Vol 18 - Issue 4 by EUROTIMES

VOLUME 18 ISSUE 4 APRIL 2013

CORNEAL COLLAGEN

CROSSLINKING

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EUROTIMES

APRIL 2013 Volume 18 | Issue 4 This ISSUE... Special Focus: Cornea

4 8 9 10 11 12

Cover Story: Potential and limits of crosslinking techniques discussed Newsmaker Interview: EuCornea president talks about his plans for the society Better understanding of risk factors should help reduce incidence of epithelial ingrowth Crosslinking and its effectiveness in treating keratoconus Careful monitoring can reduce risks after keratoprosthesis surgery Many psychological issues to be considered following OOKP surgery

Cataract & Refractive

14 Expense of femtosecond laser cataract surgery may put it out of reach for some patients 15 Good visual outcomes can be achieved after ectasia 16 Males are high risk for vitrectomy following cataract surgery, according to study 17 Lens position important for astigmatism-correcting lenses 18 Compounded products in the US under scrutiny following deaths 19 Should LASIK be avoided in dry eye patients?

Glaucoma

20 New strategies for preventing degeneration of optic nerve discussed 21 Glaucoma surgery could become less invasive with new implants

Retina

22 24 25 26 27 28

New ILM peeling method could improve closure rates in macular hole surgery The eye could be one of the most successful target organs for gene therapy to date Overcoming some of the drawbacks to retinal detachment surgery Choroidal biopsy a common procedure, but it is not without controversy Debate continues on simultaneous cataract/anti-VEGF treatment in AMD patients New approaches can improve diabetic retinopathy treatment, but surgery still an option

Ocular

29 Constantly updating skills important for successful ophthalmologist 30 Important to be aware of the link between dementia and visual decline 31 Regular eye tests and screening important in cognitively impaired patients

Global Ophthalmology

32 Learning from eye care models practised in Indian hospitals

News

34 35 36 37

39 editorial staff

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

Managing Editor Caroline Brick

Executive Editor Colin Kerr

Production Editor Angela Sweetman

Editors Sean Henahan Paul McGinn

Senior Designer Paddy Dunne

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

Eye on Technology looks at innovative implant Patient-reported outcomes to be added to EUREQUO database Prof Joseph Colin is remembered Entries invited for John Henahan Writing competition

Features

39 Resident’s Diary 40 Industry News 41 JCRS Highlights 44 Eye on Travel 46 Book Review 48 Calendar

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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.

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EUROTIMES

Editorial

ESCRS

GUEST EDITORIAL

Medical Editors

Volume 18 | Issue 4

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

CORNEA FASCINATES

These are exciting times for ophthalmologists working in the field of cornea

by François Malecaze

International Editorial Board

Emanuel Rosen Chairman ESCRS Publications Committee

t is a great pleasure for me to be associated with this month’s issue of EuroTimes devoted to the theme of cornea, a subject very close to my heart and one which continues to fascinate and challenge our profession. It is also in many ways a fitting tribute to the memory of our esteemed colleague Joseph Colin, who sadly passed away in February, and who contributed so much to the field of corneal research. It was an honour for me to collaborate with Joseph in creating the first designated French National Reference Centres for Keratoconus in France in Bordeaux and Toulouse, an important initiative in coordinating research action and patient support for this potentially debilitating disease. Although the last decade has seen tremendous progress in the diagnosis and treatment of keratoconus, the disease remains one of the main causes of corneal transplantation among young adults. But we can now offer treatment options to our patients that were not available over a decade ago and in many cases are able to delay or halt the progression of the disease. Corneal collagen crosslinking (CXL) with riboflavin, the subject of this month’s Cover Story, has been at the forefront of this evolution. Since Theo Seiler’s seminal publication, more and more CXL studies from different groups around the world have been published suggesting a consistent stabilising effect of CXL. Less significantly, but appreciable nonetheless, the studies have also shown a variable improvement in keratometric values and visual acuity. While evidence is certainly accumulating that CXL is both efficacious and safe in the treatment of progressive keratoconus, we still lack the kind of controlled, randomised prospective study conducted on a large cohort of patients with at least five years’ follow-up, to clinch the argument once and for all and raise the evidence base to a higher level. This would also help in making a stronger case to convince national governments and social security systems in different countries to reimburse those patients who currently undergo CXL treatments. By delaying the progression of the disease, these patients are perhaps avoiding the need for a more costly penetrating keratoplasty operation further down the road and actually saving money for the health system. Although crosslinking gives us a valuable weapon in the fight against keratoconus, a lot of work remains to be done. Much of the

EUROTIMES | Volume 18 | Issue 4

focus will now shift to fine-tuning CXL treatments in order to obtain the optimal results for each individual patient. What is the best way to deliver riboflavin to the cornea? What dose of UV light and what duration works best? We also need to know the optimal stromal depth at which the crosslinking treatment will be most efficient. Ideally, in the near future, we will be able to answer many of these questions and can think about establishing a set of recommended standards for CXL treatments. It is also important to bear in mind that while crosslinking may succeed in slowing down the evolution of keratoconus, it does not address the underlying pathology of the actual corneal deformation. A lot of recent work has gone into identifying possible genetic causes of keratoconus, opening up potentially exciting avenues of research in the future. While keratoconus remains a mysterious disease, there is a huge amount of effort being made to help us understand it and new techniques and technologies are bringing us ever closer to this goal. Many of these techniques and technologies will come under the spotlight at the 4th EuCornea Congress which is scheduled to take place in Amsterdam in October 2013 in conjunction with the XXXI Congress of the ESCRS. These are exciting times for those of us working in the field of cornea and this will be reflected in the rich and diverse scientific programme that we are putting together for the congress. I would hereby like to extend a warm invitation to all our colleagues to come and join in the scientific debates, catch up on the latest developments in corneal research and to play their part in making the 4th EuCornea Congress the best to date.

Noel Alpins australia Bekir Aslan TURKEY Bill Aylward UK Peter Barry IRELAND Roberto Bellucci ITALY Hiroko Bissen-Miyajima JAPAN John Chang CHINA Alaa El Danasoury SAUDI ARABIA Oliver Findl AUSTRIA I Howard Fine USA Jack Holladay USA Vikentia Katsanevaki GREECE Thomas Kohnen GERMANY Anastasios Konstas GREECE Dennis Lam HONG KONG Boris Malyugin RUSSIA Marguerite McDonald USA Cyres Mehta INDIA Thomas Neuhann GERMANY Rudy Nuijts THE NETHERLANDS Gisbert Richard GERMANY Robert Stegmann SOUTH AFRICA Ulf Stenevi SWEDEN Emrullah Tasindi TURKEY Marie-Jose Tassignon BELGIUM Manfred Tetz GERMANY

François Malecaze MD, PhD François Malecaze MD, PhD is vice-president of EuCornea and co-director of the French National Reference Centre for Keratoconus in Purpan Hospital, Toulouse, France.

Carlo Enrico Traverso ITALY Roberto Zaldivar ARGENTINA Oliver Zeitz germany

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Cover Story

CORNEAL COLLAGEN CROSSLINKING

AT THE CROSSROADS

As potential indications emerge, limits and questions also surface by Howard Larkin

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We know how to shorten irradiation time and we can reverse corneal melting. Other techniques are in development in the field Theo Seiler MD, PhD

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Don’t just look at results in the short term, you can see improvement also in the long term Paolo Vinciguerra MD

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For hyperopes, crosslinking is the key to keep long-term results stable

A John Kanellopoulos MD

EUROTIMES | Volume 18 | Issue 4

ver the past decade, corneal collagen crosslinking has revolutionised treatment of progressive keratoconus. Over the next decade, crosslinking could play a significant role treating refractory infectious keratitis and non-infectious melting syndromes, and stabilising corneas after laser refractive surgery to prevent regression and possibly ectasia. Moreover, new crosslinking techniques could make corneal crosslinking more patient-friendly. UV-A irradiation times will almost certainly shorten while targeted radiation could customise crosslinking to strengthen the cornea overall by increasing the volume of polymerised tissue, or to promote specific corneal remodelling. (Kanellopoulos AJ, Asimellis G. Clin Ophthalmol. 2013;7:329-35.) It may even be possible to eliminate the need to remove the epithelium – along with the pain, extended recovery time, corneal haze and infection risk that go with it – for at least some indications. Eventually, sunlight might replace UV-A irradiation and aldehyde sugars might replace riboflavin – or intrastromal glucose administration could supplant photosensitizers and UV-A altogether. “We know how to shorten irradiation time and we can reverse corneal melting. Other techniques are in development in the field,” said Theo Seiler MD, PhD. (Kanellopoulos AJ. Clin Ophthalmol. 2012;6:97-101.) Now at the University of Zurich, Switzerland, where he also heads the Institute for Refractive and Ophthalmic Surgery, Prof Seiler and colleagues developed corneal crosslinking at the University of Dresden in the late 1990s and early 2000s. He spoke on the future of corneal crosslinking in his keynote lecture at the 2012 cornea subspecialty day of the American Academy of Ophthalmology. But while crosslinking appears safe and has entered the mainstream nearly everywhere but the US, where FDA trials are still under way, questions remain.

Courtesy of Leopoldo Spadea MD

Biomicroscopic image of the right eye of a 27-year-old male patient with very thin cornea (345µm) one day after trans-epithelial crosslinking. The epithelium presents some superficial irregularity but the overall cornea appears very clear

Why does crosslinking fail to prevent progression of corneal steepening in about three per cent of patients? (Koller et al. J Cataract Refract Surg 2009; 35: 1358-62.) What parameters contribute to continuing corneal flattening, which often stabilises at two years, but can go on four or more years? And what are the long-term effects of greatly accelerating stiffening that naturally occurs with ageing? As experience with corneal crosslinking grows and its technology develops, both its potential and its limits are getting clearer.

Avoiding PK Crosslinking was developed to avoid penetrating keratoplasty (PK). Before crosslinking, keratoconus treatment was limited to spectacles followed by rigid contacts as the disease progressed. As many as one in five patients ultimately required PK to rescue vision. (Lass JH et al. Ophthalmology. 1990; 97(4): 433-445.) With mean graft survival estimated at 17 years for primary PK, and less for repeat procedures, the lifetime burden is high for the typically young keratoconus patient. (Borderie VM et al. Ophthalmology 2012; 119(2): 249-255.) In theory, switching to deep anterior lamellar keratoplasty (DALK) for patients with intact endothelium could extend graft survival to a mean 49 years. But this has not yet been demonstrated in practice, and DALK refractive outcomes

are no better than PK. (Reinhart WJ et al. Ophthalmology. 2011; 118(1): 209-18.) By contrast, a meta-analysis of randomised contralateral eye-controlled corneal crosslinking studies found that it not only halts keratoconus progression in nearly all adult patients at 12 months’ follow up, it actually leads to regression of 1.0 D or more in central cornea steepness in nearly half. (Gore RM et al. Eye 2012 Dec 21 epub ahead of print.) In addition, a continuous reduction in irregular astigmatism is typically seen, leading to a mean improvement in spectacle corrected vision of about two Snellen lines, generally stabilising about two years after surgery in adults. (Caporossi A et al. Am J Ophthalmol. 2010; 149(4): 585-93.) Crosslinking also appears to be safe. One IROC study of 117 eyes in 99 patients found just 2.9 per cent losing two or more Snellen lines, with sterile infiltrates seen in 7.6 per cent and central stromal scars in 2.8 per cent. Preoperative maximum keratometry of 58.0 D or more was a significant risk factor for failure, and a preoperative corrected vision of 20/25 or better increased risk for complications. (Koller JCRS 2009.) Other common complications include pain, photosensitivity, corneal haze and microbial keratitis, due to removal of the protective epithelium. Less common is endothelial damage due to thin corneas. Persistent corneal oedema and noninfectious corneal melt after crosslinking also have been reported.

The impact of age The IROC study also found patient age higher than 35 years significantly increased complication risk, illustrating one way in which age influences crosslinking outcomes. It concluded that restricting patient age to younger than 35 could reduce complication rates to one per cent. Patients 18 years and younger also respond differently to corneal crosslinking, in part because keratoconus is much more aggressive in children, said Paolo Vinciguerra MD, Instituto Clinico

