said.

contact

John S Chang - johnchang@hksh.com

The end result was that the flap could be lifted after being re-cut by the mechanical microkeratome and the laser ablation was successfully completed. The epithelium was shown to be intact on the day after surgery, and visual acuity after one year was 20/25, which equated to one line of vision lost, said Dr Chang. In a second case, a superior hinge was used for the re-cut with a mechanical blade after aborting the femtosecond flap creation due to VGB. Dr Chang noted that a microkeratome re-cut in any direction could have been achieved in this instance without risking flap shredding as the laser cut had been only partially completed. After the flap was lifted and laser ablation completed, the patient’s epithelium had healed by the eighth postoperative day and the best-corrected visual acuity was 20/20 at one year with no loss of vision. In the third case cited by Dr Chang, the femtosecond laser was halted immediately after VGB (Figure 1) and the flap was re-cut with the MK-2000 microkeratome (Nidek Co Ltd) using a 130 micron flap and a nasal hinge (Figure 2). The flap was successfully lifted and laser ablation was completed without any further complication. Dr Chang’s final example showed a case where the femtosecond laser was stopped after a second attempt at laser separation had not been successful. The flap was then re-cut with the MK-2000 keratome using a 130-micron flap and a superior hinge. The flap was lifted and the laser ablation completed. “What these cases show collectively is that there is no need to wait for another day when we encounter VGB. All these cases were successful in flap creation with a microkeratome, flap lifting and laser correction,” said Dr Chang. Putting the data in context, he said that the key is to stop immediately when VGB occurs and consider the best strategy to adopt. “No side cut should be performed once we have encountered VGB since this narrows our options considerably. We have shown that a microkeratome can be useful in some cases of intraoperative VGB during femtosecond flap creation with the cut being made in the same direction as the initial flap cut. Although the cause of VGB is uncertain, particular caution should be taken in eyes with preexisting corneal defects. We also need to inform the patients of the risk of using a microkeratome in this context, for instance flap shredding,” he said.

contacts

Steve Arshinoff - ifix2is@sympatico.ca Björn Johansson - bjorn.johansson@lio.se

Update

CATARACT & REFRACTIVE

same-day surgery

Endophthalmitis rates for bilateral cases using intracameral injections lower than for unilateral by Howard Larkin in Paris

wo large-scale retrospective reviews presented at the XXVIII Congress of the ESCRS found that postoperative rates of endophthalmitis were as low or lower for patients who underwent immediate sequential bilateral cataract surgery with intracameral antibiotics than for patients who underwent similar unilateral procedures. Injected IC antibiotics, are very effective to greatly reduce the risk of bilateral endophthalmitis when combined with proper bilateral surgical technique. Of the antibiotics commonly used intracamerally – cefuroxime, vancomycin and moxifloxacin – moxifloxacin is simplest to prepare, and seems to offer advantages over the others, according to Steve A Arshinoff MD, Toronto, Canada, president of the International Society of Bilateral Cataract Surgeons (iSBCS). “The most common fear for same-day bilateral cataract surgery is bilateral infection,” Dr Arshinoff said. He looked at the experience of all the members of the iSBCS for both bilateral and unilateral cataract cases. 30 centres in 10 countries responded, including six in Canada, five in Spain, three each in England and Finland, and one each in South Africa, the

US, the Philippines, Belgium and India. All submitted data on all bilateral cases from their first case forward for a total of 95,254. Some also provided unilateral case information. Infection rates reported for bilateral and unilateral cases were very similar. For the bilateral cases, 17 cases of endophthalmitis, all unilateral, were reported for a rate of one in 5,603. “This is lower than we would see in other studies and the reason is bilateral cataract surgeons tend to be very meticulous, good surgeons, and do not perform their anticipated most difficult cases as bilateral procedures,” said Dr Arshinoff. For the 23,847 bilateral cases in this study that were done without intraocular antibiotics the endophthalmitis rate was only one in 1,987. This nearly matches the weight averaged infection rate for cases that did use IC antibiotics reported in six major published studies, including the ESCRS study and involving over half a million patients, he said. For the bilateral cases in this study that used IC antibiotics, the results were far better – just five in 71,407 cases for a rate of one in 14,281. All five endophthalmitis cases occurred among the 46,073 cases using cefuroxime. No cases of endophthalmitis were recorded for 15,240

True COMICS

bilateral cases using intracameral Vancomycin or the 10,094 using moxifloxacin. For statistical analysis purposes, Dr Arshinoff added in unilateral cases reported in the study for Vancomycin and moxifloxacin. There was one case of endophthalmitis in 35,194 for moxifloxacin and nil cases in 19,722 cases for Vancomycin, with the overall rate for all cases using IC antibiotics at one in 16,832. This represents a reduction of 88 per cent compared with the endophthalmitis rate without IC antibiotics observed in this study, which is very much in line with the 80 per cent to 90 per cent reduction observed in other studies, he added. In terms of risk of a bilateral infection using IC antibiotics, Dr Arshinoff squared the observed rate of one in 16,832 for all IC cases and multiplied it by a linkage factor of about three. Even with plenty of fudging he still ends up with a chance of one case of bilateral endophthalmitis in about 100 million. Dr Arshinoff said he used Vancomycin for 10 years without any complications, but stopped when the only supply available in Canada was limited to a generic product linked with TASS. He presented evidence that moxifloxacin may currently be the best choice due to its broad spectrum of coverage, low incidence of allergic reaction and ease of preparation. To ensure sufficient potency to kill resistant pathogens, he recommends injecting 0.2 cc of 150 mcg moxifloxacin/0.1 cc BSS. Currently, surgeons must dilute the solution from Vigamox 0.5 per cent, but projects are under way to make a single-use preparation for intracameral use, he noted.

Infection rates lower in Sweden

For cases recorded in the Swedish National

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EUROTIMES | Volume 16 | Issue 6

Cataract Registry from 2003 through 2009, endophthalmitis rates were significantly lower following same-day bilateral cataract surgery than after unilateral procedures, according to a study by Björn Johansson MD, PhD, Linköping University Hospital, Sweden, who is also secretary of the iSBCS. He said he chose 2003 as the start of the study period because all Swedish cataract centres had switched to using prophylactic IC antibiotics in 2002. Bilateral case volume increased from about 1,000 cases in 1999 to about 3,000 to 4,000 from 2006 through 2009, or about four per cent to five per cent of the total, he noted. For the 24,214 bilateral cases reported to the registry, two unilateral infections occurred for a rate of one in 12,107, or 0.008 per cent. During the same period, 489,325 unilateral cases were reported with 184 infections for a rate of one in 2,660, or 0.038 per cent, a difference found statistically significant at P<0.02, Dr Johansson said. Strategies for minimising endophthalmitis after bilateral surgery include proper preparation of the operating field to minimise cross-contamination, complete separation of the two surgeries, including using separate instruments, different batches of viscoelastics and BSS; and surgeons at minimum re-gloving between procedures, Dr Johansson said. Many Swedish centres also add intracameral ampicillin to cefuroxime to cover additional pathogens, he added. Patient selection is also a key, Dr Johansson said. Patients in the bilateral group are more functional and have fewer co-morbidities and other risk factors. “Probably the patients selected for bilateral operations are less prone to infection than those receiving surgery in one eye only,” he said.

Update

CATARACT & REFRACTIVE

escrs on your time Symposia, free papers, videos and more from ESCRS Congresses in your home

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New toric IOL

Good predictability and stability shown in initial results with new lens

by Roibeard O’hEineachain in Istanbul

new toric IOL called the Basis Z toric (FirstQ) shows promising early results in cataract patients with astigmatism, although it does require some extra care during implantation, according to a study presented by Detlef Holland MD, Augenklinik Bellevue, Kiel, Germany, at the 15th ESCRS Winter Meeting. The study involved 41 eyes of 32 patients with cataract and a mean corneal astigmatism of -2.0 D. At a follow-up of four weeks to six months following implantation of the Basis Z IOL, subjective astigmatism was -0.5 D, while mean postoperative sphere was -0.25 D. Furthermore, among eyes with six months of follow-up, uncorrected visual acuity was 0.8 and best corrected acuity was 1.0. The patients in the study had a median age of 70 years and their corneal astigmatism ranged from -1.03 D to -5.29 D. Dr Holland and his associates excluded eyes with corneal pathologies by means of corneal topography. All underwent biometry with the Zeiss IOLMaster with an online calculator program to calculate the cylinder power, using the Haigis formula. In all cases, patients underwent implantation of the Basis Z toric with a 2.4mm clear cornea incision and the Firstinjektor (FirstQ) lens injecting system. Immediately prior to surgery, they marked the axis preoperatively in each case with Gerten marker. The implanted lenses had a median sphere of 19.0 D and a median cylinder of +2.5 D with the aim of achieving

“

The new Basis Z toric IOL is easy to implant and shows good centration and good refractive predictability. We will need a longer term follow-up concerning its rotational stability and PCO Detlef Holland MD

EUROTIMES | Volume 16 | Issue 6

Z-Flex Toric at first postoperative day

target refraction of -0.17 D sphere and -0.18 D cylinder. Dr Holland noted that all IOLs could be implanted within the capsular bag with good centration, without complications and only a very negligible impact on corneal astigmatism. The IOLs had a mean deviation three degrees from the planned axis after six months. In three of the earlier cases the IOL had to be repositioned due to rotation. However, since adopting the practice of using a 5.0mm rhexis that fully overlaps the optic by at least 1.0mm, followed by slower removal of the viscoelastic, no rotations have occurred, he reported. The basis Z toric IOL is a foldable IOL with z-haptics and is composed of hydrophilic acrylic material, he noted. It is available in spherical powers from zero to 30 D and in cylinder powers from 1.5 D to 9.0 D. It is also available in both clear and blueblocking versions, he said. Dr Holland noted that at the time of his report he and his associates had implanted 117 of the new toric lenses. In addition, they are now carrying out a study in which patients undergo phacoemulsification and implantation of the lens through 1.8mm incision, in order to reduce the astigmatic effect of the surgery to a minimum. “The new Basis Z toric IOL is easy to implant and shows good centration and good refractive predictability. We will need a longer term follow-up concerning its rotational stability and PCO,” Dr Holland concluded.

contact Detlef Holland - d.holland@augenklinik-bellevue.de

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Update

CATARACT & REFRACTIVE

Post-LASIK infections

Japanese authorities shut down LASIK clinic following keratitis outbreak by Sean Henahan in Tokyo

Japanese LASIK surgeon is facing criminal charges following an outbreak of infectious keratitis at his clinic in Tokyo, Japan. The epidemic first came to light when ophthalmologists in Tokyo began to see patients coming into their clinics with mycobacterial corneal infections, all within a narrow time period. Mycobacterial keratitis is an otherwise very rare occurrence in Japan, Hiroko BissenMiyajima MD, PhD, director, Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital, told EuroTimes. “We saw such a patient, and then another. One common finding was they had recently undergone LASIK. We sent out a request to 12 hospitals in the Tokyo area for information on any similar cases they might have encountered. Sure enough, cases were starting to appear at an alarming rate,” she said. Subsequent investigations revealed that all of the patients had undergone LASIK at a single LASIK centre in Tokyo. Japanese health authorities visited the clinic after being alerted by Dr Bissen-Miyajima and colleagues. Their investigation revealed inadequate facilities for mandatory sterile operating conditions. The authorities first shut down the operating room and then the clinic. The founder and sole proprietor of the clinic was arrested recently on suspicion of professional negligence resulting in injury. This is the first time a LASIK surgeon in Japan has faced criminal charges related to surgery. He is also facing several malpractice lawsuits, including a class action suit by 50 patients. Some of the problems discovered by the authorities included inadequate facilities and poor hygiene protocols. Interviews with staff revealed that the surgeon had allegedly not followed standard hygiene protocols, reportedly not always sterilising microkeratomes between cases, and not prepping patients adequately. Other problems included no sink in the operating room, and a malfunctioning autoclave. “We have learned that this doctor didn’t wash his hands between procedures, that he smoked in the laser room, and that he

probably used the same blade on more than one patient, and the autoclave was not working well. It is really a pity what happened here in Japan, because it was just one surgeon doing bad things, but it gave a bad impression to the public about laser refractive surgery,” Dr Bissen-Miyajima commented. The clinic in question was a freestanding LASIK clinic run by a single surgeon, which is something of an anomaly in Japan. Most patients are treated either at a handful of high-volume LASIK centres or in University clinics. Most of these centres have moved towards the all-laser LASIK approach for most patients. The clinic had run ads offering LASIK at far below market prices. When refractive laser surgery first became available in Japan some 15 years ago it was often performed by cosmetic surgeons and other non-ophthalmologists. However, the Japanese Ophthalmology Society stepped in and mounted a campaign insisting that qualified corneal surgeons should be doing this kind of surgery. Currently the majority of LASIK in Japan is performed by ophthalmic surgeons. This was the first outbreak of this kind in Japan. Dr Bissen-Miyajima compiled information on 30 patients and reports her findings in a research article now in press in the Journal of Cataract and Refractive Surgery. She details information on 39 eyes in 30 patients who developed infectious keratitis over a period of five months. All of the patients had undergone bilateral simultaneous LASIK procedures utilising a microkeratome. The average time between surgery and infection was about nine days, ranging from one to 50 days. Presentations included granular opacities beneath the flap, multiple infiltrations, and epithelial defects. Clinical examinations showed conjunctival hyperaemia, corneal oedema, anterior chamber inflammation and hypopyon. Upon referral to corneal specialists, patients were treated with a variety of topical and systemic antibiotics including amikacin, arbekacin, erythromycin, clarithromycin, imipenem, fourth

