Vol 17 - Issue 11 by EUROTIMES

VOLUME 17

ISSUE 11

NOVEMBER 2012

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ESCRS

EUROTIMES

NOVEMBER 2012 Volume 17 | Issue 11 This ISSUE... Special Focus: Global Ophthalmology

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Cover Story: Striving to meet preventable blindness targets around the world Universal free access to medical care helps reduce blindness in Israel Population growth has little bearing on vision loss burden ESCRS/ORBIS-funded project helps save children’s sight Diagnosis of retinopathy of prematurity helped by telemedicine approaches

Cataract & Refractive

12 New PresbyLASIK approach praised in French study 13 New lens helps correct irregular astigmatism 14 Tackling the problem of epithelial ingrowth 15 Lack of consensus among specialists in relation to YAG capsulotomy technique 16 Survey results on laser cataract technology practices discussed 17 Ray tracing software can be advantageous for every eye 18 Phakic IOL shows promising results in clinical trials 19 Study shows double bifocal optic can provide spectacle-free vision

Cornea

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New diagnostic tools help physicians treat ocular surface disease Good possible outcomes with paediatric corneal transplant surgery

Glaucoma

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Continuous IOP monitoring devices slowly become a reality Are leaner people at higher risk of developing glaucoma? Glaucoma filtration procedures aided by new glaucoma implant Worldwide prevalence of glaucoma to increase due to ageing population

Retina

29 Norwegian study shows no increased risk for AMD among diabetics 30 Link between fish consumption and low retinopathy incidence 31 Detecting glaucoma in diabetic patients 32 Improving treatment of DME 34 Retinal regeneration a possibility with stem cell therapy

News

John Henahan Prize-winning essay

Features

38 Eye on Travel 39 Book Review 41 Industry News 43 JCRS Highlights 44 Calendar

With this month’s issue... Enhancing Pseudophakic Vision with the Rayner Sulcoflex Lens

editorial staff

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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

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

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

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

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EUROTIMES

Editorial

ESCRS

EDITORIAL

Medical Editors

Volume 17 | Issue 11

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

A RACE AGAINST TIME

We need to look at the social, political and economic causes of blindness by José Güell MD

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK

t the XXX Congress of the ESCRS in Milan, Italy, my friend and colleague Peter Barry, the president of the society, pledged to continue to support the charity initiatives which commenced under my presidency in 2010. We are now in the third year of this important initiative between ESCRS and ORBIS and Oxfam. The ORBIS project specifically is dedicated to the training of ophthalmologists for their new paediatric unit at the Gondar Referral Hospital in Ethiopia and the Oxfam project is a long-term project to provide safe water and sanitation to the local population. As EuroTimes contributing editor Dermot McGrath points out in this month’s Cover Story, the World Health Organization (WHO) has teamed up with international NGOs and professional societies in eye care in the “VISION 2020 – The Right to Sight” programme to eliminate avoidable blindness by the year 2020. In 2010, an estimated 285 million people worldwide were visually impaired, while 39 million were classified as blind. Over 85 per cent of those who are visually impaired live in developing countries, with cataract still the most common cause of preventable blindness in more deprived regions of the globe. That is one of the reasons why we are supporting ORBIS and Oxfam, but we must also look at the bigger picture. In the last three years, the society and its members have done important work but we face bigger challenges ahead. The money we give to ORBIS and Oxfam is important, but there are other ways we can contribute. The Special Focus section in this month’s EuroTimes includes a number of articles focusing on the challenges facing countries in the developing world and I would urge you to read them to find out more about the work of the non-governmental agencies. Some of my colleagues have travelled overseas to work directly with those who cannot afford eye care. This work is extremely valuable and I commend all those involved in these initiatives. But I would also argue that we have a bigger responsibility. EUROTIMES | Volume 17 | Issue 11

Peter Barry IRELAND The reason why some of our fellow citizens do not have access to the best facilities and medical staff is because they are poor. I believe that all of us, not only ophthalmologists, have a responsibility to reduce the inequality between the rich and poor members of our society. We can do this directly by sharing some of our wealth by giving our time to help those who are suffering. We should also get involved in the international debate as to how we can reduce the burden of poverty. The ESCRS is not a political organisation but individually we can take political decisions in our own countries by supporting those parties that show the greatest commitment to an equal society. On the economic front, we can also support those companies which are also involved in charitable initiatives. I also believe that we should talk to our friends and families about how we can help organisations like ORBIS and Oxfam as private individuals. I am proud of the work that ESCRS has done in the last three years, but there is more to do. Let us not only make a pledge to eliminate avoidable blindness. Let us make a pledge to eliminate poverty.

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

José Güell MD

Oliver Zeitz germany

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Amsterdam

2013

5 -9 O C TOBE R 20 13

XXXI congress of the escrs

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Cover Story

GLOBAL OPHTHALMOLOGY

STRIVING TO MEET TARGETS

Global impact of VISION 2020’s goal of eliminating avoidable blindness by the year 2020 has been largely positive, but it must involve changing mindsets by Dermot McGrath

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We need a comprehensive rather than a cataract-centric approach to eye care

Parikshit Gogate MD

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The entire vision and eye care community now has a recognisable brand in ‘VISION 2020 – The Right to Sight’ Gullapalli N Rao MD

EUROTIMES | Volume 17 | Issue 11

welve years ago the World Health Organization (WHO) teamed up with international non-governmental organisations (NGOs) and professional societies in eye care to launch “VISION 2020 – The Right to Sight”. Its ambitious objective was to eliminate avoidable blindness by the year 2020. With just eight years to go to the VISION 2020 deadline, the statistics make daunting reading: in 2010 an estimated 285 million people worldwide were visually impaired, while 39 million were classified as blind. Over 85 per cent of those who are visually impaired live in developing countries, with cataract still the most common cause of preventable blindness in more deprived regions of the globe. But the news is not all bleak. While everyone agrees that 39 million blind people is far too many, it is still six million less blind people than when VISION 2020 first started its campaign. Other sources of encouragement lie in the fact that onchocerciasis is now largely controlled and great progress has been made in reducing trachoma. The last 10 years have also seen great strides in increasing cataract outputs, not just in India but in countries in Africa, south-east Asia, China and South America with low cataract surgical rates, according to Parikshit Gogate MD, paediatric ophthalmologist and community eye care specialist from Lions NAB Eye Hospital, Miraj and Community Eye Care Foundation, Pune, India. “There is now more focus on the outcomes, not just the output numbers,” Dr Gogate told EuroTimes. “Childhood blindness is more on the radar. Vitamin A, measles and corneal infections are being better controlled thanks to better primary healthcare and immunisation programmes. But improved neonatal care in the third world is also causing a new epidemic of retinopathy of prematurity. Glaucoma and diabetic retinopathy are being taken

Courtesy of Paul Courtright DrPH

Cataract patient and son at KCMC Hospital, Moshi, Tanzania

seriously in the public health debate and refractive errors are now considered a significant cause that needs to be addressed,” he said. One of the most significant achievements of VISION 2020 is the recognition by WHO that prevention of blindness is a priority area in its work and subsequently mandating it to member countries to include it in their national health plans, points out Gullapalli N Rao MD, chairman of the L V Prasad Eye Institute (LVPEI) in Hyderabad, India, and a leading figure in global prevention of blindness programmes. “The entire vision and eye care community now has a recognisable brand in ‘VISION 2020 – The Right to Sight’ and we have seen enhancement of funding for this activity with significant allocation by some national governments in addition to funding by private donors and organisations,” he told EuroTimes.

Huge inequities still exist While the global impact of VISION 2020 has

been largely positive, the benefits on the ground have not always been proportional to the needs of the local population, some observers feel. “Much has been achieved in the past 10 years, although it has not been even across the globe or even within individual countries. Huge inequities still exist,” is the frank assessment of Paul Courtright DrPH, director of the Kilimanjaro Centre for Community Ophthalmology (KCCO) International in Cape Town, South Africa, and Moshi, Tanzania and an acknowledged expert on ocular health in developing countries. Despite the disparities in eye care delivery worldwide, Dr Courtright said that the first decade of VISION 2020 has served as a valuable learning experience for all concerned. “A major lesson learned in the past 10 years is that there is no ‘one-sizefits-all’ solution,” he told EuroTimes. “The context varies, as do the expectations of the local population, the epidemiology of cataract, and so forth. Also our expectation

that developing a national plan would automatically lead to many ‘district’ VISION 2020 plans being developed and implemented turned out to be unrealistic,” he said. As Dr Courtright sees it, much of the problem of low service delivery is frequently due to poor management systems rather than lack of eye care providers, even though the lack of providers in some regions is definitely a problem that needs to be addressed. A tendency to ignore the private sector and focus mostly on government, especially in Africa, also proved to be a mistake, he said, noting that the private sector continues to grow in many developing countries and many interesting public-private partnership models have arisen in the healthcare sector. Another important breakthrough has been the acknowledgment within VISION 2020 of the effectiveness of district plans, with a “district” covering about one to two million people, said Dr Courtright. “This has turned out to be a very practical approach and there are many successful district plans from which we can learn. I have seen strong dedicated teams make a significant difference even in very poor countries. Examples exist in Madagascar, Burundi, Uganda and other countries,” he said.

Indian ROP project shows benefits of district-based programmes

In India, for instance, an innovative telemedicine project to combat retinopathy of prematurity (ROP) in infants has met with significant success applying many of the principles of district-based care [see EuroTimes Vol 17, Issue 5, page 42]. “In our context, the support of the district administration is germane to the success of the programme,” said Anand Vinekar MD, FRCS, head of the Paediatric VitreoRetina Department at Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India. In the Karnataka Internet-Assisted Diagnosis of ROP (KIDROP) project, district health officers have been made the point of contact in an individual zone of activity, which typically consists of six districts divided into about 300 to 400 kilometre radius of care zones. “The district reproductive and child health officer (RCHO) is our ‘nodal officer’,” explained Dr Vinekar. “He is accountable to his district health officer (DHO), who in turn is accountable to us, the private partner, via our project manager, a non-physician and the zonal team leader who is a physician,” he said. Further down the ladder of administration, Dr Vinekar has proposed the empowering of the ASHA (Accredited Social Health Activist) worker, the cadre that forms the backbone of the National Rural Health Mission (NRHM) in the country. “The ASHA is responsible for creating awareness and enrolling the ‘at-risk’ population, in this case the premature infant,” he said. Recently, Dr Vinekar published the results of “REDROP” - a novel, low-cost method of enrolling infants for ROP screening from centres which do not have screening programmes. The cost of enrolling a single infant was US$ 0.10 and relied on the fact that babies in India are weighed in most centres at birth, or within a EUROTIMES | Volume 17 | Issue 11

few days in case of home deliveries. As the private partner in the publicprivate partnership, Dr Vinekar’s institution provides free training, reading and treatment, while the government provides the funding for the equipment as well as the running costs, including the salaries of the personnel working on the project. “Public private partnerships form a very powerful medium in reaching out to the rural areas. As KIDROP has shown, technical expertise from the private sector and public funding and organisational infrastructure is key to the programme’s success in creating accessible super specialty care to the rural masses in a short time span and in a sustainable environment,” he told EuroTimes.

Funding not the most critical issue While the issue of funding remains

a perennial concern for NGOs and other organisations involved at the front-line of prevention of blindness strategies, experts agree that it is not the major stumbling block to progress. “Funding is a serious limitation, but not the most important,” said Dr Vinekar. “Resources other than mere fiscal need better utilisation. Sometimes deconstructing social biases including ignorance and illiteracy are critical in abolishing the barriers in healthcare accessibility,” he said. Another potential problem can be the resistance to change among local populations when newer technologies are being introduced, yet Dr Vinekar believes

that education and advocacy can help sway opinions. “It is important to persist with passion, so that people understand that the changes are for their betterment. We initially faced problems in promoting the use of telemedicine in rural areas. The fact that a non-physician could be the first, and sometimes the only, point of physical contact was not easy for people to accept. But once they figured out the benefit, the numbers swelled. Today we perform over 1,000 sessions a month from some of the most peripheral areas of the state,” he said. Better utilisation of available resources and better management systems are two pathways to improved eye care without drawing on enhanced funding, agrees Dr Courtright. “Much of the planning at the district level needs to focus on two issues: firstly, how to improve management and efficiency of the eye care unit, and secondly how to improve access and use of eye care services by the population. While these two require resources, the funding needs are not huge,” he said. Dr Courtright added that in his experience, interventions often require close mentoring for a number of years to help the teams solve teething problems, advocate for local resources, refine pricing and improve cost recovery.

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A major lesson learned in the past 10 years is that there is no ‘one-size-fits-all’ solution Paul Courtright DrPH

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In our context, the support of the district administration is germane to the success of the programme

Anand Vinekar MD, FRCS

Help needed closer to home

Although the major thrust of VISION 2020 efforts are understandably geared towards sub-Saharan Africa and poorer parts of

What role for the ESCRS in prevention of blindness programmes?

nder the presidency of José Güell MD, the ESCRS launched an initiative to support two charity projects: one supporting the development of a paediatric eye care service at the Gondar Referral Hospital in Ethiopia through ORBIS, and the other an ongoing long-term Oxfam programme in Uganda to provide safe water and sanitation to the local population. As Dr Guell sees it, these projects should not be seen as ends in themselves, but rather as a starting point for a long-term commitment. “I would say that this is just the first extremely small step in the right direction to support initiatives in the developing world and I sincerely believe that the ESCRS must continue and do more in the future,” he said. Dr Guell, a passionate advocate of increasing aid to developing countries, believes that while the ESCRS should be more directly involved in such projects, it is vital to define how best the society might contribute. “It makes no sense that we

José Güell

try to replicate the work that organisations such as ORBIS and Oxfam are already doing and for which they already have the required competence and experience. We need to sit down with these groups and see from a professional point of view, and not just an economic perspective, what they actually need. If we as a society of European surgeons might be able to help them in other ways than just financial aid, well let us try to organise how to do it,” he said. Nevertheless, Dr Guell acknowledges that the principal requirement for bodies such as ORBIS and

Oxfam is to maintain or increase current funding levels in order for them to achieve their goals. “What these organisations mostly need is economic cooperation because they already have their own strategies to use these funds to help people in the developing world. If we trust what they are doing and the methods they have adopted to do so, then the only thing that we can do is to make maximum efforts to provide funds to them to continue the work they are already doing, because they are professionals in that domain and it makes no sense for us to try to interfere with that,” he said. Dr Guell believes that increased funding to projects in developing countries should be given priority status rather than considered as an afterthought. “I think that what we must do as citizens of the world is to change our mentality and to change it proportionally, so we need to perhaps look at our priorities and maybe invest a little bit less in new technologies. The goal of course is not to halt

progress, such as research into femtosecond laser technology, but to diminish just a little bit the vast amounts that we invest in these projects and divert some of those funds into making our colleagues around the world better equipped to deal with the real issues that they face in saving sight every day,” he said. The bottom line, insists Dr Guell, is that we need to change mindsets and move away from the concept of charity as simply writing a cheque once a year to assuage one’s conscience. “This is not about being able to sleep well at night with a clear conscience. The stark reality is that if we continue to advance by a factor of 10 every year and only give 0.1 to the developing world, then the disparities will only increase over time. We need to treble or even quadruple our funding and continue to do so until we are able to progress together. Otherwise we will have a completely bipolar standard of care between the developed and developing world and that is in nobody’s interest,” he concluded.

contacts

Cover Story

Courtesy of Anand Vinekar MD, FRCS

GLOBAL OPHTHALMOLOGY

Parikshit Gogate – parikshitgogate@hotmail.com Gullapalli N Rao – gnrao@lvpei.org Paul Courtright – pcourtright@kcco.net Anand Vinekar – anandvinekar@yahoo.com Hugh R Taylor – h.taylor@unimelb.edu.au Jose Guell – guell@imo.es

Courtesy of Paul Courtright DrPH

Using digital images of ROP to educate rural mothers during focus group meetings

KCCO field assistant measuring vision on outreach in Kilimanjaro Region, Tanzania

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We do tend to overlook the underprivileged in our own communities

Hugh R Taylor

EUROTIMES | Volume 17 | Issue 11

Asia, the ocular health of underprivileged or minority communities in more developed nations does not always get the attention it deserves, some experts believe. For instance, blindness rates amongst indigenous Australians are six times those of the rest of the Australian population and there is a major shortfall in the provision of eye care services to indigenous communities. “We do tend to overlook the underprivileged in our own communities,” said Prof Hugh R Taylor, Harold Mitchell Chair of Indigenous Eye Health at the University of Melbourne and one of the lead authors of a recent report setting out the policy changes needed to address the unnecessary vision loss in Australian Aboriginal people. Dr Taylor’s research has shown how the dire situation currently affecting the indigenous Australians might be reversed by increasing eye care resources by about four times current levels, adopting a national and coordinated approach to policy, and delivering services in partnership with the community control sector. “We often hear the argument that it is not worth spending the money on eye care and that it is too expensive,” Prof Taylor told EuroTimes. “In fact, eye care is extraordinarily cost effective – cataract surgery costs $3,000 per quality-adjusted

life year (QALY) and diabetic retinopathy examinations $15,000 per QALY. In Australia, each $1 spent on eye care yields a $5 return,” he said. Prof Taylor also gave short shrift to the notion that Australia is already spending too much on Aboriginal health and that the money is wasted. “It is true we currently spend $1.39 on indigenous health for each $1 spent on mainstream, whereas a decade ago it was $0.80 for Indigenous health. However, as there is three times the morbidity and vision loss, one would expect to spend at least three times as much even if delivery costs to remote areas were not higher than urban areas. In terms of cataract surgery, seven times less surgery is done for indigenous people,” he said. In Prof Taylor’s view, even a limited increase in funding will go a long way to improving the eye care of Australia’s Aboriginal people. “With a relatively small increase in expenditure, there will be a huge increase in efficiency and reduction in waste for indigenous eye health services. A doubling in funding will increase glasses use by 2.5 times, diabetes eye exams by five times and cataract surgery by seven times,” he said. What is true for Australia’s Aboriginal population may also be true for many other deprived communities in developing countries as the clock ticks down to the VISION 2020 deadline. Most of those working in prevention of blindness programmes know only too well that achieving the VISION 2020 goals will be an uphill battle. And yet guarded optimism remains the watchword for those who toil daily to ensure that the “right to sight” does not become another empty slogan.