Crosslinking and LASIK As with keratoconus, the inexorable progression of iatrogenic keratectasia led Prof Seiler to turn to crosslinking in 2003. In 16 cases in which he waited, all progressed within six months by more than 1.0 D, so he decided not to wait. One of Prof Seiler’s first post-LASIK crosslinking patients was a 32-year-old female who developed a steep central island 18 months after a -5.5 D correction. Five months after crosslinking, the treated eye had not progressed, but the fellow eye had. As of late 2012, the crosslinked eye still had not progressed. If anything, there was a little bit of improvement in topography, he noted. To date, progression stopped at 12 months’ follow up in all 24 keratectasia patients, 22 post-LASIK and two postphotorefractive keratectomy (PRK) patients, that Prof Seiler has treated. None lost more than two lines of corrected vision while eight gained more than two lines uncorrected. Progression was halted in all of 12 patients reaching five years’ follow up; eight had Kmax reduced more than 2.0 D, five saw more than two lines improvement in uncorrected visual acuity and none saw deterioration of best corrected vision. One patient suffered endothelial damage in a case where a thin cornea did not swell enough when treated with hypotonic riboflavin solution. “We did the crosslinking anyway because the alternative would have been DALK. The patient took the risk but the cornea never cleared,” Prof Seiler said. After stabilising keratectasia with EUROTIMES | Volume 18 | Issue 4

crosslinking, Prof Seiler has seen good results with stromal ring segments for visual rehabilitation. One patient improved from 0.3, or about 20/70, to 0.8, or 20/25, one month after one stromal ring was inserted. Rigid contacts are another option, as is surface ablation since there is no flap to affect biomechanical stability. “We could risk it, but many patients don’t want to do laser anymore,” he noted. However, A John Kanellopoulos MD, of Athens, Greece, and NYU Medical School, New York City, US, has developed a procedure combining topo-guided partial PRK and crosslinking for keratoconus and keratectasia. Known as the Athens Protocol, a WaveLight excimer laser guided by Placido- and/or Pentacam-derived topographic imaging removes no more than 40 to 50 microns to regularise corneal topography. Mitomycin-C is applied and higher-fluence crosslinking is performed to stabilise the result. (Kanellopoulos AJ. The Athens Protocol: PRK and CXL. Chapter 8 in PRK: Present, Past and Future. Slack Incorporated 2012.) Previously he crosslinked first and PRK later (Kanellopoulos AJ, Binder PS. Cornea. 2007 Aug;26(7):891-5), but found better results doing the procedures together. Mean corrected visual acuity was logMAR 0.11+/- 0.16 for combined procedures compared with 0.16 +/- 0.22 for sequential (p<0.001), while mean K decreased 3.5 D v 2.75 D, respectively (p<0.005). (Kanellopoulos AJ and others in J Refract Surg. 2009;25(9):S812-S818; J Refract Surg. 2011 May;27(5):323-31;. J Refract Surg. 2010 Oct;26(10):S827-32.) It appears that doing both at the same time is synergistic, he noted. He emphasised, though, that this is not a refractive procedure. Corrected vision improves due to reductions in corneal asymmetry, but there is no attempt to correct refractive error. The procedure also appears safe. In a series of 412 cases treated with the Athens Protocol, less than one per cent progressed, and less than five per cent had delayed epithelial healing and/or stromal scarring. (Kanellopoulos AJ, Cho M. : Complications with the Use of Collagen Cross-Linking. Chapter 10 in: Complications in Ocular Surgery. Slack Incorporated 2012.) Dr Kanellopoulos also has combined LASIK and crosslinking to prevent keratectasia in high-risk patients. These include 43 consecutive high myopia patients who saw mean uncorrected vision improve from 20/100 to 20/16, with no signs of ectasia or regression over a mean follow up of 3.5 years. (Kanellopoulos AJ. Clin Ophthalmol. 2012;6: 1125-30.) Dr Kanellopoulos crosslinked these patients by applying a 0.1 per cent riboflavin solution to the exposed stroma after ablation, and irradiated through the repositioned flap with a higher fluence lamp delivering 10 mW/cm2 for 10 minutes through the repositioned LASIK flap using the Avedro, KXL device. He has since increased UVA fluence to 30mW/cm2 exposed for 80 seconds. Using the same approach, Dr Kanellopoulos has had success preventing the long-term regression usually seen in hyperopic LASIK treatment. Two years after surgery, 34 eyes treated with very high-fluence crosslinking, 30mW/cm2 for 80 seconds, after LASIK saw a mean change in keratometry of less than 1.0 D in treated eyes

Figure 1: A schematic step-by step description of the Athens Protocol: PTK, then topi-guided partial PRK, then MMC 0.02mg/ml X 20 seconds, then 0.1 per cent riboflavin sodium phosphate solution (not dextran based), and last high fluence CXL: 10mW/cm2 for 10 minutes

Courtesy of A John Kanellopoulos MD

Humanitas, Milan, Italy. He saw one 12-year-old patient lose 186 microns of central corneal thickness in just four months. “Don’t wait to treat these patients,” he cautioned. In a prospective case series study of 66 eyes with progressive stage II keratoconus compared with untreated contralateral eyes in patients age nine to 18 years, crosslinking halted progression in all treated eyes, and reduced irregular astigmatism, leading to significantly better vision at 12, 24 and 36 months. Mean uncorrected visual acuity improved from 20/80 to about 20/55, while mean corrected acuity improved from a little better than 20/40 to 20/25, at 36 months. Endothelial cell counts were stable and re-epithelialisation and recovery of central corneal thickness was quicker than in adults. Dr Vinciguerra noted that Kmax changed less in children than in older groups, and spherical equivalent changed very little. But over time, coma transformed into regular astigmatism, which is much easier to correct. Total higher order aberrations also declined over the central cornea. As a result, corrected vision continuously improved at one month, six months and 24 months. “Don’t just look at results in the short term, you can see improvement also in the long term.” However, after 12 months improvement slows in children, whereas in patients aged 18-39, corrected vision often improves for 36 months, though results are worse in patients past age 40, Dr Vinciguerra said. A more aggressive disease probably reduces the efficacy of crosslinking in children, while natural age-related crosslinking may limit treatment effectiveness in older adults. Nonetheless, corneal crosslinking appears safe and effective in children, Dr Vinciguerra said, noting that it can prevent the need for corneal transplantation.

Figure 2: The pivotal (and controversial) intervention: a topography-guided ablation aims to normalise the highly irregular cornea surface

compared with nearly 3.0 D with standard hyperopic LASIK in contralateral control eyes. (Kanellopoulos AJ, Kahn J. J Refract Surg. 2012 Nov;28(11 Suppl):S837-40.) “For hyperopes, crosslinking is the key to keep long-term results stable,” Dr Kanellopoulos said. The impact of LASIK instability may be even more evident when measured by long-term keratometric stability than visual acuity, he added. John Marshall PhD, of Kings College, London, UK, suggested that accelerated crosslinking should be used with all laser refractive procedures both to stabilise refractions and prevent ectasia. Any surgical intervention will increase the shift to instability in the system, including cataract surgery, he commented. LASIK weakens the cornea by one-quarter to onethird, while a -6.6 LASIK changes corneal power 0.15 dioptre in corneal power every year. Dr Marshall’s research suggests applying riboflavin beneath the flap enables crosslinking above and below the flap interface, stabilising the entire cornea. He noted that the Shinagawa Clinic in Japan found no shift in refractive power three months after combined LASIK and crosslinking, and did more than 25,000 combined procedures with no reported complications in 2012. But citing a lack of standardisation in the procedure and very few controlled studies, Perry Binder MD, of the University of California-Irvine, US, objected to routine

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We can play around with the power-time complex to deliver the same amount of energy to the cornea in less time John Marshall PhD

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Current transepithelial crosslinking may be effective in very thin corneas, children and uncooperative patients Leopoldo Spadea MD

contacts

Cover Story

Courtesy of A John Kanellopoulos MD

CORNEAL COLLAGEN CROSSLINKING

Theo Seiler – claudia.kindler@iroc.ch Paolo Vinciguerra – info@vincieye.it A John Kanellopoulos – ajk@laservision.gr John Marshall – eye.marshall@googlemail.com Perry Binder – Garrett23@aol.com Leopoldo Spadea – lspadea@cc.univaq.it

Figure 3: Result case number 1: left are the pre-op pentacam and topometric indices, right the post-op documenting the dramatic improvement in shape and ISV and IHD

prophylactic crosslinking after LASIK. He noted that after LASIK, the endothelium is closer by 110 to 160 microns, or more with mechanical microkeratomes, increasing the risk of UV-A endothelial damage. Also, the impact of crosslinking on refractive outcomes is largely unknown, while proven alternatives including PRK and phakic intraocular lenses exist for high-risk patients, Dr Binder said. “Do not perform crosslinking on a LASIK patient until such time as we can determine the risks and benefits.”

Easing the pain Though preferable to transplantation, standard crosslinking is still inconvenient and painful. It takes 30 minutes of riboflavin soak, reapplied frequently, followed by 30 minutes of UV-A at 3 mW/cm2. Moreover, removing the epithelium is painful, taking several weeks to recover. Techniques are in the works that may address these problems. Cutting irradiation time by increasing source power may be the easiest. “Tissue absorbs energy, not power, and energy is power times time. We can play around with the power-time complex to deliver the same amount of energy to the cornea in less time,” Dr Marshall explained. Dr Marshall’s research suggests that three minutes at 30 mW/cm2 is safe. “It’s clear we can shorten the irradiation with the optimum power somewhere between 10 and 20 or 25 mW,” said Prof Seiler, who established the current standard through hundreds of experiments. Irradiation devices with higher fluence and customisable depth may also make possible custom crosslinking that strategically reinforces corneal tissue rather than stiffening the maximum volume, which may stress surrounding tissues including the limbus, trabecular meshwork, iris and crystalline lens, Dr Kanellopoulos said. “In the near future, we may be crosslinking ‘beams’ or ‘patterns’ of cornea tissue and not entire areas.” Shortening riboflavin imbibition time is more difficult, Dr Seiler said. It takes 30 minutes for riboflavin to soak in 330 microns, which is essential to maximise the volume of crosslinked tissue he noted. A 15 minute soak cuts the depth to about 200 microns.

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Do not perform crosslinking on a LASIK patient until such time as we can determine the risks and benefits Perry Binder MD

EUROTIMES | Volume 18 | Issue 4

Figure 4: Result case number 2: the normalisation INDUCED more myopia, although the CDVA was much better due to improvement of the topometric indices IHD and ISV

Leaving the epithelium intact has advantages, including quicker healing and reduced infection risk, but is problematic. Riboflavin is a large molecule, and it will not penetrate the tight junctions of the epithelium unless they are loosened, with agents. Nonetheless, trans-epithelial crosslinking using permeability enhancing agents, such as trometamol, EDTA and BAK, has been successful. (Filipello et al. J Cataract refract Surg. 2012 Feb; 38(2): 283-91.) Iontophoresis, which uses a negative charge on the eye to pull in riboflavin, may also help. (Vinciguerra P ESCRS 2012.) However, trans-epithelial crosslinking is limited to about 100 to 140 microns (Caporossi A Eur J Ophthalmol 2012), and the stiffening effect is about one-fifth that of the standard technique. (Wollensak G et al. J Cataract Refract Surg 2009; 35: 540-546.) Worse, at two years, it has shown signs of regression. (Caporossi A EVER 2012.) Prof Seiler finds these defects fatal, but is confident that trans-epithelial methods will be devised that will equal the soaking performance of the epithelium-off standard. Still, current transepithelial crosslinking may be effective in very thin corneas, children and uncooperative patients, noted Leopoldo Spadea MD, associate clinical professor of ophthalmology, chief of corneal and refractive surgery – Eye Clinic, S. Salvatore Hospital, University of L’Aquila, Italy. But will it succeed? “Only time will tell.”

Future uses and techniques In addition to biomechanical effects, crosslinking also has cytotoxic and biochemical properties, Prof Seiler said. These may lead to new applications. Crosslinking kills keratocytes down to about 300 microns. It also kills everything else, making it a remarkably effective broad-spectrum anti-microbial, Prof Seiler said. In one study, infectious corneal melting was halted in five eyes, avoiding emergency keratoplasty. (Iseli HP et al. J Refract Surg. 2011 Mar;27(3):195-2011.) Biochemically, crosslinking makes the cornea more resistant to enzyme erosion, Prof Seiler said. As a result, it can also heal inherited non-infectious corneal melting. In a normal cornea, the extracellular matrix is synthesised by keratocytes at the same rate it is eaten up by enzymes in the tear film. But in melting syndromes, synthesis doesn’t keep up, Prof Seiler explained. Crosslinking inhibits enzyme catalysis, bringing it back into balance with synthesis. He has used it to arrest and reverse a case of Terrien’s marginal degeneration, for which no other treatment is known. Eventually, the entire riboflavin/UV-A process could be replaced, Prof Seiler said. Sunlight is as effective as a UV-A lamp. And glucose will stiffen the cornea just as well as riboflavin. The problem is it takes about 20 days. “It could be that you take eye drops a few times a day and sit in the sun and you get well,” Prof Seiler said.

Figure 5: Postoperative UDVA and CDVA in a large series showing the improvement of CDVA which is the main benefit from the Athens Protocol, essentially eliminating the threat for a penetrating graft, especially in patients that are unable to wear contact lenses

STANDARDISED STUDIES

s president of EuCornea, Jose L Guell MD, Barcelona, Spain, often hears from surgeons confused by conflicting case reports about new corneal collagen crosslinking applications. He believes international clinical José Güell societies can help by standardising patient evaluation practices and ensuring that studies are properly designed and adequately powered. “When a new instrument is in the hands of doctors we have a tendency to invent new indications and this is often very useful. But only properly designed, longterm studies will clearly show to everyone if something is working. Big societies must organise or co-organise these studies,” Dr Guell said. Standardising evaluation and outcomes reporting will also help address concerns that available topographic and tomographic instruments are less accurate detecting changes in highly aberrated eyes. “If we all use the same techniques to examine patients, then we can compare the results,” Dr Guell said. A panel assembled by EuCornea, the Cornea Society and the South American Cornea Society are developing standards for newer strategies for managing keratoconus, Dr Guell said. Long-term controlled studies of higher power UV devices and new riboflavin solutions to shorten treatment time, and iontophoresis to promote trans-epithelial procedures, are under way. “In the next one or two years we will have enough data from good controlled studies to know if they are effective and safe.” Confirming new crosslinking indications, including reducing chronic corneal oedema and stabilising corneal grafts in keratoconic or trauma patients, will take longer. “From an economical point of view, these other indications are not very significant. Crosslinking appears very useful to control infectious keratitis, but we all need a significant number of cases and follow-up before we can understand it not as a single case, but to demonstrate this is a useful technique. This will take three or four years depending on the level of interest,” Dr Guell said.