Don’t miss Oxfam Report, see page 34 EUROTIMES | Volume 16 | Issue 6

generation quinolones, and topical antifungal agents (voriconazole, fluconazole). Patients presented with visual acuities ranging from worse than 0.1 to 1.0 or better. More than half presented with acuities of 0.5 or worse. Most responded well to treatment, but two eyes were still worse than 0.1, and five were 0.5 or worse after treatment. Some cases were quite serious. 10 eyes required flap amputation because of flap necrosis. Five eyes were considered candidates for keratoplasty because of severe corneal scarring and poor visual acuity. Subsequent laboratory analyses of corneal scrapings from 29 eyes confirmed the role of Mycobacterium in 31 per cent of cases. Mycobacterium Chelonae was identified in all but one of those cases. Those samples were shown to be resistant to treatment with several standard treatments including isoniazid, rifampicin and streptomycin. Lab studies failed to identify causative organisms in 62 per cent of cases. The outbreak took the Japanese ophthalmology community by surprise, notes Dr Bissen-Miyajima. Patients involved in the outbreak presented at different times and in different centres, so it took some time to recognise that an outbreak was under way. This experience also shows a lack of standardisation in the treatment of post-LASIK infectious keratitis. She notes that the lessons learned from the epidemic should lead to more awareness of the potential for mycobacterial keratitis, and should prompt discussion on the best way to manage such cases. “I’m also concerned about the effect this outbreak has had on the public perception of LASIK in Japan. This story got a lot of media attention in Japan. The problem is, the media did not report that it was a rare situation involving just one surgeon. This created an impression among the public that LASIK was very dangerous. LASIK volume was already down because of economic conditions, but it wouldn't surprise me if this hadn't also had an effect,” she added.

“

I’m also concerned about the effect this outbreak has had on the public perception of LASIK in Japan. This story got a lot of media attention in Japan

Hiroko Bissen-Miyajima MD, PhD

Editor’s Note

Emanuel Rosen Chairman ESCRS Publications Committee

he rogue case in Japan highlights that LASIK and indeed all ophthalmic surgical procedures have to be performed according to stringent protocols, as is always the case in Europe. There can be no excuse for cavalier surgery which will only serve to create public concern. In allowing this case to be highlighted because it has occurred, EuroTimes is being responsible and reminds surgeons and public alike that public scrutiny of surgical standards is an encouragement, as if one were needed, for all participants in the process. From the ESCRS's perspective we are indeed fully confident in corneal laser surgery undertaken in this part of the world.

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Update

CORNEA NON PENETRATING APPROACH

PARADIGM SHIFT

MINIMAL INVASIVE

New drug holds promise for blepharitis treatment

NATURAL RESTORE OF IOP

by Dermot McGrath in Crete

he broad-spectrum antimicrobial compound azithromycin (Inspire Pharmaceuticals, Azasite) is helping to effect a paradigm shift in the treatment of blepharitis, according to Marguerite McDonald MD, FACS. “Azithromycin is a newer broad-spectrum topical macrolide antimicrobial with longlasting concentrations and significant antiinflammatory effects. The evidence over several clinical trials suggests that it may be an effective and safe treatment for anterior and posterior blepharitis,” Dr McDonald told delegates attending the Aegean Cornea X meeting. Dr McDonald, clinical professor of ophthalmology, New York University School of Medicine, explained that blepharitis is a descriptive term referring to a group of disorders that produce inflammation of the lid margin and associated adnexal structures. “It constitutes one of the most common ocular diseases encountered in general ophthalmology practice. However, discussion of blepharitis is often complicated by the absence of a simple, widely accepted definition for the condition, as well as by terminology that is outdated and commonly misused,” she said. Blepharitis has two basic forms: anterior blepharitis, affecting the outside front of the eyelid and posterior blepharitis, linked to dysfunction of meibomian glands within the eyelids that secrete oils to help lubricate the eye. It is common to have a mixture of both anterior and posterior forms of blepharitis at the same time, but in different degrees of severity. Traditional treatment options for anterior blepharitis include hot compresses, commercial lid scrubs, antibiotic ointment to the lid margin and corticosteroids for persistent inflammation. For meibomian gland disease treatment, Dr McDonald said that treatments include lid hyperthermia, antibiotic and corticosteroid ointments, oral tetracycline antibiotics, nutritional supplements and topical cyclosporine. The addition of azithromycin one per cent solution to the list of available treatments constitutes an important evolution in the treatment of blepharitis, said Dr McDonald, who presented some of the recent trial data relating to azithromycin. In the first study, a prospective, singlecentre open-label study of 150 eyes of 75 patients with clinical chronic mixed anterior EUROTIMES | Volume 16 | Issue 6

blepharitis, azithromycin was administered to 67 patients and erythromycin to eight patients. Patients were treated for either four or eight weeks and both eyes of each patient were treated with azithromycin ophthalmic solution one per cent or erythromycin ophthalmic ointment. Efficacy endpoints were the presence of collarettes, ulcerations at the base of eyelashes, matting of eyelashes, or lid margin erythema. The total clinical resolution after four weeks was 98.5 per cent for the azithromycin treated group and 37.5 per cent for the erythromycin treated group. “The study conclusion was that patients treated with azithromycin solution showed clinically significant improvement with approximately one month of treatment,” said Dr McDonald. The final trial cited by Dr McDonald was a single-centre, open-label, randomised pilot study of the safety and efficacy of azithromycin in combination with mechanical therapy compared to mechanical therapy alone for two weeks in patients with posterior blepharitis. Dr McDonald noted that in this particular trial, individual severity scores were rated by the investigator, who was unaware of the patient randomisation to treatment group. In terms of the intensity of the lid margin hyperaemia there was a 69 per cent improvement in mean from baseline with azithromycin versus 10 per cent with warm compresses alone. The degree of meibomian gland plugging showed a 71 per cent improvement with azithromycin versus seven per cent with warm compresses alone and 44 per cent of patients treated with azithromycin had a complete resolution of meibomian gland plugging in at least one eye. Three-quarters of patients in the azithromycin group rated the efficacy as excellent or good compared with 18 per cent in the hot compresses alone group. No safety issues associated with the drug were detected during the study and there were no significant changes in ophthalmoscopy, biomicroscopy or external eye exam, visual acuity or IOP measurements. Dr McDonald reiterated that topical azithromycin one per cent solution appears to be safe and effective in the treatment of anterior, posterior, and mixed blepharitis.

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Update

CORNEA

Keratoconus risk

New ORA parameters may help identify suspects with less overlap by Howard Larkin

n early test of new parameters for risk scoring data generated by an ocular response analyser (Reichert) found it was more reliable than basic Pentacam (Oculus) topography keratoconus indices in identifying keratoconus suspects. This suggests that combining corneal biomechanical information with clinically significant risk factors for ectasia could improve the chances of identifying corneas at risk for developing ectatic disorders before refractive surgery, said J Bradley Randleman MD, Emory University, Atlanta, US. “This is pilot data. We are looking at

Pentacam data and correlating it with ocular response analyser data. It is really not specifically abnormal topographical patterns we are looking at, but ‘at-risk’ eyes and the way we evaluate risk,” Dr Randleman told a symposium of the XXVIII Congress of the ESCRS. The difficulty with existing risk scoring systems is they aren’t very precise. Dr Randleman’s scoring system, which assigns risk based on abnormal topography in addition to magnitude of spherical error, corneal thickness, residual stromal thickness and age, is a useful tool (Ophthalmology 2008 Jan; 115(1):37-50), but has been criticised by

some for potentially generating many false positives. Characteristic patterns of corneal hysteresis and corneal resistance generated by ORA devices have been associated with keratoconus, normal, post LASIK and postPRK eyes (Luce J, J Cataract refract Surg, 2005). But using existing identification factors, there is so much overlap between normal and abnormal topography, thick and thin corneas, keratoconic and normal post-LASIK eyes that the data are not very useful for assessing individual patient risk, Dr Randleman noted. Still, Dr Randleman and colleagues, including co-authors Karolinne Maia Rocha MD, PhD, David Luce PhD and R Doyle Stulting MD, PhD, believe that biomechanical ORA data can be useful if properly analysed. They developed six specific ORA waveform parameters with associated risk scores. The parameter scores were combined and averaged to generate a final probability score. Raw ORA data were sent out to a blind reviewer, who applied the six parameters and sent back a risk score identifying the eye as keratoconus,

J Bradley Randleman - jrandle@emory.edu

keratoconus suspect or normal. Pentacam topography risk factors were applied to the same patient groups. Overall, the Pentacam identified 100 per cent of the 122 keratoconus patients, and 100 per cent of the normals, but only 13 per cent of the keratoconus suspects (as determined by corneal topography). The ORA parameters identified 100 per cent in each of the three groups at a statistical level of p<0.05, Dr Randleman reported. “The ORA data were able to distinguish between the groups. But the analysis did not answer the ultimate question about whether or not these ‘suspect’ eyes are reasonable candidates for surgery. We ideally would love to get a screening system simplified to a two-choice system, yes or no, not yes, no or maybe. Maybe makes us all nervous,” Dr Randleman said. Nevertheless, he believes that adding properly analysed biomechanical data moves the field toward a more reliable risk assessment tool. Efforts to refine and further test the ORA parameters are ongoing.

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EUREQUO gives a unique opportunity to monitor and compare results Quality registries create a sufficient basis for studying rare diseases, treatments and complications

Improve treatment and standards of care for cataract and refractive surgery

Develop evidence-based guidelines for cataract and refractive surgery across Europe

Join the network

Make significant impact on the exchange of best practice between practitioners in relation to patient safety

Collecting data will support you to make an audit report The collection of your data will facilitate the analysis of surgical outcomes and the development of evidencebased European Quality Guidelines

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EUROTIMES | Volume 16 | Issue 6

ESCRS

EUROTIMES

™

During the XXIX Congress of the ESCRS Reed Messe, Vienna, Austria

Practice Development Workshops

Saturday 17 September – Sunday 18 September 2011

Marketing Your Practice Saturday 17 September Rod Solar, LiveseySolar Practice Builders Market positioning and competition n Developing a website and internet marketing n Bringing new patients to your practice n Improving patient communications and services n

Managing Your Practice Sunday 18 September Paul McGinn, barrister at law, EuroTimes editor Tom Harbin, MD and author of “What Every Doctor Should Know but was Never Taught in Medical School” Kris Morrill, managing director, Kam Communications Effective practice management n Your practice management bag n Staffing requirements and incentivising staff n A legal audit for your practice n

Workshops are free of charge but capacity is limited. Early registration is essential at: www.escrs.org

contacts

Update

retina

Myopic CNV

Careful retinal examination can help prevent loss of vision for myopes

by Roibeard O’hEineachain in Paris

yopic eyes always merit close examination for potentially sight-threatening maculopathies and other retinal disorders, the presence of which can have a bearing on the treatment choices for cataracts and refractive error, according to two presentations at a joint ESCRS/ EURETINA symposium at the XXVIII Congress of the ESCRS. “In myopic eyes, the fundus undergoes a slowly progressive chorioretinal stretching, which results in posterior pole abnormalities, optic disc crescent, atrophic chorioretinal areas and myopic maculopathies,” said Borja Corcostegui MD, Institut Microcirurgia Ocular, Barcelona, Spain. The myopic maculopathies include lacquer cracks, round haemorrhages and choroidal neovascularisation (CNV) and tractional macular schisis.