The road ahead Much has been learned over the past decade and a broad consensus is emerging on what needs to be done if VISION 2020 is to achieve its targets in eight years’ time.

“We need more emphasis on cataract outcomes, better spectacle compliance and enhanced education to dispel myths and highlight concerns about diabetes and glaucoma,” said Dr Gogate. “In short, we need a comprehensive rather than a cataract-centric approach to eye care,“ he added. For Dr Rao, a three-pronged approach will be required if the targets are to be achieved. “First we need to replicate the success achieved at the global scale at regional, national and district levels. Second, we must learn from the successful models and replicate them with appropriate local modifications. Finally, we need to enhance high-quality human resources development programmes to bring it all together,” he said. For Dr Courtright, several key points need to be taken on board. “We must remember that cataract is still the leading cause of blindness globally. Efforts are needed to improve both the quantity and quality of cataract surgery, as one without the other is useless,” he said. The next ingredient is to focus on local team building, comprising an ophthalmologist, nursing staff, optometrist, and manager, he said. “We should not expect financial sustainability in terms of complete cost recovery from patient or public funding in the poorest environments but work first to develop organisational sustainability,” he said. Some positive encouragement and feedback also goes a long way in boosting morale and spreading best practices to other populations in need. “We should not forget to celebrate our successes,” Dr Courtright concluded. “Many of the rapid assessments of avoidable blindness (RAABs) in Africa have shown a cataract surgical coverage of 70 per cent or more, so teams need to be recognised for what they have accomplished. Ultimately, VISION 2020 is about people receiving a high-quality service and that is what our focus should always be.”

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

ESCRS

Special Focus

GLOBAL OPHTHALMOLOGY

REDUCING BLINDNESS

Decade of data from Israel present a story of success by Cheryl Guttman Krader in Fort Lauderdale

ecent advances in treatment for ophthalmological diseases combined with widely available and universal free access to medical care seem to be powerfully effective for reducing the incidence of blindness, according to experience in Israel. At the 2012 annual meeting of the Association for Research in Vision and Ophthalmology, Alon Skaat MD, updated findings from a recently published populationbased study that assessed time trends in the incidence and causes of new cases of blindness in Israel between 1999 and 2008 [Am J Ophthalmol 2012;153:213-21]. The research was initiated by Michael Belkin MD, professor of ophthalmology, Tel Aviv University. Using patient information extracted from annual reports issued by Israel’s National Registry of the Blind, the investigators calculated annual age-standardised rates of newly registered legal blindness, defined as BCVA less than 3/60 in the better eye or visual field loss less than 20 degrees. Almost 20,000 new cases of blindness were registered over the study period, but time trend analysis showed the age-standardised rate of blindness certification decreased continuously and fell by more than 50 per cent between 1999 and 2008 from 33.8 to 16.6 cases/100,000 residents. Analyses of disease-specific rates of blindness showed the annual age-standardised rate per 100,000 residents also decreased significantly by ≥50 per cent for all four leading causes of blindness: age-related macular degeneration (AMD), glaucoma, diabetic retinopathy and cataract. “According to global data from the World Health Organization, there were about 161 million visually impaired people in 2002, of whom about 37 million were blind, and the number of blind people in the world is expected to continue to rise because of population growth and increasing longevity,” said Dr Skaat, clinical lecturer, Department of Ophthalmology, Goldschleger Eye Institute Sheba Medical Centre, Tel Hashomer, Israel. “The results of our study indicate that progress in eye care and its improved delivery in our clinics in Israel have been very successful in addressing this major public health issue.” Noting that a few other high-income countries have also reported a reduction in blindness incidence over the same time period, Dr Skaat observed that the magnitude of reduction was greater in Israel. He attributed the difference both to the universal free access to healthcare in Israel and to the density of ophthalmologists (~100 per one million people), which is higher than in most other countries. However, specific developments in both ophthalmological care and national healthcare policy also contributed to the declining rate of blindness over time. For AMD, the reduction in annual blindness rate first began in 2004, which is the year when bevacizumab (Avastin, Genentech) treatment for exudative AMD came into widespread use in Israel, Dr Skaat said. The decreased annual rate of glaucoma-related blindness could be explained by the availability of new treatments. In this case, the beginning EUROTIMES | Volume 17 | Issue 11

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With these developments, the wait time for cataract surgery, which previously could be two-to-three years, was virtually eliminated Alon Skaat MD

of the decline followed the commercial introduction of prostaglandin analogues as first-line treatment. “We know from published studies investigating patients with other chronic diseases that medication adherence is probably higher among patients in Israel than in other countries. Our data on the decline in glaucoma-related blindness seem to exemplify the value of combining good patient compliance with good therapy,” he said. Although there were no major advances in treatment for diabetic retinopathy over the study period, an initiative to optimise diabetic patient care was launched by the Ministry of Health in 1993-94. “As a result of this national programme, almost every diabetic patient in Israel receives regular screening for diabetic-related eye disease that is important for preventing vision loss,” Dr Skaat said. The time trend for change in cataract-related blindness showed the annual rate fell through 2004 and was stable thereafter. Here as well, the explanation involved changes in healthcare delivery with the establishment of private ophthalmology clinics that were allowed to perform highvolume cataract surgery and the beginning of private insurance offered by the HMOs. “With these developments, the wait time for cataract surgery, which previously could be two-to-three years, was virtually eliminated,” said Dr Skaat. He said there are limitations for analyses based on registry data. However, it is believed that most blind people in Israel are both diagnosed because there is universal free access to healthcare, and entered into the registry, because persons issued with a Certificate of Blindness derive financial and social service benefits. Furthermore, the accuracy of the registry data was validated in a 1998 study using information from other government registries. “Although the registry was started in 1990, we chose to start our study using data from 1999, the year after the validation. We believe any errors in reporting are probably due to malingering. However, that would have a negligible effect on our findings given the length of our study period,” Dr Skaat said. Dr Skaat acknowledges the contribution of the researchers Dr Ofra Kalter-leibovici and Ms Ancela Chertit from the Gertner Institute of Epidemiology and Health Policy Research, in Tel-Hashomer.

contact

Alon Skaat – skaatalon@gmail.com

Special Focus

GLOBAL OPHTHALMOLOGY Feel the New Pulse in Perimetry… OCTOPUS® 600

VISION LOSS

Updated database provides wealth of information and describes prevalence and trends by Cheryl Guttman Krader in Fort Lauderdale

he age-standardised prevalence of blindness and visual impairment has decreased around the world over the past 20 years, although the total burden of vision loss changed little due to population growth, according to the Global Burdens of Disease, Injuries and Risk Factors Study (GBD Study). Findings from the study showed the global age-standardised prevalence of blindness decreased from 0.9 per cent in 1990 to 0.5 per cent in 2010,which represented an estimated 34 million blind (defined as VA <3/60 in the better eye). In addition, the GBD Study estimated there were 200 million visually impaired (VA <6/18 to 3/60 in the better eye) people in the world in 2010, reported Rupert Bourne MD, who presented the data at the 2012 annual meeting of the Association for Research in Vision and Ophthalmology, on behalf of the 79 members of the GBD Vision Loss Expert Group. “The long, comprehensive span of data sources used in this project gives strength to the temporal observation of a decrease in global age-standardised blindness prevalence. Despite the variability in availability of population-based data across regions, the findings from the GBD Study highlight geographic differences in the burden of blindness and vision loss, and they should be a useful source for policymakers worldwide,” said Dr Bourne, professor of ophthalmology, Vision & Eye Research Unit of Anglia Ruskin University, Cambridge, UK. The GBD Study was commissioned with funding from the Bill & Melinda Gates Foundation in 2007. Estimation of global trends in visual impairment and blindness prevalence between 1990 and 2010, along with its uncertainties by sex, for 190 countries and territories in the 21 GBD sub-regions, was performed by accessing published and unpublished data from population-based studies of visual impairment and blindness for the period 1980 to 2012. A total of 14,908 abstracts were identified, 1,334 articles reviewed, and the information was supplemented by additional data obtained from contacting the principal investigators for some studies. In total, 6,500 data points were extracted into the database from 259 sources.

EUROTIMES | Volume 17 | Issue 11

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“

The long, comprehensive span of data sources used in this project gives strength to the temporal observation of a decrease in global age-standardised blindness prevalence Rupert Bourne MD

Dr Bourne noted the literature search identified relatively few studies from the 1980s, and while the number of publications increased during the 1990s, especially from Asian countries, there were still no data from six GDP regions. Analyses of the data by region showed marked reductions in age-standardised prevalence of blindness in North Africa, the Middle East, Asia, the Indian subcontinent, and sub-Saharan Africa as compared with a less marked reduction in high income and eastern and central European countries, where, among these regions, the prevalence was lowest. Worldwide, there were 1.4 times more blind women than men, and the gender difference was even more marked in certain regions, particularly in Eastern Europe. “This discrepancy is mainly due to the reduced life expectancy for men in this region,” Dr Bourne said. Additional work is ongoing. The Visualisations Project will make the wealth of data from the GBD Study accessible to many users. One of Dr Bourne’s PhD students, Mr John Somner, prepared an early version of such a visualisation, which was demonstrated at the meeting. In addition, cause-specific analyses of low vision and blindness are under way, future projections accounting for population growth are being done and disability weights associated with the burden of vision loss, calculated as disability-adjusted life years, will be released soon.

Spe A. John USA MD ( Chris n E. Hill, MD (DK) ) e , r r n a e (USA ls W as O t, MD Thom el Maske t.com u Sam strei

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Special Focus

GLOBAL OPHTHALMOLOGY

ORBIS GONDAR PROJECT

ESCRS supporting establishment of paediatric eye care team at Gondar University Hospital in Ethiopia by Dermot McGrath in Milan

ust one year after its official launch, an ESCRS-funded project in collaboration with ORBIS is already starting to make significant headway in the battle to save the sight of thousands of children in North West Ethiopia. “It is still very early days but a lot of progress has been made in putting the proper structures in place to develop a fully functional paediatric eye care service at Gondar Referral Hospital in order to serve the eye care needs of the local population,” Allan Thompson of ORBIS told EuroTimes. Starting in 2011, the ORBIS Gondar Project has been working to establish a fully equipped Child Eye Health Tertiary Facility (CEHTF) with a trained paediatric eye care team at Gondar University Referral Hospital to ensure delivery of high-quality eye care in the Amhara regional state, located about 725km north of the Ethiopian capital Addis Ababa. With an estimated 6,300 blind children in the Amhara regional state, and another 31,500 children with low vision, ORBIS set out to strengthen the referral network and follow-up system within the local region and raise awareness of the importance of seeking prompt medical advice for children’s eye conditions to ensure early detection and treatment. Asamere Tsegaw MD, one of the ophthalmologists in Gondar who recently completed ESCRS/ORBIS-sponsored shortterm surgical training in India, believes that the CEHTF will have a real impact in tackling blindness and low vision in the region. “As well as establishing the paediatric eye care facility, which includes training specialised personnel specifically for children’s ophthalmology, we have also been developing the medical infrastructure in terms of equipment, management structures and so forth. One year has now passed since

From left to right: Allan Thompson, ORBIS; Mulusew Asferaw, assistant professor of ophthalmology at the University of Gondar; Yared Assefa, head of the Ophthalmology Department at the University of Gondar; and Asamere Tsegaw, assistant professor of ophthalmology at the University of Gondar

the opening of the centre and the project is already making a difference,” he said. “Although the current most common causes of childhood blindness observed in our patients are childhood cataracts, nutritional deficiencies and refractive error, we expect more childhood retinal problems such as retinopathy of prematurity (ROP) in the future as the general healthcare system of Ethiopia is expected to improve and more premature infants survive. My recent ESCRS/ ORBIS-sponsored short-term training in India was an important addition to the skills of the paediatric eye care team in Gondar to better take care of a wide range of childhood eye problems and prevent unnecessary blindness,” Dr Tsegaw added. A key part of the ORBIS project lies in ensuring that the local ophthalmic and healthcare personnel receive the best possible hands-on training to deal with the specific

needs of paediatric patients, explains Mr Thompson. “This is where the ESCRS funding has made a huge difference. It has contributed in a variety of ways, by helping to finance a recent hospital-based training programme in Gondar led by Irish ophthalmic surgeon Donal Brosnahan, and also supporting fellowships and other training programmes for local ophthalmologists and other personnel. The funding really was instrumental in getting this project off the ground,” he said. The importance of running training courses specifically adapted to the needs of the local physicians has played a key part in the success of the ORBIS-Gondar partnership, points out Yared Assefa, head of the Ophthalmology Department at the University of Gondar. “Dr Brosnahan has been coming for

contacts

many years to Ethiopia and he provides high-quality hands-on training in treating paediatric cataract and strabismus, which are really a major problem in our region. The prevalence of blindness from these conditions is about five times the level that it would be in Europe,” he said. With a catchment population of roughly 16 million people in the Amhara area, Dr Assefa acknowledges the difficult task facing the Gondar team in catering to the ocular health of such a large and widely dispersed population. “As well as our own direct catchment area we also have adjacent regions which are not well served in specialised healthcare such as paediatric ophthalmology. So what we are planning, and have already started to do, is to make our hospital a centre of excellence, first in paediatric ophthalmology, and then under the umbrella of this paediatric ophthalmology, to strengthen and extend our other ophthalmic services. To that end, we have started training general health personnel in the region, enabling them to refer, diagnose or detect childhood and adult eye problems that need intervention,” he said. The referral network will also be extended into the education system, said Dr Assefa. “We are also planning to train school teachers to detect refractive errors in their schools and to be able to refer students to the secondary health centres or directly to our centre in the case of severe problems,” he added. In addition to building a robust paediatric eye care team, Gondar University Hospital is also looking to improve the quality of epidemiological data from the region. “We have started to conduct research in the past few months on the knowledge, attitude and practice of childhood blindness in the Amhara region,” explained Mulusew Asferaw MD, a paediatric ophthalmologist who recently completed an ORBISsponsored fellowship training in paediatric ophthalmology at CCBRT Disability Hospital, Dar es Salaam, Tanzania. “This is very important indeed to the ongoing ORBIS project so that we can better target our care to the actual needs of the population. And it will also be a great help in assessing the actual impact of the project on the prevalence of blindness in the region,” he said.

Read EuroTimes on the move! Visit the new EuroTimes mobile website at

http://m.eurotimes.org EUROTIMES | Volume 17 | Issue 11

Allan Thompson – athompson@orbis.org.uk Yared Assefa – assefabi2003@yahoo.com Mulusew Asferaw – muasf@yahoo.com Asamere Tsegaw – asameret@yahoo.com

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

contact

Michael Chiang – chiangm@ohsu.edu

Special Focus

GLOBAL OPHTHALMOLOGY

ROP diagnosis

Application of telemedicine holds promise for improving access to and quality of patient care by Cheryl Guttman Krader in Milan

nnovative telemedicine and teleeducation approaches are helping to overcome current limitations in the diagnosis of retinopathy of prematurity worldwide, according to Michael F Chiang MD, Knowles Professor of Ophthalmology & Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, US. Speaking at the 2nd World Congress of Paediatric Ophthalmology and Strabismus, Dr Chiang reviewed research showing that telemedicine offers an accurate, costeffective and efficient method for diagnosing ROP, and he discussed tele-education as a method for training ophthalmologists to be competent in managing ROP. “Telemedicine for ROP appears to perform well for achieving the right diagnosis, and it has the potential to improve the quality, accessibility, and cost of ROP care. Now, major real-world telemedicine programmes are ongoing in the US and internationally, along with additional studies to further define its role,” said Dr Chiang. “In addition, tele-education appears to offer a good approach for addressing significant gaps in ROP diagnosis training and competency. We are excited about collaborative projects ongoing in this area and the efforts under way to apply these principles worldwide to ROP care.” Telemedicine diagnosis of ROP involves remote expert review of digital images captured at the point-of-care by a nurse or other personnel trained to properly operate a wide-angle contact camera (e.g. RetCam, Clarity Medical Systems). Compared with the current approach to ROP evaluation and monitoring by serial bedside indirect ophthalmoscopy and documentation of the findings with handdrawn pictures, the photographic method has an advantage for providing more reliable, objective information for detecting disease and its progression. The appropriateness of telemedicine for ROP diagnosis has been investigated in a number of studies that compared its accuracy to dilated ophthalmoscopy by an expert. In a project sponsored by the American Academy of Ophthalmology, Dr Chiang and colleagues conducted an in-depth review of 28 published studies on detection of clinically significant ROP using wide-angle digital retinal photography

EUROTIMES | Volume 17 | Issue 11

[Ophthalmology 2012;1272-80]. The articles included seven papers with 458 infants that were rated as Level I evidence; three other papers, which included 1,462 infants, were considered Level III evidence. In the Level I papers, the sensitivity of the telemedicine approach ranged from 76 per cent to 100 per cent for diagnosing Type2 or worse ROP and from 87 per cent to 100 per cent for Type-1 disease, although in many papers, the sensitivity rates were at the upper end of those ranges. Rates for both sensitivity and specificity in all Level III papers were 99 per cent or 100 per cent. Noting that all of the studies in the literature considered bedside ophthalmoscopic exam as the gold standard for ROP detection, Dr Chiang discussed another study, including 206 eyes, that investigated intraphysician agreement of diagnoses based on indirect ophthalmoscopy versus digital images [Ophthalmology 2008;115:1222-8]. The results showed there was a discrepancy between the two methods in 14 per cent of eyes. In onethird of the latter cases, ROP that was identified on the digital images was missed on ophthalmoscopic exam. In 29 per cent of discrepancies, zone I disease was diagnosed by ophthalmoscopy whereas the telemedicine exam diagnosed zone II ROP. “Review of digital images offers the potential for making a more accurate diagnosis in some cases because it enables identification, scrutiny, and direct measurement of landmarks, which can be difficult when examining a moving baby at the bedside,” Dr Chiang said. Results of cost-utility and timemotion analyses also provide support for telemedicine in showing it to be about 40 per cent more cost-effective than ophthalmoscopy [Arch Ophthalmol 2008;126:493-9], and at least three times faster [Am J Ophthalmol 2009;148:136-42].

Broadening and improving training Use of tele-education for

ROP diagnosis teaching aims to increase accessibility to adequately trained physicians throughout the world. A shortage of ophthalmologists able to diagnose ROP is a particular problem in developing countries, but research also highlights there are gaps in patient care and physician competency even in the US.