Contact: Jose L Guell guell@imo.es

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Special Focus – Newsmaker Interview

Cornea

José Güell – guell@imo.es

A PROMISING START

Keeping the interest alive among young European ophthalmologists

Jose Güell MD has been a driving force in the promotion and exposition of corneal research and surgery, in addition to his pioneering work in refractive surgery. Four years ago he helped found EuCornea, the first Europe-wide organisation devoted to the treatment of corneal disease. Since that time the organisation has come a long way to becoming an established feature in the landscape of corneal research. He spoke with EuroTimes contributing editor, Roibeard O’hEineachain, about EuCornea’s aims and prospects.

he main reason for the establishment of EuCornea was that there were ophthalmologists throughout Europe who had a significant interest in corneal diseases and diseases of the ocular surface and in surgery of the cornea. And although there were several international societies dedicated to anterior segment surgery, most were focused on cataract and refractive surgery. Over the last decade or so the ESCRS has had a cornea subcommittee, but obviously it was a small part of the ESCRS. In the meantime, there have been nationallybased societies around Europe dealing with the cornea and ocular surface. These were relatively small organisations. They began to acquire an international dimension when our group in Spain, which held a meeting every two years, began working in closer cooperation with a group in Italy, which held a meeting every year. Together we thought that perhaps it would be a good idea to create an international, paneuropean cornea society. Around this same time, some key leaders like Ulf Stenevi, Peter Barry and others provided us with some support and encouragement and we started this organisation four years ago and hopefully it will continue into the future. My main goal as president – as it has also been for my two predecessors as this is a relatively new society – is to take EuCornea from these early stages to a point where it may truly be claimed a success. So far it

EUROTIMES | Volume 18 | Issue 4

has shown signs of being very successful, if we look at the meetings we've held until now, starting from Venice and Paris and especially last year in Milan. The Milan meeting was very successful from an economic point of view, which is important because we are just starting up and our power as an organisation is still fairly insignificant and running the society is a relatively expensive adventure. Therefore, my main goal is to keep the interest alive among young European ophthalmologists and instil an enthusiasm among those treating the ocular surface to participate in the meetings and cooperate with the society and its projects. If we are able to create this interest and if we can continue with this close relationship with the ESCRS, which I think is beneficial for both societies, we will hopefully find that this project will not be just a project any longer, but a reality. And that is my main goal: to make this project a reality. Areas of research into corneal and ocular surface that are currently generating a lot of interest include the use of stem cells in ocular surface reconstruction. That includes in, between other projects, stem cells used to create an artificial cornea and stimulators for endothelial cells. There have also been important developments in the surgical techniques in keratoplasty procedures. Lamellar transplants have been increasingly adopted by corneal surgeons throughout Europe as an alternative to penetrating keratoplasty. Endothelial keratoplasty techniques have taken on an important relevance as have related changes in eye-banking, and the preparation of endothelial lenticules, which is completely different from the creation of standard corneal button used in penetrating keratoplasty. There is also the culturing of cells for ocular surface transplantation where the eye-banking work is also very important. To summarise, I would say that research into eye banking, research into cellular expansion and the new techniques, specifically lamellar surgery and posterior lamellar surgery, are the hottest topics today. There is also a continual need for updating the pharmacology for the treatment of ocular surface infections and diseases.

José Güell MD, president of EuCornea, speaking at the Opening Ceremony of the 3rd EuCornea Congress in Milan last year

New important research is being done with new antibiotics, new routes of delivery such as intraocular use and use of other drugs such as the new steroids and the use of anti-VEGF agents to prevent corneal vascularisation. The treatment of ocular infections is often less exciting than some of the other topics at our meetings but it is nonetheless very important because corneal and ocular surface infections and deficiencies are the things we most commonly have to deal with on a daily basis. Another field of constant investigation is collagen crosslinking which is now being used by ophthalmologists all over Europe, perhaps to excess. Our idea is to put together what we know up to now about crosslinking and, as a society, develop guidelines regarding what should be done and what should not be done. We need to determine the status of this technology and the limits of its use, and to fine tune its indications. The same is true of other treatments for one of the commonest problems the corneal surgeon needs to deal with – keratoconus – such as

“My main goal is to keep the interest alive among young European ophthalmologists and instil an enthusiasm among those treating the ocular surface to participate in the meetings and cooperate with the society and its projects” the use of intracorneal ring segments and deep anterior lamellar keratoplasty. So my intention is to try during the next two years to organise, with all interested colleagues, the research in this field and determine, perhaps with a joint effort with other supranational cornea societies, what should be the standard of care for this pathology.

Special Focus

CORNEA

Single-Use

Instruments

good outcomes

Most cases of eipthelial ingrowth are selflimiting and simply require monitoring by Priscilla Lynch in Brighton

Vacuum Trephine

“

...it should be noted that in most cases of epithelial ingrowth the visual outcomes are quite good

Michael O’Keefe FRCOphth EUROTIMES | Volume 18 | Issue 4

Courtesy of Michael O’Keefe FRCOphth

ew surgical techniques and better understanding of risk factors should help reduce the incidence of epithelial ingrowth in the future, delegates attending the XXXVI UKISCRS Congress heard. Michael O’Keefe FRCOphth, Mater Private Hospital, Dublin, Ireland, spoke about how to treat epithelial ingrowth, which is one of the most common complications of LASIK with an incidence rate varying between .03 per cent to 9.1 per cent. Key risk factors for epithelial ingrowth include trauma, flap dislocation, enhancements and intraoperative epithelial defects, he explained. Normal levels of epithelial ingrowth do not affect vision, and most cases are selflimiting and simply require monitoring. However, an excessive recurrence rate can cause serious problems including loss of vision, irregular astigmatism and flap melting so direct intervention is vital when this occurs, he told delegates. Quoting a number of peer-reviewed journal articles on the topic, Dr O’Keefe said research has found that patients treated for hyperopia or patients who are hyperopic and have enhancements due to flap lifting are at an increased risk of developing endothelial ingrowth. “It has also been confirmed that there is an increased risk of epithelial ingrowth with a microkeratome assisted LASIK flap lift as it produces a tapered flap edge and the blade slides along the stromal surface,” he said. Furthermore, research published this year in the US suggests that if surgeons use a less traumatic form of flap lift they can reduce the risks of epithelial ingrowth, he reported.

Severe epithelial ingrowth

In the rapid flaporhexis technique, the flap edge is opened by one clock hour with a Sinskey hook and the flap is peeled back after the exposed edge is grasped with a forceps. When necessary, further blunt retraction of the flap is performed with a triangular polyvinyl acetate sponge. After ablation and before the flap is replaced, a triangular sponge is used to clear epithelial remnants from the interface. This method consistently produces a smooth epithelial dissection and decreases the risk of epithelial cells being retained beneath the flap and escalating to epithelial ingrowth, according to the researchers. When severe epithelial ingrowth does occur, Dr O’Keefe said treatment options include surgical lifting-debridement, alcohol application, mitomycin C, fibrin glue, phototherapeutic keratectomy, suturing and amniotic membrane. “The most common way to deal with severe cases of epithelial ingrowth is lifting, debridement – making sure that you scrape both the back of the flap and the stromal part of the cornea – and suturing. Leave in the sutures for about four weeks and then take them out and the outcome in these cases is quite good,” he told delegates. However, the recurrence rate can be quite high, varying between five per cent to 60 per cent. “That said, you might not have to do anything further in the vast amount of these cases and it should be noted that in most cases of epithelial ingrowth the visual outcomes are quite good,” Dr O’Keefe concluded.

contact Michael O’Keefe – mokeefe@materprivate.ie

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contacts

Silvia Schumacher – silvia.schumacher@ irocscience.com Rita Mencucci – rita.mencucci@unifi.it Michael Mrochen – michael.mrochen@ irocscience.com

Special Focus

CORNEA

Corneal crosslinking

“

It represents an exciting new frontier in ophthalmic therapeutics

Techniques now in testing could reduce treatment time, improve effectiveness by Howard Larkin in Milan

Rita Mencucci MD

ew techniques for improving corneal crosslinking now in development could significantly shorten treatment times, improve corneal strength and increase the flattening effect in treating keratoconus, presenters told the XXX Congress of the ESCRS. “The standard protocol takes 70 minutes. This is too long and needs to be shortened,” said Silvia Schumacher PhD, IROC Science to Innovation AG, Zurich, Switzerland. Research suggests it may be possible to achieve similar clinical results while shortening by half or more both the riboflavin pre-soak time and the ultraviolet-A irradiation time, currently 30 minutes each. To achieve adequate penetration of riboflavin deep enough in the cornea for effective crosslinking to occur at 300 microns or more, the standard crosslinking protocol calls for maintaining a riboflavin solution layer 100 microns thick on the corneal surface by replenishing it every five minutes for 30 minutes, Dr Schumacher noted. Theoretically, this soak time could be shortened by increasing the riboflavin available on the surface either by shortening the re-administration interval or increasing the thickness of the solution layer. By shortening re-administration intervals to three and one minute while maintaining the 100 micron solution layer and 30 minute soak time, Dr Schumacher and her colleagues did observe higher than standard concentrations of riboflavin at all corneal depths. Indeed, one-minute intervals produced a concentration curve very close to the theoretical ideal of their diffusion model. However, shorter intervals would also require more nursing time to administer, she noted. But by increasing the depth of the riboflavin solution on the cornea to 400 microns using rings to hold it in place and sticking with a five minute re-administration interval, Dr Schumacher was able to nearly duplicate the diffusion profile of the standard protocol with just 15 minutes' soak time. Riboflavin concentrations in the stroma were very slightly lower than standard at the surface, but slightly higher at intermediate depths down to about 325 microns, which is the layer where crosslinking occurs. EUROTIMES | Volume 18 | Issue 4

Figure 1

Figure 2

Courtesy of Rita Mencucci MD

Figure 3

Halving pre-soak time would reduce costs and improve patient experience. But Dr Schumacher emphasised that the approach is still theoretical and has not been clinically tested. “Changing the application protocol of riboflavin affects your clinical results. Wait for clinical validation before trying this at home,” she cautioned.

Iontophoresis Another potential approach to speeding riboflavin corneal diffusion is iontophoresis, said Rita Mencucci MD, University of Florence, Italy. Known since the late 1800s, it works by applying an electrical current to an ionisable substance to increase its mobility across a surface. Riboflavin is a good candidate because it has a small molecular weight, is negatively charged at physiological pH and is highly soluble in water, Dr Mencucci said. By applying a charge of 1.0 mA/cm2, riboflavin solution is pulled into the cornea, potentially reducing soak times to five minutes. However, critical questions remain unanswered, including whether the process

Figure 4

actually works, whether it is safe and what are optimal exposure parameters. In an ex vivo study assessing potential impact on the stroma, keratocyte population and potential endothelial damage, Dr Mencucci compared a control group of untreated human corneas with groups exposed to five minutes iontophoresis and riboflavin only, to iontophoresis plus 30 minutes of UVA at 3mW/cm2, and iontophoresis plus nine minutes of UVA at 10 mW/cm2 (Figure 1). Histological and immunohistochemical analysis 48 hours after treatment showed no difference in endothelial cell condition among the four groups, suggesting the crosslinking protocols maintained an adequate endothelial safety margin (Figure 2). However, in the two UVA-irradiated groups, keratocyte apoptosis was detected and fewer keratocytes were visible in the anterior stromal layers than in the untreated and iontophoresis-only groups (Figures 3 and 4). Loss of keratocytes is considered a necessary first step to initiate crosslinking. Both irradiated groups also showed thicker collagen fibres in the outer

layers, with the 10 mW group showing thicker fibres and a better defined border between crosslinked and uncrosslinked areas than the 3 mW group. The results suggest the 10 mW/cm2 nine minute irradiation time could be safe and effective, Dr Mencucci said. It also suggests potential for combining iontophoresis with crosslinking. “It represents an exciting new frontier in ophthalmic therapeutics.”

Increasing peripheral strength

The strength of crosslinked corneas might also be improved by increasing the volume of crosslinked tissue, said Michael Mrochen PhD, also of IROC Science to Innovation AG. This could be done while maintaining an endothelial safety zone by altering the UVA beam profile to deliver more power peripherally. UVA exposure currently is calibrated to crosslink tissue down to a safety margin at the central cornea, which is about 536 microns thick in a normal eye. However, with a homogenous beam profile, tissue is crosslinked to the same depth peripherally even though the safety margin is progressively deeper due to a steeper angle of incidence and greater corneal thickness. At 5.0mm peripherally, the average corneal thickness increases to 711 microns, which means crosslinking depth should be increased 63 per cent to reach the safety margin, Dr Mrochen said. For eyes with keratoconus, the cornea is thinnest over the cone, but is near normal peripherally, he noted. Increased crosslinking depth can be achieved by using a 25 per cent higher light intensity at the periphery, Dr Mrochen said. This achieves two things, a larger volume of crosslinked tissue and stronger crosslinking effect within the first 100 microns of stroma. Both contribute to increased biomechanical strength while reducing central light intensity, which may reduce corneal haze. Six-month data from trials in Ireland and Germany indicate that enhanced beam profile induces a greater flattening effect than standard crosslinking, Dr Mrochen said. Clinical research is ongoing.

Special Focus

CORNEA

COMPLICATIONS

One of the main complications for OOKP is laminar resorption

Trust VisionBlue by DORC

by Priscilla Lynch in Brighton

hile laminar resorption remains a serious complication following osteo-odontokeratoprosthesis (OOKP) surgery, surgeons can minimise the risk and address any further complications early on with careful monitoring, Venkata Avadhanam MD told a session of the XXXVI United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Annual Congress. OOKP is the keratoprosthesis of choice, with a proven track record, for end-stage corneal blindness not amenable to corneal transplantation in dry or non-blinking eyes and eyes with lid defects. It is a complex procedure, with a number of separate stages, which basically involves harvesting a tooth from the patient or a donor. A carrier lamina with a piece of tooth and jawbone, typically fashioned from a canine, is prepared and a PMMA optical cylinder is incorporated, through an aperture drilled through the centre of the dentine. The lamina is implanted in the patient’s cheek under the orbicularis muscle for two to three months to enable vascularised soft tissues to grow around it. It is then removed after 2-3 months for implantation in the eye. “Compared to other types of keratoprostheses, the OOKP is the most successful procedure but we still have the problem of laminar resorption,” Dr Avadhanam, Anterior Segment Fellow, Sussex Eye Hospital, Brighton, said. One of the important causes for OOKP failure is laminar resorption, occurring in an estimated 20 per cent of the patients in the UK. The risk is higher in the young and those suffering from persistent inflammation, or those in whom allografts have been implanted, he explained. The complications of laminar resorption can be serious. The more obvious clinical signs of laminar resorption include decreased bulk, decreased visual acuity, unstable cylinder, aqueous leak, change in refraction and loss of foveal fixation. However, the clinical signs of early laminar resorption are subtle and by the time they are noticeable significant resorption would have occurred, hence patients must be carefully monitored. CT scanning of the lamina is currently the most useful and widely employed modality of investigation for these patients, Dr Avadhanam said.