Lacquer cracks occur in 4.3 per cent of eyes with an axial length greater than 26.5mm, but only reduce visual acuity when they involve the fovea, he noted. When examined by biomicroscopy they appear as yellowish lines of irregular width in the deepest layers of the retina. Under fluorescein angiography they show up as a hyperfluorescence without leakage, he added. “They need to be distinguished from irregular growths of the pigment epithelium because they can more easily lead to the development of choroidal neovascularisation.” Lacquer cracks can also induce round haemorrhages, which make them more difficult to detect. Fluorescein angiography will not detect lacquer cracks beneath the haemorrhages, because the haemorrhage covers the subretinal space. Like lacquer cracks, they tend to be asymptomatic

Eye Chat with Oliver Findl

“

Practice Trends in US and Europe

Dr Oliver FIndl talks with Dr David Leaming about similarities and differences in clinical practice among US and European refractive surgeons.

Listen to our podcasts at

www.eurotimes.org

podcast EUROTIMES

ESCRS

Podcasts are also available on iTunes EUROTIMES | Volume 16 | Issue 6

™

Oliver Findl

David Leaming

and have a good prognosis if they are not near the visual axis. Indocyanine green angiography can sometimes help rule out CNV.

Myopic CNV Myopic CNV is the second most common type of CNV after AMD, Dr Corcostegui noted. The risk for the condition increases with degree of myopia and occurs in younger patients of working age, he said. Its most common symptoms are a sudden and painless decrease of vision and the presence of metamorphopsia, he added. In its natural course, CNV in myopic eyes generally leads to progressive chorioretinal atrophy with poor visual outcome. Only 10 per cent to 15 per cent of untreated cases maintain visual acuities of 20/50 or 20/60, he pointed out. “Early intervention with anti-VEGF treatment changes the prognosis of this group of patient, enabling them to maintain good levels of visual acuity,” Dr Corcostegui added. He noted that myopic CNV is bilateral in 12 per cent to 41 per cent of cases. However, it is often difficult to assess. Its biomicroscopic features include thin and scarce haemorrhages without hard exudates. Fluorescein angiography is useful in detecting the neovascular lesions, he said. Foveoschisis is another condition that frequently affects myopes. It occurs in nine per cent to 34 per cent of highly myopic eyes. However, it tends to remain fairly stable and changes slowly over time and patients do not report visual impairment. Surgical intervention provides little benefit until such time as foveal detachment or a macular hole develops, Dr Corcostegui said. Myopic retinal detachment risks after surgery The unusual dimensions

of highly myopic eyes render them more susceptible to retinal detachment and that risk is increased following cataract surgery, and possibly LASIK as well, said Philip Polkinghorne MD, University of Auckland, Auckland, New Zealand. Studies showing an association between cataract surgery and retinal detachment include retrospective and prospective review studies, cohort studies and casecontrol studies, he noted. The evidence of a similar risk among refractive surgery patients is limited to retrospective studies, he said. He noted that the published research indicates that there can be a delay between cataract surgery and retinal detachment of up to 30 years. However, 90 per cent of cases occur within 10 years, and 70 per cent occur within the first year. He added that the findings of the Northern

Borja Corcóstegui - corcostegui@imo.es Philip J Polkinghorne - pjpolk@pjpolk.co.nz

“

Early intervention with anti-VEGF treatment changes the prognosis of this group of patient, enabling them to maintain good levels of visual acuity Borja Corcostegui MD

New Zealand Rhegmatogenous Retinal Detachment Study, which he co-authored, indicate that retinal detachment following cataract surgery is strongly influenced by age and axial length. In that study, one third of patients with retinal detachment were myopes, one third were pseudophakes, and in one third the detachment was due to other causes such as trauma. The incidence of retinal detachment following cataract surgery was six per cent among patients younger than 50 years, compared to only 0.6 per cent among patients over 70 years of age. Furthermore, the risk of the complication after cataract surgery was five times higher among patients with an axial length greater than 24mm than it was among patients with shorter eyes. Estimates of the risk of retinal detachment associated with excimer laser eye surgery range from 0.06 per cent to 0.36 per cent. As is the case with cataract surgery, the risk appears to be higher in younger patients, those with high refractive error, and those with retinal abnormalities and pathologies.

The role of PVD A feature common to nearly all cases of retinal detachment is a previous posterior vitreous detachment (PVD) and resulting retinal breaks. That could explain why retinal detachment is less common after cataract surgery in older patients, who will most likely already have undergone a less traumatic PVD as their eyes aged, Dr Polkinghorne said. There are several potential strategies to prevent retinal detachment following cataract and refractive surgery. One approach is to induce PVD in a more gentle way through vitreolysis. Another approach is to develop surgical techniques that are less likely to induce trauma, Dr Polkinghorne added. “If we delay PVD until the patient is older, the internal limiting membrane will have thickened, as it does with age, potentially making PVD safer,” he said.

Update

retina

RETINAL SURGERY

Scleral buckling still has role to play in retinal detachment surgery by Dermot McGrath in Berlin

lthough more surgeons are opting for pars plana vitrectomy as their preferred technique for the repair of rhegmatogenous retinal detachment, scleral buckling surgery still has an important role to play in modern retinal practice and should not be dispensed with lightly, according to Heinrich Heimann MD. “There is a definite trend towards using vitrectomy for retinal detachment in recent years which is reflected in the scientific literature, and there are some hospitals that now never use scleral buckling at all. While there are some understandable reasons for this trend, I believe it is still too early to call time on scleral buckling surgery because there is good evidence that in certain cases it can deliver better results than vitrectomy,” he told delegates attending the World Ophthalmology Congress. Dr Heimann, who works as a consultant ophthalmic surgeon at St Paul’s Eye Unit, Royal Liverpool Hospital, Liverpool, UK, said that there were a number of obvious ‘push’ and ‘pull’ factors underlying the shift from scleral buckling to pars plana vitrectomy. In terms of the ‘pull’ factors working in favour of vitrectomy, Dr Heimann cited advantages such as better intraoperative control and the ability to remove vitreous opacities and membranes during the surgery. The uncomplicated nature of the surgery is also alluring, he said. “With vitrectomy you have ‘instant success’. Whatever you do during the surgery, you just put in a gas bubble and you can tell the patient afterwards that their retina is reattached. You also avoid the submacular fluid, which has been shown to be a real problem in scleral buckling surgery. There is also the point that not only is it harder to learn scleral buckling as a trainee surgeon but it is also a lot harder to teach the technique as well,” he said. Dr Heimann noted that for many surgeons the debate has already shifted to a consideration of which gauge size is more appropriate for the vitrectomy, rather than which technique should be used in the first place. He said that while this shift was understandable, the reality was that the actual success rates for retinal reattachment surgery had not improved on the initial results achieved by the surgeons who pioneered the scleral buckle technique over 60 years ago. “This should prompt us to stop and think. In our main indication of bread and butter EUROTIMES | Volume 16 | Issue 6

surgery there has been no real improvement in the primary success rate over the past 60 years. So on the one hand we have all the bells and whistles, but we have to ask ourselves if we are actually changing the treatment for the better for our patients,” he said. Recent studies have attempted to shed further light on this question, said Dr Heimann, notably the Scleral Buckling versus Primary Vitrectomy in Rhegmatogenous Retinal Detachment (SPR) study, a European multicentre randomised controlled trial comparing pars plan vitrectomy to scleral buckling. For that trial, 45 surgeons in 25 centres enrolled 416 phakic and 265 pseudophakic patients with “mediumsevere” retinal detachments. Patients were randomised to receive scleral buckle or pars plana vitrectomy, although patients treated with pars plana vitrectomy could also receive SB at the discretion of the treating surgeon. The primary endpoint was change in bestcorrected visual acuity at one year, while secondary endpoints consisted of various anatomic factors, including single-operation success rate (SOSR). The study group concluded that scleral buckling was preferable in phakic eyes with “medium-severe” retinal detachment, and pars plana vitrectomy was preferable in pseudophakic eyes, based on the more favourable anatomic results. Using statistical modelling, the study group reported that pars plana vitrectomy was associated with an increased risk of recurrent retinal detachment in the phakic group and a decreased risk of recurrent retinal detachment in the pseudophakic group. Dr Heimann noted that one of the main criticisms of the SPR study was that the results might have been unduly skewed by the performance of individual surgeons. “We analysed this surgical factor as well, and while it was clear that while the surgeon did make a difference it was not necessarily because of the technique that was used. In other words, a good surgeon did well with scleral buckling and with vitrectomy, and the bad surgeon likewise,” he said. Dr Heimann said that the evidence clearly showed that it was too early to write the obituary for scleral buckling as an effective treatment for primary retinal detachment.

contact Heinrich Heimann MD – heinrichheimann@gmail.com

17-21 SEPTEMBER REED MESSE VIENNA AUSTRIA

Available at www.escrs.org: n

Congress Registration

Courses and Wetlabs

Scientiﬁc Programme

Hotel Bookings

BINKHORST MEDAL LECTURE M.J. Tassignon

Antwerp University Hospital, Belgium

‘To bag or not to bag’ Sunday 18 September 10.30 – 11.00

instructional courses and wetlabs For full details go to www.escrs.org

INSTRUCTIONAL COURSES ARE NOW FREE OF CHARGE

OTHER HIGHLIGHTS Saturday 17 September

Sunday 18 September

08.30 – 17.00

14.00 – 16.00

REFRACTIVE SURGERY DIDACTIC COURSE

JOURNAL OF CATARACT & REFRACTIVE SURGERY SYMPOSIUM

09.00 - 16.00

Controversies in Cataract and Refractive Surgery 2011

YOUNG OPHTHALMOLOGISTS PROGRAMME

Chairpersons:

O. Findl AUSTRIA C. Zetterstrom SWEDEN

T. Kohnen GERMANY E. Rosen UK

14.30 – 16.30

16.15 – 17.45

AUSTRIAN OPHTHALMOLOGY SOCIETY SYMPOSIUM

VIDEO SYMPOSIUM ON CHALLENGING CASES

Improving Outcomes of Cataract Surgery

Chairperson:

R. Osher USA

Monday 19 September

Sunday 18 September

08.00 – 10.00

08.15 – 17.45

COMBINED SYMPOSIUM OF CATARACT & REFRACTIVE SOCIETIES

WORKSHOP ON VISUAL OPTICS Chairpersons:

I. Pallikaris GREECE M.J. Tassignon BELGIUM

New Options in Evaluating and Correcting Astigmatism

Monday 19 & Tuesday 20 September 14.00 – 16.00

SURGICAL VIDEO SYMPOSIA

MAIN SYMPOSIA The 2nd EuCornea Congress will take place from 16–17 September at the Reed Messe in conjunction with the ESCRS Congress. A joint Symposium will take place on Saturday. For full details of the EuCornea programme please go to www.eucornea.org

Saturday 17 September 14.00 – 16.00

ESCRS/EUCORNEA SYMPOSIUM CATARACT AND THE ENDOTHELIUM Chairpersons:

H. Dua UK (EuCornea) J. Guell SPAIN

Sunday 18 September

Tuesday 20 September

11.00 – 13.00

FEMTOSECOND CATARACT SURGERY

DECISION-MAKING IN PRESBYOPIA

Chairpersons:

G. Grabner AUSTRIA R. Nuijts THE NETHERLANDS

11.00 H. Lubatschowski GERMANY Technological requirements of femtosecond lasers in cataract surgery

11.00 H. Burd UK Why we become prebyopic: finite element analysis modelling - the engineer’s approach

11.15 Discussion

11.15 G. Barrett AUSTRALIA Monovision: does it still have a place?

11.22 Z. Nagy HUNGARY My experience with femtosecond laser cataract surgery with the LenSx laser 11.37 W. Culbertson USA My experience with femtosecond laser cataract surgery with the OptiMedica laser 11.52 Discussion 11.59 R. Krueger USA My experience with femtosecond laser cataract surgery with the LensAR laser

14.00 S. Patel USA The endothelium: physiology, preoperative evaluation and post-surgical evolution

12.14 G. Auffarth GERMANY My experience with femtosecond laser cataract surgery with the Femtech laser

14.15 Discussion

12.29 Discussion

14.18 F. Kruse GERMANY Surgical approaches and the timing of cataract extraction in the presence of endothelial disease

12.36 P. Rosen UK Femtosecond laser cataract surgery: will it become a cost-effective technology in the European health care environment?