Dr Chiang observed that while, in general, neonatal care in the developing world is rapidly improving, training in ROP diagnosis is still often absent or limited. Online education could be a viable way to solve this problem because these countries often have a good Internet infrastructure. Yet, results of various studies highlight there is a need for better education on ROP diagnosis even in the US. For example, research in collaboration with Paul Chan MD, evaluating diagnosis of ROP by physicians in US retina and paediatric ophthalmology fellowship programmes found that significant errors were not uncommon. Retina fellows overcalled clinically-significant ROP in up to 50 per cent of cases and missed it completely 10 per cent of the time [Retina 2010;30:95865]. In the study of the paediatric ophthalmology fellows, the sensitivity for diagnosing clinically significant ROP averaged only 50 per cent, and of the five participants, some made the wrong diagnosis two-thirds of the time [J AAPOS 2011;15:573-8]. Dr Chiang also cited the findings of a survey to characterise ROP education in paediatric ophthalmology and retina fellowship programmes showing significant variation in the level of training and quality of clinical care. Regarding the latter, up to two-thirds of ROP exams in about 30 per cent of the programmes were done

“

Telemedicine for ROP appears to perform well for achieving the right diagnosis, and it has the potential to improve the quality, accessibility, and cost of ROP care Michael F Chiang MD

only by the fellow and not by an attending ophthalmologist as well. Preliminary evidence suggests that ROP tele-education works well. To investigate this issue, Dr Chiang collaborated with Tom Lee MD, and others on a proof of concept study in Armenia. After one week of in-country education, the local ophthalmologists did weekly eye exams and captured digital retinal photographs that provided a basis for remote mentoring. “Anecdotally, the diagnostic skills of the Armenian ophthalmologists seemed to improve using this approach. Now, we are collaborating to develop analyses to see if we can confirm that impression,” Dr Chiang said.

Update

Cataract & refractive

new approach

Presbyopic solution lauded in French study

by Dermot McGrath in Paris

EUROTIMES | Volume 17 | Issue 11

Courtesy of Frederic Hehn MD

refined version of PresbyLASIK is capable of delivering highquality vision at all distances for both eyes in presbyopic patients and represents a definite improvement on traditional monovision approaches, according to a French study presented here. “We have been successfully using this technique called advanced Isovision since October 2010 for our presbyopic patients. It has given us very satisfactory, predictable results that are a definite improvement on those obtained with other techniques such as conventional presbyLASIK or monovision,” Frederic Hehn MD told delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting. Dr Hehn, in private practice in Nancy, France, explained that the technique consists first of all in correcting the patient’s distance vision using a standard refractive treatment to modify the central keratometry. This is then followed by treatment for near vision on the same eye using the F-CAT profile of the Wavelight Allegretto laser (Alcon Laboratories). “There is no induced myopia (see figure) and the patient sees perfectly at all distances with the same eye. In this way, the two eyes can be treated in the same manner independent of ocular dominance. The patient usually has excellent near vision almost immediately, and the distance vision usually takes just a couple of days to allow the patient to drive comfortably,” said Dr Hehn. Dr Hehn added that only a small percentage of patients, in the range of less than 10 per cent, required a further refractive fine-tuning procedure for their distance vision, and none at all for their near vision. “This technique gives excellent quality of vision which is evident from the defocus curves that we have obtained. There is no ‘gap’ in intermediate vision, as found with diffractive multifocal IOLs, and there is very little diminution in contrast sensitivity since the treatment is performed on a large, fixed optical zone of 6.5mm for both distance and near vision. The clinical results are excellent based on the fact that the technique does not penalise near or distance vision – there is no compromise like we see in traditional presbyLASIK or monovision,” he said.

No myopisation

“

We have been successfully using this technique called advanced Isovision since October 2010 for our presbyopic patients Frederic Hehn MD

Dr Hehn noted that the key to the success of the Isovision approach stems from the Wavelight system’s ability to minimise the induction of spherical aberrations during the treatment. “Understanding how negative spherical aberrations work allows us to increase the depth of focus without the deleterious effects of positive spherical aberrations. Positive spherical aberrations are well known to give a bad quality of vision in scotopic conditions, with associated problems of glare and haloes. Controlling these factors gives us excellent and natural near vision and very good intermediate vision with an excellent defocus curve. The technique is superior to phakic multifocal IOLs especially in terms of the quality of intermediate vision,” he said. Dr Hehn said that one of the advantages of the treatment is that Isovision, in contrast to monovision, is not limited by patient age. All presbyopic patients from 40 to 75 years of age can benefit from the treatment and it is available for myopic, emmetropic and hyperopic eyes from -8.0 D to +4.0 D, which makes it an attractive option for a large number of patients, he added.

contact ci r e d e r

F –hn henhf@aol.com e H

contact

José L Güell – Guell@imo.es

Update

Cataract & refractive

ASTIGMATISM

Currently available lenses can provide significant visual benefits by Roibeard O’hEineachain in Prague

orrecting the regular component of an eye with irregular astigmatism with toric intraocular lenses can often result in a satisfactory visual outcome, said Jose Güell MD, director of the Cornea and Refractive Surgery Unit at IMO Autonomous University of Barcelona, Barcelona, Spain. “When you're able to compensate the regular component in eyes with irregular astigmatism, visual improvement is so significant in a large number of cases that the patient does not regard the irregularity as significant,” said Dr Güell at the 16th ESCRS Winter Meeting. Toric IOLs provide an alternative to rigid gas-permeable contact lenses, which is the standard treatment for irregular astigmatism, whether the condition results from keratoconus or corneal grafting, he said. The lenses that have been used with success include pseudophakic, phakic and piggyback IOLs. Customised IOLs, specifically designed for an individual’s corneal optics, are another option that has recently become available, and the future will hopefully see light-adjustable IOLs employed in a similar manner, he predicted.

Patients with irregular astigmatism often require a highly individualised treatment. Therefore, the peer-reviewed literature regarding specific lenticular approaches is fairly sparse, Dr Güell noted. However, several case-studies derived from his own experience show that those approaches can be of considerable benefit to some patients. As an example, he cited the case of a woman in her mid-50s with irregular astigmatism from congenital corneal lesions and coloboma. She wanted refractive surgery but was an unsuitable candidate for refractive laser ablation. Following clear lens extraction and implantation of an AcrySof pseudophakic IOL she had significant improvements in her vision, despite some residual irregular astigmatism, Dr Güell said. Another patient who achieved a good result with a pseudophakic IOL had irregular astigmatism as well as cataract. The irregularity of the cornea was a result of keratoplasty, itself performed to correct irregularities after radial keratotomy, Dr Güell said. “One of the advantages of using these phakic IOLs (Toric Artiflex) is that they can be introduced through a 3.1mm incision and, especially, when you use

this posteriorly located limbal incision the amount of astigmatism induced is clinically insignificant,” he explained. Toric phakic IOLs are also a useful option in some cases. Dr Guell reported that implantation of phakic IOLs has produced good results at his centre in eyes with keratoconus, after he and his associates first stabilise the ectasia by stiffening the corneal collagen through collagen cross-linking. Another option is to use piggyback IOLs. He noted that Rayner produces a type of IOL that is specifically designed for sulcus implantation, including a model with an astigmatism-correcting component. He noted that such IOLs are particularly useful in cases where the cornea is best left untouched, such as in eyes with forme fruste keratoconus Occasionally a patient who has undergone piggy-back IOL implantation may require further correction, Dr Güell said. He described the case of a man with irregular astigmatism who had undergone a radial keratotomy many years previously. The patient had since undergone implantation of two IOLs, one in the capsular bag and the other in the sulcus. To correct the residual ametropia, Dr Güell and his associates implanted a third lens in the anterior chamber, an iris-fixated Artisan/Verisyse lens (AMO) to correct the still residual sphere and cylinder. “Once this was done, visual acuity improved to 0.8 in spite of the residual irregular astigmatism, which was not as significant,” Dr Güell said. He noted that the ophthalmic device company, Topcon, has introduced a service that could bode well for the treatment of astigmatism in general. It produces a made-

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EUROTIMES | Volume 17 | Issue 11

“

Hopefully, the different companies will arrange some kind of agreement in order to combine the available technologies so we can achieve this aim José Güell MD

to-order toric IOL, the Lentis T Plus, which provides individual astigmatism correction. Surgeons using the IOL can use an online calculator to specify the IOL’s dimensions. “You can send this data and they can prepare a customised lens for you, not only to correct sphere and cylinder, but also higher order aberrations. Although only with preliminary experience, we have found vision can be improved significantly when we've corrected higher order aberrations, even when the corneal irregular astigmatism remains unchanged,” Dr Güell said. Another development along similar lines is the light-adjustable lens, which allows postoperative correction of residual sphere and cylinder and could theoretically be used to correct irregular astigmatism and higher order aberrations as well. “Today we can only theoretically correct irregular astigmatism with IOLs experimentally but it will happen in the near future because we already have this technology available,” he concluded.

contact

Update

Cataract & refractive

Charles Ghenassia – charles.ghenassia@wanadoo.fr

EPITHELIAL INGROWTH

Flap removal effective as last resort in difficult epithelial ingrowth cases by Dermot McGrath in Paris

ith the thin flap technique with microkeratome or femtolaser, amputation of the LASIK flap (90 to 110 microns) is a radical yet effective means of tackling problems of recalcitrant epithelial ingrowth that have failed to respond to conventional treatment methods, according to Charles Ghenassia MD. “Ablation of the flap is never an easy decision to take, but sometimes we are left with no other option when repeated cleaning of the flap and interface fail to prevent recurrence of the ingrowth. While this really is the last resort when all other methods have failed, our own experience, as well as the rare cases found in the scientific literature, point to reasonably satisfactory outcomes after the flap has been removed,” he said. Addressing delegates attending the French Implant and Refractive Surgery Association (SAFIR) annual meeting, Dr Ghenassia, in private practice in Nice, France, said that flap-related complications in LASIK procedures have been well chronicled over the years. “There are the intraoperative complications related to flap creation such as incomplete flap, buttonholes, torn flaps, small diameter flaps and so forth. Flap striae, large folds and flap irregularities can also cause problems. Other postoperative complications to be wary of include recurrent epithelial ingrowth, multilayered squamous epithelium, corneal decompensation and opacities of the central cornea,” he said. While epithelial ingrowth into the corneal stromal interface is usually asymptomatic, Dr Ghenassia noted that in rare cases the proliferation of cells may lead to decreased vision due to irregular corneal astigmatism, direct intrusion of cells into the visual axis and potential melting of the overlying flap in worst-case scenarios. Treatment is generally indicated in instances where there

“

Ablation of the flap is never an easy decision to take, but sometimes we are left with no other option when repeated cleaning of the flap and interface fail to prevent recurrence of the ingrowth Charles Ghenassia MD

is decreased vision or threat for a flap melt. The general treatment for removing epithelial ingrowth is to lift the flap and scrape the epithelial cells from the stromal bed and under-surface of the flap, followed by application of 30 per cent alcohol on the stroma for around 20 seconds, said Dr Ghenassia. This is then typically followed by placement of a therapeutic contact lens. Excimer laser phototherapeutic keratectomy (PTK) may also be used in combination with manual scraping to remove epithelial cells and prevent further recurrence of the ingrowth. The use of an Nd:YAG laser may also be indicated when epithelial cells are encroaching the visual axis. For refractory epithelial ingrowth, amputation of the flap may ultimately be indicated in order to preserve visual acuity and minimise damage to the stroma. Before removing the flap in such recalcitrant cases, Dr Ghenassia advised evaluating the ingrowth using OCT imaging to determine its depth and to obtain a full topographic analysis of the lesion. The corneal topography may also be useful in showing irregular astigmatism due

Ingrowth and topography

to the epithelial cells affecting the corneal contour of the overlying corneal flap. If PTK or cleaning does not work, the last resort is flap removal, said Dr Ghenassia. This can be carried out under topical anaesthesia. The edge of the flap can be scored and lifted using an instrument such as a Seibel hook to separate the epithelium. This is followed by careful debridement of the epithelial cells from the stromal bed and application of 30 per cent alcohol solution for 15 to 20 seconds on the stroma. The final steps include PTK of 5.0 microns on the anterior stroma followed by ablation of the flap at the hinge with the use of a Vannas scissors and the placement of a therapeutic contact lens for 48 hours. The disadvantages of flap amputation include postoperative pain, transitory haze and myopic shift that can be treated by PRK if the corneal thickness allowed it, said Dr Ghenassia. In the 10 cases of flap amputation reported by Dr Ghenassia, the removal of the flap resulted in an improvement of mean refractive cylinder from 2.47 D preoperatively to 1.10 D postoperatively. Visual acuity was also considerably improved after treatment, with six patients recording between 8/10 and 10/10 best corrected visual acuity with or without PRK enhancements, he said. Interestingly, Dr Ghenassia remarked that the flap ablation also appeared to increase the prolate shape of the cornea and modify the quantity of spherical aberration, resulting in an improved depth of focus and better near vision for these patients.

Courtesy of Charles Ghenassia MD

Infection

Don’t miss Eye on Travel, See page 38 EUROTIMES | Volume 17 | Issue 11

Post-op A five months

Post-op B 3 months

contact

Edward Loane – edwardloane@yahoo.com

Update

Cataract & refractive

Nd:YAG LASER CAPSULOTOMY

Variation in technique amongst ophthalmologists compared to best practice guidelines by Roibeard O’hEineachain in Dublin

here is variation amongst ophthalmologists compared to best practice guidelines, suggested by published research, when performing Nd:YAG Laser capsulotomies, according to Edward Loane PhD, MRCOphth, Mater Misericordiae University Hospital, Dublin. “We have confirmed through an audit that there is a large variation among Irish ophthalmologists when performing YAG capsulotomy and the variation we found nationally here is comparable to international findings. It emphasises to me that even ‘simple’ things can be done better,” Dr Loane said at a meeting of the Irish College of Ophthalmologists. He noted that Nd:YAG laser capsulotomy was introduced in the early 1980s and is now the standard treatment for posterior capsular opacification following cataract surgery. The intervention is required in about 25 per cent of cases within five years of surgery. The incidence tends to be lower in eyes implanted with square-edged optic IOLs. “YAG laser capsulotomy is usually the first laser procedure that ophthalmic surgeons learn and it is considered quite a simple procedure. However, despite this, there is a lack of consensus on the technique and post procedural management after the laser,” he said. Dr Loane therefore conducted an audit of Nd:YAG laser capsulotomy as practised by the membership of the Irish College of Ophthalmologists. For that purpose, he designed an online questionnaire using the Google platform. It consisted of 15 questions and was designed to be completed in less than four minutes. He used the questionnaire from a similar audit conducted in the UK as a template. There were 52 respondents to the questionnaire, representing about 30 per cent of those who were invited to participate, he said. Most of the respondents were consultants.

Practice variations Regarding their technique, 100 per cent dilate their patients’ pupils before performing Nd:YAG laser capsulotomy. Research favours this approach since it allows for capsulotomies larger than the undilated pupil, which in turn reduces the incidence of glare and haloes. Approximately twoEUROTIMES | Volume 17 | Issue 11

thirds of respondents said they made their capsulotomies larger than the undilated pupil. However, 24 per cent said they make their capsulotomies the same size as the undilated pupil, and five per cent said they made their capsulotomies smaller than the undilated pupil. A high proportion (42 per cent) perform circular capsulotomies, which have the disadvantage of often resulting in a large floater, although it does avoid the central visual axis, he said. However, the inverted-U technique, the choice of 23 per cent of respondents, also avoids the central visual axis but does not have the potential to cause a large floater, Dr Loane pointed out. The cruciate technique, preferred by 27 per cent of respondents, has the advantage of fewer laser shots but crosses the visual axis. In terms of laser defocusing, 84 per cent said they defocus posteriorly, an approach which research suggests is the best because it reduces the incidence of lens pitting, Dr Loane said. Only four per cent defocused anteriorly, and the remaining 12 percent did not defocus their laser at all, he added. Dr Loane noted that just 58 per cent used a contact lens specifically designed for Nd:YAG laser procedures, despite the many advantages it provides. Among those who did use a lens for the procedure, the reasons cited were to stabilise the eye, to improve the delivery of laser energy, and for magnification purposes, which are all benefits use of the lens can provide, he said.

More lens pitting than there should be Regarding the frequency of

lens pitting, half of respondents said that it occurs sometimes in their patients, 40 per cent said it occurs rarely, and 10 per cent said it occurs often. Dr Loane said that with good technique, which includes defocusing the laser posteriorly and using a specific contact lens for the procedure, lens pitting should only occur rarely. He noted that the majority of respondents reported a very thorough approach to the recording of the details of their procedures. All noted the procedure in the patient's file. Around three-quarters recorded the number of laser shots and the amount of laser energy used. Just over 80 per cent recorded details concerning any drops used after the procedure.

Less commonly reported were details concerning the shape of the capsulotomy, the use or non-use of a contact lens, and the incidence of lens pitting. Another finding of the audit was that a high proportion of Irish ophthalmologists give their patients IOP-lowering medication much more often than necessary. In fact, 70 per cent said they use them always, and 20 per cent use them sometimes or rarely. Among the surgeons who use these drops, the vast majority (80 per cent) only apply them once at the end of the procedure. “I think this could be improved and it is suggested internationally it should only really be used in eyes that are at risk. That is, in patients with glaucoma. Otherwise patients don't really need topical IOPlowering drops because the small incidence of a pressure rise following YAG laser is not damaging to a healthy eye,” Dr Loane said.

Ophthalmic Women Leaders

“

We have confirmed through an audit that there is a large variation among Irish ophthalmologists when performing YAG capsulotomy and the variation we found nationally here is comparable to international findings. It emphasises to me that even ‘simple’ things can be done better

Edward Loane PhD, MRCOphth

The respondents also tended to followup on their patients more thoroughly than may be necessary. The current thinking is that follow-up visits should be restricted to those with co-morbidities. However, it was conceded that this was a controversial point and that all patients should receive clear instructions regarding retinal detachment warning signs at the very least.