EUROTIMES | Volume 18 | Issue 4

OOKP lamina on axial CT scan

Clinical examination cannot identify volume loss in all cases but a 3D-CT imaging is particularly useful for detecting early laminar resorption before clinical signs set in. An automated laminar volume analysis with 3D-ALA (advanced lung analysis) software is a significant step forward in this technology, he reported. Prevention, where possible is obviously the best approach to laminar resorption, and this risk can be minimised by using a tooth that is healthy with good bulk, and having a lamina size of at least 3.0mm thick with a minimum of 1.0mm margin of dentine around the optical aperture, he said. When laminar resorption does occur, proactively addressing the inflammation with immunosuppression, reducing osteoclastic activity using Fosamax (a bisphosphonate), and careful and more frequent clinical and radiological monitoring of the patient are advisable. In addition, prompt surgery - repair of buccal mucous membrane and pre-emptive laminar removal/exchange, may be needed if substantial resorption develops, Dr Avadhanam elaborated. In recent years interest in synthetic OOKP laminae has increased. Some patients do not have suitable teeth and it is now known that allografts and tibial keratoprostheses have a shorter lifespan, thus the synthetic option can be more suitable, he acknowledged. There are many potential advantages of the synthetic option. Research is ongoing in improving this technology, Dr Avadhanam concluded.

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contacts Venkata Avadhanam – venky.avadhanam@gmail.com Christopher Liu – cscliu@aol.com 109-xxx_ADV_VB_Eurotimes-120x300.indd 1

08-03-13 16:43

Special Focus

CORNEA

RISK FACTORS

Psychological screening important in patients before and after OOKP surgery

by Priscilla Lynch in Brighton

sychological issues including depression and anxiety are observed in patients receiving osteo-odonto-keratoprosthesis (OOKP) surgery, and these issues need to be assessed, monitored and where indicated, treated proactively, Angela Busuttil Psych.D told delegates at the XXXVI United Kingdom and Ireland Society of Cataract and Refractive Surgery (UKISCRS) Annual Congress. Dr Busuttil, consultant clinical psychologist, Sussex Eye Hospital, Brighton, UK, discussed the psychological issues surrounding OOKP surgery during a dedicated session on the procedure. She said that OOKP surgery can be both physically and mentally demanding for patients as it involves multiple surgeries, living with changed appearance, adapting to living with sight yet with some uncertainty about whether sight would be maintained. There is also a commitment to lifelong follow up. Quoting research undertaken at Sussex Eye Hospital, Dr Busuttil said patients report experiencing “an emotional rollercoaster” with joy at being able to see again, but also challenges that could cause anxiety and feelings of isolation. For example, some reported premature withdrawal of practical and emotional support from others who may assume, “Oh you can see now so you must be ok”. This resulted in anxiety problems for a small but significant number of our patients. “It is natural to think that sight restoration is positive and it is, but patients have also reported that it may be accompanied by complex feelings. For example there is evidence that loss of ‘blindness’ is experienced by some as they miss some aspects of being blind,” Dr Busuttil commented. Research shows that the challenges accompanying sight restoration differ for those who lose sight after late childhood when sight has been developed and the brain has learnt to effectively process visual stimuli in context, as compared to those who lost sight early in childhood, when the visual system had not fully developed, she said.

Sight restoration, for those who lost sight early, can be associated with psychological distress as the brain learns to make sense of visual stimuli. This can trigger depression and anxiety in some. There are a few documented early case reports of patients who failed to adapt to living with sight. In the most severe cases this was accompanied by depression and even suicide in a small number. Such negative outcomes have not been reported by patients at Sussex Eye Hospital or in recent case reports but it is nonetheless important to ensure that restoring good visual acuity is accompanied by appropriate support measures, she said. Challenges for patients in this latter group, include making sense of depth perception, reflections and using sight in social contexts. “It is said that 70 per cent of our communication involves body language. If you haven’t seen or used body language you do not know how to make sense of the body language other people use, or how to use body language, eye contact and facial expressions yourself. This may lead to misunderstanding in social situations,” Dr Busuttil said. Clinics thus need to consider providing more support and education on adapting to living with vision to adequately prepare these patients, she contended. For some patients living with OOKP the cosmetic element is an issue and we found this in about one fifth of our patients. Sussex Eye Hospital offers a cosmetic lens for suitable patients which gives a good cosmetic result, Dr Busuttil said. Concluding, Dr Busuttil said there is a strong basis for carrying out psychological screening as part of the multidisciplinary assessment with patients before and after OOKP surgery. Combined with good patient support this is likely to lead to better outcomes.

contacts Angela Busuttil – angela.busuttil@ sussexpartnership.nhs.uk Christopher Liu – cscliu@aol.com

Don’t miss Industry News, see page 40 olixia adv-half page vertical-Eurotimes-ENG EUROTIMES | Volume 18 | Issue 4 care-1301v06jmo.indd

01.03.13 13:57

AMSTERDAM 2013

4 EUCORNEA CONGRESS TH

4-5 OCTOBER 2013 Registration and Hotel Bookings available online

www.eucornea.org

contacts

Richard L Lindstrom – rllindstrom@mneye.com Roberto Bellucci – roberto.bellucci@ ospedaleuniverona.it Sheraz Daya – sdaya@centreforsight.com

Update

Cataract & refractive

PAYING FOR SURGERY

Femtosecond laser cataract surgery increases costs because equipment is more expensive and machines require perfect control of ambient air by Roibeard O’hEineachain in Milan

ataract surgeons in both private and public practice will probably require some form of co-payment from the patient if they are to avail of the new femtosecond laser cataract surgery systems for the time being, although that may change if the laser systems prove superior to conventional phacoemulsification in terms of safety, according to speakers at a symposium at the XXX Congress of the ESCRS. Richard Lindstrom MD Minneapolis, Minnesota, US, noted that although femtosecond laser systems for cataract surgery have only been commercially available for a year, there already appears to be a wide consensus that they are here to stay. Notably, the business prognosticator, Marketscope, has stated that it sees an exponential proliferation of the new technology over the next five years. However, the high expense of the devices may put them out of reach of patients who rely completely on Medicare to pay for their cataract procedures. Furthermore, 82 per cent of surgeons participating in a survey conducted at last year’s ASCRS Congress cited the expense of the systems as their main reason for reluctance to adopt the technology. “The femtosecond laser is really a computer-driven precise scalpel which creates very precise incisions and imageguided intraocular surgery. If we believe that has some value, then it makes sense for us to offer it to patients, but there really is a cost involved,” Dr Lindstrom said. On the other hand, he pointed out that since 2005 it has been possible for patients in the US on Medicare to pay the excess charges for technology that enhances refractive outcomes. That includes such things as multifocal and toric IOLs. “Our position is that the femtosecond laser enhances refractive accuracy both in terms of defocus and astigmatism. And if you're implanting multifocal or toric IOLs postoperative refraction, half a dioptre of target is necessary to get the best possible performance from the lenses,” Dr Lindstrom said. He added that when provided with the option, 30 per cent of his patients choose to undergo femtosecond laser cataract surgery despite the extra cost. At that rate, a cataract surgeon would have to be performing EUROTIMES | Volume 18 | Issue 4

“

These patients put their trust in us, so if this is the best device to use it is best to use it in everyone and spread the cost evenly across the patient population Sheraz Daya FRCS

Bausch + Lomb Cannula

Courtesy of Sheraz Daya FRCS

Applying suction ring

around 1,000 procedures per year for the femtosecond laser to be a profitable investment. “There are reasons why a patient would want to pay this additional fee: the predictable outcomes, increased precision and safety. We really are entering a new era as patients become aware of this technology,” Dr Lindstrom added.

Co-payment in public hospitals It is mainly the potential safety advantages, rather than those relating to visual outcome, that could lead to the gradual adoption of femtosecond cataract surgery into use for public patients at public institutions, said Roberto Bellucci MD. “The more precise final refraction Richard Lindstrom was pointing out is of somewhat

less interest to the public system, and the better results that we might achieve with premium IOLs are also not a consideration since we will not be using the lenses in public patients and the public system,” Dr Bellucci said. Of greater interest to a public health system would be a reduction in intraoperative complications when compared to ultrasound phacoemulsification. That could in turn reduce some costs and possible litigation so that the new technology could pay for itself to some degree. Similarly, the precision in creation of capsulotomies that the lasers afford could reduce the chance of late dislocations and the need for interventions to treat them, he noted. However, even if the early evidence of

a safety advantage is borne out as data accumulates, some form of co-payment for using the technology may be the economic reality for the time being, given the overstretched resources of the healthcare systems of many countries with socialised medicine. “Femtosecond laser cataract surgery will increase costs because the equipment is more expensive and the machines require the perfect control of the ambient air. It also requires additional training for the surgeons and assistants, you also need trained laser personnel. The surgical time is increased for nurses, for doctors, and probably there are hidden costs,” Dr Bellucci said. In Italy, the new technology will probably first enter public health systems by way of scientific institutes or universities which are affiliated with public hospitals that receive special funding to test and implement new devices, machines and procedures. However, the general adoption of the laser systems into public medicine is likely to be a more drawn-out process and whether they are treated at private or public institutions, patients may have to provide some sort of co-payment to avail of the technology for the foreseeable future. “Recent legislation now permits co-payment in Italy but is not yet implemented. So the fact that two hospitals in Italy have co-payment does not mean that co-payment is the current reality in our country. Also there are ethical and practical problems that need solutions and we're far from having co-payment as a standard practice in Europe,” Dr Bellucci commented. In the discussion that followed, Sheraz Daya FRCS, UK argued that co-payment policies that deliver the safest and most effective treatment only to those wealthy enough to afford it run contrary to the goal of safe and equitable cataract surgery. “These patients put their trust in us, so if this is the best device to use it is best to use it in everyone and spread the cost evenly across the patient population. It also makes economical sense since it would increase the cost by a reasonable amount for everyone instead of increasing the cost astronomically for a few,” Dr Daya said.

Update

Cataract & refractive

ectasia

Ectasia can be slow to develop but early diagnosis important to achieve best outcomes

Courtesy of Jan Venter MD

by Priscilla Lynch in Brighton

hile ectasia is one of the most devastating complications that can occur following LASIK or PRK, it can now be treated very successfully and good visual outcomes can be achieved in most cases, delegates attending the XXXVI United Kingdom & Ireland Society of Cataract & Refractive Surgeons (UKISCRS) Annual Congress heard. Jan Venter MD emphasised that the occurrence of post-LASIK ectasia, could be reduced with careful preoperative and surgical management. Rigorous patient screening and selection is vital in reducing the development of ectasia. Avoiding enhancements on topographically suspicious eyes, performing surface ablation where appropriate and using phakic IOLs when indicated also help decrease the risks. “Ectasia can be slow to develop but early diagnosis is important to achieve the best outcomes,” Dr Venter stressed. Warning signs of ectasia include increasing myopia, irregular astigmatism, loss of uncorrected visual acuity, often loss of bestcorrected visual acuity, and progressive corneal steepening, usually inferior, following LASIK. Explaining his ectasia management advice, Dr Venter presented Optical Express Centre data on 205,285 patients (402, 583 eyes) who had undergone various laser vision correction options between 2007 and 2011. During standard follow-up, ectasia was detected in 58 patients. The patients who developed ectasia were more likely to be younger than the cohort’s average age (31.1 years versus 38.2 years), to be male, to have a higher preoperative sphere and rates of astigmatism, as well as thinner EUROTIMES | Volume 18 | Issue 4

Pre and post intacs

corneas. The average time to the development of ectasia was 24.5 months though its presentation varied from four to 55 months. All 58 patients with ectasia received corneal crosslinking according to the Dresden protocol, Dr Venter reported. After waiting for 12 months minimum to ensure stability of the topography and refraction, there were no notable improvements in BCVA and decisions on treating the residual refractive error were taken. Nine eyes did not have any further refractive surgical treatment, with seven of these cases choosing glasses, one a rigid gas permeable contact lens, while one received a lamellar graft. If the remaining ectasia patients had irregular astigmatism with poor BCVA, they received Intacs. One segment was implanted on the steepest corneal meridian according to the topographic image, with a corneal thickness of more than 400 microns at the site of implantation, aiming at maximal corneal flattening. Two segments were implanted whenever myopic refraction was present. The remaining ectasia cases had satisfactory BCVA and received either PRK if the predicted ablation depth to correct the remaining refraction was less than 50 microns, while the remaining 16 cases received phakic IOLs as the predicted ablation depth was more than 50 microns. Following treatment, 88 per cent of these eyes achieved a BCVA of 6/7.5 or better, while 84 per cent had 6/12 or better UCVA, though one eye needed a second corneal collagen crosslinking (CXL) treatment.

contact Jan Venter MD – janventer@opticalexpress.com

Update

New OCULUS Keratograph 5M

Cataract & refractive

VITRECTOMY

Western Australian population study finds higher risk for male and younger cataract patients

by Howard Larkin in Milan

Topography and advanced external imaging for dry eye assessment

•

High-resolution colour camera

•

Imaging of the upper and lower meibomian glands

•

Non-invasive tear film break up time and tear meniscus height measurements

•

Assessment of the lipid layer and tear film particles

•

Grading of the bulbar redness

•

Image and video documentation

www.oculus.de

EUROTIMES | Volume 18 | Issue 4

population study involving patients receiving cataract surgery during 21 years in Western Australia found the overall rate of those also requiring anterior vitrectomy at about 1.2 per cent, but with risks significantly elevated for several subgroups, Jonathon Ng PhD, MD, Eye & Vision Epidemiology Research (EVER) Group, Perth, Australia, told the XXX Congress of the ESCRS. Risks were higher in male patients and patients aged under 50 years, and retinal detachment was the most likely complication. Data for the study were drawn from the Western Australia Data Linkage System, which combines eight million medical records from hospitals and registries going back to 1980. The system encompasses the geographically isolated and stable population of the state of Western Australia, currently about 2.4 million, creating opportunities for large-scale wholepopulation studies, Dr Ng said. The current study is part of a larger long-term study of cataract surgery complications. For the period 1980 to 2001, 129,082 cataract/lens procedures were identified from the Hospital Morbidity Data System and of these procedures 6,286 potentially had a sight-threatening complication at the time of or after the original cataract surgery. Chart review of these cases confirmed that 1,390 had an anterior vitrectomy at the time of cataract surgery, Dr Ng reported. The number of cataract surgeries performed annually climbed steadily from a handful in 1980 to nearly 14,000 in 2001. For the entire period, the overall rate of concurrent anterior vitrectomy was 1.2 per cent, dropping from almost five per cent in 1980 to around one per cent in the late 1980s, and fluctuated between one and two per cent through to 2001. Male gender was found to be a significant risk factor for anterior vitrectomy with cataract surgery, at 1.23 times the risk of females (p<0.001). Similarly, patients aged under 50 years had 1.31 times increased risk compared with those aged 80+ years, (p<0.03), Dr Ng said. Compared with privately owned hospitals, patients operated at public hospitals had 1.99 times the risk of anterior vitrectomy (p<0.001), and compared to metropolitan