14.33 Discussion

P. Rosen UK O. Findl AUSTRIA

11.30 Discussion 11.34 S. Pieh AUSTRIA Multifocal IOLs: optics, options and outcomes 11.49 D. Spalton UK Accommodating IOLs: do they work? 12.04 Discussion 12.08 G. Grabner AUSTRIA The corneal approach: presbylasik and inlays; are they realistic options? 12.23 M. Fromm GERMANY The femtosecond approach: procedures on the cornea and crystalline lens 12.38 Discussion 12.42 O. Nishi JAPAN Lens refilling: the holy grail 12.57 Discussion

14.36 R. Bellucci ITALY Endothelial protection during cataract extraction in normal and grafted eyes

12.51 Discussion

14.51 Discussion

Monday 19 September

11.00 – 13.00

APHAKIA AND ANTERIOR SEGMENT RECONSTRUCTION

14.54 S. Hannush USA The triple procedure: classical vs modern approach 15.09 Discussion 15.12 S. Kinoshita JAPAN Future non-surgical techniques for endothelial enhancement: mitotic stimulations and gene therapy

13.00 End of session

REFRACTIVE ADJUSTMENTS AFTER OCULAR SURGERY Chairpersons:

B. Cochener FRANCE M.J. Tassignon BELGIUM

Wednesday 21 September

Chairpersons:

P. Barry IRELAND S. Binder AUSTRIA

11.00 O. Findl AUSTRIA Failed IOL implantation: implications and prevention

15.27 Discussion

11.00 S. Morselli ITALY Refractive surprises after monofocal cataract surgery

15.30 F. Larkin UK Posterior lamellar keratoplasty in pseudophakic and aphakic bullous keratopathy

11.15 M. Knorz GERMANY Enhancement after LASIK: custom or standard; on or under the flap

15.45 Discussion

11.30 Discussion

16.00 End of session

11.37 P. Rozot FRANCE Management of unsatisfied patients with multifocal IOLs

11.37 R. Steinert USA Reconstruction of other anatomy: iris, cornea, and vitreous

11.52 Discussion

11.59 R. Nuijts THE NETHERLANDS Optimizing vision after penetrating or lamellar corneal surgery

11.59 J. Güell SPAIN Secondary IOL implantation: iris claw is best?

11.15 G. Jakobsson SWEDEN Late dislocation of IOLs: what is causing this new epidemic and how do we re-locate or replace these lenses? 11.30 Discussion

12.14 M. Amon AUSTRIA How effective are the add-on IOLs?

12.14 G. Scharioth GERMANY Secondary IOL implantation: scleral fixation is best?

12.29 Discussion

12.36 B. Dick GEMANY Is there a place for light adjustable IOLs?

12.36 H.R. Koch GERMANY Aphakia and aniridia: how is it best managed?

12.51 Discussion

13.00 End of session

CLINICAL RESEARCH SYMPOSIA Saturday 17 September 08.30 – 10.30

13.30 – 15.30

ADVANCED OPTICS OF THE EYE, GULLSTRAND ANNIVERSARY

NEW CORNEAL SURGICAL TREATMENTS

Chairpersons:

T. Olsen DENMARK M.J. Tassignon BELGIUM

08.30 D. Koch USA Post-LASIK corneas and IOL power calculation 08.45 J. Rozema BELGIUM Project Gullstrand: normal biometry variation 09.00 M. Dubbelman THE NETHERLANDS Normal asphericity of the anterior and posterior corneal surface 09.15 S. Marcos SPAIN Quantitative anterior segment imaging and ocular aberrations: measurement, relationship and clinical significance

Chairpersons:

D. Gatinel FRANCE J. Murta PORTUGAL

13.30 E. Spoerl GERMANY Cross linking for KC: different approaches 13.45 S. Yoo USA Advanced corneal surgery with FS technology 14.00 M. Busin ITALY Posterior lamellar corneal transplantation: Ultrathin DSAEK vs DMEK 14.15 P. Rama ITALY Limbal stem-cell therapy and long term corneal regeneration 14.30 K. Engelmann GERMANY Corneal endothelial cell transplantation

09.30 M. Belin USA Topography vs tomography of the cornea

14.45 P. Fagerholm SWEDEN Bioengineered human cornea

09.45 J. Einighammer GERMANY Ray tracing used for IOL modeling

15.00 Discussion

10.00 Discussion

15.30 End of session

10.30 End of session 11.00 – 13.00

15.30 – 17.30

ESCRS/EUCORNEA SYMPOSIUM BIOTREATMENT OF THE CORNEA

CAPSULAR BAG TRANSPARENCY

Chairpersons:

J. Alio SPAIN F. Malecaze FRANCE (EuCornea)

Chairpersons:

P. Sourdille FRANCE D. Spalton UK

11.00 H. Levis UK Regeneration of the ocular surface

15.30 P. Stodulka CZECH REPUBLIC Early capsule changes affecting anatomy and visual function

11.15 W.B. Jackson CANADA Recombinant collagen for corneal substitution

15.45 M. Wormstone UK TGF Beta and bag fibrosis

11.30 F. Arnalich SPAIN Stromal stem cell therapy for regeneration of corneal stroma

16.00 T. Van den Berg THE NETHERLANDS Light Scatter and Straylight from PCO

11.45 S. Kinoshita JAPAN Endothelial cell regeneration in the human: is it possible? 12.00 J. Alió SPAIN Biological activation of the ocular surface with platelet rich plasma: clinical evidence 12.15 F. Malecaze FRANCE Gene therapy of the cornea 12.30 Discussion

16.15 O. Stachs GERMANY Pharmacological control of LEC proliferation for bag refilling 16.30 I. Pallikaris GREECE Peripheral capsule reconstruction 16.45 L. Werner USA Open bag devices 17.00 Discussion 17.30 End of session

13.00 End of session

17-21 SEPTEMBER REED MESSE VIENNA AUSTRIA

XXiX congress of the escrs

vienna

luncHtime sYmposia saturdaY 17 septemBer 13.00 – 14.00

17-21 september 2011

13.00 – 14.00

lUmenis satellite sYmPOsiUm – lasers in OPHtHalmOlOgY

BrOmFenaC, a neW POtent tOOl in inFlammatiOn COntrOl POst CataraCt sUrgerY

leaDing tHe WaY FOr VisiOn reJUVenatiOn

Room: Stolz 1

Room: Strauss 1

Sponsored by:

Moderator: M. Tetz GERMANY Welcome D. Spalton UK Reﬁ ning Quality of Vision: A New Glistening-Free Material • Development of a New, Glistening-Free, Hydrophobic Material for IOL’s • Beneﬁ ts This Will Offer to Patients G Altman (BAUSCH + LOMB) In Pursuit of Excellence: Designing a New Toric Lens • The R&D Processes Behind a New Toric Lens E. Mertens BELGIUM Changing the Face of Cataract Surgery: The Next Generation of Procedures

Q&A Sponsored by:

13.00 – 14.00

tHe FUtUre starts nOW: FemtO-CataraCt sUrgerY anD PresBYOPia sOlUtiOns

13.00 – 14.00

CataraCt sUrgerY – WHere eVerY COmPOnent DeliVers Room: Stolz 2 Moderator: A. Brezin FRANCE, O. Findl AUSTRIA Speakers: A. Brézin FRANCE O. Findl AUSTRIA

Ocular Infl ammation After Cataract Surgery – Still an Issue? Optimal Control of Infl ammation with NSAIDs Post Cataract Bromfenac: A New Standard in NSAID Effi cacy E. Donnenfeld USA Concluding Remarks Sponsored by:

K. Petermeier GERMANY E. Marques PORTUGAL Sponsored by:

13.00 – 14.00

mgD: tHe mOst COmmOn OCUlar sUrFaCe Disease anD its sUrgiCal imPliCatiOns

CHallenges in CataraCt sUrgerY -tOriC iOl anD POst lasiK Patients WitH lenstar ls 900

Room: Lehar 1

Room: Schubert 1

Sponsored by:

Moderator: J. McCulley USA

Sponsored by: 13.00 – 14.00 13.00 – 14.00

Room: Strauss 3

Zeiss satellite meeting

Moderator: S. Daya UK

Room: Schubert 4

Speakers: C. Albou-Ganem FRANCE

Moderator: E. Donnenfeld USA Welcome and Introduction

• A New Approach to Cataract Surgery • Looking to the Future with Laser Phacoemulsiﬁ cation

Room: Strauss 3

Sponsored by:

raYner iOls: PaeDiatriC PiOneers FOr 60 Years Room: Lehar 3 Sponsored by:

G. Auffarth GERMANY 13.00 – 14.00

S. Göker TURKEY D. Pietrini FRANCE K. Prasad Reddy INDIA

sundaY 18 septemBer

Sponsored by:

13.00 – 14.00

innOVatiOns in CataraCt sUrgerY 13.00 – 14.00

Ziemer’s FemtO lDV: leaDing FemtOseCOnD teCHnOlOgY FOr reFraCtiVe anD COrneal sUrgerY Room: Lehar 4

Room: Strauss 1 Sponsored by:

HigH DeFinitiOn laser VisiOn COrreCtiOn – WaVeFrOnt anD BeYOnD Room: Lehar 4 Moderator: K. Greenberg USA Speakers: K. Greenberg USA J. Stevens UK G. Grabner AUSTRIA B. Jackson CANADA Sponsored by:

Sponsored by:

satellite education programme 13.00 – 14.00

CrOma PHarma satellite meeting

innOVatiOns in Patient CentriC PrOCeDUres

Room: Stolz 1

Room: Strauss 2 Sponsored by:

Moderator: B. Malyugin RUSSIA Welcome

13.00 – 14.00

leaDing teCHnOlOgY in reFraCtiVe sUrgerY Room: Stolz 2 Sponsored by:

13.00 – 14.00

niDeK satellite meeting Room: Stolz 3 Sponsored by:

B. Dick GERMANY Weighing the Advantages of Combined Surgery • Results of Literature Review on Post-Surgery Cataract Formation R. Bellucci ITALY MICS: The Next Steps • Future Innovations for MICS and IOL’s • IOL’s for a 1.4mm Incision R. Packard UK Bromfenac: A New NSAID • Eifﬁ cacy of Bromfenac In Reducing Inﬂ ammation • Which Patients are Suitable for Treatment with Bromfenac • Under Which Circumstances Would Bromfenac be Used?