Women In Ophthalmology

Monday, November 12 • 5:30 to 7 pm Hyatt McCormick Place • Chicago, IL (USA) Ophthalmic Women Leaders (OWL) and Women in Ophthalmology (WIO) partner to present this signature reception featuring the WIO presentation of the prestigious Suzanne Veronneau-Troutman Award, exciting silent and live charity auction, OWLtinis and more. Free for OWL and WIO members. $25 for non-members. For details and to register, visit www.owlsite.org. Ophthalmic Women Leaders

Update

Cataract & refractive

First Module 2013

Second Module 2013

Orbital, lacrimal & ophthalmic plastic surgery

Surgical Retina

slow uptake

Reluctance to introduce new procedure among European and American surgeons

by Howard Larkin in Milan

Valletta, Malta 21 – 25 January 2013

Lugano, Switzerland 4 – 8 February 2013

Faculty

L. Baldeschi, M. González-Candial, C. Hintschich, R. Medel, S. Morax, U. Schaudig, P. Schembri-Wismayer, A. Tyers, L.M. Vásquez

C. Azzolini, S. Charles, B. Corcóstegui, C. Forlini, C. Mateo, R. Rejdak, K. Rezaei

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

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28.9.2012 14:43:58 Uhr

Courtesy of David Leaming MD

nterest in femtosecond laser-assisted cataract surgery remains high, but only two per cent of European and four per cent of US surgeons performed the procedure in 2011, while only four per cent and three per cent respectively said they planned to add it within the next six months, according to the latest surveys of ESCRS and ASCRS members by David Leaming MD, Palm Springs, California, US. The results were presented at the XXX Congress of the ESCRS in Milan, Italy. When asked what was keeping them from doing laser cataract surgery, “not cost effective” was the top response at 67 per cent in Europe and 78 per cent in the US, followed by “no good data to prove it’s better” at 32 per cent in Europe and 46 per cent in the US. Surgeons also expressed concern about the extra time laser cataract surgery would take with “takes too long” listed as a factor by 15 per cent in Europe and 27 per cent in the US. While overall interest in laser cataract surgery was high, the level of interest in specific aspects of laser surgery varied considerably. European surgeons rated laser capsulorhexis and laser lens softening an average of +8 and +7 respectively, while Americans ranked them -13 and -15. However, US surgeons gave laser limbal relaxing incisions a +20 compared with -7 for Europeans. Differences also were seen in techniques for correcting astigmatism at cataract surgery. While 19 per cent of European and 10 per cent of US surgeons reported no change in technique or operating on the same axis in patients with significant astigmatism, 21 per cent of European and six per cent of US surgeons reported operating on the steep axis, 12 per cent and five per cent respectively reported using LRIs, and three per cent and two per cent used excimer surgery after cataract surgery. Toric IOLs remained the most common astigmatism correction approach, with 43 per cent of Europeans using them in patients with significant astigmatism – up five per cent from 2010 – and 66 per cent of US surgeons. In a separate question on types of IOLs used overall, toric IOLs were the most common premium IOL, with 61 per cent of European surgeons using them, up 12 per cent from last year, and 85 per cent of US surgeons. By comparison, 44 per cent

of European and 72 per cent of US surgeons used multifocal IOLs, and accommodating IOLs were used by only 12 per cent in Europe and 25 per cent in the US, down seven per cent from 2010. Intracameral antibiotics remained much more popular in Europe with 60 per cent reporting using them, compared with 18 per cent in the US, though this figure has risen slowly over the years. Bilateral same-day cataract surgery also was more common in Europe at nine per cent, compared with just 0.4 per cent in the US. Finland reported the highest bilateral rates at 65 per cent followed by Sweden at 32 per cent and Serbia at 29 per cent. The surveys reported were concluded in November 2011, with 512 responses from 3,660 email invitations to ESCRS and 463 responses to 4,649 e-mail invitations to ASCRS members. These are the 13th annual ESCRS and 28th annual ASCRS surveys. * See leamingsurveys.com.

contact David Leaming– eyeopr8@aol.com

Update

Cataract & refractive

Visit Angiotech Booth 1151 during AAO

RAY TRACING SOFTWARE

Advantage of ray tracing over existing IOL power calculation formulae is that it works for every eye

The Surgeon’s Edge

by Cheryl Guttman Krader in Fort Lauderdale

EUROTIMES | Volume 17 | Issue 11

Courtesy of Kazuno Negishi MD

mproving the predictability of refractive outcomes has become an important focus in cataract surgery. Ray tracing software for IOL power calculation is a promising method for achieving this goal, according to studies presented at the annual meeting of the Association for Research in Vision and Ophthalmology, . A real ray tracing module (OphthaRAY) found on a commercially available video-topometer (OphthaTop, Hummel AG) was developed by Thomas Bende PhD, Jens Eininghammer PhD, and colleagues. The programme uses topography data acquired with the OphthaTop and separately obtained biometric information (IOLMaster, Carl Zeiss Meditec or Lenstar LS 900, Haag-Streit). A next-generation device (OphthaSTAR), which is expected to be available late in 2012, will have integrated biometry so that all of the data necessary for IOL calculations will be captured with the push of a single button, noted Dr Bende, head of the Foundation for Basic Research in Ophthalmology, University of Tuebingen. “The advantage of ray tracing over existing IOL power calculation formulae is that it works for every eye, regardless of axial length, astigmatism, or history of corneal surgery, and it can be applied in the future to eyes that undergo yet unknown methods of refractive surgery,” Dr Bende told EuroTimes. “However, the output still depends on the quality of the input. As we believe accuracy can be optimised by integrating the software with the measurement device, we’ve developed a platform for obtaining all of the necessary measurements used in the ray tracing software,” he commented. With the OphthaRay programme, ray tracing is performed at each of the approximately 10,000 measured topographical points over a 9.0mm diameter. “Our programme provides localised information about aberrations and thus can describe a truly customised lens that minimises total wavefront error. Currently, lens geometry specifications are divided so that surgeons can pick the best commercial lens in terms of spherocylindrical power and asphericity. Information on residual aberrations is provided as Zernike coefficients or ablation profiles for excimer laser or spectacle correction,” Dr Bende said. Dr Bende and colleagues reported findings from a retrospective study comparing performance of the ray tracing software and the SRK/T formula for IOL power calculation in 50 virgin eyes that had been implanted with the ZCB00 single-piece aspheric acrylic posterior chamber IOL (Tecnis, AMO). Calculations with real ray tracing were done using the manufacturer’s geometric specification of the IOL and the preoperative topographic (C-Scan, Technomed) and biometric data (IOLMaster). The SRK/T formula calculations used the same preoperative data and the latest constants from the User Group for Laser Interference Biometry. Based on comparisons to the actual postoperative manifest refractive outcomes, use of the real ray tracing offered slightly better power prediction overall. Mean absolute error (MAE) of prediction in the overall cohort was 0.44 D for the ray tracing and 0.41 D for SRK/T. Analyses with eyes subdivided into three groups by axial length showed the benefit of ray tracing was driven by improved

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Percentages of eyes within ±0.5 D and ±1.0 D of intended correction

accuracy in long eyes (24-27 mm, n=13) where MAE was 0.26 D using ray tracing and 0.37 D using the SRK/T. In another retrospective study, Kazuno Negishi MD, associate professor of ophthalmology, Keio University School of Medicine, Tokyo, Japan, and colleagues investigated the accuracy of IOL power calculations using OKULIX (OKULIX) ray tracing software in 23 eyes with a history of myopic LASIK. Prediction errors from calculations performed with the ray tracing software were compared with those obtained using the Haigis-L, Camellin-Calossi, and Shammas-PL formulae. The ray tracing calculations were performed using axial length measured with the IOLMaster and keratometry measured with the TMS2N (Tomey). Mean arithmetic error was hyperopic using the ray tracing software (+0.64 D) and myopic using the three formulae (range -0.34 D to -0.86 D). MAE using the ray tracing software was 0.81 D and not significantly different compared with that obtained using any of the three formulae (range 0.63 to 1.16 D). In predictability analyses, there were no statistically significant differences between ray tracing and the formula methods in proportion of eyes within 0.5 D of target refraction (39 per cent vs. 19 per cent to 50 per cent). However, the proportion of eyes within 1.0 D of target was higher using the ray tracing software (74 per cent) or the Camellin-Calossi formula (75 per cent) compared with Haigis-L (43 per cent). “OKULIX is very useful software to calculate IOL power in normal eyes, and this study shows it has value in eyes with a history of myopic LASIK, although surgeons should keep in mind a tendency for a hyperopic outcome,” said Dr Negishi. “We believe the results of ray tracing might be even better using keratometry data based on anterior and posterior corneal curvatures rather than anterior curvature only, as is measured using the TMS2N. However, this requires validation.” Dr Negishi added that the relatively poor results obtained using the Haigis-L contrast with previous reports, and she postulated they may be partly due to the use of three nonoptimised constants for a specific IOL in the study.

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contacts Thomas Bende – t.bende@deos-tuebingen.de Kazuno Negishi – fwic7788@mb.infoweb.ne.jp

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Update

Cataract & refractive

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Angle-supported lens found safe and effective at four and five years in clinical trials

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EuroTimes_nov2012_GALILEI_G4_ad_120x300.indd EUROTIMES | Volume 17 | Issue 11

28.09.12 08:31

n angle-supported phakic intraocular lens (IOL) provided stable and predictable refractive results with acceptable endothelial cell loss and minimal intraocular inflammation for up to five years, according to four- and five-year results of prospective trials reported at the ASCRS symposium. Studies of the Alcon AcrySof Cachet Phakic Lens are ongoing to assess longer term outcomes and risks, presenters said. “After five years’ follow-up what is amazing is the iris ovalisation. Only two cases of small ovalisation of less than 1.0mm,” in 360 subjects, said Beatrice Cochener MD, PhD, of Brest University, France, who reported on global prospective trials for the Cachet. These and other promising safety results at five years are a marked improvement over several phakic IOLs that were pulled from the market in France after three years, she noted. Studies also were reported from the US and Canada. Methodology and exclusion criteria were similar in all the studies. Participants were at least 18 years of age with stable moderate to high myopia. Excluded were patients with previous ocular surgery, glaucoma, cataract, astigmatism of greater than 2.0 D, mesopic pupil size greater than 7.0mm and anterior chamber depth of less than 3.2mm. The Monarch II IOL Delivery System was used to deliver the lens into the anterior chamber. In a US phase I and II prospective clinical trial involving 60 eyes in 60 patients, 93 per cent achieved 20/40 or better uncorrected and 64 per cent 20/20 or better uncorrected at five years, said Jeffrey D Horn MD, Tennessee, US. All patients achieved 20/30 or better corrected with 95 per cent reaching 20/20 and 73 per cent 20/16 or better corrected. For the group, mean five-year uncorrected VA was 0.06 +/- 0.20 logMAR, or a little better than 20/25, with mean corrected VA -0.10 +/- 0.09 logMAR, or about 20/16, Dr Horn said. Refractions were also predictable and stable for the period, said Dr Horn, who is a consultant for Alcon. At five years, 84 per cent were within 0.5 D of the target refraction and 96 per cent within 1.0 D. The patients were moderate to high myopes with a preoperative mean spherical equivalent of -10.09 +/- 2.13 D, ranging from about -8.0 to -12.5 D, and results were for first eye implants only.

At the fourth year follow-up of a five-year Canadian prospective study of 73 second eye Cachet implants, 97 per cent achieved 20/40 or better uncorrected and 75 per cent 20/20 or better, said Thaddeus T Demong MD of the University of Calgary, Canada. All patients achieved 20/32 corrected with 96 per cent reaching 20/20 and 77 per cent 20/16 corrected. Mean uncorrected distance visual acuity was -0.04 +/- 0.16 logMAR, or slightly better than 20/20, which was better than mean corrected distance visual acuity preoperatively, Dr Demong noted. Refractive predictability was also good in the Canadian study, with 74 per cent within 0.5 D and 95 per cent within 1.0 D of target at four years, said Dr Demong, who is a member of an Alcon advisory board. The Canadian patients also were moderate to high myopes with a preoperative mean spherical equivalent of -10.5 +/- 2.2. “Similar to Dr Horn’s presentation we find the refraction remains stable to four year,” Dr Demong said. The interim results reported were from a study involving 120 patients overall of which 105 received bilateral Cachet implants.

Low endothelial cell loss Fouryear safety results were also promising in the Canadian trial, according to a poster presented by Simon P Holland MB, FRCSC, Canada. Mean chronic annualised percentage change in central endothelial cell density in 57 patients was -1.22 per cent from six months to four years postoperatively. From the preoperative stage to four years, 42 per cent of 73 subjects had no change in corrected visual acuity, while the remaining patients gained one or more lines. At four years none of 95 patients had aqueous cells or flare, corneal or peripheral oedema, or corneal haze. The study is ongoing and five-year results will also be published. Similar safety results were reported for a five-year global prospective trial involving 360 first-eye implants reported by Dr Cochener.

contacts Beatrice Cochener – beatrice.cochener@ ophtalmologie-chu29.fr Simon Holland – simon_holland@telus.net Jeffrey Horn – jeff.horn@bestvisionforlife.com Thaddeus Demong – thad@demong.com

Update

Cataract & refractive

meet

positive results

A new trifocal IOL uses novel diffractive optics to provide spectacle-free vision by Roibeard O’hEineachain in Prague

new diffractive IOL (FineVision, Physiol) can provide patients with good near, intermediate and distance vision with very little sacrifice of distance vision under mesopic conditions, said Erik L Mertens MD, FEBO, Antwerp, Belgium, at the 16th ESCRS Winter Meeting. In a series of 139 eyes of 70 patients who underwent cataract or refractive lens exchange surgery with the implantation of the FineVision IOL, all reported having achieved complete spectacle independence for all activities, and none reported any significant problems with glare when driving at night, Dr Mertens said. The patients in the study included 70 women and 69 men ranging in age from 47 to 80 years with a mean age of 61 years. Their preoperative spherical equivalent had a mean value of +0.39 D and ranged from -5.75 D to +4.50 D. Their preoperative sphere had a mean value of +0.62 D (range -5.50 D to + 5.00 D) and their preoperative cylinder had a mean value of -0.14 D and ranged from -1.0 D to 0.00 D. Dr Mertens noted that, since the lens itself does not have an astigmatism-correcting component, he used incisional techniques to correct corneal astigmatism in some patients.

Sharp acuity over broad range of distances Among 119 patients with one

months’ follow-up, the uncorrected distance visual acuity was 20/20 or better in 68 per cent, 20/25 or better in 85 per cent, and 20/30 or better in 97 per cent. Another two per cent were 20/40 and the remaining patients were 20/50 or worse. Regarding near visual acuity at 40cm, monocularly 97 per cent were J2 or better, 52 per cent were J1 or better, and two per cent were J1+ or better. Binocularly, all were J2 or better and 86.0 per cent were J1 or better. The intermediate visual acuity results with the new lens were also very good, all eyes were J2 or better, 69 per cent were J1 or better, and 13 per cent were J 1+ are better. As regards refractive predictability, the mean postoperative spherical equivalent was -0.01 D (range -0.75 to +1.25 D) the mean sphere was 0.06 D (range 0.75 D to 1.50) and the mean cylinder was -0.14 D. In terms of the defocus equivalent, all eyes were within 1.0 D and 88 per cent were within 0.5 D of intended refraction. EUROTIMES | Volume 17 | Issue 11

Aberrometry performed with a Topcon device (KR1W) indicated that eyes implanted with the lens had point spread functions and MTF curves conducive to good vision. The lens induces a mean of -0.1 microns of spherical aberration, he noted.

Double diffractive profile Dr Mertens noted that the Physiol FineVision IOL is composed of hydrophilic acrylic material with 25 per cent water content. The lens has a bi-convex, aspheric and trifocal optic 6.15mm in diameter and an overall length of 10.75mm with a 5° angulation of its haptics. It is designed for implantation through a 1.8mm incision. “The lens has four haptics. It is easily placed into the bag and, of course, the capsulorhexis with these kinds of lenses is very important. It must cover the 360 degrees of the edge of the optic,” he added. The lens achieves its trifocal effect by combining two bifocal diffractive profiles, Dr Mertens said. One diffractive profile combines a distance focus with a +1.75 D addition for intermediate vision and the other diffractive profile combines a distance focus with a +3.50 D addition for near vision, he explained. Moreover, in order to improve night vision, the lens distributes light in a pupil dependent manner, increasing the amount given to the distance focus as the pupil gets larger, he noted. He said that when using the same targeting imaging as is used by the US Air Force, the Physiol FineVision lens provides a good image of objects at intermediate distance with a 3.0mm and 5.0mm pupil. In contrast, other mulitfocals produce very blurry images of objects at intermediate distances with both 3.0mm and 5.0mm pupil diameters, he noted. “No patients in our series required glasses for any activities, and although there was glare and haloes at night, it was not significant enough to affect driving. Moreover, this lens provides excellent intermediate vision without a compromise for distance and near visual acuity and so far of all the lenses I've used, it provides the best intermediate vision ever reported with an IOL in my clinic,” Dr Mertens summarised.