“

These differences highlight the importance of monitoring performance Jonathon Ng PhD, MD

hospitals, rural patients had 1.4 times higher risk (p<0.001). “This probably reflects to a degree the different case mix between the different locations,” Dr Ng said. Using extracapsular cataract extraction as a reference, phacoemulsification carried a 0.85 times reduced risk (p<0.04), Dr Ng noted. Much more significantly, other cataract and lens-related procedures carried more than 11 times the risk of anterior vitrectomy. “This reflects that these surgeries are most likely complicated and difficult cases.” One finding that is difficult to explain is a 1.62 times increased risk for procedures done from 1995 compared with 1980 to 1984 (p<0.001), though this may also be related to case mix, he added. If an anterior vitrectomy was required, the risk of potentially sight threatening complications were also increased, with the chances of IOL dislocation 21 times greater, corneal oedema 27 times greater and endophthalmitis 3.6 times greater. Most frightening was the risk of retinal detachment. Although the relative risk was 18.5, when looked at in terms of the number needed to harm, for every 12 anterior vitrectomies there was one retinal detachment, Dr Ng said. “These differences highlight the importance of monitoring performance,” Dr Ng concluded.

contact Jonathon Ng – jonathon.ng@curtin.edu.au

contact

Jaime Aramberri – jaimearamberri@telefonica.net

Update

Cataract & refractive

TORIC IOLS

by Roibeard O'hEineachain in Milan

ccurate toric IOL power calculation for astigmatic eyes requires the use of the correct ratio of corneal to IOL plane astigmatism, and that ratio will vary primarily in accordance with the effective lens position, said Jaime Aramberri MD, San Sebastian, Spain. “Correcting corneal astigmatism with the toric IOL is just as simple as implanting a lens the correct magnitude of cylinder in the correct axis, but we have to perform some calculations in order to get accurate results,” Dr Aramberri told the XXX Congress of the ESCRS. The surgeon’s first challenge is the calculation of the IOL plane astigmatism necessary to cancel out the corneal plane astigmatism. The standard method is to calculate the power difference between the two corneal meridians and entering that value into a standard formula which will yield ratio of the IOL astigmatism over the corneal astigmatism. However, the correct approach is to use the average K to calculate the same effective lens position for both meridians. That requires the use of a formula that allows the

independent calculation of effective lens position, Dr Aramberri said. Using this calculation technique provides a more accurate estimation of the ratio of the IOL plane astigmatism to the corneal ratio. The ratio mainly depends on the effective lens position and is not influenced by the eye’s axial length or corneal curvature, he noted. Dr Aramberri described a study in which he created a pseudophakic astigmatic eye model, with three variable biometric parameters, which were the axial length, curvature and effective lens position. His ray tracing analysis showed that independently varying the axial length or curvature did not substantially change the ratio between corneal and IOL plane astigmatism. That is, in an eye with an axial length of 20.5mm and a corneal curvature of 44 D to 43 D and an effective lens position of 5.0mm, the ratio of the IOL astigmatism to corneal astigmatism would be 1.39. Increasing the axial length to 23mm or 30mm but leaving the other values unchanged yields precisely the same value. Similarly, in an eye with a corneal curvature of 47 to 46 D and an axial length

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Effective lens position an important variable in astigmatism-correcting lenses

An astigmatic corneal topography

of 23mm and an effective lens position of 5.0mm, the corneal plane/IOL plane astigmatism ratio would be 1.43. Leaving the other values unchanged but decreasing the corneal curvature to 44 to 43 D decreases the ratio slightly to 1.39. Decreasing the corneal curvature further down to 41 to 44 D decreases the ratio to 1.36. In contrast, in an eye with an axial length of 23mm and a corneal curvature of 44 to 43 D, changing the effective lens position from 4.0mm from the cornea to 6.0mm to the cornea increased the ratio from 1.29 to 1.5. “Anterior chambers tend to be shallower in shorter eyes and deeper in longer eyes, so axial length plays an indirect role, but this is because of the effective lens position, not because of the axial length per se,” Dr Aramberri said. He noted that for every one millimetre of error in the effective lens position there will be 0.1 D of error per dioptre of cylinder

in the IOL plane. Special care is therefore necessary in eyes where calculating effective lens position is particularly prone to error. Such eyes include short eyes, those that have been treated with LASIK or PRK, those with keratoconus, corneal scars, or zonular pathology, as well as those that have undergone vitrectomy and those with megalocornea. Dr Aramberri said that online calculators vary regarding how they calculate the IOL cylinder/corneal cylinder ratio. For example, in an eye requiring a 6.0 D IOL, therefore a long eye, which also has 6.01 D of astigmatism at the corneal plane, the Oculentis calculator uses a ratio of 1.36, giving a value of 8.19 D at the IOL plane. However, in a short eye requiring a 30 D IOL and with 6.01 D of corneal astigmatism, the Oculentis calculator uses a ratio of 1.3, giving a value of 7.78 at the IOL plane. Dr Aramberri said the Rayner calculator gives values closer to those of his own eye model. That is, in the longer eye example the ratio between the IOL and the corneal astigmatism would be 1.44, while in the shorter eye example it would be 1.2. The AcrySof calculator, on the other hand, gives the same corneal/IOL plane astigmatism ratio, 1.46, for both short eyes and long eyes. That means the calculator would provide accurate results for long eyes with deep anterior chambers but would over correct the astigmatism of shorter eyes. “There are significant differences in the cornea plane/IOL plane cylinder ratios among calculators and this can explain some astigmatic over and under correction,” he said.

contacts

Update

Cataract & refractive

COMPOUNDING PHARMACIES

US federal and state crackdown seen after deaths, endophthalmitis by Howard Larkin in Chicago

n the wake of an outbreak of fungal meningitis traced to compounded steroids that has claimed at least 48 lives1, US federal and state governments are tightening rules and beefing up enforcement of compounding pharmacies. The moves also may reduce contamination risks for compounded intraocular drugs, including bevacizumab, triamcinolone and Brilliant Blue-G, all of which have been tied to endophthalmitis outbreaks in the past three years. “We are absolutely going to see a regulatory intervention and the American Academy of Ophthalmology is working to ensure that rules or regulations result in compounded products of the highest safety, accuracy and efficacy. It is equally critical that these drugs be immediately available when medically needed,” David W Parke II MD, executive vice-president and CEO of the American Academy of Ophthalmology (AAO) told EuroTimes. Efforts to grant the federal Food and Drug Administration as well as state pharmacy boards more authority to set standards and police compliance are afoot in the US Congress and statehouses across the country, and regulators have already closed several commercial operations. Dr Parke welcomed appropriate regulation of compounding pharmacies, including stricter credentialing standards and greater oversight, to minimise the risk of contamination or dilution errors of drugs prepared outside tightly regulated manufacturing facilities. Ophthalmologists also can help protect patients from improperly prepared drugs. An AAO clinical guidance document recommends dealing only with pharmacies accredited by the Pharmacy Compounding Accreditation Board, which ensures that pharmacies adhere to quality standards for aseptic compounding as outlined by the US Pharmacopeia standard 797. It also recommends tracking lot numbers of medication vials and syringes received from compounding pharmacies to facilitate tracking tainted compounds in the event of an outbreak.

Don’t miss Eye on Travel, see page 44 EUROTIMES | Volume 18 | Issue 4

“

We are absolutely going to see a regulatory intervention and the American Academy of Ophthalmology is working to ensure that rules or regulations result in compounded products of the highest safety, accuracy and efficacy David W Parke II MD

Ophthalmic outbreaks While the meningitis outbreak, which does not include any ophthalmic preparations, has garnered the headlines propelling reforms in pharmacy oversight, several endophthalmitis outbreaks have been traced to substandard compounding practices in recent years. These include both fungal and bacterial infections. While the overall incidence is low, these outbreaks fuel resistance to practices such as compounding bevacizumab for wet AMD, even though the Comparison of AMD Treatments Trials (CATT) shows it is similarly effective to ophthalmic ranibizumab at about 1/40th the cost per dose. At $2,000 a dose, ranibizumab currently consumes about 10 per cent of the entire outpatient medication budget for the US Medicare public insurance program for the elderly. To date, CATT also has found no statistically significant difference between endophthalmitis rates for the two. However, some believe its results may not be representative of real-world risks because participants receive injections preloaded as opposed to obtaining them independently from compounding pharmacies with varying production processes.

“

It’s important to be aware that it has been an aetiology of outbreak

Rachel Smith MD The impact can be devastating. Of 12 patients infected in a July 2011 outbreak in Florida, all but one had count-finger vision or worse in the affected eye, and three required enucleation within four months (Goldberg RA et al. Am J Ophthalmol. 2012 Feb;153(2):204-208). The injections, which had been administered by four ophthalmologists, were traced back to the same lot prepared by a compounding pharmacy, and cultures of unused syringes tested positive for the same strains of Streptococcus mitis/oralis cultured from 10 of the patients. A subsequent investigation by the FDA found insufficient monitoring of processes, dirty equipment and a boiler leak near the pharmacy’s clean room. Contamination of syringes was thought the most likely cause. Smaller bevacizumabrelated endophthalmitis outbreaks in 2011 included one involving five patients at a US Veterans Administration hospital, another involving VA and community patients in Los Angeles and one in Minneapolis. In March 2012, nine cases of fungal endophthalmitis following vitrectomy with epi-retinal membrane peeling were reported by a California surgery centre. A county health department traced the outbreak to Brilliant Blue-G dye contaminated with Fusarium incarnatumequiseti species complex mould from Franck’s Compounding Lab in Florida. A subsequent CDC investigation uncovered 47 fungal endophthalmitis cases in nine states linked to the dye as well as triamcinolone products contaminated with Bipolaris hawaiiensis from Franck’s.

Rachel Smith – vih9@cdc.gov David Parke – kwalter@aaodc.org

Unopened bottles and syringes of the dye collected by the FDA also cultured positive for several bacteria, including Rhodotorula, Bullera, Pseudomonas and Enterobacter species. An FDA site visit also found contamination in Franck’s clean room. In May, Franck’s recalled all sterile products manufactured from late 2011 through 2012. Rachel Smith MD, one of the scientists at the US Centres for Disease Control and Prevention who monitored the case, noted that fungal endophthalmitis is unusual. “It’s important to be aware that it has been an aetiology of outbreak.”

Who regulates? The pharmacy involved in the meningitis outbreak, the New England Compounding Centre, has been closed. But it had numerous brushes with the FDA and state regulators over the years, raising questions about why it wasn’t shut earlier. Similarly, Franck’s has repeatedly tangled with the FDA, and once won a lawsuit claiming the FDA did not have jurisdiction over a case in which several horses were killed due to dosing errors by Franck’s veterinary division. The problem is that pharmacies are regulated by states while drug manufacturers are regulated by the federal government. Large-scale compounding operations fall into a grey area. In December, the FDA and representatives from all 50 states met to discuss closing the loopholes. The US Senate also held hearings with some members pledging to expand the FDA’s role. A bill introduced in the House of Representatives in November went nowhere. But as the death toll from the meningitis outbreak creeps higher, pressure remains. Massachusetts already has instituted tighter licensing and oversight of compounding pharmacies. Other states are following. The changes will help, Dr Parke said. “Stronger oversight will help ensure that compounding pharmacies adhere to the highest quality standards with a renewed commitment to patient safety, which is better for all parties involved.” But costs could go up as a result of the cost of complying with new regulations, and spot shortages could develop if suppliers are shut down. Reference:

1. http://www.cdc.gov/hai/outbreaks/ meningitis-map-large.html

contacts

Christopher Rapuano – cjrapuano@willseye.org Eric Donnenfeld – ericdonnenfeld@gmail.com

Update

Cataract & refractive

LASIK WITH DRY EYE?

Pre-op diagnosis, careful management make some patients good candidates by Howard Larkin in Chicago

he few patients who develop severe chronic dry eye symptoms after refractive surgery can be the most dissatisfied in your practice, Christopher J Rapuano MD told the refractive surgery subspecialty day of the annual meeting of the American Academy of Ophthalmology (AAO). Pain, photophobia and visual disturbances are typical, with many also experiencing loss of visual function for reading, driving and other daily activities. Some become depressed or even suicidal. Studies also show that preoperative dry eye may be the biggest risk factor for postoperative dry eye problems. So should LASIK be avoided in dry eye patients? For patients with active dry eye signs and symptoms, the answer is definitely yes, said Dr Rapuano, who is director of the cornea service and co-director of refractive surgery at Wills Eye Institute, Philadelphia, US. “Refractive surgery is an elective procedure. We want to enhance a patient’s lifestyle and well-being, not make them miserable.” Patients with post-LASIK dry eye are also more likely to regress. So it is not just a quality of life issue, it is also a refractive issue, Dr Rapuano commented. However, if dry eye is successfully controlled with treatment, some patients may become LASIK candidates, Dr Rapuano said. Preoperative counselling and informed consent are essential to establish reasonable outcomes expectations.

Eric D Donnenfeld MD went further, noting that dry eye patients often seek LASIK because they cannot wear contact lenses. He believes that proper pre-treatment to control dry eye, surgical approaches designed to minimise nerve damage and post-surgery dry eye treatment can reduce the risk to an acceptable level. “Yes, we should exclude some dry eye cases, but that is the exception rather than the rule. The majority of patients with dry eye are excellent candidates for LASIK,” said Dr Donnenfeld, who is a clinical professor at NYU Medical School in New York City, US.

Identifying dry eye Identifying dry eye patients before laser refractive surgery is a critical first step. In addition to raising the risk of postoperative dry eye, preoperative dry eye also interferes with topography readings, throwing off ablation calculations, Dr Donnenfeld said. “They will have irregular topography and you won’t get good treatments. You will get irregular outcomes.” Dr Donnenfeld screens patients by applying what he calls the stoplight theory. “If a patient has lissamine green, fluorescein yellow or rose bengal red staining of the cornea, they should not have LASIK immediately. You have to fix these corneas before surgery and they are often very treatable.” He also looks for aberrations characteristic of dry eye.