DOrC satellite meeting

13.00 – 14.00

Zeiss satellite meeting

13.00 – 14.00

neW PersPeCtiVes tO UtiliZe COrneal BiOmeCHaniCal PrOPerties Room: Lehar 2 Speakers: C. Roberts

Host Surgeon: Z. Z. Nagy HUNGARY Moderator: D.N. Serafano USA Sponsored by:

sundaY 18 septemBer 18.00 – 20:30

18.30 – 19.30 - Symposium 19.30 – 20.30 - Reception Buses will depart from the congress centre at 18.00

Sponsored by:

FROM 18.00

VisiOn teCH satellite meeting Room: Stolz 3 Sponsored by:

P. Vinciguerra

mondaY 19 septemBer

Sponsored by:

FROM 18.00

Room: Strauss 3 Sponsored by:

Live Surgery Broadcast: 18.30 – 20:30

R. Ambrosio Jr

13.00 – 14.00

starr sUrgiCal lUnCH sYmPOsiUm

Registration: 18.00 –18.30

18.00 – 18.30 - Registration Heldenplatz Entrance

mondaY 19 septemBer

Sponsored by:

Room: Hall A1

Room: Imperial Palace Hofburg

Sponsored by:

Room: Strauss 1

liVe sUrgerY: Presenting aDVanCing teCHnOlOgies FOr aDVanCing teCHniQUes

Sponsored by:

Room: Stolz 1

innOVatiOns in glaUCOma sUrgerY: imPrOVing PreDiCtaBilitY in FiltratiOn sUrgerY

18.30 – 20.30

innOVatiOns in reFraCtiVe iOl & laser teCHnOlOgY

Room: Schubert 1 & 2 Sponsored by

saturdaY 17 septemBer

Q&A 13.00 – 14.00

vienna

13.00 – 14.00

eVening sYmposia

13.00 – 14.00

elleX satellite meeting

meDiPHaCOs satellite meeting Room: Stolz 2 Sponsored by:

Room: Stolz 3 Sponsored by:

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News

oxfam

A BASIC NEED

ESCRS is supporting an Oxfam project to provide safe drinking water in Uganda

fter more than 20 years of conflict between rebels and government forces in Uganda, the victims of the conflict who were forced to flee their homes and live in camps are slowly starting to rebuild their lives. As a result of a new initiative launched by the ESCRS, urgent funding is being raised to support an Oxfam project to bring clean, safe drinking water to the people in the Kitgum district.“A lack of clean, safe drinking water and proper sanitation facilities, together with a general lack of knowledge about the importance of good hygiene, leads to unnecessary illnesses and preventable deaths from water-borne diseases such as cholera and diarrhoea,” said Peter Anderson, head of fundraising, Oxfam Ireland. “Lack of water for bathing also facilitates the spread of ‘water-washed diseases’ that affect the eyes, such as trachoma and conjunctivitis. The security situation has significantly stabilised in Uganda and many people are returning to their home villages. Average access to latrine and sanitation facilities in Kitgum district is just 31 per cent in the villages that people are returning to. Oxfam will be working to set up water facilities in these villages and then teach the community how to maintain the facilities and to promote safe hygiene practices,” he said. While the communities have emphasised the need for latrines, the actual construction of these facilities has been relatively low due to lack of knowledge and skills and the materials for construction. To meet this need Oxfam has helped establish Community Water Management committees in the villages of Kitgum. The local people in these committees are being

Deirdre Miller – deirdre.miller@oxfamireland.org

taught the skills needed to maintain water sources and sanitation facilities in the long term. Motorised water pump systems are also being repaired and modified to provide a water supply to the local communities. Oxfam is also co-ordinating communitybased sanitation and hygiene promotion to educate villagers about the importance of safe hygiene practices which will help reduce incidences of intestinal diseases. An important part of this campaign is the support for School Health Committees which are helping to educate school children in the importance of safe hygiene practices. “As a result of the support we receive from ESCRS and other bodies,” said Mr Anderson, “we will be able to prevent unnecessary deaths from diseases such as cholera, typhoid and diarrhoea. People will remain healthy so that they rebuild their lives and they will no longer have to use unsafe water sources such as streams and ponds as they did when their water sources were damaged. They will also no longer risk contracting ‘water-washed’ illnesses such as trachoma and conjunctivitis because they lack access to clean water and adequate sanitation facilities.” This is the second initiative that the ESCRS is supporting, alongside the ORBIS project, which is aiming to reduce blindness in the Gondar area in North West Ethiopia. “I am delighted that the ESCRS has decided to support Oxfam in this very important project,” said José Güell MD, president of ESCRS, “and I would urge members and delegates attending our XXIX Congress in Vienna to pledge a donation to help support the project.”

EUROTIMES | Volume 16 | Issue 6

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News

esaso

AMD and retina

Congress hopes to create awareness of specific treatments for individual patients

he 11th international AMD and Retina Congress which will be held in Lisbon, Portugal, from 4-5 November, 2011, will feature a scientific programme which includes plenary sessions, panel discussions, case studies and meet-the-expert sessions delivered by distinguished speakers from all across the world. In addition to this programme, a scientific poster exhibition is planned and the best poster presented at the congress will be nominated by the Scientific Committee. Other highlights will be the 2nd ESASO Graduate Award Ceremony and the 2nd XOVA Award Ceremony, supported by Novartis. “The field of age-related macular degeneration and retinal diseases is very challenging,” said Prof Francesco Bandello MD, chairman of the Scientific Committee for the congress. “There are a lot of changes happening in clinical practice and the treatment of these diseases day by day. The need we have is to discuss these changes and to try and be updated on what we can do with different drugs and different diseases.” Prof Bandello said that the Lisbon congress was an ideal venue for the discussion of AMD and retinal diseases as it would bring together leading ophthalmologists from all over the world. “This year we hope to have new data concerning the use of intravenous therapies,” he said, “not only for AMD but also for other diseases such as diabetic retinopathy and particularly diabetic macular edema and retinal vein occlusion.” Prof Bandello pointed out it was important that delegates attending the congress would get involved in discussion and interactive sessions. “As well as the main sessions,” he said, “we will have expert-meets-expert sessions where one or two speakers will discuss with 20 or 30 attendees specific subjects to encourage the exchange of ideas.” The congress will also offer an opportunity for young doctors who have attended ESASO courses to meet with their teachers and fellow students. During the congress, ESASO will hold the Graduation Ceremony and will hand out the diplomas to students who completed their studies. “ESASO is the European School for Advanced Studies in Ophthalmology

“This year we hope to have new data concerning the use of intravenous therapies, not only for AMD but also for other diseases such as diabetic retinopathy and particularly diabetic macular edema and retinal vein occlusion” Francesco Bandello MD

which teaches young residences and young eye doctors in the different fields of our specialty,” said Prof Bandello. “The aim of the school is to improve the level of ophthalmology in different countries and at our congress in Lisbon in November, young doctors who are anxious to improve themselves can meet their teachers and tutors and discuss and exchange ideas.” Prof Bandello hopes that one of the key messages that will come out of the 11th international AMD and Retina Congress is the need to look at specific treatments for individual patients. "The studies we have done up until now have had wide exclusion criteria," he said. "We included all patients with new vessels, for example, for AMD or all patients with diabetic macular edema or retinal vein occlusion without any sub-classification of these patients. Because of that, today we are not able to say what is the best treatment for each patient. What we must do now is to try to recognise that there are different sub-types of clinical diseases. I am convinced that if we are able to make these classifications more precisely it will help us to improve the efficacy of each treatment."

contacts Francesco Bandello – cancellieri.laura@hsr.it Gabriella Skala – gabriella.skala@esaso.org

Fourth Module 2011

Fifth Module 2011

Cataract and intraocular refractive surgery

Glaucoma

Lugano, Switzerland 5 – 10 September 2011

Lugano, Switzerland 12 – 16 September 2011

Faculty

B.S. Aslan, R. Bellucci, F. Malecaze, I. Prieto, P. Rosen, F. Simona, M-J. Tassignon, V. Trubilin

K. Barton, O. Bernasconi, B. Cvenkel, F. Grehn, P. Khaw, H. Lemij, N. Pfeiffer, T. Shaarawy, I. Stalmans, J. Thygesen, C.E. Traverso, A. Viswanathan

Under the auspices of ESCRS (European Society of Cataract and Refractive Surgeons)

Under the auspices of EGS (European Glaucoma Society)

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

www.esaso.ch

Don’t miss Book Review, see page 43 EUROTIMES | Volume 16 | Issue 6

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20.4.2011 9:01:46 Uhr

contacts

News

eurequo

EMBRACING TECHNOLOGY

European-wide registry is testimony to the enabling power of cooperation by Dermot McGrath

Stefan Pieger – pieger@datagraph-med.net David Johnston – david@medisoft.co.uk

“

So far, consultant ophthalmologists at about 20 NHS Trusts have agreed to submit their data to EUREQUO

David Johnston, Medisoft Limited

Courtesy of Ingenieurburo Pieger GmbH

he successful rollout of the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) in 14 participating countries has rightly been hailed as an example of cross-border cooperation working for the greater good. But the story of EUREQUO is also one that showcases the enabling power of technology, bringing coherence and meaning to the disparate layers of data across the participating countries. One of the primary challenges facing a European-wide registry has been to ensure that it is interfaced with the multiple preexisting electronic medical records (EMR) systems available in different hospitals and clinics across Europe, thereby avoiding double data entry by surgeons.

Screenshot of Datagraph-med

In the UK, for example, EUREQUO has been working with Medisoft, supplier of the most widely-used ophthalmology EMR in the UK. The Medisoft EMR is in use at over 50 National Health Service Trusts and at many private hospitals and independentsector treatment centres. Hundreds of thousands of cataract operations and their outcomes are recorded on the various instances of the system. So far, consultant ophthalmologists at about 20 NHS Trusts have agreed to submit their data to EUREQUO, explained David Johnston, managing director of Medisoft Limited. “Medisoft was approached to see if doctors would like to have pseudo-anonymised data uploaded onto the EUREQUO database so that they could compare their own cataract

surgery outcomes with those of their European colleagues. If the doctors approve in writing, then a subset of patient data can be extracted and passed to EUREQUO. In the case of NHS Trusts, the Caldicott Guardian, a senior person responsible for protecting the confidentiality of patient and user information, must also give approval. Once these steps have been taken, Medisoft can then extract the data using a speciallywritten program and the data can be securely transmitted to the EUREQUO database,” said Mr Johnston. A similar partnership has also been implemented with German-based company Ingenieurbüro Pieger GmbH, creator of Datagraph-med, outcomes analysis software for all types of refractive surgery. As Stefan Pieger, president of Ingenieurbüro Pieger explains, the initial cooperation with EUREQUO started in September 2010. “Our aim was to allow Datagraph-med users to participate in the EUREQUO data collection project without entering their existing patient data twice. We wanted them to be able to automatically transfer selected patient data simply by clicking an “Export to EUREQUO” button. With the EUREQUO user ID and password the data can then be transferred to the online database where it can be edited and finalised,” he said. For Mr Johnston, one of the key tasks in such a project is to secure formal permission from busy practitioners.

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“The main challenge is securing written permission from busy doctors and Caldicott Guardians to allow extraction of data. Many more doctors have said that they want their cataract data in EUREQUO as well as at their place of work than have put this in writing,” he said. The importance of doctors being reassured that their identity will not be revealed to other doctors participating in EUREQUO is a key element in soliciting maximum support, he added. In addition to such concerns, Mr Pieger points to more technical issues as potential stumbling blocks in a project like EUREQUO. “County specific keyboard settings and characters are still a challenge for programmers these days. Datagraph-med simply takes the ‘regional settings’ of the individual computer, but when uploading to a centralised database it must be specified whether the decimal delimiter is a dot or a comma for example. Besides this, we had to learn that the Internet security settings of many hospital networks make it difficult to upload data to an online database like EUREQUO. The excellent technical support of the Integration AG/EUREQUO team has helped us a lot with these issues,” he said. While technical frustrations are part and parcel of any project with the scope of EUREQUO, participation in such an ambitious registry has many positive elements for the companies involved. “The most satisfying aspect of working on EUREQUO is helping doctors in the UK become part of a larger community of ophthalmologists throughout Europe that are pooling data to help improve patient care,” says Mr Johnston. Mr Pieger said that while he was initially concerned that Datagraph-med and EUREQUO would be in direct competition, he now feels that both systems will ultimately benefit from each other. “Both Internet-based outcomes analysis and benchmarking with other users/ countries is one thing, but to keep a more comprehensive and personal database locally allows the expert user a far more detailed look into his/her patient data. Simple things such as making slides on your notebook while on the way to the next conference are not yet possible with an online system, so I see a good future for both database systems,” he concluded.