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contact

Beatrice Cochener – beatrice.cochener@ ophtalmologie-chu29.fr

Update

CORNEA

OCULAR SURFACE DISEASE

Focus shifts to detecting OSD preoperatively

Courtesy of Beatrice Cochener MD

by Dermot McGrath in Milan

new range of diagnostic tools which are beginning to make their way into clinical practice have the potential to play an important role in helping physicians diagnose and treat ocular surface disease (OSD), according to Beatrice Cochener MD. “The growth of refractive surgery in recent years has driven new interest in research into dry eye and OSD. We know that a common source of dissatisfaction after refractive surgery is related to issues concerning ocular surface disease, which is why we have seen a shift to making the diagnosis preoperatively rather than postoperatively on the basis that it is always better to prevent than to treat,” she said. Addressing the 3rd EuCornea Congress here, Prof Cochener, professor and chairman of the Ophthalmology Department at Brest University Hospital, France, noted that preoperative dry eye is a risk factor for more severe dry eye after surgery. “This is why it is important for it to be identified and treated before surgery. The problem, of course, is that we tend to underestimate the role played by ocular surface changes and do not really look for them preoperatively in the absence of obvious symptoms,” she said. Following on from the Dry Eye Workshop (DEWS) report in 2007, dry eye is now deemed a multifactorial disease of the tears and ocular surface, involving especially inflammation, that results in symptoms of discomfort, visual disturbance EUROTIMES | Volume 17 | Issue 11

and tear film instability with potential damage to the ocular surface, said Prof Cochener. OSD is also a common comorbidity of other ocular conditions, she added, “Up to 50 per cent of cataract patients will complain of dry eye and the figure is around 30 per cent or higher for those who have undergone LASIK or other refractive procedures.” Prof Cochener stressed the importance of looking for clinical signs of dryness in preoperative examinations and patient questionnaires. “Symptoms of dryness include foreign body sensation, burning, itching, stinging, lid heaviness and corneal punctate epithelial keratopathy. These symptoms may be combined with fluctuating vision, regression, decrease in best-corrected visual acuity, glare, night vision problems and severe discomfort,” she said. Risk factors to watch for before surgery include blepharitis, which can predispose patients to infection and inflammation,

“

The growth of refractive surgery in recent years has driven new interest in research into dry eye and OSD Beatrice Cochener MD

epitheliopathy, which can induce dry eye and recurrent keratalgia, as well as defects during LASIK such as epithelial ingrowth or diffuse lamellar keratopathy. Allergies can also cause irritation, inflammation and dryness and alter the transparency of the cornea. In terms of the risk factors for cataractrefractive surgery, Prof Cochener cited studies showing that the prevalence of dry eye signs and symptoms in patients undergoing cataract surgery is more common than frequently reported. “If the dry eye is not diagnosed preoperatively, it can affect topography, aberrometry and keratometry measurements and may also impact on the accuracy of IOL power calculation, and axis measurements and degree of astigmatism for toric IOL implantation,” she said. Before any decrease in visual acuity, OSD usually induces a deterioration of vision quality, with instability reflected in the aberrometric and topographic images and OCT measurements, said Prof Cochener. In screening patients with preoperative dry eye, Prof Cochener advised careful examination of the patient’s systemic and ocular history, contact lens use, medication history and so forth. “All these factors may contribute to ocular surface disease and we need to pay particular attention to medications such as diuretics, anticholinergics, antidepressives, antihistamines, arthritis drugs and other allergy treatments which can all play a major role in altering the integrity of the

ocular surface,” she said. The sequence of clinical tests for standard diagnosis of dry eye should include symptoms and clinical history, break-up time, ocular surface fluorescein staining, Schirmer’s test and examination of the lid and meibomian gland morphology, said Prof Cochener. Although measuring tear film osmolarity has traditionally been limited to research laboratories, Prof Cochener said that a micro-osmometer (TearLab Osmolarity System, TearLab Corp.) is now commercially available and may prove useful in the diagnosis of OSD, dedicated to clinical trials on OS. “While it is not always easy to collect enough tears to get these measurements, the device provides a quick and simple method for determining tear osmolarity using nanolitre (nL) volumes of tear fluid collected directly from the eyelid margin,” she said. Another new test that can detect a marker for inflammation in a minuscule sample may also provide evidence of the early presence of OSD, said Prof Cochener. Known as the RPS InflammaDry Detector (Rapid Pathogen Screening), the device works by detecting the presence of MMP9, a cytokine produced by epithelial cells experiencing inflammation, that appears to be a reliable marker for the presence of early OSD and dry eye. Prof Cochener said that valuable diagnostic information may also be obtained using the Optical Quality Analysis System (Visiometrics), based on a doublepass technique that measures the scatter light. By the way it provides an objective measurement of the optical quality of the eye, including tear film integrity as the first medium passed by the light. “The basic idea is that the optical quality of the retinal image is the result of light passing through the ocular structures. Even small changes in the tear film can increase the light scatter and degrade the retinal image quality,” she said. Another new diagnostic tool, the LipiView Ocular Surface Interferometer (TearScience), is a non-invasive device that captures live images of the patient’s tear film and measures lipid content and quality, said Prof Cochener. To treat the patient, the device can be combined with the LipiFlow Thermal Pulsation System, a combined lid warmer and lid massager. While it will be some time yet before these devices are widely used in day-to-day clinical practice, Prof Cochener said that it was encouraging to see new developments emerging in the field of OSD. “If nothing else, it shows that we are doing great brainstorming between what we understood, what we can diagnose and now what we can treat,” she concluded.

contact

Update

CORNEA

Gerald W Zaidman – pedkera@aol.com

PAEDIATRIC CORNEAL SURGERY

Challenges abound, but advancing techniques and appropriate care make good outcomes possible by Cheryl Guttman Krader in Milan

hile advances in partial thickness procedures have revolutionised the field of corneal transplantation in adults, changes in paediatric corneal transplant surgery continue to occur at a slower pace. Currently, penetrating keratoplasty (PKP) remains the technique of choice for all graft procedures in children, and it will likely remain the dominant surgery, at least in younger children, considering the underlying indications for paediatric corneal transplantation, according to Gerald W Zaidman MD. However, just as developments in technique enabled increased adoption of PKP in children, deep anterior lamellar keratoplasty (DALK) is being performed increasingly in paediatric eyes with appropriate indications, and it is likely that with future advances, there will be greater use of endothelial keratoplasty [ie, Descemet’s stripping (automated) endothelial keratoplasty (DSAEK)] in paediatric patients with endothelial dysfunction, he said. Speaking during a joint symposium of the 2nd World Congress of Paediatric Ophthalmology and Strabismus and the 3rd EuCornea Congress, Dr Zaidman discussed corneal transplantation in children, focusing on PKP and DSAEK. Outcomes he reported from his personal experience and other published series showed that results for graft survival and visual function can be very good. “While there was a general feeling for 60 to 70 years after the first human corneal graft procedure that corneal transplantation should not be done at all in children, the situation changed in the 1980s thanks to the work of some well-known corneal specialists who categorised paediatric corneal disease and described transplantation techniques for this population. Since then, outcomes have further improved thanks to the development of better methods,” said Dr Zaidman, director of ophthalmology, Westchester Medical Centre, and professor of ophthalmology, New York Medical College, Valhalla, NY.

Differences in diagnoses The reason why PKP is the predominant type of corneal transplant surgery in children relates to the distribution of underlying diagnoses. Whereas data from North America show that among adults, endothelial disease is the leading indication for a corneal graft procedure followed by keratoconus, paediatric corneal transplantation is for a congenital corneal opacity in about two-thirds of cases and for endothelial disease in just about 20 per cent. “Considering all children with congenital, acquired and trauma-related corneal opacities, the only patients who are candidates for endothelial keratoplasty are those with a congenital hereditary endothelial dystrophy (CHED), congenital glaucoma and corneal oedema, and failed grafts.” Endothelial keratoplasty pros and concerns

DSAEK has several advantages compared with PKP as the partial thickness procedure is a closed globe operation, affords a stronger wound, minimises induced astigmatism EUROTIMES | Volume 17 | Issue 11

“

The aim of the procedure is to provide vision that will allow the child to perform normal routine tasks, such as feeding and dressing one’s self, and to interact with the world. It is not to provide legal driving vision Gerald W Zaidman MD

4-month-old with CHED

Courtesy of Gerald W Zaidman MD

5-month-old with Peter’s Anomaly Type I

and results in faster visual rehabilitation. However, a steep learning curve has limited its adoption even in the adult population, and the surgery is more technically challenging in children because of their shallower anterior chamber and the difficulty of visualising Descemet’s membrane, said Dr Zaidman. In addition, limited available data indicate that re-bubbling is needed even more often in children than in adults (in about one-third of paediatric cases), and it must be done in the OR, he added. Reviewing the literature on DSAEK in children, Dr Zaidman noted there have been only 33 reported cases of surgery for eyes with CHED. Mean age of the patients was eight years, with very few infants operated on, and the reporting surgeons all described the significant intraoperative challenges and frequent need for re-bubbling. “However, as in adults, graft clarity was excellent and visual rehabilitation was faster than with PKP. Presumably

the rates of endothelial cell loss and rejection are the same as in adults, but there are limited data available on those outcomes,” Dr Zaidman said. In 2007, Dr Zaidman published his experience with PKP in a series of 30 eyes (24 children) with Peter's anomaly Type I [Am J Ophthalmol 2007;144:104-8]. Regrafting was needed in two eyes, and after a mean follow-up of 79 months, 90 per cent of eyes had a clear graft. In verbal children, visual acuity was 20/100 or better in 54 per cent of eyes, of which more than half had 20/50 or better visual acuity. No eyes were lost, and none had no light perception vision. Most of the eyes with visual acuity of 20/200 and worse had glaucoma. However, Dr Zaidman observed that they still had ambulatory vision, which is the goal of corneal transplant surgery in young children. “The aim of the procedure is to provide vision that will allow the child to perform normal routine tasks, such as feeding and dressing one’s self, and to interact with the world. It is not to provide legal driving vision,” said Dr Zaidman. He also cited recently published results from the Australian graft registry that included 765 patients under 20 years of age [Ophthalmology 2011;118:492-7]. In the sub-group of children younger than five years old, in whom Peter's anomaly/congenital defects was the leading underlying diagnosis, 56 per cent had a clear graft. The clear graft rate was 62 per cent among children ages five to 12 years, of whom almost two-thirds were operated on for keratoconus, and 90 per cent in those aged 13 to 19, who mostly had keratoconus. “Graft clarity after PKP in children varies depending on patient age and underlying diagnosis. The results are better when the problem is more a pure corneal disease and there is less involvement in the anterior chamber,” Dr Zaidman said. Despite its challenges, the surgery itself may not be the limiting step in achieving a good outcome after paediatric corneal transplantation, noted Dr Zaidman. Family cooperation plays a critical role as the postoperative course involves a marathon of exams, including multiple exams under anaesthesia, and over the long-term, vision outcome depends on treatment of amblyopia and glaucoma.

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Update

GLAUCOMA

IOP MONITORING

Devices for continuous IOP monitoring move closer to clinical reality by Dermot McGrath in Abu Dhabi

ew devices that will allow researchers to perform temporary continuous intraocular pressure (IOP) monitoring of patients with glaucoma are slowly but surely making their way into clinical use and should prove a major advance on current methods of performing periodic IOP measurements during regular office hours, according to Georg Michelson MD. Addressing delegates attending the World Ophthalmology Congress, Dr Michelson, Department of Ophthalmology at FriedrichAlexander University Erlangen-Nurnberg, Germany, said that while many problems remain to be solved in the development of a continuous monitoring system for IOP, advances in materials and technology are bringing the prospect of such a device closer to clinical reality. “As a clinical ophthalmologist it is necessary to be able to measure the intraocular pressure and we are continually on the lookout for a system that might allow us to achieve a continuous monitoring for IOP in the management of glaucoma. The fact is that continuous monitoring of IOP opens new perspectives in the management

of glaucoma and will be an important tool in designing and evaluating therapy for glaucoma patients,” he said. Dr Michelson noted that IOP is a dynamic physiologic parameter with regular circadian variations and unpredictable short-term and long-term fluctuations. “IOP has a range of 0-70 mmHG and is not constant. There are fast changes of between one-per-second to one-per minute due to heart beat associated changes in choroidal blood volume, posture associated changes; blood pressure associated changes, and changes derived from the autonomic nerve system. There are also slow changes in aqueous humour production and outflow over a 24-hour period which impact on the IOP reading,” he said.

Three approaches In a literature review of continuous IOP measurement devices that are currently under development or already on the market, Dr Michelson cited three different approaches which have been tried with varying degrees of success. The first device, an implantable telemetric pressure transducer system adapted to monitoring anterior chamber IOP, has been

successfully tested in non-human primates by Crawford Downs et al of the Ocular Biomechanics Laboratory, Devers Eye Institute, Portland, Oregon, US. The current version of the IOP telemetry implant is based on an existing, commercially available, battery-powered, implantable pressure monitor of proven design (T30F13B; Konigsberg Instruments). The researchers set out to conduct continuous IOP telemetry in three nonhuman primates to characterise IOP dynamics at multiple time scales for multiple 24-hour periods. Summarising the study outcomes, Dr Michelson said that IOP fluctuated as much as 10 mmHG from day to day and hour to hour and that snapshot IOP measurements were therefore inadequate to capture the true dynamic character of IOP over time. When IOP data were averaged across multiple 24-hour periods within animals, a weak nycthemeral (relating to the alternation of night and day) rhythm was present in the non-human primate, in which IOP tended to be highest at night. The authors concluded that IOP fluctuations of this frequency and magnitude may be an important yet unknown contributor to IOPrelated glaucomatous damage. The second device in the literature survey, a novel wireless ocular telemetry sensor (OTS) (Triggerfish, Sensimed AG), is already commercially available, said Dr Michelson. The Triggerfish Sensor is a soft hydrophilic single-use contact lens, containing passive and active strain gauges embedded in the silicone to monitor fluctuations in the diameter of the corneoscleral junction, which is directly correlated to fluctuations in IOP. The output signal is sent wirelessly to an

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EUROTIMES | Volume 17 | Issue 11

Georg Michelson – georg.michelson@uk-erlangen.de

antenna that is worn around the eye and is connected to a portable recorder through a thin flexible data cable. In two studies of the Triggerfish sensor published to date, the device showed a good safety and tolerability profile, said Dr Michelson. But he said that more work needs to be done on the calibration and validation of such systems before they can become a routine part of glaucoma management. “There are also open questions concerning the effect of nighttime changes in corneal thickness and ocular movements when using the device,” said Dr Michelson. Another interesting approach perhaps more suited to longer continuous IOP monitoring is the technique devised by Walter, Schnakenberg and colleagues at the University of Cologne using a silicone IOL with a fully encapsulated IOP sensor. In a study in 2000, the device was successfully implanted into enucleated pig eyes and into rabbit eyes in vivo. The in vivo and in vitro tests in both the rabbit and pig eyes demonstrated that the implanted system worked with the same precision as established techniques for IOP determination, said Dr Michelson. “The device serves as a functioning model for the realisation of a telemetric IOP sensor for integration into an artificial IOL,” he said. Looking forward, Dr Michelson said that other promising devices under development include a fluid-filled catheter capable of conducting IOP to a transducer in the orbit, and a foldable IOL with integrated IOP sensor. He said, however, that some unsolved problems remain before these devices can take their place in daily clinical practice.

Update

GLAUCOMA

Omega-3 Eye drops

BODY MASS INDEX

Chinese population study suggests leaner people are at higher risk of glaucoma by Roibeard O’hEineachain in Copenhagen

atients with a high body-mass index tend to have greater neuroretinal rim areas, suggesting a protective effect of cerebrospinal fluid pressure against glaucoma, according to a study presented by Jost Jonas MD at the 10th European Glaucoma Society Congress. A multivariate analysis of 2,917 participants in the population-based cross-sectional Beijing Eye Study showed a statistically significant association between a higher body mass index and a larger neuroretinal rim size (P<0.001), said Dr Jonas, University of Heidelberg, Mannheim, Germany. “That association persisted after adjustment for disc area, refractive error, age, gender, open-angle glaucoma, intraocular pressure (IOP), blood pressure and ocular perfusion pressure,“ he added. The patients in the study ranged in age from 45 to 89 years and had a mean age of 59.8. Dr Jonas and his associates digitalised optic disc photographs from all of the patients’ eyes. They measured the optic disc borders using a planimetric software program. They then measured the width of the neuroretinal rim and measured the diameters of the optic cup and optic disc in the vertical meridian, and used their measurements to calculate the vertical cup/ disc diameter ratio and the optic cup area. Then, by subtracting the cup area from the disc area they obtained the neuroretinal rim area, he explained. Dr Jonas noted that the patients’ mean neuroretinal rim area was 1.97 mm2, and mean body mass index was 25.5. Their mean IOP was 15.6 mmHg, their mean diastolic blood pressure was 79.0 mmHg, and their mean systolic blood pressure was 133.5 mmHg. The multivariate analysis showed that, in addition to the association between a larger neuroretinal rim area and higher body mass index, a larger neuroretinal rim area was also significantly associated with lower IOP (P = 0.004), and lower mean arterial blood pressure (P = 0.02). There was also a marginally significant association between a larger neuroretinal rim area and a higher ocular perfusion pressure (P = 0.068).

“ Since body mass index is associated with cerebrospinal fluid pressure, the latter may be associated with neuroretinal rim area” Dr Jonas noted that a decreased neuroretinal rim area can serve as a surrogate for glaucomatous optic nerve damage. In addition, body mass index appears to correlate with cerebrospinal fluid pressure, and increased cerebrospinal fluid pressure may compensate for high IOP by exerting counter-pressure through the trans-lamina cribrosa, thereby preventing loss of neuroretinal rim and the development of glaucomatous optic neuropathy, he said.