“

We want to enhance a patient’s lifestyle and well-being, not make them miserable

Christopher J Rapuano MD “I like to look at the Hartman-Shack. If you see a drop out at the front, the surface is damaged enough that I am not going to get a reading and I am not going to get a good treatment.” Dr Donnenfeld also screens for patients at risk of dry eye using tear osmolarity, which provides instant results. Another test in the pipeline will quantify tear film issues by measuring MP9 concentration. Tear film breakup time and Schirmer tests are also useful. Treatment to restore the corneal surface and improve tear film stability include artificial tears for lubrication, topical cyclosporine or topical steroids for inflammation and nutritional supplements. “Pure omega-3 reduces inflammation and improves meibomian gland secretions,” Dr Donnenfeld said. Any lid disease also should be treated before surgery is considered, Dr Rapuano

said. Hot compresses or lid scrubs, topical antibiotics and oral doxycycline help. Surgery can usually be safely performed if only mild residual dry eye signs remain after treatment, though patient counselling and informed consent is a must. However, if significant dry eye signs or symptoms persist, surgery is usually best avoided, he said. Dr Donnenfeld also recommends tailoring the LASIK procedure to minimise dry eye. Severing corneal surface nerves when the flap is created reduces corneal sensitivity and is thought to interfere with the tear production feedback loop, he said. Ablating the neural plexus may exacerbate the problem. Femtosecond lasers help by allowing thinner, smaller planar flaps, Dr Donnenfeld noted. “We used to do a 9.5mm flap; now we are down to 8.3mm. You cut the surface area in half and you get much less dry eye.” He also makes a bevel side cut, which promotes recovery of corneal sensitivity by increasing corneal nerve apposition. However, while it has been thought that a superior flap interferes with corneal nerves less, more recent studies suggest there is no difference in outcomes between nasal or superior hinge. After surgery, continuing topical lubricants, nutritional supplements and immunosuppressive therapy improves visual outcomes and keeps dry eye at bay, Dr Donnenfeld said. Even patients with autoimmune disease have had good LASIK results with appropriate management, he noted. Another advantage to treating patients with dry eye before surgery, and counselling them on their post-surgery risk, is it sets appropriate expectations, Dr Rapuano said. “You need to remind them after surgery that they are different from their 50 friends who had LASIK but did not have dry eye. You need them to remember that they had this problem before.”

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EUROTIMES | Volume 18 | Issue 4

Luca Rossetti – lucamrossetti@libero.it Stefano Gandolfi – s.gandolfi@rs.rsadvnet.it Leopold Schmetterer – leopold.schmetterer@ meduniwien.ac.at

contacts

Update

GLAUCOMA

NEUROPROTECTION

Research reveals new strategies in preventing degeneration of optic nerve by Roibeard O’hEineachain in Milan

herapeutic strategies aimed specifically at the protection or restoration of the optic nerve in eyes with glaucoma are beginning to show promise, but the clinical validation of candidate agents is likely to be a prolonged process, according to a series of presentations at the Glaucoma Day sessions at the XXX Congress of the ESCRS. “There is a considerable bulk of evidence that glaucoma is a neurodegenerative disease. The rationale for neural protection for glaucoma is supported by more than a dozen successful studies in glaucoma animal models, and yet none has been translated into clinical therapy,” Luca Rossetti University of Milan San Paolo Hospital, Milan, Italy. He noted that of nearly 74,000 agents with proven neuroprotectant effects, only eight have made it to the clinical trial stage. Of those, only brimonidine has shown real evidence of a clinically relevant effect, in the Low-Pressure Glaucoma Treatment Study (LOGTS), and that also requires further validation (Krupin et al. Am J Ophthalmol, 2011 ;151:671– 681). Conducting trials into the neuroprotective treatment of glaucoma has many special challenges, he said. Like other neurodegenerative diseases, glaucoma has a long slow course with an unpredictable rate of progression. In addition, randomised controlled trials would also have to compare treatment groups having similar IOP, to exclude that parameter as a confounding factor. Moreover, agents would have to have

a fairly neutral effect on a patient’s quality of life to be acceptable to those who remain asymptomatic. The LOGTS study fulfilled the first of those two criteria. It showed that eyes with low-tension glaucoma that were treated with brimonidine had significantly less visual field loss than those receiving timolol, despite the IOP being very similar in the two treatment groups. However, the agent failed to meet the second criterion in that 40 per cent in the brimonidine group were lost to follow-up because of allergic reactions. In addition, further research will be needed to determine whether brimonidine has a neuroprotective effect or if other possible explanations may be more likely. For example, it might be that brimonidine has a neutral effect but timolol had a neurotoxic effect in eyes with normal tension glaucoma, he noted. “What is certain is that the considerable number of patients lost to follow-up limits the validity of this study. Moreover, it can be applied only for patients without an allergy to brimonidine. However, the LOGTS findings have been encouraging so we should not abandon the concept of neural protection strategy in glaucoma,” Dr Rossetti added.

Cure may trump prevention In the case of glaucomatous damage to the optic nerve, an ounce of cure may be easier to prove or disprove than a pound of prevention, said Stefano Gandolfi, MD, University Eye Clinic, Parma, Italy.

The unpredictable nature of glaucoma onset and progression means that proof of an agent’s protective effect in a randomised controlled trial would require patients to undergo lifelong treatment to prove its efficacy. In contrast, treatments that aim to restore the damaged neural tissue would tend to have as their endpoint a restoration of visual function within a specified time. Furthermore, the re-growth of axons in retinal ganglion cells may not be as impossible as conventional wisdom would suggest. One recent study, in particular, showed that damaged retinal ganglion cells from glaucomatous rat eyes can have a regenerative capacity, mediated, in part, by activated retinal glia (Lorber et al, Neurobiology of Disease 2102; 45:243-252). “When we're looking for the restoration of vision in previously blind areas as the clinical endpoint there is no need for complicated functional tests, the routine test of standard automated perimetry would be enough and we certainly could use a real-time approach and it's extremely aggressive, Dr Gandolfi added. Therefore, we should move, from the concept of neuro- “protection”, into the world of neuro-“rescue”, he said. The preliminary results of a long-term trial on brimonidine vs laser trabeculoplasty (Gandolfi et al., Inv. Ophthal. Vis. Sci, ARVO abstract, 2004), on top of matching with the LoGTS outcomes, are tracing for brimonidine an interesting profile as a potential “neuro-rescuer” in responder patients.

The neurovascular unit At present, IOP is the only modifiable risk factor for glaucoma to have the support of evidence from numerous randomised trials. There are also some potentially modifiable neurovascular risk factors said Leopold Schmetterer MD, Medical University of Vienna, Austria. “Associations between glaucoma and low perfusion pressure, migraine, vasospasm and autonomic dysfunction indicate that there is also a vascular factor involved, This corresponds well with the studies with Alzheimer's disease indicating the neurovascular unit could be a target,” he said. The neurovascular unit is what forms the interface between circulatory system and the nervous system. It is a complex of vascular endothelial cells, glial cells and neurons. There is evidence that vascular endothelial cell dysfunction throughout the body is common in patients with normal tension glaucoma, Dr Schmetterer said. Astrocytes in the neurovascular unit may also be a target for glaucoma therapy, since the star-shaped glial cells play a very important role in the signalling between the vascular cells and neurons. In particular, astrocytes mediate the increase of blood flow that usually occurs in response to neural activity in order to deliver oxygen and glucose and other nutrients to the active cell. With regard to neuroinflammation, the loss of the retinal nerve fibre layers and ganglion cells appears to result in the up-regulation of many inflammatory parameters, such as the levels of TNF receptors and colony stimulating factors. “If you want to have a successful neuroprotection strategy you’ve got to target neurodegeneration itself and at the same time you have to target neurovascular damage and neuroinflammation,” Dr Schmetterer added.

Glaucoma Day ESCRS

Friday, 4th October 2013 Amsterdam, The Netherlands Available Online: Registration and Hotel Bookings

www.escrs.org EUROTIMES | Volume 18 | Issue 4

Scientific Programme organised by

contacts

Manfred Tetz – manfred.tetz@atk-spreebogen.de Alan Crandall – alan.crandall@hsc.utah.edu

Update

GLAUCOMA

IOP-LOWERING

“

It didn’t get to the low teens, but a significant reduction of IOP is shown in the original study of this device

Minimally invasive devices have much to offer in the future by Howard Larkin in Milan

range of implants designed to lower intraocular pressure (IOP) now under investigation could make glaucoma surgery less invasive, more predictable and more reliable, Manfred Tetz MD, of Eye Center Spreebogen and the Berlin Eye Research Institute, Berlin, Germany, told the XXX Congress of the ESCRS. Newer implants offer many approaches to improving outflow, including enhancing canal surgery, filtering surgery and uveoscleral outflow. They are made from plastic, metal or collagen, and some are delivered ab interno and others ab externo. “One thing they have in common is trying to standardise the current approach for lowering IOP and make the outcome more predictable. We will have to see in the future if that is successful.”

Bypassing trabecular meshwork

The iStent (Glaukos) is a titanium microshunt inserted ab interno into Schlemm’s canal through a 1.5mm corneal incision. It is designed to enhance the natural outflow mechanism by bypassing the trabecular meshwork, which is the area of highest resistance, Prof Tetz said. The initial design has established a record for effectively lowering IOP for two years or more, with initial one-year results lowering mean pressure from 21.7 mmHg to 17.4 mmHg while reducing topical medications by 1.2 average at 12 months, Prof Tetz noted.

Manfred Tetz MD “It didn’t get to the low teens, but a significant reduction of IOP is shown in the original study of this device.” Newer generations of the implant resemble a collar button more than an angled tube, Prof Tetz said. He believes the newer designs may work better, especially if they are placed near large collector channels in the canal. Citing the work of Robert Stegmann MD, he noted that surgery doesn’t just bypass the meshwork it also opens the canal for partial circumferential flow. “You need to be in the vicinity of a collector that functions. If you are too far away, the canal may be collapsed in the intermediate pathway.” Prof Tetz cited one patient in whom he implanted two iStents in a patient failing two-medication therapy with a pre-op IOP of 25 mmHg. At one year average pressure was in the 14 mmHg range with one medication, which is much better than the original with one implant.” The Stegmann canal expander (Grieshaber Ophthalmic Research) is a perforated polyimide implant inserted ab externo into Schlemm’s canal during viscocanalostomy. Since it is implanted from the outside it can be visualised directly during insertion, Prof Tetz said. The tube functions as a scaffold, keeping the canal open and allowing aqueous to flow in from the trabecular meshwork and out to collector channels. Prof Tetz has placed more than 65 expanders, mostly in patients who have

failed trabeculectomies. In one series of 10 patients, mean preoperative IOP dropped from 24.8 mmHg to 15 to 16 mmHg one, two and three months after surgery. “For failed eyes the postoperative pressure of 15 mmHg was quite satisfactory and continues in this range with these problem eyes. We will now try it in virgin eyes and see how the pressure responds.” The Hydrus intracanicular implant (Ivantis), is an 8.0mm long nickel-titanium scaffolding placed ab interno into Schlemm’s canal using an injector visualised with gonioscopy. The device also holds open the canal, allowing aqueous to pass through. Prof Tetz is currently involved in a 12-month multicentre trial using the Hydrus in 69 patients with and without cataract surgery. At six months, the cataract surgery group has seen mean pressures drop from 21.1 mmHg with 2.1 medications to 15.6 mmHg with 0.4 mean medications. Patients without concurrent cataract surgery saw pressures drop from a mean 21.6 mmHg with 1.7 meds before surgery to 16.9 mmHg and 0.6 meds at six months.

Subconjunctival filtering The AqueSys implant (Aquesys Xen ®) is a permanent, flexible collagen tube inserted ab interno with an injector from the anterior chamber through the trabecular meshwork into the subconjunctival space. It creates

a drainage channel without touching the external conjunctiva, greatly reducing filtration surgical trauma. The implant is also flexible when hydrated and removable, but will not move when in place, Prof Tetz said. Gonioscopy is not required since the insertion can be made anywhere in the vicinity of the meshwork. The first study, involving 107 patients observed for 30 months, is under way. Over time patients have seen a 30 per cent reduction in IOP and reduction of meds of more than one-half. Some changes have been made to the implant and the injector during the course of the study, and some patients have received injections of antimetabolites, but these are not unusual for trabeculectomy, he noted. The Gold Shunt (Solx), is a 2.0mm by 6.0mm gold device inserted through a pocket incision in the cornea, with one end in the anterior chamber and the other inserted into the suprachoroidal space. “Gold was chosen because it is fairly inert. However, it is fibrin active and can cause inflammation,” said Alan Crandall MD, of the Moran Eye Center, University of Utah, Salt Lake City, US. As a result, the device often is encapsulated and must be removed, he added. Movement may exacerbate the problem. A new design is inserted 4-5mm posteriorly and sits in a pocket in the suprachoroidal space. The CyPass Micro-Stent (Transcend Medical, Menlo Park, California, US) is a 6.5mm tube constructed of non-degradable polyimide material that has been used in implants for years, Dr Crandall said. It is inserted in the supraciliary space to increase suprachoroidal outflow. “The initial data are quite good,” Dr Crandall said. Patients have maintained a 30 per cent drop in IOP for over a year, and the device is easily implantable during cataract surgery.