TH E F IR ST MICRO- INCIS ION IOL WITH OUT COMPROMISE 180째 Contact angle between the loops and the capsule 360째 Sharp edge that deserves the name 6 mm optic diameter, 13 mm overall diameter Mix of hydrophobic & hydrophilic monomers

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Update

bio-ophthalmology

Courtesy of Gearoid Tuohy PhD

Retinal images of normal (left) and atrophied (right) fundus. The atrophied retina shows a sharply delineated area of de-pigmentation which may reflect an absence of retinal pigment epithelia (RPE). Current research from the University of Kentucky suggests that non-coding genetic sequences may be responsible for initiating cell death in the RPE leading to geographic atrophy

‘Junk DNA’

New target for treating dry AMD shows promising potential by Gearoid Tuohy PhD

hen the term “junk DNA” was introduced to the genetics lexicon by the eminent evolutionary biologist, Prof Susumu Ohno in 1972, its now critical role in human health and disease could not have been anticipated. In recent years, however, junk DNA has become one the most fascinating fields in human genetics research. Known more politely as “non-coding DNA,” junk DNA has generated significant research attention of late. An abundance of non-protein coding genes have unveiled a universe of biology now thought to mediate large “administrative” functions in organising how genomes are used and controlled within biological systems. Not least of all in this new universe is a study from researchers in the US showing that one of the most common non-coding DNA – termed “Alu elements” – may contribute to the pathogenesis of age-related macular degeneration (AMD). In the context of AMD the demise of the retinal pigment epithelium (RPE) at the back of the eye is often associated with widespread geographic atrophy. As such, much attention has been applied to understanding what triggers RPE degeneration and what can be done to intervene and block such cell death. EUROTIMES | Volume 16 | Issue 6

New research from the University of Kentucky has now identified a link between reduced levels of an enzyme called DICER1 (DICER1ribonuclease type III) and dry AMD. Levels of the micro-RNA processing enzyme were found to be approximately 65 per cent lower in patients with the eye disorder compared to non-AMD control eyes (p=0.0036). Examination of eyes that had suffered other retinal diseases showed that levels of DICER1 were normal, hinting that the observation may be specific to dry AMD alone. Intrigued that the reduction in this enzyme might be specific to AMD, the Kentucky-based researchers, led by Dr Jayakrishna Ambati MD, went on to demonstrate a mechanism through which the reduced levels of DICER1 might lead to geographic atrophy. Lower levels of DICER1 appeared to allow an accumulation of cytotoxic RNA sequences in the RPE layer leading to degeneration of the tissue in the retina and macula. These RNA sequences appeared to derive from Alu elements – the previously termed junk DNA – with no particular biological function but now thought to be potential contributors to the evolution of animal genomes. There are an estimated one

million Alu elements, of about 300 bases in length, in the human genome, accounting for approximately 10 per cent of our DNA. For the most part such sequences have little functional impact unless they move and land in the middle of a gene causing it to either turn on, off or sometimes speed up, in which case a variety of diseases may be triggered. The current research, however, reveals a potentially new mechanism of pathology. Rather than disrupting an independent gene, the Kentucky research team have proposed that a reduction in the level of DICER1, which would normally “dice” up 300 basepair long double-stranded RNA, has allowed the Alu elements to stick around, and it is the accumulation of these unwanted sequences that may lead to the triggering apoptosis in the RPE cells. The researchers found clear evidence of caspase-3 cleavage in the RPE of human eyes with geographic atrophy, a telltale signature of apoptotic cell death. To confirm their findings the research group used a specific antibody that detected double-stranded RNA (dsRNA) in eyes with geographic atrophy but not in normal eyes. Animal models that had the DICER1 gene blocked uniformly underwent RPE degeneration, whereas contra-lateral eyes with functioning DICER1 appeared healthy. Knocking out DICER1 increased Alu RNA cytotoxicity, whereas enforced expression of DICER1 had a protective effect. Transfecting human RPE cells with increased Alu elements reduced cell viability and subretinal injection of Alu RNAs induced RPE degeneration in wild-type animal models. Taken together the combined data presented by Ambati and colleagues supported the idea that Alu RNA accumulation is a specific molecular response to reduced DICER1. The clear medical implication is that we may now have two new therapeutic targets for

the treatment of AMD – either increase the levels of DICER1 in the RPE or decrease the levels of Alu RNAs. Both approaches may now be actively pursued. In tackling the therapeutic opportunity, the research team designed “anti-sense” nucleotide sequences to bind and mop up the excess Alu RNA cytotoxic sequences that were not being processed due to lower levels of DICER1. The results showed that such an approach blocked cellular degeneration in the RPE. In respect of developing a therapeutic strategy, Dr Ambati commented that “compared with complement inhibitors, which modulate the immune system, targeting Alu RNA could have less potential to increase the patient’s risk of infection. And compared with visual cycle inhibitors, an anti–Alu RNA approach might have lower rates of non-tolerance by avoiding the negative effects visual cycle inhibitors can have on night vision.” Given the multi-factorial nature of dry AMD, it will be interesting to determine if an anti-sense Alu RNA approach is capable of dealing with both the late and early phases of the disease. The research findings mark a further major advance in AMD research and simultaneously open diagnostic and therapeutic opportunities for this major ocular pathology. The findings are clear, according to Dr Ambati: “Alu transcripts are elevated in human disease, that Alu transcripts recapitulate disease in relevant experimental models, and that targeted suppression of Alu transcripts successfully inhibits this pathology.” If nothing else, the research led by Dr Ambati provides a reminder of the resourcefulness of the human body and its capacity to adapt the most unlikely players into the most unlikely roles.

Vienna

2nd EuCornea Congress 16–17 September 2011 Vienna, Austria

Immediately preceding the XXIX Congress of the ESCRS

Friday 16 September

Saturday 17 September

EuCornea Lecture

Dry Eye: What’s New

Peter Laibson USA Wills Eye Institute

Corneal Imaging

J. Merayo

L. Modis

Spain,

SATELLITE EDUCATION PROGRAMME

P.J. Pisella

Hungary,

M. Belin

France

satellite education

USA

Eye Banking for the Corneal Surgeon J. Hjortdal

invited symposia

France,

R.Nuijts the Netherlands

G. Grabner

Austria,

UK,

P. Hossain

Cornea Diseases and Corneal Research in Asia

Germany

Keratoprosthesis

The Neuropathic Cornea H. Dua

C. Liu

Asia Cornea Society

programme

Croatia

Cornea Society

New Research in Cornea T.A. Fuchsluger

I. Dekaris

Conjunctival and Limbal Disorders

Corneal Complications after Refractive Surgery B. Cochener

Denmark,

EUROTIMES

™

Friday 16 September 18.00

allergan satellite meeting Room: Lehar 1 & 2 Sponsored by:

Managing Corneal Ectasias F. Malecaze

France,

T. Seiler

Switzerland

Anterior Lamellar Keratoplasty F. Malecaze France, R. Nuijts L. Laroche France

the Netherlands

Amniotic Membrane/Ocular Surface Surgery J. Güell

Spain,

M. Nubile

Italy

www.eucornea.org

Feature

Book review

See the beauty! Latest trends

Impressive effort distils wisdom and experience of host of ophthalmic leaders This is the 10th iteration of recent advances in ophthalmology, a series which has now been running for over 20 years. Longevity in medical publishing is difficult to come by – there are a handful of texts which become known by the original author’s (or authors’) name, resisting any change even when the authors are entirely new. These are the totemic, iconic books for medical students and junior doctors (and indeed senior doctors) for generations – Brain’s Neurologies, Gray’s Anatomies, and so on. This series is not perhaps quite there yet. However, it is an impressive effort, with a multinational team of both contributors and of editorial board members contributing to this book. It contains a selection of chapters on cornea, uvea, secondary glaucoma, lens, retina, oculoplastic surgery and neuro-ophthalmic disorders. And for the first time in the history of this series, there are three editorials on specific issues – the artificial cornea, diabetic retinopathy and endophthalmitis. These editorials are at the start of the book and set the tone for what follows. There are five separate articles as well as the editorial on the subject of the cornea. There is a chapter by Sinha and co-authors on corneal dystrophies which describes them in great detail, and discusses prevalence, international classification, inheritance, histopathology, clinical features, and treatment. Padmanabhan and Gupta provide a chapter which elaborates the management of keratoconus including sclera lens, collagen cross-linking, intracorneal ring segments, deep anterious lamellar keratoplasty and penetrating keratoplasty. The ubiquitous Ashok Garg contributes a chapter written on his own on corneal collagen cross-linking, describing the current situation and possible future developments. Like all the chapters this is extensively footnoted and provides a good example of evidence-grounded practice. The book overall has 20 chapters, all written in great detail, which are extensively illustrated with full colour photos, graphs and EUROTIMES | Volume 16 | Issue 6

diagrams. The book’s highlights also include a pictorial description of the implantation of keratoprosthesis, and a step-by-step guide to the surgical technique of DALK. It also describes the latest trends in the management of ocular surface disorders, and the pathogenesis and treatment of diabetic macular oedema. Given the continuing rise of the Internet as a source of information for practitioners, publishers are increasingly under pressure to find ways of distinguishing their books from the mass (or morass) of information available more or less freely online. One way is to emphasise the authority and judiciousness of the written word, and the role of books which distil the wisdom and experience of a host of expert contributors perhaps mark one way of achieving this. Overall this book is aimed at a specialised readership and covers the topic inside in great detail. It is a book for the qualified and practising ophthalmologist and the advanced trainee rather than the undergraduate student or the newly qualified doctor.

The Matterhorn, Wallis, Switzerland

AdvAnced to the MAxiMuM

Engineered in Switzerland

The new FEMTO LDV Crystal Line for Z-LASIK and corneal surgery books editor: Seamus Sweeney publication Recent Advances in Ophthalmology 10 Editors H V Nema and Nitin Nema published by Jaypee Publishers New Delhi, India, 2011 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

Z-LASiK, the obvious choice. www.ziemergroup.com

Ziemer ophthalmic Systems AG a Ziemer Group Company Allmendstrasse 11, 2562 Port, Switzerland

Feature

industry news

Recent developments in the vision care industry

SCHWIND AMARIS 750S

CROMA launches EYE-Cee One

CROMA has announced the launch the EYE-Cee One, a new hydrophobic one-piece aspheric intraocular lens with blue light filter. A company spokesman said the EYE-Cee One IOL combines well proven and new technologies to guarantee the best results for surgeon and patient. EYE-Cee One features a dense polymer network to reduce glistening or whitening of the material to guarantee long-term stability. According to CROMA, 360° sharp edges in the haptic root keeps cells from using the haptic-optic junction and improves capsular fusion. "Innovative anchor-wing haptics optimally balance the naturally given capsular bag contractions. The 90° haptic-optic position guarantees maximal capsule contact for a stable IOL fixation in the capsular bag," said a CROMA spokesman. Dr Jean-Michel Bosc, an ophthalmic surgeon with extensive experience in cataract surgery at the Clinique Sourdille in Nantes, France said in his opinion the material stability of EYE-Cee® One is excellent. "There are no microvacuoles at all," he said. "The EYE-Cee® One is very stable thanks to the anchor-wing haptics over time. The EYE-Cee® One could be an ideal IOL as basis for a toric lens. The EYE-Cee® One is immediately well centred after implantation and does not rotate. Until now I have not experienced PCO nor fibrosis during my follow-ups of the patients and patients are very happy with their quality of vision and do not complain of glare," he said. Dr Bosc said he has experienced a very easy implantation of EYE-Cee® One. "With the sand-blasted-like feature haptic stickiness is minimised and the haptic visibility is improved," he said. "I am also very satisfied with the implantation, the behaviour of the lens and the refractive outcome for the patient."

SCHWIND says that six-month data for myopia treatment with the SCHWIND AMARIS® 750S shows comparable results for LASIK and LASEK. “Recent six-month data document extremely high predictability, precision and safety with the SCHWIND AMARIS 750S applying laser spots with a repetition rate of 750 Hertz onto the cornea,” said a company spokeswoman. “They also show that treatment with the high-speed excimer laser leads to comparable excellent results with both LASIK and LASEK methods,” she said. The study was carried out by Dr Maria Clara Arbelaez, Muscat, Oman, and considered data from125 myopic patients (250 eyes), either pure or with astigmatism. “The results of the study show that LASIK and LASEK treatments with the SCHWIND AMARIS 750S are very safe, efficient and predictable,“ said Dr Arbelaez in a presentation at the recent ASCRS congress in San Diego, US.

OZURDEX positive opinion

Allergan has announced that the Committee for Medicinal Products for Human Use (CHMP) has recommended extending the Marketing Authorisation for OZURDEX (dexamethasone 0.7mg intravitreal implant in applicator) to include the treatment of inflammation of the posterior segment of the eye characterised as noninfectious uveitis. “We are pleased with the committee’s positive opinion today supporting the licensure of OZURDEX® to treat non‑infectious intermediate and posterior uveitis. This is a crucial step in the process to bring this innovative anti-inflammatory treatment option to physicians and their patients suffering from uveitis,” said Mr Douglas Ingram, president, Allergan Ltd, Europe, Africa and the Middle East. “This is also an important milestone for Allergan’s retina franchise and demonstrates our continuing commitment to developing innovative new treatments that can help preserve vision for patients suffering from retinal diseases.”