Difference in results He pointed out that various population studies, such as the Nurses’ Health Study and the Health Professionals Follow-up Study and the Barbados Eye Study, have shown a correlation between higher body mass index and a reduced incidence of glaucoma. Other studies have shown the opposite to be the case. He also cautioned that the association between body-mass index and cerebrospinal fluid pressure remains controversial. “In the population we studied, neuroretinal rim as equivalent of the optic nerve fibres is related to a higher body mass index. Since body mass index is associated with cerebrospinal fluid pressure, the latter may be associated with neuroretinal rim area. It may serve as an indirect hint for an association between cerebrospinal fluid pressure and glaucoma,” Dr Jonas added.

contact Jost Jonas – jost.jonas@augen.ma.uni-heidelberg.de

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EUROTIMES | Volume 17 | Issue 11

GLAUCOMA

NEW GLAUCOMA IMPLANT

Collagen implant effective at modulating wound healing in filtering surgery by Dermot McGrath in Abu Dhabi

new collagen matrix implant could provide a viable alternative to traditional antimetabolites such as mitomycin C (MMC) and 5-fluorouracil in glaucoma filtration procedures, according to Steven R Sarkisian Jr MD. “Initial results with the Ologen Collagen Matrix Implant (Optous) are very promising indeed and offers the potential for safer and effective glaucoma surgery which avoids most of the dreaded late complications associated with MMC use,” he told delegates attending the World Ophthalmology Congress. Dr Sarkisian, glaucoma fellowship director at the Dean A McGee Eye Institute and clinical associate professor at the University of Oklahoma in Oklahoma City, US, explained that Ologen is a porcine extracellular matrix made of atelocollagen cross-linked with glycosaminoglycan. The biodegradable scaffolding matrix induces a regenerative wound healing process without the need for antifibrotic agents. The surgeon places the device over the scleral flap during the filtering procedure. While antimetabolites such as MMC and 5-fluorouracil have traditionally been used to modulate wound healing in glaucoma filtering surgery, complications such as hypotony, wound leaks, and endophthalmitis are often associated with their use, said Dr Sarkisian. Explaining the concept behind the new implant, Dr Sarkisian said that Ologen works by guiding fibroblasts to grow through the matrix scaffold in a less random fashion, thereby avoiding the ring of steel of scar tissue which limits bleb formation. “The implant inhibits scar formation by acting as a spacer and prevents the fibroblasts from laying down in organised fashion. The implant is biodegradable in 90 to 180 days or more, leaving in its wake a porous skeleton of connective tissue, although in my experience I have seen the implant present in some fashion even after nine to 12 months,” said Dr Sarkisian. While the implant has been shown to be efficacious in several animal studies, there are currently no published human studies using the refined version of Ologen, which uses atelocollagen obtained by pepsin treatment and is thus lower in immunogenicity than the previous version of the implant, Dr Sarkisian said. He added, however, that a large multicentre prospective randomised comparative study of Ologen is currently under way in the US and other studies of the new collagen matrix are also expected in the near future. “The new version is also thinner than the initial Ologen which enables easier laser suture lysis after trabeculectomy,” he said. Looking at the published data for Ologen without atelocollagen, Dr Sarkisian cited a 2011 prospective randomised study by Cillino et al comparing the safety and efficacy of Ologen as adjuvant compared with low-dosage mitomycin C in 40 patients with two-years’ follow up. “They found that the final mean pressure was 16 mmHg in the mitomycin C group and about 16.5 mmHg in the

Ologen group compared to mean preoperative IOP of 26.5 mmHg and 27.3 mmHg for MMC and Ologen respectively,” he said. There was no difference in the rate of complete and qualified success between the two groups, but there was a higher bleb height in the Ologen group,” he said. Another study by Rosentreter et al in 2010 showed an advantage in terms of IOP lowering for MMC compared to Ologen in 10 patients. Although the complete success rate was lower for the Ologen group, the bleb morphology was significantly better for patients treated with the collagen matrix, said Dr Sarkisian. A more recent consecutive retrospective case study series by Dr Sarkisian looking at trabeculectomy with the ExPress glaucoma shunt (Alcon Laboratories) and the newer version of Ologen found a qualified success rate of 94.4 per cent at 12 months in 36 eyes. “Five of the 36 patients were on medications, and the average pressure was 12.1 mmHg at 12 months. So it does seem that the pressure seems to be better controlled with the newer version of Ologen, although clearly this needs to be confirmed in further randomised studies with longer follow up,” he said.

Clinical experience Dr Sarkisian also offered some pearls for getting the best from Ologen based on his own clinical experience. Patient selection is critical, he said. “I use Ologen in about 90 per cent of my glaucoma filtering surgeries but that may differ based on your patient population. I usually do not open the Ologen until I have started the surgery and made the conjunctival incision. If the Tenon’s capsule is very thick, which is often the case in younger patients, I might use MMC instead. I do not use both, I pick one or the other,” he said. “Patients with thicker Tenon’s capsules tend to have a lower success rate anyway with glaucoma surgery,” said Dr Sarkisian. “I might even use MMC for three minutes in those patients or even longer. It is also important to remember that you cannot titrate Ologen as you would with MMC as the methodology of wound modulation is fundamentally different,” he said. While some surgeons have found suture lysis problematic with Ologen due to poor visualisation through the collagen and conjunctiva, Dr Sarkisian said that using a Blumenthal suture lysis lens helps to deal with this issue. Finally, Dr Sarkisian warned against treating Ologen patients in the same way as those being treated with mitomycin C. “This means not using three to seven sutures in the flap and not tying the sutures too tightly. Ologen will tamponade the flap if it is placed correctly. It is also important not to wait three weeks before cutting the sutures,” he concluded.

contact

Steven R Sarkisian Jr – steven-sarkisian@dmei.org

Update

GLAUCOMA

AGEING POPULATION

Glaucoma prevalence set to increase by one-third worldwide over next decade by Roibeard O’hEineachain in Copenhagen

n ageing world population will lead to an increasing worldwide prevalence of glaucoma, warned Roger Hitchings MD, Moorfields Eye Hospital in a keynote address at the 10th European Glaucoma Society Congress. “With increasing age there is a steady increase, and in some countries and some ethnic groups, a dramatic increase, in the prevalence of glaucoma. The older you are the more likely you are to get the disease,” he reported. There are, according to current estimates, roughly 39 million blind people in the world today, around 80 per cent of whom are above the age of 50 and around 12 per cent of whom lost their vision because of glaucoma. In fact, glaucoma is second only to cataract as a cause of blindness. At present there are about 60 million people with openangle and angle closure glaucoma. By 2020 that number will likely increase to around 80 million, with prevalence in different regions varying according to the age distribution of their populations, Dr Hitchings said. Currently, the greatest number of patients with glaucoma live in China, where there are around 16 million people with the disease, followed by Europe and India with 12 million each, and Africa with six-and-a-half million. In addition, there are an estimated six million people with glaucoma in Latin America, four million in Southeast Asia and around three million in Japan, he said. He noted that blindness has a particularly severe impact on people in the developing world, where 90 per cent of blind people are unemployed and where blindness reduces life expectancy by about one-third. Blindness also reduces an individual’s social standing, along with their authority in the community and in the home. In all regions of the world, the prevalence of glaucoma rises gradually with age staying at below one per cent of the population below the age of 50 of most ethnicities and rising to around five or six per cent in Europe, Japan and India by age 65, but reaching over 10 per cent in Africa, Latin America and China. Among those reaching 80 years of age in those latter regions, the prevalence increases to around 15 per cent. Generally speaking the ratio of glaucoma patients to the population over the age of 40 ranges from around two per cent to four per cent. EUROTIMES | Volume 17 | Issue 11

Since 1950 the shape of the age distribution of world’s population has been changing in a dramatic fashion. In 1950 it resembled a pyramid, with the greatest numbers at the youngest ages and the lowest numbers at the oldest ages. It has since been changing to resemble a tower, with a more even age distribution. However, the change in age distribution has not been uniform throughout the world. Some countries, like India, continue to have a pyramid-shaped age distribution; other countries like the US and China have sort of a bulge in the middle because of a trend towards a reduction in family sizes in more recent decades. Dr Hitchings pointed out that if the world’s top 10 most populous countries were placed on a graph in a logarithmic style, India and China would be two major outliers, between them accounting for 2.6 billion of the world’s approximate seven billion population. Dr Hitchings noted if current projections are correct, by 2020 there will be further increases in the older age groups in China and India, a trend which is likely to continue well into the century. Moreover, by 2020, in China the number of people with glaucoma will have risen from 17 million to 22 million and in India it will have risen from 12 million to 16 million. In addition, the number of people with glaucoma will increase by about a half to around six million in Southeast Asia and by around one-third in Latin America to eight million. Africa will probably see its population of glaucoma patients rise by about two million to nearly eight and half million. There will be only fairly modest increases in Europe and Japan. However, the Middle East will become one of the top-ranking countries with the disease, with over two million affected individuals. “Over the next 20 years there'll be a big increase in the world population, what actually happens will depend on fertility rates, gross domestic product and politics. The expected increase in longevity will mean an inevitable increase in the prevalence of glaucoma and a disproportionate increase in the Middle Eastern countries,” he concluded.

contact Roger Hitchings – roger.hitchings@moorfields.nhs.uk

am ur 13th EURETINA Congress

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Maja Gran Erke – Maja.g.erke@uit.no

Update

retina

DIABETES AND AMD

Study suggests no increased risk for age-related macular degeneration among diabetic patients by Roibeard O’hEineachain in Dublin

iabetic patients do not appear to be at any increased risk of developing age-related macular degeneration (AMD) compared to the general population, according to findings from the Tromsø Eye Study, reported by Maja Gran Erke MD at the 22nd Meeting of the European Association for the Study of Diabetes’ Eye Complications Study Group. “In the Tromsø Eye Study, we did not observe any statistically significant association between diabetes mellitus and AMD. This is consistent with results from Eurotimes Ad 245x150:TPV 11/6/12 other cross-sectional population-based

studies,” said Dr Erke, University Hospital of North Norway, and Tromsø Norway. She noted that the Tromsø Eye Study is a sub-study of the multipurpose Tromsø Study conducted in 2007-2008 in the municipality of Tromsø, Norway. The Tromsø studies were initiated in 1974 in an attempt to help combat the high mortality due to cardiovascular diseases in Norway and were gradually expanded to include many other diseases, she said. In their study of the association between diabetes mellitus and AMD, the Tromsø 14:52 Página 1 Eye Study investigators included 2,605

Caucasians aged 65 to 87 years with gradable digital retinal photographs and available data on their diabetes status. The Tromsø Eye Study team graded the retinal photographs based on the international classification system for AMD, Dr Erke said. They defined the predominant phenotype as that of the more severe lesion present in either eye. They defined diabetes mellitus as nonfasting blood glucose of 11.1 mmol/L or more, an HbA1c greater than 6.5 per cent, or the current use of anti-diabetic medication. The researchers could find no statistically significant relationships between diabetes and AMD, in univariate or multivariate analyses. Geographic atrophy or neovascular AMD was present in 12 (4.8 per cent) of 249 diabetic individuals and 80 (3.4 per cent) of 2,356 of those without diabetes. Dr Erke noted that the absence of a significant association between diabetes and AMD persisted after adjustment for potential confounders, such as age, sex, smoking status, alcohol consumption, education, body mass index, waist-to-hip ratio, blood pressure, physical activity, blood lipids.

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EUROTIMES | Volume 17 | Issue 11

For example, the age- and sex-adjusted odds ratios were 0.92 (95 per cent CI 0.681.25) for intermediate drusen 63.0 μm to 125.0 μm in size, 0.8 (95 per cent CI 0.561.14) for large drusen greater than 125.0 μm in size, 1.92 (95 per cent CI 0.70-5.28) for geographic atrophy, and 0.93 for neovascular AMD (95 per cent CI 0.41-2.13). On the other hand, the researchers found that diabetic individuals were significantly more likely to abstain from alcohol, have an inactive lifestyle, to have higher body mass index, waist-to-hip ratio, and serum blood lipids than non-diabetic individual (p ≤ 0.001 in all cases). Dr Erke noted that Tromsø Eye Study’s findings are at variance with findings of some other studies. For example, the EUREYE study, which involved participants from seven European countries, and the Blue Mountains Eye Study from Australia both showed an association between diabetes and AMD. She also pointed out that there may have been potential confounders in the Tromsø Eye Study, which might include mis-classification of AMD status and diabetes status.

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oderate consumption of long-chain polyunsaturated fatty acids (PUFAs) may protect against diabetic microangiopathy, suggests a study of a Norwegian coastal population of diabetic patients. “In other words, dietary intake of PUFAs may provide low-cost prophylaxis of diabetic retinopathy,” said Knud Erik Alsbirk MD, private practice, Sotra Eye Clinic, Bergen, Norway, at the 12th EURETINA Congress. He undertook a study to document the prevalence of visual impairment and diabetic retinopathy among diabetic patients in his clinic population based on his impression from over 20 years of practice that the rates were low, and his hypothesis that it might be related to a high PUFA intake from dietary fish. “My ophthalmological practice is located in an island district on the west coast of Norway where there is a long tradition for and good access to high-quality fish intake,” Dr Alsbirk explained. Further support for his hypothesis derived from the case of a patient with a 12-year history of Type II diabetes who presented with intraretinal microvascular abnormalities (IRMA) that reversed six months after he recommenced taking an omega-3 supplement. The study included 519 randomly selected patients with diabetes, of whom about 10 per cent had Type I disease. Approximately 85 per cent of patients knew their HBA1c level and at least half were taking an antihypertensive, a statin medication, and an omega-3 fatty acid supplement regularly. Diagnosis of diabetic retinopathy was made from fundus photographs using criteria of Wilkinson et al. and was identified in 47 per cent of Type I diabetics and 22 per cent of those with Type II disease. However, it was rarely sightthreatening and generally received timely treatment with laser, vitrectomy and anti-VEGF medications if needed. Only 11 per cent of Type I diabetics and five per cent of Type II diabetics had diabetic macular oedema; rates of proliferative diabetic retinopathy in the two subgroups were 13 per cent and three per cent, respectively. Visual function remained good overall. BCVA was less than 6/12 in less than two per cent of the Type II diabetics and in none of the patients with Type I disease. “The few cases of poor BCVA were all in patients with no or simplex grade I diabetic retinopathy and were attributable to other eye morbidities,” Dr Alsbirk reported.

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EUROTIMES | Volume 17 | Issue 11

Retina after 50 years of Type II diabetes

Courtesy of Knud Erik Alsbirk, MD

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Retina after 34 years of Type I diabetes

Information on fish consumption from dietary history showed an average weekly intake of 3.2 meals by the Type I patients and 4.4 meals for those with Type II diabetes. When intake of omega-3 supplements or cod liver oil was added in, the average number of fish meals/week increased to 6.3 for the Type I patients and 8.0 for the Type II patients. Dr Alsbirk noted there are mixed results from previously published preclinical studies investigating the influence of PUFA intake on diabetic retinopathy. In 1996, Hammes et al. reported that fish oil administration to diabetic rats accelerated retinopathy. However, a decade later, Connor et al. found a 40 per cent reduction in pathological angiogenesis in mice with experimentally induced retinopathy given omega-3 PUFAs. To reconcile the conflicting findings, Dr Alsbirk suggested the answer may lie in the amount of PUFA intake. “It seems safe to conclude from our study that a moderate consumption of PUFAs does not accelerate the progression of diabetic microangiopathy in humans. The adverse effect in the rat study may be because the animals received an average omega-3 dose of 500 mg/kg/day, which is 40-50 times greater than the daily recommended dose,” he said. The authors have no financial disclosure.

contact

Knud Erik Alsbirk – alsbirk@online.no

Update

retina

SCREENING

Opportunistic screening for glaucoma in diabetic patients a worthwhile practice by Roibeard O’hEineachain in Dublin

he inclusion of optic disc assessment in diabetic retinopathy screening programmes can be an efficient way of detecting glaucoma in diabetic patients, according to studies presented at the 22nd Meeting of the European Association for the Study of Diabetes’ Eye Complications Study Group. “Our findings indicate that the opportunistic screening of diabetic patients for glaucomatous discs is worthwhile and does not place an unmanageable burden on the glaucoma services,” said Maxwell Treacy MD, Mater Misericordiae University Hospital, Dublin, Ireland. He presented results of a prospective study in which trained graders assessed the optic discs of 3,697 patients participating in a diabetic screening programme. He noted that the graders identified 111 patients’ optic discs as having features suggestive of glaucomatous damage, and of those, consultant ophthalmologists confirmed 91 as suspicious and referred the patients to a glaucoma clinic. Moreover, of the 63 patients who subsequently attended the glaucoma clinic, 15 were diagnosed with glaucoma, 34 are being followed as glaucoma suspects, and 14 were diagnosed as not having glaucoma or any elevated risk for the disease and were discharged back to the diabetic screening programme with normal examination, he said.

Special training Dr Treacy noted that the graders in the diabetic retinopathy screening programme at the Mater Misericordiae Hospital in Dublin do not have medical qualifications, but have received training in identifying the features of diabetic retinopathy in retinal photographs. In 2010 they received further instruction from two consultant ophthalmologists on the identification of suspicious disc signs on retinal photographs. Those signs included cup/disc ratio greater than 0.6, abnormal cup configuration, asymmetry between cup/ disc ratios greater than 0.2, visible lamina cribrosa, notches and nasal cupping, and abnormal neuroretinal rim. The graders also received instructions on detecting disc haemorrhages, retinal nerve fibre loss and peripapillary atrophy. EUROTIMES | Volume 17 | Issue 11

“Our findings indicate that the opportunistic screening of diabetic patients for glaucomatous discs is worthwhile and does not place an unmanageable burden on the glaucoma services” Maxwell Treacy MD

“This scoring system allowed graders to identify suspicious discs and make appropriate referrals. By alerting our graders to glaucomatous disc changes, detection of sight-threatening glaucoma can occur within a diabetic screening programme, Dr Treacy added. The protocol for referring patients from diabetic retinopathy screening programmes to glaucoma clinics is one that may need to be revised as experience grows with such programmes, said Pat Hart MD, who heads the diabetic screening programme in Northern Ireland. She noted that of 73 patients referred from the screening programme for suspect glaucomatous discs, 43 (58.9 per cent) were later confirmed as having glaucoma. Of those, only 39/43 (63 per cent) had a cup/ disc ratio of 0.7 or more, but 91 per cent had cup/disc ratio 0.5 or greater and were referred according to protocol. A further four cases had a cup/disc ratio less than 0.5, two with a notch and disc asymmetry, and two with a notch. “If the protocol for referral had been a cup/disc ratio of 0.7 or greater it would have excluded 37 per cent of those subsequently diagnosed, but if the protocol had been a cup/disc ratio of 0.7 or greater, or another feature, such as notch or disc asymmetry greater than 0.2, 100 per cent of glaucoma patients would have been referred,” Dr Hart said.

contacts Maxwell Treacy – max@treacy.ie Pat Hart – Pat.hart@doctors.org.uk

contacts

Update

Courtesy of Jesse Jung MD

RETINA

(A) Colour fundus photo of the right eye of a study patient with DME before treatment; (B) represents fluorescein angiogram (FA) of the right eye prior to NAVILAS treatment; (C) colour fundus photo of the right eye after treatment showing reduction in exudates and microaneurysms; (D) represents FA of the right eye after treatment showing reduced macular oedema; (E) an image overlay composed and displayed over the pre-treatment FA showing a single no-treatment zone over the fovea; (F) an image overlay over the pre-treatment FA showing the planned elements of microaneurysm treatments