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EUROTIMES | Volume 18 | Issue 4

Subhendu Kumar Boral – drsubhendu@ yahoo.co.uk

contact

Update

RETINA

FILM SURGERY

Novel approach to ILM peeling may improve closure rates in macular hole surgery by Dermot McGrath in Milan

new method to calculate the area of internal limiting membrane (ILM) peeled in macular hole surgery may provide a simple and effective means of improving the closure rates of symptomatic idiopathic full thickness macular holes, according to a study presented at the 2012 EURETINA Innovation Awards. “Our approach uses a novel standardised reproducible method to calculate the area of ILM peeled intra-operatively in macular hole surgery by using Boral’s ring, a video overlay of three equidistant concentric rings created using Adobe Photoshop,” said Subhendu Kumar Boral MD, Disha Eye Hospitals and Research Centre, Barrackpore, Kolkata, India. “The method is easily reproducible and can be applied by anyone using Adobe Photoshop. The video overlay is simple to use and can be made easily without any financial investment,” he added. Dr Boral said that no study to date has described a standardised and reproducible method of calculating the area of ILM peeled in macular hole surgery or examined the association between the perioperative ILM peeled area and the postoperative pattern of macular hole closure. He noted that the overall presence of macular holes is about 3.2 cases per 1,000 in persons older than 55 years. In the Beijing Eye Study, 1.6 out of 1,000 elderly Chinese were affected, and it is believe that the prevalence is similar in Europe. Reviewing the scientific literature, Dr Boral said that macular hole closure pattern is variable and not predictable. Hole diameter and ILM peeling were found to be the only significant factors in successful hole closure in a study by Brooks et al in 2000, while Ip et al in 2002 reported anatomical closure in 92 per cent of eyes with preoperative macular hole diameter of less than 400 microns but only 56 per cent in eyes with more than 400 microns. Another study by Kumagai et al in 2004 found that ILM peeling increased the macular hole closure rate, with anatomic closure in 92 per cent of ILM peeling patients compared to 81 per cent of patients in the non-ILM peeling group. Furthermore, a study by Kang et al to evaluate the clinical significance of macular hole closure types assessed by optical coherence tomography (OCT) distinguished two types of closure: type I, without any foveal neurosensory defect, in 61 per EUROTIMES | Volume 18 | Issue 4

“

(a) Three equidistant concentric circles were made in Adobe Photoshop CS2 in PSD format

(b) Smallest circle was fitted according to the longest disc diameter in the final still frame of the ILM peeling from recorded

The method is easily reproducible and can be applied by anyone using Adobe Photoshop

Subhendu Kumar Boral MD cent of patients, and type II, with foveal neurosensory retinal defect, in 39 per cent of patients. As Dr Boral noted, calculating the area of ILM peeled has traditionally been measured on the basis of visual impression according to the perioperative size of the optic disc head, not on any scientific reproducible basis. “The previous studies did not highlight how much area of ILM has to be peeled for better centripetal tissue mobilisation according to the preoperative macular hole diameter in order to ensure postoperative macular hole closure without any foveal neurosensory retinal defect,” he said. To bridge the gap, Dr Boral came up with the idea of using three equidistant concentric circles as a video overlay during the surgery in order to calculate the area of ILM peeled and its relation with hole closure pattern on OCT in idiopathic full thickness macular hole cases. To test the technique, Dr Boral and co-workers carried out a prospective singleblind study of 105 eyes of symptomatic full thickness macular hole patients. All patients remained in prone position for at least seven days after surgery, with a minimum postoperative follow-up of six months. The minimal diameter of the macular holes (MDMH) was calculated on OCT and patients were divided into two groups: 75 patients in group one with macular holes greater than 400 µm and 30 patients in group two with macular holes smaller than 400 µm. All patients underwent 23-gauge vitrectomy, ILM peeling, and gas injection to seal the holes. The final area of ILM peeled (AIP) was calculated using Adobe Photoshop CS2 in disc diameter (DD) measurements taken from video still frames. Looking at the results, the full thickness macular holes were closed in 97 out of the

(c) 3 circles were shifted to the AIP to note whether the margin of the AIP was crossing the outermost circle at least in 3 quadrant

(d) Intra-operatively use of video overlay (Boral’s Ring)smallest circle was fitted to the longest disc diameter

Courtesy of Subhendu Kumar Boral MD

(e) Now the surgeon can measure AIP using video overlay centring the macular hole

GROUP MDMH AIP I I II II

>400µ >400µ <400µ <400µ

Type I closure of macular holes in Group one patients when more than 3DD area of ILM peeled

Type I closure

>3DD <3DD >3DD <3DD

32 08 16 08

Type II closure 12 15 03 03

p value <0.01 NS <0.01 NS

Table shows relationship between Area of ILM Peeled and Macular hole closure pattern considering MDMH

total of 105 eyes (92 per cent), with a closure rate in group one of 67 out of 75 eyes (89 per cent) and 30 out of 30 in group two (100 per cent). Patients in group one with an ILM peel of more than 3 DD showed a statistically high incidence of type I closure (without any foveal neurosensory defect, 72 per cent) compared to type II closure (with foveal neurosensory defect, 27 per cent).When the ILM peels were less than 3DD in size for the same group, the type I closure was 35 per cent and type II was 65 per cent. In group two patients where the ILM peeled was greater than 3 DD again showed a significantly high incidence of type I closure

(84 per cent versus 16 per cent of type II), said Dr Boral. “We can conclude from our study that Adobe Photoshop CS2 is a useful tool to measure final area of ILM peeled in macular hole surgery. We found that type I closure was significantly higher for patients with AIP greater than 3DD in both large and small idiopathic macular holes. This method will enable the surgeon to adjust the extent of the ILM peeling during the surgery, taking account of the preoperative macular hole diameter, in order to get a better closure pattern postoperatively,” he concluded.

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contacts

James Bainbridge – j.bainbridge@ucl.ac.uk Ian MacDonald – macdonal@ualberta.ca Luk Vandenberghe – luk_vandenberghe@ meei.harvard.edu

Update

RETINA

GENE THERAPY

As early techniques move through clinical trials, new approaches emerge by Howard Larkin in Chicago

wo decades on, retinal gene therapies targeting individual gene defects show real impact in clinical trials, making the eye one of the most successful target organs for gene therapy to date, presenters told the retina subspecialty day at the American Academy of Ophthalmology annual meeting. At the same time, neuroprotective and anti-inflammatory gene therapies may slow progression of complex retinal diseases, and animal studies of optogenetic agents offer tantalising hints that one day vision may be restored even in patients without functioning photoreceptors. However, many questions remain to be answered before any gene therapy enters the clinical realm, said James W Bainbridge MA, PhD, FRCOphth, of Moorfields Eye Hospital and the UCL Institute of Ophthalmology, London, UK. Among other things, further clinical trials are needed to develop condition-specific optimal intervention windows that define when the benefits outweigh the risk, and when retinal degeneration has progressed too far for therapeutic benefit.

Therapy targets The eye has many advantages over other organs for gene therapy, said Dr Bainbridge, whose pioneering work targeting Leber’s congenital amaurosis, established the shortterm safety and efficacy of viral vectors delivered in the subretinal space. Because it is small and enclosed, stable results are possible with small amounts of vector, and its immune privilege reduces immune response. Function and structure changes are also easily observed. Generally, photoreceptor and retinal pigment epithelium cells are targeted.

Because direct injection of DNA is inefficient, vectors that insert genes into living cells are used, commonly adenoassociated viruses or lentiviruses. Subretinal injections are required to reach these cell layers. The most developed gene therapy approach is treating loss-of-function conditions caused by a single known gene defect, Dr Bainbridge said. These conditions are generally recessive, and Leber’s is an example. “One can imagine that by simply replacing the defective gene and providing a normal copy one might expect improvement,” Dr Bainbridge said. Three independent clinical trials of AAV2-vector therapies for RPE65 have demonstrated improved vision and safety (Bainbridge JW et al. N Engl J Med 2008; 358: 2231-2239. Maguire AM et al. N Engl J Med 2008; 358: 2240-2248. Hauswirth WW et al. Hum Gene Ther 2008; 19: 979-990). Dr Bainbridge is currently conducting an early phase II open-label study of larger doses of an AAV2 vector therapy targeting RPE65. So far the subretinal injections have generally been well-tolerated, immune responses infrequent and mild, with no signs of tumour formation to date. He also reported, “robust improvements in vision. That’s hugely exciting in a condition that before was considered untreatable.” Another single-gene replacement therapy that has shown early success targets choroideraemia, said Ian MacDonald MD, of the University of Alberta, Canada. It also uses an AAV vector to target a CHM gene mutation that causes a deficiency of Rab escort protein-1, which is necessary for intracellular trafficking in the retina.

“

Each step we go deeper in the retina we capture more retinal processing, which may help restore a more natural form of vision Luk H Vandenberghe PhD

The vector is injected subretinally, ensuring delivery to photoreceptor and RPE cells. Despite the need to detach the macula using pre-injections of BSS prior to delivering the vector, the first six patients to undergo the treatment have tolerated it well and their retinas have reattached, demonstrating the short-term safety of the approach, Dr MacDonald said. Since choroideraemia is progressive, typically resulting in a precipitous loss of central vision around age 50, slowing disease progress is an important endpoint. Technologies including microperimetry, OCT, electrophysiology and autofluorescence make it possible to monitor functional and structural changes in fellow treated and untreated eyes. Other retinal gene therapy applications include suppressing toxic proteins created by single-gene mutations, which are often dominantly inherited, and treating diseases with a broader range of genetic origins by inserting genes that express anti-VEGF or neuroprotective factors, Dr Bainbridge said. “At UCL, we have a pipeline of therapies that target not only RPE, but photoreceptors and complex diseases.” These include clinical trials for photoreceptor degeneration including Stargardt disease and Usher syndrome, choroideraemia, and age-related macular degeneration.

Optogenetic approaches

Optogenetics is another approach that holds potential for treating a wide range of retinal disorders, said Luk H Vandenberghe PhD of the Massachusetts Eye and Ear Infirmary at Harvard Medical School, Boston, US. It

does so by inserting genes expressing opsins that may resensitise damaged photoreceptor cells, or create light sensitivity in other retinal cells. When the correct opsin is deployed in the appropriate retinal neuron, this could restore light perception or vision in eyes with degraded retinas. Three optogenetic molecular tools have drawn the most attention for this approach, Dr Vandenberghe said. They are channel rhodopsin, derived from algae, which depolarises cells in response to light; melanopsin, from retinal ganglion cells of vertebrates, where it is involved with regulating circadian rhythm and pupillary; and halorhodopsin, from archebacteria, which help single-cell organisms move toward light and can be used to hyperpolarise a neuron. These sensor proteins can be placed in retinal ganglion cells, amacrine cells, bipolar cells to create photosensitivity, or into remnant cone cells to restore it, Dr Vandenberghe said. “Each step we go deeper in the retina we capture more retinal processing, which may help restore a more natural form of vision. This may sound to some like science fiction, but we have proof of concept for three of these four strategies in animal models where fairly complex forms of light perception and vision can be restored.” However, many hurdles must be cleared before clinical applications are possible, Dr Vandenberghe noted. One is the difficulty of targeting genetic transfer to specific retinal cell targets. Another is that current photosensitive proteins require much light and have a dynamic range of one to two orders of magnitude, compared with seven or more for natural vision, and restored vision signals may not be tolerable, Dr Vandenberghe said. These might be addressed with a head-mounted display with variable light sensitivity and signal modulation that might in turn be used to activate genetically treated cells in the retina. A successful optogenetic solution will likely require mutually supporting advances in basic optogenetics, gene therapy delivery, understanding of retinal circuitry and advanced optical-electrical engineering, he added.

EUROTIMES

ESCRS

Türkiye TURKISH LANGUAGE EDITION NOW ONLINE EUROTIMES | Volume 18 | Issue 4

Visit: www.eurotimesturkey.org

™

contact

Diego Ruiz-Casas – druizcasas@hotmail.com

Update

RETINA

RETINAL DETACHMENT

Microparticles show exciting potential in vitreoretinal surgery by Dermot McGrath in Milan

ntraocular magnetic microparticles may offer a potentially safe and effective method of sealing retinal tears and overcoming some of the current drawbacks of traditional retinal detachment surgery. “This novel device draws on advances in nanotechnology and could be potentially used in retinal detachment to seal retinal tears by means of pressure and also adjusted to surpass tractional forces in proliferative vitreoretinopathy (PVR) cases,” according to Diego Ruiz-Casas MD. In recognition of their ground-breaking research, Dr Ruiz-Casas, Ramon Y Cajal University Hospital, Madrid, Spain, and his team of co-workers were awarded first prize in the EURETINA Innovation Awards, a prize established by EURETINA in 2011 to support and encourage innovation in the field of retinal medicine. In a presentation summarising his team’s research, Dr Ruiz-Casas said that using magnetic microparticles may help to overcome some of the drawbacks associated with current retinal detachment (RD) techniques such as scleral buckling, pneumatic retinopexy and vitrectomy. “Some of the main drawbacks of current treatments include the eye wall deformation by scleral buckle, the delayed effect with retinopexy and the need for an intraocular tamponade by means of interfacial tension,” he said. He noted that there was a clear need for more effective treatments for RD. “Rhegmatogenous retinal detachment occurs in approximately seven to 18 out of 100,000 people a year, which

21 22 23 st

“Rhegmatogenous retinal detachment occurs in approximately seven to 18 out of 100,000 people a year...” means that anywhere between four and 12 million people worldwide will have it,” said Dr Ruiz-Casas. Discussing the concept behind his team’s research, Dr RuizCasas explained that there are two principal components to the proposed ocular magnetic device (OMD). First, a scleral magnetic explant (SME) is sutured to the sclera. The magnet, which is 6.0mm in diameter and 2.0mm in height, requires no indentation and is coated with different biocompatible layers where drugs can be attached. The second part of the proposed solution comes in the form of suspended magnetic microparticles of about 100 microns, which are directed towards the area of the retinal tear through the magnetic field created by the magnet sutured to the sclera. Much of the research effort by Dr Ruiz-Casas’ team has been directed at determining the optimal target pressure that needs to be exerted between the explant and the microparticles to keep the retina attached. Noting that mild local retinal damage is acceptable to induce retinopexy, a target pressure of 0.75 mmHg was

JUne 2013

defined as the optimal value, which is about the pressure of a 10.0mm bubble of air in water. To test the performance of the device in vitro, an eye model was used to understand the magnetic interaction between the microparticles and the explant. In a test lasting 30 days, the microparticles were shown to migrate from one magnet to another, and they maintained their position at the end of the trial. In vivo testing of the OMD also showed stable biomechanics and good biocompatibility of the device, with no movement of the microparticles during follow-up in rabbits’ eyes, he said. The microparticles were found to be located directly under the explant in 100 per cent of cases, and the specimens with iatrogenic RD kept the retina attached where the ocular magnetic device was located by pressure, said Dr Ruiz-Casas. In terms of an objective evaluation of the OMD, Dr Ruiz-Casas said the approach offered several advantages, including the delivery of localised treatment of retinal tears by using pressure. The fact that the magnet is sutured to the sclera also eliminates the need for the patient to maintain an uncomfortable posture in the immediate postoperative period. Other benefits of the OMD include the maintenance of a clear visual axis with preservation of the non-treated retina. Furthermore, the pressure used is adjustable, with no eye wall deformation and therefore offering potentially multiple uses in vitreoretinal surgery. Among the downsides of the proposed device, Dr RuizCasas said that multiple tears would require multiple scleral magnetic explants, and potential issues of retinopexy/necrosis on the outer retinal layers and toxicity risk/siderosis also required further investigation. Summing up, Dr Ruiz-Casas said that the OMD could be potentially used in retinal detachment to seal retinal tears by means of pressure and also adjusted to surpass tractional forces in PVR cases. Other intriguing possible applications include vitreoretinal dissection/drainage, localised drug release and treatment of intraocular tumours, he said.