Journal Watch

Optical signals to activate sensory cells An innovative series of experiments with rat heart cells and toadfish innerear cells could lead to the development of new retinal prostheses. Researchers at the University of Utah showed that short pulses of infrared laser light delivered via optical fibre can activate heart cells and inner-ear cells related to balance and hearing. The research also showed that infrared activates cardiomyocytes by triggering the movement of calcium ions in and out of mitochondria. The same process University of Utah bioengineer Richard Rabbitt appears to occur when infrared light stimulates inner-ear cells. The researchers note that the optical stimulation approach could also provide ways to create artificial vision in people with retinitis pigmentosa. This could involve wearing glasses with a camera mounted on the frames with electronics that would convert signals from the camera into pulses of infrared radiation that would be patterned onto the diseased retina that normally does not respond to light but would respond to the pulsed infrared radiation. Vision implants that use optical rather than electrical signals would not have to penetrate the brain or other nerve tissue because infrared light can penetrate a considerable amount of tissue, so devices emitting the light have potential for excellent long-term biocompatibility. n R Rabbitt et al., Jnl of Physiology, “Intracellular calcium transients evoked by pulsed infrared radiation in neonatal cardiomyocytes”, March 15, 2011 589 (6)1295-1306.

EUROTIMES | Volume 16 | Issue 6

PRACTICE DEVELOPMENT

“

HIRE A PRACTICE MANAGER

It was a good experience to see how things work and how things can be done, and how some other surgeons think about things

Finance, marketing, and human resources require expertise, but trust and training take time by Howard Larkin

n 2009, Nader Robin MD, hired a manager for Presbyview, his practice in Grenoble, France, for one simple reason: “Surgeons are not good business managers.” Running the front desk, training staff, paying bills and payroll, marketing the practice, and dealing with France’s Byzantine employment and business regulations required expertise he didn’t have – and took time away from surgery that he couldn’t afford. Enter Celine Reibel, who now directs Presbyview, which provides a range of cataract, laser refractive, and general ophthalmology services. While she had no experience in a medical practice, she brought a range of skills, insights and contacts that Dr Robin has come to rely on. These include human resources management, operations, and customer relations skills that Ms Reibel cultivated working for a major airline, car rental firm, and manufacturer of endoscopic surgical equipment. Dr Robin was not only impressed by the manner in which Ms Reibel took care of the daily ins and outs of running the office. He was also impressed with Ms Reibel’s industry background. “We need to develop relationships with industry, especially in France,” he says. “The surgical centre must be managed as a small industrial unit.” For her part Ms Reibel acknowledged that she had a lot to learn about medical practice management. And it took Dr Robin time and effort to develop a solid working relationship with her. “It took many months to build a relationship, to be confident with her,” Dr Robin recalls. “Slowly, I let her take over the management, and now I do not regret that decision.”

Basic skills Ms Reibel believes Dr Robin hired her in part to get an outsider’s perspective on marketing and business operations. “He wanted to bring in some fresh air, but I didn’t know anything about refractive surgery,” she recalls. So she attended the EuroTimes ESCRS Practice Management Programme in Barcelona. “It was a good experience to see how things work and how things can be done, and how some other surgeons think about things.” She also attended the EuroTimes ESCRS Practice Development Workshops in Paris EUROTIMES | Volume 16 | Issue 6

Feature

in 2010. A presentation on how answering the phone can improve marketing success by Rod Solar of LiveseySolar Practice Builders particularly impressed her. Mr Solar offers staff training in English, but Ms Reibel would prefer to bring in a French-speaking trainer rather than try to translate the training into French and present it herself. “Sometimes, it helps if the message comes from an outside consultant, not just from the boss,” she said. Ms Reibel also attends practice management programmes presented by the American Society of Ophthalmic Administrators at the annual ASCRS meeting. Although sessions on insurance coding and billing is often of little use because it is so specific to the American market, many topics are of international appeal, Ms Reibel says. For instance, she learns much from hands-on sessions about developing specific ophthalmology-related management skills, such as hiring and training employees, managing patient records and improving the efficiency of practice workflow. One topic, on building a new practice, was particularly helpful for Presbyview which needed to build a new identity after Dr Robin left his previous practice last year. Because of what she learned, the practice lost no patients and Presbyview continues to grow. Market research and dealing with social security systems are other areas Ms Reibel believes are important for practice managers to master. But it’s difficult to run a general class because markets and regulations vary so much from place to place in Europe. Obtaining reliable market research is also a challenge, she adds. Still, Presbyview has a sophisticated website, including links to explanations of presbyopia, myopia and hyperopia, as well as techniques for treating them. The site also features quotes from satisfied patients. Ms Reibel is also interested in integrating social media into the practice’s marketing mix.

Building trusting relationships

Dr Robin was in no way disappointed by the amount of time it took to transfer the management of his practice to Ms Reibel. To the contrary, he says he expected it and was pleased with the outcome.

“It is like everyday relationships,” he observes. “If you discover a new friend, you are not confident in that person on the first day; it takes a little bit of time. But soon, it became obvious to me that we could trust each other.” Dr Robin believes in teamwork both within his practice and between the profession and industry. He would like to see more courses on team-building at the ESCRS meeting. He also believes in collaborating closely with industry suppliers to improve tools and techniques. “Isolated surgeons cannot do it by themselves,” he notes. Here again, Ms Reibel’s background in endoscopy has given him new insight into how he can work more effectively with industry. Ms Reibel’s industry experience is invaluable inside the practice as well. And the investments he has made in sending her to ESCRS and ASCRS conferences also have more than paid off. Her management and team-leadership experience have made it possible for him to concentrate on surgery, Dr Robin says.

Celine Reibel

“

Management experience plus human resource experience make a good combination for a practice administrator Nader Robin MD

“She has a human resources background and that helps me with my team,” Dr Robin adds. “Management experience plus human resource experience make a good combination for a practice administrator. I now let her take care of everything that has to do with my staff. I even try to avoid addressing the team if I am not involved in the issue.”

Journal Watch Avastin for ROP?

The long list of retinal disorders that appear to benefit from treatment with bevacizumab could be expanding to include retinopathy of prematurity (ROP). A US clinical study showed that a single injection of Avastin into premature babies' eyes prevented blindness more effectively than conventional laser surgery. The prospective, controlled, randomised trial enrolled 150 infants with advanced disease. Infants were randomly assigned to receive intravitreal bevacizumab (0.625mg in 0.025ml of solution) or conventional laser therapy, bilaterally. ROP recurred in four infants in the bevacizumab group and 19 infants in the lasertherapy group. The researchers note that while a significant treatment effect was found for zone I retinopathy of prematurity, this was not the case for zone II disease. Further studies will be needed to establish the safety of this approach. n HA Mintz-Hittner et al., NEJM, “Efficacy of Intravitreal Bevacizumab for Stage 3+ Retinopathy of Prematurity”,2011; 364:603 – 615.

NEI Photography Department, Casey Eye Institute, Portland, OR

contact

Celine Reibel – celine.reibel@presbyview.fr

Premature infant with retinopathy of prematurity (ROP) being examined by paediatric ophthalmologist

ESCRS

EUROTIMES

â&#x201E;˘

During the XXIX Congress of the ESCRS Reed Messe, Vienna, Austria

Masterclass in Practice Development Monday 19 September 2011

Developing High Performance Practices Keith Willey, BSc, MBA Associate professor of strategic and international management and entrepreneurship at London Business School UK. Course fee: â&#x201A;Ź200 50 places available In this Masterclass, Prof Willey will share the profiles of participants taken from a pre-course survey and offer comparison to businesses in other sectors and will discuss growth models, entrepreneurial leadership, organisation and planning. He will examine at length the interface between the professional and commercial facets of the practice with input from leading European ophthalmologists who have developed successful business models. Key discussion points: n Are you growing revenues? n What are your most pressing problems? n How can you solve these problems?

To register see: www.escrs.org

Feature

eu matters

Patently cheaper?

EU plans to streamline patent process could promote innovation in ophthalmic devices by Paul McGinn

espite judicial rejection of plans for an independent European Patent Court, the European Union is pressing ahead with plans to reform its patent law – a move that could speed up the rate at which cuttingedge technology reaches the hands of ophthalmologists. Under the plan, unveiled in April, inventors, ophthalmologists, and patients alike could ultimately benefit from a significant reduction in the bureaucracy and cost of patents through a single registration and validation system. “The purpose of unitary patent protection is to make innovation cheaper and easier for businesses and inventors everywhere in Europe,” said internal market and services commissioner Michel Barnier, in announcing the initiative on April 13. “It will mean a big reduction in terms of costs and red tape, and provide a stimulus for European innovation.” Under the current European patent system, complexity and expense are the order of the day. Those drawbacks can be particularly challenging for small-time researchers and start-up research companies in gaining – and exercising – patent rights. Much of the problem begins after an inventor receives a patent from the European Patent Office. Once an inventor receives a patent, she or he must then apply to each European country separately to validate the European patent in that country and thus come within the protection of that particular country’s patent laws. As one would expect, such a validation process involves a lot of translation into national languages and mounting administrative costs. If an inventor were to validate her or his patent in all 27 EU countries, the bill would amount to about €32,000, of which €23,000 would arise from fees for translators. By comparison, the fee for a patent in the US – which is enforceable in all 50 states without any extra validation requirements – costs about $2,500. And that’s not all. To maintain a patent, inventors have to pay an annual renewal fee in each country. And if an investor wants to buy the rights to use a patent through a licensing agreement, that agreement, too, has to be registered country by country. EUROTIMES | Volume 16 | Issue 6

“The purpose of unitary patent protection is to make innovation cheaper and easier for businesses and inventors everywhere in Europe” Internal Market and Services Commissioner Michel Barnier Under the new proposal, a Europeanwide patent with unitary effect will ultimately cost €680. During a transitional period, the patent will cost less than €2,500. The highlights of the new programme include: 1. Inventors can apply for unitary patent protection for the territory of 25 Member States at the European Patent Office in Munich, Germany. The patent will ensure the same level of protection for their inventions in all participating EU countries without the need for any validation. 2. Inventors can submit patent applications in any language. However, building on its existing working procedures, the patent office will continue to examine and grant applications in its official languages: English, French and German. 3. For a transitional period of up to 12 years, inventors holding European patents with unitary effect that were granted in French or German will need to translate their patents into English. The ones granted in English will need to be translated into another official language of the EU.

Under the new programme, translation requirements will continue only until high-quality computerised translation becomes available. The announcement of the new patent plan followed by one month a ruling by the EU's highest court – the European Court of Justice – that the proposed European Patent Court to adjudicate patent disputes independent of oversight by the Court of Justice, was contrary to existing European Union law. In its ruling, the Court of Justice stated that the creation of an independent patent court would deprive national courts and the Court of Justice itself from ensuring that EU law was correctly and uniformly interpreted throughout the European Union. (For more details about the court’s ruling, please see this column in the May issue of EuroTimes.) Much of the problem for the proposed European Patent Court – and thus for the legal effect of European patents – arises from the fact that 11 non-EU countries recognise such patents through the European Patent Convention. Despite the

new proposal, it remains to be seen how a dispute about a European patent can be resolved without the parties involved having to litigate their disputes in multiple countries – inside and outside of the EU. In December of last year, at the same time as the Court of Justice was reviewing the proposal for an independent European Patent Court, the European Commission, the EU’s executive institution, launched the new patent proposal under the EU’s so-called “enhanced cooperation” procedure. The commission’s involvement followed a request from 12 of the EU’s 27 countries to act. Under the enhanced cooperation procedure, as few as nine EU countries can decide among themselves to adopt a commission proposal if the EU cannot reach agreement on the programme as a whole. Other EU countries can then opt to join at a later stage. Since December, 13 more EU counties have submitted requests to join the enhanced cooperation programme. Only two EU countries – Italy and Spain – have to date declined to participate. Whether the proposal for a streamlined patent system ultimately becomes EU law may be more dependent on political than economic considerations. Under EU legislative procedure, the proposed patent system must be approved by all of the three legislative institutions of the EU: the European Commission, which proposed the new patent system, the Council of Ministers, on which each national government has a vote; and the European Parliament, which represents the direct interests of EU citizens. For more details about the patent proposal, visit: http://ec.europa.eu/internal_market/ indprop/patent/index_en.htm

Journal Watch Wiring the brain for vision Scientists from the Max Planck Institute for Medical Research in Heidelberg reported an important progress in understanding the neural connections occurring between the eye and the brain that result in vision. They used a novel technique of serial block-face electron microscopy and two-photon calcium imaging to demonstrate that the dendrites of mouse starburst amacrine cells make highly specific synapses with direction-selective ganglion cells depending on the ganglion cell’s preferred direction. The electron microscopy technique the researchers used allowed high three-dimensional resolution of tissue slices thinner than 25 nanometres. The methods and findings derived from this study will play an indispensable role in the clarification of the circuit patterns of all regions of the nervous system in the future, the researchers note. n KL Briggman et al., Nature, “Wiring specificity in the direction-selectivity circuit of the retina”, Nature 471, 183-188 (9 March 2011).