DME treatment

Novel laser system improves treatment accuracy, efficiency, efficacy and safety by Cheryl Guttman Krader in Fort Lauderdale

novel navigated retinal laser system (Navilas, OD-OS) provides a safe and effective treatment option for patients with diabetic macular oedema (DME) reported independent groups of investigators at the annual meeting of the Association for Research in Vision and Ophthalmology. The platform is a scanning slit-based instrument that integrates navigated retinal laser therapy by a 532-nm laser photocoagulator with digital imaging capabilities (live colour fundus, red-free, infrared, and fluorescein angiography). It allows digital pre-planning of the treatment, while real-time registration between the diagnostic images, treatment plan and the live retinal image assures the laser spots are delivered to their intended target. The system generates digital documentation of the applied treatment. In a poster presentation, Marcus Kernt MD, and colleagues reported findings from a comparative study that showed benefits of using the navigated laser system versus a conventional laser for treating clinically EUROTIMES | Volume 17 | Issue 11

significant DME. They analysed data from 46 eyes treated with the navigated laser and 28 control eyes treated by conventional laser. The controls were selected through propensity score matching based on age, gender, baseline visual acuity (VA), number of laser spots and follow-up time from a contemporarily treated group of 119 eyes. “This is an important study because it is the first comparison between the navigated laser and conventional laser treatment for DME in terms of clinical outcomes, and while it is not a prospective randomised trial, it used a sophisticated technique to create well-matched study groups,” Dr Kernt told EuroTimes. Baseline mean logMAR VA was similar in the navigated laser and matched control group (0.48 and 0.49). Mean number of laser spots planned was greater for the navigated laser group compared with the control eyes (105 vs. 74), although the difference between groups was not statistically significant. VA remained within three lines of baseline in all eyes at three and six months, and there were no significant differences

between groups in mean VA at any followup. Data from follow-up at one, three and six months showed VA gradually increased after the navigated laser treatment whereas it deteriorated slightly during the first three months after conventional laser treatment. Analyses of re-treatments by Kaplan-Meier analysis showed a statistically significant difference favouring the navigated laser group for needing fewer re-treatment procedures during the first six months, and a separation between groups was noticeable as early as two months, reported Dr Kernt, Department of Ophthalmology, LudwigMaximilians-University. He proposed that the differences between groups in number of spots placed and the post-treatment outcomes may be explained by the ability to provide more complete and more accurate treatment using the navigated laser. A study published in Ophthalmology, for example, demonstrated that navigated laser allows more precise execution of the pre-planned laser spots to close microaneurisms, he said. Pre-planning of the laser treatment based on diagnostic images seems to lead to a more complete treatment, which is reflected by a higher amount of laser spots applied compared to conventional slit-lamp based lasers. “Surgeons may under-treat when using a conventional laser due to concern about damaging critical structures. This tendency is minimised using the navigated laser that allows careful preplanning and precise delivery,” he said. Dr Kernt noted that even if not investigated in this study, the data may support the idea that there may be a benefit

Marcus Kernt – Marcus.kernt@med.uni-muenchen.de Irene Barbazetto – Irene Barbazetto ibarbazetto@gmail.com Jesse Jung – jung.jesse@gmail.com

combining the navigated laser treatment with intravitreal pharmacotherapy as faster stabilisation of DME through more complete treatment, which might result in patients needing fewer repeat injections as well as fewer laser re-treatments. Data presented by investigators from Bellevue Hospital, New York, at this meeting are consistent with this idea, although the researchers noted that their study was not designed to investigate this specific issue. Several investigators in the US and Europe are validating a combination therapy of Anti-VEGF and navigated laser therapy to prove this concept. Irene Barbazetto MD, Jesse Jung MD and Jonathan Huz MD, reviewed their experience using the navigated retinal laser for focal treatment of DME in nine eyes of patients with poorly controlled diabetes (mean HbA1c = 9.2), including six that had received prior intravitreal bevacizumab (Avastin, Genentech). They reported the laser treatment (mean shots=30, mean energy=94.8 mW) was well tolerated. Data from pre-treatment to 12 months’ follow-up showed that the treatment was safe and resulted in statistically significant improvements from baseline in mean logMAR VA (0.62 to 0.47) as well as in OCT-measured anatomic endpoints, including largest subfield of macular thickness (358 to 320 microns). Among the patients who had prior anti-VEGF treatment, only three (50 per cent) received additional bevacizumab injections, and only one needed monthly injections. “This is a small pilot study, but it is important to keep in mind that the good outcomes were achieved in a cohort of poorly controlled diabetics who are usually excluded from clinical trials,” said Dr Barbazetto, a vitreoretinal specialist and attending physician at New York University School of Medicine (NYU) and Bellevue Hospital. “I believe the technology definitely increases the safety of focal photocoagulation, and our findings support undertaking further studies to investigate a possible benefit for using this laser system in a combination approach that might reduce anti-VEGF injection burden.” Dr Barbazetto added that thanks to its documentation feature, the system might also allow researchers to design improved treatment strategies for DME. She also noted the novel laser system has been an excellent teaching tool. Her co-author, Dr Jung, an ophthalmology resident at NYU, concurred. “The need to manually locate each microaneurysm and select the correct energy for closure makes conventional focal laser treatment of DME challenging for residents and requires close supervision. Using the navigated retinal laser system, microaneurysms closer to the fovea can be accurately targeted, and the non-contact technique makes it easily tolerated by patients,” Dr Jung said.

EURETINA

WINTER MEETING

ROME ‘Innovation in Management of Retinal Disease’

1-2 FEBRUARY 2013

Rome Cavalieri Waldorf Astoria Hotel

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Update

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Stem cells show promise for retinal degenerative diseases

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tem cell-based therapy provides a promising approach that may one day help to restore and sustain retinal function for patients with retinal degenerative diseases, according to Ting Xie PhD. “It is still early days and a lot of obstacles remain to be overcome but much progress has been made in the field of stem cell research in recent years and we are moving closer to our ultimate goal of being able to generate patient-specific retinal pigment epithelial (RPE) cells, photoreceptor cells and retinal ganglion cells for treating retinal degenerative diseases,” Dr Xie told delegates attending the World Ophthalmology Congress. Dr Xie, investigator at the Stowers Institute for Medical Research in Kansas City and professor at the Department of Anatomy and Cell Biology at the University of Kansas School of Medicine, US, noted that retinal degeneration is found in many different forms of retinal diseases including retinitis pigmentosa (RP), age-related macular degeneration (AMD), diabetic retinopathy and glaucoma. In a broad overview of progress made to date, Dr Xie said that researchers have demonstrated that stem-cell transplants can survive, migrate, differentiate and integrate within the retina. Different types of stem cells can be applied to treat retinal degenerative disease including human embryonic stem cells (hESCs), induced pluripotent stem cells (iPSCs), Müller cells and induced neural progenitor cells (iNPCs).

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REGENERATION

01.10.2012 13:23:04

Breakthroughs Major advances have been made in recent years in the generation of hESC-derived retinal pigment epithelium, said Dr Xie. He cited key breakthroughs such as the differentiation of primate embryonic stem cells into functional RPE cells by the Takahashi group in 2004, the differentiation of hESCs into RPE cells by the Coffey group at the University of London in 2008, and the generation of functional RPEs from hESCs by both the Lund group in Oregon and the Reubinoff group in Hadassah-Hebrew University in 2009. In 2011, Advanced Cell Technology (ACT) was given FDA approval to treat dry AMD using hESC-derived RPE cells. Earlier this year, Schwartz et al at the University of California and scientists in ACT announced

the clinical trial preliminary report on AMD which showed that the hESC-derived RPE cells showed no signs of hyperproliferation, tumorigenicity, ectopic tissue formation or apparent rejection after four months. Using stem cells for the generation of photoreceptors has also proved a fruitful line of research, said Dr Xie. In 2005, Hara et al at Nara Medical University in Japan generated photoreceptors from mouse ESCs in co-culture with chicken retina. A year later, Kirk et al at the University of Missouri-Columbia produced mouse ESCderived retinal progenitor cells, followed by Reubinoff et al at Hadassah-Hebrew University and Reh et al at the University of Washington who produced human ESCderived retinal progenitors. In 2009, the Reh group also showed that hESC-derived photoreceptors restored the function of the cone-rod homeobox (crx)-deficient eye. In another important study, Lamba et al in 2009 showed that after transplantation of hESC cells into the subretinal space of adult Crx deficient mice, the hESC-derived retinal cells differentiated into functional photoreceptors and restored light responses to the animals. Turning to patient-specific pluripotent stem cells (iPSCs), Dr Xie said that researchers have shown the ability of iPSCs to generate RPE cells that are functional in vivo. Earlier this year, Lako et al at Newcastle University developed an efficient strategy to differentiate human ESCs and iPSCs into photoreceptor cells. “The advantage of this approach is that the generation of patient-specific retinal cells for transplantation may minimise potential immune rejection,” said Dr Xie. In terms of the potential of using retinal progenitor cells (RPCs) and Müller cells to treat retinal degenerative disease, Dr Xie said that Cepko et al. at Harvard University have shown in 2000 that Müller cells in mice can proliferate following injury. In 2007, the Khaw and Limb groups at the Institute of Ophthalmology in London showed that human Müller cells exhibit neural stem cell characteristics differentiating into retinal lineages, while the following year Reh et al showed that Müller cells can regenerate retinal neurons, but not photoreceptors, in mice.

contact

Ting Xie – tgx@stowers.org

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

Warsaw, Poland 15 – 17 February 2013

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News

John Henahan Prize 2012

time to treat

This year's winning John Henahan Prize essay tells how a routine examination was not quite what it seemed By Sorcha Ní Dhubhghaill

o, it was a typical busy morning. The outpatient clinics were overbooked and the waiting room was getting restless. I looked over the next chart, half of the notes were missing but that was not unusual. Here was a gentleman who had neovascular AMD and had finished a course of intravitreal injections. There were two questions to ask here: had he improved? and did he need more treatment? We were pressed for time so, to get things moving, I asked for an OCT before seeing him. As I busied myself with other tasks, the nurse sidled up to me and told me there was a problem. The man was unable to have all his scans because he was falling asleep at the machine. He was getting drowsy and couldn’t hold his gaze for the split second needed to take the image. I remember feeling annoyed because I really needed the scan. A fluorescein angiogram would be out of the question. The time was ticking past lunch hour and hunger was adding to my poor humour. “His ambulance transport is here, he has to go back home soon,” the nurse added, so I decided to press on seeing him regardless. I called his name and in trundled an elderly man about five foot four with a thin layer of white hair. His tattered chart suggested that he had been with us for a number of years so I wasn’t surprised when he sat himself down and silently slotted his head into the slit lamp. His vision measurements had been poor, he could barely see the largest letter for the past few years. Today was no different so I could not rely on any change in his vision to determine his treatment. I began by examining the eye being treated but found that he was squirming in his seat. Eventually I saw a large central scar with some thickness to it. Perhaps it could use more injections but it was not the clearest-cut case. So I asked him

if he had noticed any difference after the treatment. He looked at me and tried to form words but his speech was very poor. “This is typical. Running late with the patient with a speech impairment and half his notes are missing,” I thought.

Missing words I sighed at my bad luck and examined his fellow eye. I remembered it. It had an unusual linear macular scar from an injury a long time ago. The eye was damaged when the patient was parachuting into Germany in 1945 at the age of 18. On his first mission as a paratrooper a stray branch had caught him in the eye. By the evening he had learned to aim with his other eye and was “back to shooting Nazis”. I knew this story because the last time I had seen this patient, he had told me all about it with great pride. In fact, it was difficult to get him to stop talking! So I pushed the slit lamp out of the way, looked at him and said: "When did you lose your words?" He stuttered as if his tongue were in his way. I made some guesses at the meaning, but he growled and rolled his eyes at me. Just as frustrated with me as I had been with him. Finally he took my pen and scratched: “Last night I was okay”, on the table in front of me and followed this with, “I drank milk and it spilled on me”. He had ruined the table but his graffiti told me what I needed to know. Some time last night he had had a stroke. I contacted the medical team and discussed his case. He was outside the window for thrombolysis but still needed a full work-up and stroke rehab. They could arrange it today. I told the hovering ambulance driver he could leave and I sat with the patient. I explained what I thought had happened and how, for the moment, his eye was not the priority. As I finished my explanation I told him that I remembered his story. Then he smiled and mimed his story again to me as we waited for the medics. Time management I saw him in the clinic recently. After his rehabilitation his words improved and he has even entertained us with some French and Italian. He is a cheerful character and I am always happy to see him, but on some level I am ashamed of how initially I felt towards him. He was out of the ordinary, causing problems and he was slowing me down. I was frustrated and impatient. But for the fact that I knew his eye, I might have sent him home. As a young ophthalmologist I feel that the biggest problem we face is time. With the advent of intravitreal injections, conditions that previously couldn't be treated now have a much brighter outlook. The prognosis for the patients is certainly improved, but the prognosis for the services might actually be suffering. The need is so great that clinics are routinely booked over capacity. Surgical trainees are spending ever more time in the injection suite, and less in the surgical theatre and training positions are fast becoming service jobs. So how do we strike a balance between treating all the patients the way they deserve to be treated, while providing a cost-effective and efficient

EUROTIMES | Volume 17 | Issue 11

Oliver Findl, chairman of the Young Ophthalmologists Forum with Sorcha Ní Dhubhghaill, winner of the John Henahan Prize and Emanuel Rosen, chairman of the ESCRS Publications Committee

service? Some patients will always require more time and attention than others. With a conveyor belt approach, we risk missing something for the sake of not looking. Double so when patients are queuing and time is ticking. * Sorcha Ní Dhubhghaill, winner of the 2012 John Henahan Prize, is a third-year basic trainee at St Vincent's University Hospital, Dublin, Ireland.

From the Archive DMEK results favourable in Stockholm

eratoplasty has had a remarkable evolution over the past decade, with surgical procedures now removing less and less tissue, while providing better visual results and faster recovery times. These improvements are the results of the tireless efforts of a handful of corneal surgeons, including Gerrit Mellles MD, The Netherlands, Institute for Innovative Ocular Surgery, whose innovations have helped drive progress in this field. Dr Melles presented the latest results of a procedure he calls Descemet's membrane endothelial keratoplasty (DMEK) during a session at the XXV Congress of the ESCRS. The prospective clinical study included seven patients with Fuchs' endothelial dystrophy. He believes that DMEK, with its minimal removal of tissue and atraumatic approach to graft insertion, has the potential to deliver faster and better visual rehabilitation than current approaches. * From EuroTimes Volume 12, Issue 11, November 2007

Update

EYE ON TRAVEL

WARSAW ON THE UP

Science and an artists’ quarter provide diverse entertainment for visitors by Maryalicia Post

ne Warsaw building you can't overlook even if you want to – and most Polish people seem to want to – is the 42-storey Palace of Culture and Science in the centre of the city. Presented as a “Gift to the People of Poland” from the “People of Soviet Russia,” it was perceived as a stamp of Stalinist authority and a reminder that Big Brother was watching. Variously known as Stalin's Tooth, the Russian Wedding Cake, and several other less quotable tags, the building was erected between 1952 and 1955 by a contingent of 3,500 Soviet workers who were housed at Poland’s expense in a new suburban complex. Originally dedicated to Stalin, the dictator's name has been revoked from the title of the building, removed from the lobby and chiselled off a book held by one of the sculpted figures. The building has 3,240 rooms and holds, among other things, a university on two floors, the largest swimming pool in Warsaw, cinemas, the Museum of Technology, a 500-seat concert hall and a 2,800-seat congress hall. The building’s most interesting feature for the tourist, however, is the observation deck on the 30th floor. To access it, enter the building from Plac Defilad, turn right on the mezzanine at the top of the flight of marble stairs and buy a ticket from the small shop. A lift takes you up to the roofed

Palace of Culture and Science, Stalin’s gift to the Polish people

but windswept terrace. In clear weather you will see all over Warsaw. The new National Stadium, built on the far shore of the Vistula River for Euro 2012, stands out like a crown on the flat landscape. The viewing terrace is open daily from 9.00 to 18.00. Admission is 20 PLN. The Museum of Technology is almost domestic with its lace curtains and unsmiling lady attendants. I wanted to see its copy of

Journal Watch Myopia and daylight exposure The incidence of myopia appears to be increasing significantly among children in some regions, particularly in parts of Asia. A link between lack of outdoor activity and increased risk of myopia has been suggested in previous studies. A recent study took a different approach to this issue, seeking to determine whether conjunctival ultraviolet autofluorescence (UVAF), a biomarker of outdoor light exposure, is associated with myopia. The cross-sectional study recruited 636 volunteers aged 15 years and above. All completed a sun-exposure questionnaire and underwent non-cycloplegic EUROTIMES | Volume 17 | Issue 11

autorefraction. The researchers measured conjunctival UVAF with a novel system, a specially adapted electronic flash system fitted with UV-transmission filters (transmittance range 300–400 nm, peak

the “Enigma Machine,” whose code was cracked by Polish cryptologists, but although I searched diligently on the museum's several levels, I never found it. I did wander through a model of a coal mine, a room full of mechanical music makers, and an exhibition of antique washing machines. For information, visit: www.muzeum-techniki. waw.pl. Entrance to the museum is on the left hand side of the Palace of Culture. Open 09:00 to 17:00, Tuesday through Friday and from 10:00 to 17:00 on Saturday and Sunday. Closed Monday. Admission is 12 PLN. Warsaw loves shopping malls; there are more than 20 in the city. Though it’s not the biggest – that’s the Arkadia with 230 shops – the most interesting is Zlote Terasy, or “Golden Terraces,” which rises just behind the Palace of Culture. Designed by an architectural partnership based in the American state of California, the mall opened in 2007. In addition to a couple of high-rise office and residential buildings, it incorporates a leisure complex, cinema, restaurants and more than 200 shops under an undulating glass roof. The wavy roof pays homage to the trees in Warsaw's parks, the only elements of the city that escaped the devastation of World War II. Złota 44, the city's first unabashedly luxury residential tower is rising near the Zolte Terasy. It's a skyscraper designed by Polishborn American Daniel Libeskind, the master architect who rebuilt the World Trade Center site after 9-11. At 54 stories high, Złota 44 bends in a graceful glass and steel ark to 192 metres. The building itself is four metres higher than the “Palace” building, but 45 metres shorter than the tip of the spire that sits atop the Palace. Projects by other famous architects such as Chicago's Helmut Jahn and Iraqi-born Zaha Hadid are in various stages of development in the city. With no pre-war buildings to preserve, Warsaw is making the best of a clean sheet, architecturally speaking. 365 nm) as the excitation source. They measured temporal and nasal conjunctival UVAF in both eyes using computerised photographic analysis. The analysis revealed that the prevalence of myopia decreased significantly with an increasing quartile of total UVAF. Median total UVAF was significantly lower in patients with myopia. Even after employing a multivariable model that adjusted for age, sex, smoking, cataract, height and weight, UVAF was independently associated with myopia. The analysis also revealed that UVAF was significantly associated with myopia when analysis was restricted to subjects younger than 50 years of age, and in moderate-severe myopia. n JC Sherwin et al., Invest Ophthal Vis Sci, 20212;53(8):4363-4370.

Section of Ghetto Wall, traced in bronze

Invitation to play Europe’s newest Science Museum, the Copernicus Science Centre, is deservedly popular, attracting about 2,500 visitors a day. It’s a massive three-storey building that swallows up the opening-hour queue efficiently, but long lines develop within the hour, especially at the weekend. There are over 450 interactive experiments to enjoy, not to mention a theatre where the actors are robots. You activate the activities with the electronic card that comes with your ticket. You could easily spend a day here, breaking off for lunch or a quick snack at the inviting, inexpensive restaurant on the ground floor. The gift shop is full of scientific toys and unusual souvenirs. The museum is open Tuesday through Friday from 9:00 to 18:00 and on Saturday and Sunday from 10:00 to 19:00. Last admission at cash-desk is one hour prior to closing. The museum is closed on Mondays. General admission is 22 PLN. For more details, visit: www.kopernik.org.pl/en/. Praga, over the river Praga, across the river from the Old Town, did not share the devastation visited on the West bank in 1944 nor has it been much refurbished since. So, the bullet-pocked tenements, crumbling warehouses, gritty streets on the East side of the Vistula River remain much as they were. Artists and craftsmen looking for cheap studios are moving in to disused factories and Praga is on its (slow) way to becoming Warsaw’s artists’ quarter. A disused redbrick Vodka factory is home to a theatre, “Teatr Wytwórnia,” and a cultural association, as well as an art gallery or two. ul. Ząbkowska 27/31. If you don’t have the time to get utterly lost, see Praga with a guide. Mine was the knowledgeable Hubert Pawlik, who showed me everything from a mechanised musical band to the inside of a Russian Cathedral. Visit, www.warsaw-guide.waw.pl.

Review

Book REVIEW

LASIK Surgery

Think Thin SBK newsletters now on line

Fine-tuning glaucoma diagnosis

“It is a great paradox that although we have the latest technology to diagnose glaucoma and a number of new medications/laser/ surgical techniques to treat glaucoma, glaucoma remains the leading cause of irreversible blindness worldwide.” So begins the preface to “Pearls in Glaucoma Therapy: A Practical Manual with Case Studies.” This concise text, written by Tanuj Dada, Parul Ichhpujani & George Spaeth, and published by Jaypee Brothers Medical Publishers, is an excellent and readable refresher course for those clinicians who are interested in fine-tuning their glaucoma diagnosis and management skills. Glaucoma is one of the few sub-specialties in ophthalmology that can be practised almost entirely by a general ophthalmologist. This is because glaucoma is very common and can, for the most part, be treated without surgical intervention. Further, it is a frequent complication of other ocular pathology and surgical procedures, so every ophthalmologist, whether general or subspecialist, is confronted with glaucoma on a regular basis. Thus, it is essential that the ophthalmologist feels comfortable with this pathology and keeps up with the recent developments in diagnosis and treatment. This 130-page book is organised into 10 chapters, each with a simple goal: to answer the core questions in glaucoma treatment. The most clinically useful are “Chapter 3: How to Work Up a Glaucoma Patient?” - Chapter 4: When to Start Therapy?” and “Chapter 5: How to Set Target IOP?” These chapters are packed with the basic information and especially some up-to-date tips that a clinician might ask a glaucoma specialist, given the opportunity. For example, when should optic disc imaging techniques such as HRT, Gdx or OCT be used? How many baseline visual fields are required for the diagnosis of glaucoma, and how many more are needed to determine progression? What are common mistakes made in the initiation of glaucoma treatment? Also useful is the chapter dedicated to compliance issues. Compliance is a particularly important issue in glaucoma, which is a chronic, generally asymptomatic disease requiring daily topical treatment with many potential side effects. Chapter 8 begins with the quotation, “Drugs don’t work in patients who don’t take them.” The question is: why don’t many of our patients correctly EUROTIMES | Volume 17 | Issue 11

use their eye drops? The authors provide insight into the causes of this problem, and their solutions. Of course, theoretical knowledge is nice to have, but applying this knowledge in the clinic is a different story entirely. Fortunately, this book includes case studies and clinical scenarios in which the reader can test his or her knowledge in the decision making regarding a particular case, and compare it to the advice provided by the authors. Each chapter ends with a “Key Points” section that summarises the central issues and provides the reader with a rapid overview of the chapter’s essential information. After having read the book, the reader can rapidly scan these sections as a reminder of what (s)he has learned. Because of the book’s concise nature, it is ideal for a quick read rather than a great, sustained effort. It assumes a basic level of knowledge regarding glaucoma, and does not delve into the complex pathophysiology of the disease. So, it discusses the ocular hypotensive medications primarily in terms of their clinical value rather than their molecular structure and pharmacologic mechanisms of action. Instead, it focuses on clinically useful information that can immediately be applied to patient care. Thus, this book will appeal to residents during their glaucoma rotation; glaucoma fellows just starting their fellowship training; and general ophthalmologists interested in a rapid update of their glaucoma management knowledge and skills.

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Richard J. Duffey, MD (Mobile, AL, USA) Duffey RJ. Moria One Use-Plus SBK microkeratome: predictably thin, smooth, planar flaps for faster visual recovery. 26th annual meeting of the ESCRS; Sept 1317 2008; Berlin, Germany. Dr. Duffey has no financial interest and is not a paid consultant for Moria. IntraLase® is a product and registered trademark of Abbott Medical Optics, Inc (Irvine, CA, USA).

BOOKS EDITOR Leigh Spielberg PUBLICATION Pearls in Glaucoma Therapy

Download our compendium of clinical and laboratory cases (#66083EN): www.moria-surgical.com

Authors Tanuj Dada, Parul Ichhpujani & George Spaeth PUBLISHED BY Jaypee Brothers Medical Publishers (P) Ltd 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

MORIA S.A. 15, rue Georges Besse 92160 Antony FRANCE Phone: +33 (0) 1 46 74 46 74 - Fax: +33 (0) 1 46 74 46 70 moria@moria-int.com - www.moria-surgical.com

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Feature

industry news

Recent developments in the vision care industry

Intraocular lens study

Multifocal intraocular lens

Alcon announced the launch of the AcrySof® IQ ReSTOR® +2.5 D multifocal intraocular lens (IOL) during the XXX ESCRS meeting in Milan, Italy. Built on the proven AcrySof® IQ IOL platform, the new AcrySof® IQ ReSTOR® +2.5 D multifocal lens is designed to deliver sharp distance vision for cataract patients with distant dominant visual needs. “The AcrySof® IQ ReSTOR® +2.5 lens is our latest technology advancement in the family of AcrySof® IQ ReSTOR® IOLs. The AcrySof® IQ ReSTOR® family

provides surgeons lens options to tailor treatment for their cataract patients’ vision and lifestyle needs,” said Stuart Raetzman, head of global commercial strategy, Alcon. “With the addition of the AcrySof® IQ ReSTOR® +2.5 IOL, Alcon continues to bring surgeons the broadest portfolio of presbyopia correcting IOLs. The optic design of the new lens is made to optimise visual performance at intermediate and far distances,” Said Mr Raetzman. n www.alcon.com

WaveScan Studio aberrometer

IOL scissors and forceps

For IOL explantation through smallest incisions, Geuder has developed, in collaboration with Michael E Snyder MD and Robert H Osher MD, an IOL scissors and an IOL forceps. “The Snyder-Osher IOL scissors have highest cutting efficiency, thanks to their sturdy and sharp scissors blades,” said a Geuder spokeswoman. “Grooves on the lower cutting blade prevent sliding of the lens during cutting. In addition, the special handle geometry facilitates a wide opening angle of the scissor blades. “The Snyder-Osher IOL forceps enables a secure holding of the lens while cutting it inside the capsular bag. Thanks to the special grooves in the grasping area, the lens fragments can be easily removed,” she said. n www.geuder.com/explantationset

EUROTIMES | Volume 17 | Issue 11

Oculentis has announced that in a comparative clinical study conducted by Dr Jan Venter between November 2009 and September 2011, 9,366 eyes of 4,683 patients were treated with a LENTIS Mplus intraocular lens. “During a six-month followup among other parameters the pre- and postoperative results obtained for visual acuity at near, intermediate and far distance of 4,240 LS-312 MF30-IOL models (C-loop design) and 5,126 LS-313 MF30-IOL models (plate haptic design) were measured and analysed. The visual acuity results at all distances was excellent for both models,” said an Oculentis spokesman. n www.oculentis.com

Abbott has obtained European CE Mark for the iDesign Advanced WaveScan Studio aberrometer, a next-generation diagnostic tool for mapping and analysing corneal aberrations in the eye for wavefront-guided LASIK procedures. “The iDesign system measurement makes an individual “blueprint” of the eyes, mapping the imperfections and creating a treatment plan. Once a corneal flap is created using the iFS Femtosecond laser, this iDesign treatment plan is then executed using the STAR S4 IR Excimer Laser system for a computer-driven custom laser correction, unique to each patient,” said an Abbott spokesman. n www.abbottmedicaloptics.com

Innovative products

Alamedics GmbH & Co KG has been established by Bettina Lingenfelder and Dr Christian Lingenfelder, both veterans in medical device business. The company is located in Dornstadt, a small town north of Ulm. “The company has received all certificates (DIN EN IS0 9001 und DIN

EN ISO 13485) to allow for manufacturing of advanced medical devices. Currently the company is focusing on development, manufacturing and sales of devices for ophthalmic surgery. Additionally, alamedics is offering its services as OEM manufacturer,” said a company spokeswoman. n www.alamedics.de

Diabetic macular oedema

In the RESTORE extension study, Prof Paolo Lanzetta from the Department of Ophthalmology, University of Udine introduced results from 240 patients with diabetic macular oedema (DME) who received individualised treatment with ranibizumab in a regimen consistent with the European Union label, the standard of care in wet AMD. The data presented at the 12th EURETINA Congress in Milan, Italy, showed that patients who were originally treated with ranibizumab received an average of 13.9 injections over three years. The mean of seven letters of visual acuity gained in the RESTORE core study were maintained with an average of 3.7 injections in the second year and 2.7 in the third year.

Sterilisable lens

For micro-invasive glaucoma surgery and goniotomy procedures, Volk says its new Surgical Gonio Lens provides clear anterior chamber angle images. “With a 1.2x image magnification, the contact lens’ high quality Volk optics delivers crisp, high resolution views. The Surgical Gonio is particularly well suited for MIGS and all surgical gonio procedures. The lens’ small profile is equally useful for paediatric postoperative gonioscopy,” said a company spokeswoman. “The lens is compatible with both steam and gas sterilisation, constructed to withstand repeated sterilisation cycles without image degradation over time,” she said. n www.volk.com

Precision Laser System

OptiMedica Corp. has announced US Food and Drug Administration 510(k) market clearance of its Catalys Precision Laser System for creating single-plane and multi-plane arc cuts/incisions in the cornea during cataract surgery. The system, which was CE mark approved for these incisions in March of 2012, is now both CE mark approved and FDA market cleared for this indication as well as capsulotomy and/or lens fragmentation, said a company spokesman. n www.optimedica.com.

Program Chairs r& e t s i g Edward J. Holland, MD Re sing u o Stephen S. Lane, MD kH g o r o . o B Roger F. Steinert, MD ate rUpd e

.Wint w w w

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

Faculty Brock K. Bakewell, MD John D. Banja, PhD Rosa M. Braga-Mele, MD Robert J. Cionni, MD Terry Kim, MD Richard L. Lindstrom, MD Nick Mamalis, MD Nancey K. McCann Stephen A. Obstbaum, MD Robert H. Osher, MD E. Ann Rose Thomas W. Samuelson, MD R. Doyle Stulting Jr., MD, PhD

Preliminary Program online

Revitalize Your Practice. Innovate and Strategize in a Relaxing Environment.

Attend the Educational Retreat for Anterior Segment Surgeons. Join us for an open exchange of ideas and solutions to help improve your practice.

Cataract | Cornea | Glaucoma | Refractive

www.WinterUpdate.org

Review

JCRS HIGHLIGHTS

Journal of Cataract and Refractive Surgery

Attitudes regarding the practice of immediate sequential bilateral cataract surgery (ISBCS) have evolved considerably in recent years. The once controversial concept has become regular practice in some areas such as Finland and the Canary Islands, and is gaining adherents in other parts of Europe. JCRS co-editor Emanuel Rosen MD, FRCSEd discusses the current state of ISBCS in light of recent clinical studies and economic analyses. Potential advantages in favour of doing both eyes at once include rapid patient rehabilitation and significant economic benefits, he notes, citing compelling economic and quality-oflife research in favour of ISBCS. However, this must occur in a context of hard rules, including surgery by experienced cataract surgeons with an excellent personal safety track record; a solid institutional track record, especially in regard to limitation of postoperative endophthalmitis and toxic anterior segment syndrome incidence; careful exclusion criteria; and a database confirming outcomes and ability to modify techniques according to study of outcomes. However, an argument in favour of delayed sequential cataract surgery is the ability to consider the refractive outcome in the firsteye surgery and modify the IOL power in the second-eye surgery. Dr Rosen cites an article appearing in JCRS that provides additional support for ISBCS. Dr Serrano-Aguilar and colleagues in the Canary Islands conducted a study that randomised patients (1614 eyes) with cataracts requiring bilateral surgery to immediate or delayed sequential bilateral cataract surgery. At one month as well as at one year follow-up, they saw no differences in intraoperative or postoperative surgical complications, visual acuity, or self-perceived visual function between the two techniques. In particular, there were no differences in terms of surgical complications between the two groups. The authors emphasise that these safety and effectiveness outcomes were related to careful patient selection, surgical expertise, and the systematic use of standardised surgical guidelines to ensure aseptic and independent surgery in each eye. n E

Rosen, JCRS, “Editorial: Immediate sequential bilateral cataract surgery”, Volume 38, Number 10, 1707-08. P Serrano-Aguilar et al., JCRS, Immediately sequential versus delayed sequential bilateral cataract surgery: Safety and effectiveness, Volume 38, Number 10, 1734-1742.

EUROTIMES | Volume 17 | Issue 11

TELL ME AND I’LL FORGET;

Phaco for glaucoma Early cataract surgery could be “a great option” for patients with mild to moderate glaucoma who have demonstrated less than ideal IOP control with standard medical treatment, say R Chang and colleagues in a guest editorial. The clinical researchers note that modern clear corneal temporal phacoemulsification with posterior chamber intraocular lens implantation appears to offer the characteristics of what would otherwise be considered a blockbuster treatment - lowering intraocular pressure approximately 4.0 mmHg for at least three years and improved vision in over 90 per cent of those who used it with minimal adverse consequences, and perhaps even improved safety with regard to future glaucoma surgery. They review the evidence for this idea in the literature including the findings of a recently completed analysis from the observation group of the Ocular Hypertension Treatment Study arm. Comparing this approach with other surgical approaches to glaucoma they attest that the benefits of early cataract surgery outweigh the risks in most patients with mild, moderate and, in some circumstances, advanced glaucomatous disease. They add that the case appears to be even stronger for patients with exfoliative glaucoma and those with higher pressures and/or narrow angles for whom an even greater IOP reduction may be anticipated. n R

Chang et al., JCRS, “Guest Editorial: Timely cataract surgery for improved glaucoma management”, Volume 38, Number 10, 1709-10.

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

UNDER

STAND - Old Chinese Proverb

Cataract surgery immediate sequential or delayed sequential?



Learn and explore key aspects of modern anterior segment surgery



Prepared by ESCRS in partnership with Society opinion-leaders



Earn CME points

Over 20 hours of interactive, assessed and accredited eLearning 

Refractive Surgery Didactic Course

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Cataract Surgery Didactic Course

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Workshop on Visual Optics

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Cornea Didactic Course (coming soon)

Gain access to all of this and more online at

http://elearning.escrs.org Thomas Kohnen associate editor of jcrs FURTHER STUDY Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

Reference

CALendAr OF eVents

Dates for your Diary

November

December

AAOâ&#x20AC;˘APAO Joint Meeting

New Horizons in Cataract Surgery

19th Annual Scientific Meeting of the MCLOSA and Regional Scientific Meeting of the IOSS

5th Amsterdam Retina Debate

2012

10-13 CHICAGO, IL, USA www.aao.org

2012

16 LONDON, UK

www.newhorizons2012.co.uk

2012

7 AMSTERDAM, THE NETHERLANDS www.amc.nl/retinadebate

30 LONDON, UK

www.mclosa.org.uk/annualmtg.html

January

February

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

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

3rd EURETINA Winter Meeting

17th ESCRS Winter Meeting

2013

17-20 HYDERABAD, INDIA

1-2 ROME, ITALY

2013

15-17 WARSAW, POLAND www.escrs.org

www.euretina.org

www.ophthalmictrainings.com

www.apaoindia2013.org www.aios.org

February

June

July

European Society of Ophthalmology (SOE) 2013

International Meeting on Anterior segment surgery

26th APACRS Annual Meeting

www.soe2013.org

www.femtocongress.com

9-11 VIENNA, AUSTRIA

2013

27th International Congress of HSIOIRS 28-3 MARCH ATHENS, GREECE www.hsioirs.org

2013

8-11 COPENHAGEN, DENMARK

2013

22-23 VERONA, ITALY

11-14 SINGAPORE www.apacrs.org

July

September

October

5th World Glaucoma Congress

13th EURETINA Congress

4th EuCornea Congress

XXXI Congress of the ESCRS

www.worldglaucoma.org

www.euretina.org

www.eucornea.org

www.escrs.org

2013

17-20 VANCOUVER, CANADA

2013

26-29 HAMBURG, GERMANY

2013

4-5 AMSTERDAM, THE NETHERLANDS

2013

5-9 AMSTERDAM, THE NETHERLANDS

Advertising Directory: Alsanza: Page: 12; Anterior segment surgery meeting: Page: 24; Angiotech: Page: 17; ASCRS / Eyeworld: Pages: 23, 36, 42; Benz: Page: IBC; CXL: Page: 11; D.O.R.C.: Page: 19; ESASO: Page: 16; Haag Streit: Pages: 9, 34; Katena: Page: 30; Medicel: Page: 13; Moria: Page: 39; NIDEK: Page: 31; Oertli Instruments Ag: Page: IFC; OWL: Page: 15; Rumex: Page: 8; Schwind: Page: OBC; Technolas: Page: 29; TRB Chemedica: Page: 25; VSY: Page: 27; Ziemer: Page: 18

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