Cells and synapses reconstructed from serial block face electron microscopy data. A single starburst amacrine cell (yellow, note synaptic varicosities) and two direction-selective ganglion cells (green). Even though there is substantial dendritic overlap with both cells, all connections (magenta) go to the right ganglion cell. © Kevin Briggman

Review

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JCRS Highlights Journal of Cataract and Refractive Surgery Helping presbyopes read The diminution of reading ability that accompanies ageing can significantly decrease quality of life. The desire to read without glasses is a major motivation for presbyopic patients looking for surgical solutions to regain good uncorrected vision. These patients have an ever-increasing array of IOL options. A multicentre prospective randomised controlled clinical study compared the effect of four different IOLs on reading ability. 152 patients had bilateral phacoemulsification and implantation of Acri.Smart 48S monofocal (Carl Zeiss Meditec), AcrySof ReSTOR SN6AD3 apodised multifocal (Alcon), Acri.LISA 366D diffractive multifocal (Carl Zeiss Meditec), or ReZoom refractive multifocal IOLs (AMO). All groups had a significant improvement in uncorrected and corrected distance visual acuities postoperatively. The apodised multifocal and diffractive multifocal groups had significantly better uncorrected reading acuity than the monofocal and refractive multifocal groups one month and six months postoperatively. Uncorrected reading speed measured using the Salzburg Reading Desk with log-scaled reading charts (ie, German and Spanish versions of the Radner Reading Charts) was significantly worse in the refractive multifocal group than in the monofocal group at one month. The monofocal group had the greatest uncorrected reading distance at one month and six months. Multifocal IOLs with a diffractive component provided a comparable reading performance that was significantly better than the one obtained with refractive multifocal and monofocal IOLs. n J Alio et al, JCRS, ”Postoperative bilateral reading performance with 4 intraocular lens models: Six-month results”, Vol. 37, Issue 5, 842-852.

Unhappy multifocal IOL patients

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

EUROTIMES | Volume 16 | Issue 6

Presbyopic patients undergoing multifocal IOL implantation have higher expectations and higher rates of dissatisfaction than standard cataract patients. Researchers in the Netherlands conducted a retrospective chart review of 49 patients to analyse the symptoms, aetiology, and treatment of patient dissatisfaction after multifocal IOL implantation. Blurred vision (with or without photic phenomenon) was the leading complaint, reported in 94.7 per cent of eyes, followed by photic phenomena (with or without blurred vision) in 38.2 per cent of eyes. One third of patients reported both symptoms. Residual ametropia and astigmatism, posterior capsule opacification, and a large pupil were the three most significant aetiologies. Sixty-four eyes (84.2 per cent) were amenable to therapy, with refractive surgery, spectacles, and laser

capsulotomy the most frequent treatment modalities. Intraocular lens exchange was performed in three cases. The researchers note that the cause of dissatisfaction after implantation of multifocal IOLs can be identified and effective treatment measures taken in most cases. n N deVries et al., JCRS, “Dissatisfaction after implantation of multifocal intraocular lenses”, Vol. 37, Issue 5, 859-865.

PCO pathology

Posterior capsule opacification continues to be one of the most common postoperative complications associated with cataract surgery. IOL designers attempt to minimise lens epithelial cell (LEC) proliferation and migration by making a sharp (square) edge on the posterior optic IOL surface. Researchers compared the rate of capsular bag opacification in 219 eyes that had previous implantation of square-edged one-piece or three-piece hydrophobic acrylic IOLs. They determined the site of PCO initiation in each IOL, which would represent the site of breaching of the barrier effect provided by the square edge of the IOLs. There was no difference in central or peripheral PCO between the two IOL designs. In 63 of 84 eyes with a one-piece IOL and peripheral PCO, the optic–haptic junction was the site of initiation. In eyes with a three-piece IOL, initial peripheral PCO was observed at nearly the same rate whether there was full 360-degree anterior capsulorhexis overlap of the optic or no overlap. In the latter, the site of PCO initiation was in areas lacking capsulorhexis coverage in 46 per cent of eyes. The researchers hope to gain better knowledge of preventive measures for PCO and other complications as the series increases and new IOL designs become commercially available. n P Ness et al., JCRS, “Pathology of 219 human cadaver eyes with 1-piece or 3-piece hydrophobic acrylic intraocular lenses: Capsular bag opacification and sites of square-edged barrier breach”, Vol. 37, Issue 5, 923-930.

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

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Feature

eye on travel

Light-hearted Vienna

Explore an eccentric building, a beloved dance and a 'landmark' in the sky by Maryalicia Post

or delegates attending the XXIX ESCRS Congress and 2nd EuCornea Congress in Vienna, one of Vienna's top tourist attractions is an eccentric building constructed between 1983 and 1986 at the intersection of Kegelgasse and Lowengasse. Until 2010, it was known as the Hundertwasser Haus. When Joseph Krawina won his lawsuit to be recognised as co-designer it became the Hundertwasser-Krawinahaus. The plans were a gift to the city by the architect Friedensreich Hundertwasser, whose aim was to “prevent something ugly” from being constructed on this site near the Danube. He proposed a 52-apartment structure with grass on the roof and trees that grow inside, their branches stretching out through the windows. Designed without straight lines, even the floors undulate. “An uneven floor is a divine melody to the feet,” explained Hundertwasser. Tourists come just to see the facade; the interior is private. For an idea of the inside, visit the nearby Kunsthaus Wien, an old factory redesigned by Hundertwasser as a museum, souvenir shop and cafe-restaurant.

EUROTIMES | Volume 16 | Issue 6

Riesenrad at the Vienna Prater

Its floors undulate like a tiled sea in a heavy storm and surprisingly, you quickly get used to it. For details, please visit: www.kunsthauswien.com

Everybody waltz! With Napoleon safely out of the way in Elba, the heads of the countries of Europe met in Vienna in 1814 to redraw the map of the continent. A dazzling programme of entertainment was organised to lighten their load: masked balls, sleigh rides, balloon ascensions and dancing. The runaway attraction of the Congress of Vienna diversions was the newly-created “waltz.” Based on an Austrian country dance, it was highly controversial; men and women faced each other, in close physical contact, while the fast whirling movement exposed ladies' ankles to view. Naturally, it became an instant international success. The new map devised by the congress didn't last; neither did the AustrianHungarian Empire that hosted the congress. But the Viennese Waltz, the first “ballroom dance,” has endured. In 2010, UNESCO listed the Viennese Waltz as an “Intangible Cultural Heritage.”

Each year, there are some 450 balls listed on the Viennese Ballkalender, at www.ballkalender.com. All of the balls feature the Viennese Waltz. From schoolchildren to distinguished jurors, each group or association has its own ball. These are lavish affairs, held in the most sumptuous palaces of the city. Evening dress is required, but all are welcome. Around 250,000 locals and 115,000 guests attend each season’s balls. And everybody waltzes. Locals learn at dance schools such as Elmayer's in the city centre. The school is in a handsome building on Braunerstrasse off Graben. The reception room might remind you of a busy hotel or a buzzing health spa; the dance rooms vary from large to small, wood-panelled and elegant. The basics of the quick, spinning Viennese Waltz step can be learned in 50 minutes of private instruction. Tourists are gladly accommodated. At the end of the hour they will qualify for a yellow Wiener Walzer Certificate, a unique souvenir of Vienna. Cost is €59 for an hour's instruction for a couple or for an individual who will be partnered by an instructor. To arrange for a private waltz class, contact the studio at: www.elmayer.at or telephone +43 (0) 1 798 68 67.

A circle in the sky Until 1766, when Emperor Josef II opened the Prater to the public, the Prater's green riverside acres were the exclusive hunting grounds of Hapsburg aristocrats. The emperor permitted restaurants and later bowling alleys, rides and dance pavilions to be built along its edge; the amusement area that developed became known as the Clown's Park or Wurstelprater. For the celebration of the Golden Jubilee of Emperor Franz Joseph in 1890, a giant Ferris wheel was erected in the Wurstelprater by two British engineers. The 65-metre high observation wheel – the “Riesenrad” – circling at a sedate 2.7 kilometres an hour became a symbol, not only of the Prater, but of Vienna itself. Severely damaged by fire in the last year of World War II, the Riesenrad was back in service only two years later. Although only 15 of its original 30 carriages were salvageable, its repair was a post-war priority along with the rebuilding of St Stephen's Cathedral and the National

Hundertwasser-Krawinahaus, Vienna, Austria

Theatre. In 2002, the wheel was treated to a face lift and lights were added; after dark, they mark the hour by pulsating, the visual equivalent of a bell tolling. A small museum was installed at the base in some of the old carriages. A defining moment in the wheel's history came in 1949, when it featured in a key sequence in the classic spy thriller, The Third Man. The film, starring Orson Welles and Joseph Cotton, introduced the Viennese Riesenrad to the world. (The Third Man Private Collection, a privatelyrun exhibition dedicated to the film and to occupied Vienna, is open Saturday afternoons from 14:00 to 18:00. For details, visit: www.3pcm.net. The restaurant at the base of the Riesenrad, Zum Eisvogel, was also destroyed in the 1945 fire. It only reopened in 2008. Now called the “Stadtgasthaus Eisvogel,” this elegant restaurant quickly regained its reputation as the place for fine dining in the Prater. On request, the Stadtgasthaus Eisvogel will serve coffee and cake as you take in the view from one of the Riesenrad's special cabins. The cost is €14 per person plus a charge of €25 for the cabin. Candlelight dinners aloft are among a number of other possibilities. For details: click on “luxury cabines” at www.wienerriesenrad.com.

The 2nd EuCornea Congress takes place in Vienna from 16-17 September and the XXIX Congress of the ESCRS from 17-21 September 2011. For more details visit: www.eucornea.org and www.escrs.org

Reference

Calendar of events Dates for your Diary

June

2011

Geneva, Switzerland

PRESBYMANIA 2011 www.presbymania.com

4-7

GENEVA, SWITZERLAND

Joint Congress of SOE/AAO www.soe2011.org

July 2011

September

16-17 17-21

8-10

2nd EuCornea Congress www.eucornea.org

September 2011

October 2011

5-8 Porto Alegre, Brazil 6-7 DUBLIN, IRELAND XXXVI Ophthalmology Brazilian Congress www.cbo2011.com.br/

13th International Paediatric Ophthalmology Meeting Dublin

Gothenburg, Sweden 13-16 SEOUL, KOREA 8-9 1st World Congress on Surgical Training 2011 APACRS-KSCRS Annual Meeting www.surgicon.org

www.apacrs.org

23-24 Bordeaux, France

22-25 ORLANDO, FL, USA

January

February

2012

rome, ITALY

2nd EURETINA Winter Meeting www.euretina.org

Retina in Progress present and future 2011 www.retina3000.it

29-2

PARIS, FRANCE

World Glaucoma Congress 2011 www.worldglaucoma.org

2011

21-23 Israel

Dead Sea,

Fifth International Symposium on Refractive Surgery, Cataract and Cornea www.dead-sea2011.co.il/

Crete, Greece

12th Aegean Retina Meeting www.aegeanretina.gr

XXIX Congress of the ESCRS www.escrs.org

Eurokeratoconus II www.jbhsante.fr

Leuven, Belgium

Leuven Retina Meeting www.leuvenretinameeting.eu

vienna, austria

9-11

Milan, Italy

July

1-3

2011

November 2011

23-26

MILAN, ITALY

December

1-4

2011

vienna, austria

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

91st SOI National Congress www.soiweb.com

American Academy of Ophthalmology Annual Meeting www.aao.org

3-5

2012

prague,

czech republic

16th ESCRS Winter Meeting www.escrs.org

September

MILAN, ITALY

6-7 8-9

2012

3rd EuCornea Congress www.eucornea.org

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

2012

6-9 8-12

12th EURETINA Congress www.euretina.org

XXX Congress of the ESCRS www.escrs.org

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