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TECHNIQUES IS CATARACT SURGERY F-CHANGING? SPECIAL CASES END of CONFERENCE

Organizer: Roberto Bellucci M.D. Director of the ophthalmic Unit, hospital of Verona

Under the patronage of

EUROTIMES | Volume 18 | Issue 4

Information and online registration: www.femtocongress.com

contacts

Update

RETINA

INTRAOCULAR BIOPSY

Advances in technique improve efficacy and safety, but other issues may still limit widespread use by Cheryl Guttman Krader In Milan

iopsy of choroidal tumours is becoming routine at some ocular oncology centres, but others remain very critical of the procedure. Speaking at the 12th EURETINA Congress, Heinrich Heimann MD and Marc Veckeneer MD, discussed use of choroidal biopsy and issues surrounding the controversy. At the Ocular Oncology Unit, Royal Liverpool University Hospital, Liverpool, UK, choroidal biopsy is offered to all patients and data indicate that the majority choose to have the procedure. Excluding patients who had enucleation, about twothirds of ocular melanoma patients have a biopsy, which is performed transclerally or transretinally with a 25-gauge needle, a 23-gauge biopsy forceps or a 25-gauge vitrectomy cutter, said Prof Heimann, consultant ophthalmic surgeon. However, he acknowledged that justifying intraocular biopsy as a routine clinical procedure requires that it be critically appraised against a set of six factors. A review of those issues suggests that some further developments are needed before biopsy becomes standard practice at all institutions. Prof Heimann noted that biopsy can address important clinical questions about diagnosis and prognosis, and when performed for either of those indications, it can dramatically impact patient care. Moreover, it appears that the ability to obtain answers about diagnosis and prognosis through biopsy is reasonable thanks to improving tissue acquisition techniques, said Prof Heimann, citing statistics from his own centre. “In our first 68 patients, the biopsy sample was adequate for histology in only 76 per cent of cases and for prognostic testing in only 68 per cent. More recently, however, considering tumours with an ultrasound thickness of 2.0mm or greater, those success rates have improved to at least 90 per cent,” he said. Costs of the procedure, including cytogenetic testing, are in a range that would make routine biopsy acceptable as well. However, more progress is needed to improve safety, widespread applicability and protocols for aftercare, according to Prof Heimann. Referring again to data from the first cohort of patients undergoing biopsy at

EUROTIMES | Volume 18 | Issue 4

“For surgeons, the challenge of performing intraocular biopsy extends beyond becoming skilled with the technique” Heinrich Heimann MD

Transvitreal, transretinal biopsy using forceps

Biopsy trough cannula port system limits contact with ocular tissue Courtesy of Marc Veckeneer MD

Small sample size requires diligent processing to allow complete diagnostic evaluation

his institution, Prof Heimann reported that five of 68 patients needed a secondary vitreoretinal procedure to manage a biopsyrelated complication. “We are constantly refining our surgical techniques to make the procedure safer, but we are not at the stage quite yet where we can say definitively that it is not associated with potential complications,” he said. Discussing widespread applicability, Prof Heimann noted that currently, the biopsy specimen must be sent to specialised centres since accurate histopathological interpretation of the tissue depends on a high level of expertise. Additionally, very

few centres have the capability to perform cytogenetic testing for prognostication. “There is no point in intraocular biopsy becoming routine if the specimen analysis is not backed up by adequate laboratories,” Prof Heimann said. Lastly, he noted that before biopsy becomes routine, surgeons will need to modify their infrastructure of patient care so that they can meet the responsibilities of this new aspect of their role as ocular oncologist. “For surgeons, the challenge of performing intraocular biopsy extends beyond becoming skilled with the technique. Now, they will be the ones delivering bad news that a patient has a high-risk malignant tumour. They have to be able to counsel those patients about treatment and screening strategies and be equipped to provide supportive care,” said Prof Heimann. “Centres need to gear up for these tasks. That will require some major changes in the service and developing close collaborations with general oncologists and psychologists.” At the Rotterdam Eye Hospital biopsy is being done routinely in cases where there is major diagnostic uncertainty and high-risk clinical characteristics, said Marc Veckeneer MD. Currently, the procedure is performed using a specialised 23-gauge biopsy forceps (D.O.R.C. Dutch Ophthalmic Research Center, Zuidland, The Netherlands) as this technique appears to optimise both safety and the likelihood of obtaining an adequate sample. “In the past 12 years, I have tried several techniques for biopsying very flat tumours. My experience was that both 27-gauge needle biopsy and use of a 23-gauge vitrectomy cutter were unreliable in yielding sufficient tissue. The forceps technique permits patients to undergo an invasive procedure

Heinrich Heimann – heinrich.heimann@gmail.com Marc Veckeneer – veckeneer.icare@gmail.com

with potentially 100 per cent certainty of getting a diagnosis,” Dr Veckeneer said. Dr Veckeneer reported that over the past 18 months, he has performed forceps biopsy in seven eyes with a tumour smaller than 3.5mm in thickness, and the diagnosis was successfully made on a pathological basis in all cases. Dr Veckeneer said that when using the forceps in combination with a cannula port system, local seeding is unlikely because there is no contact between the tumour tissue and the eye. Although the potential for metastatic spread is controversial, he remains concerned about the risk. “Extensive surgical manipulation of a malignant tumour, as in resection, has been reported to be associated with a high risk of early metastatic death if the patient is not treated preoperatively with radiotherapy. Biopsy with the forceps technique causes some tumour disturbance, but we are not performing radiotherapy at that time because the indication for biopsy is major diagnostic uncertainty. However, the fact that treatment may be delayed for up to several weeks if the lesion turns out to be a malignant tumour is an issue in need of review.” Dr Veckeneer also commented on the importance of good communication with the pathologist to assure proper management of the biopsy specimen. “Just as important as the surgeon doing an uncomplicated biopsy is what happens to these small specimens when they are processed downstream. They need to be treated with extreme diligence,” he said. Dr Veckeneer noted that use of an automated cell block system (Cellient) can optimise the evaluation of the limited specimen. “Laboratories using this system will usually be able to perform all of the necessary histopathological stains and still send some of the specimen off for gene testing,” he said. Dr Veckeneer mentioned a video which demonstrates the transvitreal, transretinal choroidal tumor biopsy technique using a 23-gauge forceps and cannula port vitrectomy system (http://youtu.be/ jiZbm9Zb4SA).

“Laboratories using this system will usually be able to perform all of the necessary histopathological stains and still send some of the specimen off for gene testing” Marc Veckeneer MD

Update

RETINA

AMD PROPHYLAXIS

No benefit in prophylactic anti-VEGF treatment for AMD patients undergoing cataract surgery by Dermot McGrath in Milan

here is currently no firm evidence for improving the outcome of visual impairment in age-related macular degeneration (AMD) by opting for prophylactic anti-VEGF treatment at the time of cataract surgery, according to Frank Holz MD. “There has been some debate recently on whether it is sensible to perform prophylactic anti-VEGF therapy injections at the time of cataract surgery in patients with age-related macular disease. Our view, however, based on the current scientific evidence is that prophylactic anti-VEGF treatment cannot be recommended at this point in time,” Dr Holz told delegates attending a joint ESCRS/EURETINA symposium at the XXX Congress of the ESCRS. Dr Holz said that it was important to look for any signs or symptoms of exudative AMD before proceeding with cataract surgery. “We recommend performing spectraldomain OCT and fluorescein angiography before cataract surgery if symptoms or clinical signs are suggestive of an active exudative manifestation of AMD. If this is confirmed, then it is better to treat first and try to attain some stability in terms of best-corrected visual acuity, fluid reduction on SD-OCT and disease progression before removing the cataract,” he said.

Age as risk factor Dr Holz noted that the advanced age of many cataract patients greatly increases the likelihood of ocular comorbidities, including AMD. “There is the common risk factor of age. The Beaver Dam Eye Study showed that 27 per cent of all patients over 75 years of age have AMD and cataract. So it is a rational question to ask if we could possibly improve the outcome in these patients if we combine treatment for the macula and at the same time get rid of lens opacification,” he said. One of the theoretical aims of prophylactic anti-VEGF therapy would be to counteract stimuli for increased disease activity potentially induced by cataract surgery, said Dr Holz. “It is well known that any intraocular surgery including cataract surgery elicits some molecular processes that may have an impact on the macular tissue. The real question, however, is to decide if it is of relevance for a particular AMD patient. The idea of anti VEGF prophylaxis before cataract surgery might be to eliminate additional hyperpermeability of existing new vessels, inhibit further growth of choroidal neovascularisation or prevent the possibility of RPE tear in the presence of pigmented epithelial detachment and new haemorrhage,” he said. Dr Holz said that it was important to distinguish different progression scenarios in patients who have both cataract and AMD. While the visual function is usually quite good in patients with early to intermediate dry AMD, clinicians should focus more attention on those patients with more advanced forms of the disease. “Of greater concern are those patients who progress from early stages to advanced exudative AMD or atrophic stages, which is usually associated with a major threat for vision. EUROTIMES | Volume 18 | Issue 4

We also need to be alert to patients with existing latestage AMD phenotypes, with choroidal neovascularisation or geographic atrophy, where there is a risk of atrophic progression or a small CNV becoming larger or more hyperpermeable,” Dr Holz said. Several studies have demonstrated benefit in visual acuity after cataract surgery in patients with late-stage AMD, he said. “There is currently no evidence that cataract surgery has an adverse effect on patients with geographic atrophy. On the contrary, these patients need to have early cataract surgery because they may well benefit from improved contrast sensitivity and other visual improvements after cataract extraction,” he said. Reflecting on the goal of anti-VEGF therapy, Dr Holz stressed the importance of calibrating the treatment to individual patient needs. “We want to have the best possible outcome for our patients but we do need to avoid unnecessary treatment or overdosing, wasting resources and putting patients at unnecessary high risk in terms of endophthalmitis and other safety issues associated with VEGF inhibition. At the same time, too little treatment can be harmful to the patient. If we under-dose, the patient may lose visual function that cannot be recovered by further treatment later on,” he said. In terms of the purported association between cataract surgery and the stimulation of dormant AMD or acceleration of underlying disease, Dr Holz noted that recent evidence – the AREDS study and a Cochrane meta-analysis carried out in 2012 – suggests no adverse effect of modern cataract surgery techniques on AMD progression. “There is therefore no rationale to combine the surgery with anti-VEGF therapy. And as we have no evidence for effectiveness, we cannot tell the patient that we would help him or her to avoid conversion from early to late stage AMD or that we can halt progression of an existing wet AMD,” he said. Nor is there any justification for treating patients prophylactically on the basis that they might be one of the unlucky few to suffer a rebound effect from the cataract operation, said Dr Holz. Furthermore, Dr Holz noted that there is no evidence that the outcome of anti VEGF treatment is any worse if administered postoperatively in those patients who exhibit increased wet AMD activity after their cataract surgery. He also pointed out that the burden of care factor, which is often cited as an argument for simultaneous cataract/antiVEGF treatment in AMD patients, is not necessarily valid. Bearing in mind the chronic nature of macular degeneration, Dr Holz said that there may be an argument for combining cataract surgery with anti-VEGF treatment on the same day for selected individual patients with mobility issues or those who have difficulty returning to the clinical for regular injections.

contact

Frank Holz – Frank.Holz@ukb.uni-bonn.de

CALL

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Update

RETINA

RETINOPATHY

There are still situations in which surgery remains the primary treatment modality

by Leigh Spielberg MD in Milan

26–29 September 2013 Registration and Hotel Bookings available online

www.euretina.org

EUROTIMES | Volume 18 | Issue 4

lthough new pharmacologic approaches have undoubtedly improved the treatment of diabetic retinopathy, there is still a need for surgery in diabetic retinopathy, Anat Loewenstein MD, told the 12th EURETINA congress. Dr Loewenstein, chairman of the Department of Ophthalmology, Tel Aviv Sourasky Medical Center, listed eight clearcut indications for vitrectomy. These were primarily related to vitreous haemorrhage, retinal detachment and fibrovascular proliferation. Despite the encouraging results of the RISE, RIDE and BOLT trials, which support the use of anti-VEGFs for diabetic macular oedema, there are still many situations in which surgery remains the primary treatment modality, said Dr Loewenstein. “This is because of the limitations of anti-VEGF treatment. Macular hypoxia is not alleviated with anti-VEGF and treatment requires multiple injections over extended periods.” In contrast, the theoretical benefits of vitrectomy on diabetic macular oedema include relief of vitreomacular traction and retinal vasoconstriction associated with increased oxygen supply from the ciliary body. Dr Loewenstein also highlighted the role of posterior vitreous detachment (PVD). She cited considerable research showing that diabetic patients with PVD are less likely to develop macular oedema. Spontaneous resolution of the oedema was seen in 55 per cent of eyes with vitreomacular separation compared with 25 per cent of eyes with vitreomacular adhesion. Thus, Dr Loewenstein argued that there is still an important role for diabetic vitrectomy, especially considering the ongoing advances in vitreoretinal surgical instrumentation and technique. She made the case for vitrectomy in cases of DME that are unresponsive to pharmacological treatment. This applied even in cases with no vitreomacular traction present. “Some patients are unwilling or unable to undergo multiple anti-VEGF or steroid injections,” she added. An interesting question was raised by a delegate. “What about the problem of persisting macular oedema even after vitrectomy? Without a vitreous to slow

“

Some patients are unwilling or unable to undergo multiple anti-VEGF or steroid injections Anat Loewenstein MD

clearance of drugs out of the posterior chamber, aren’t we then left with no options besides laser?” Dr Loewenstein replied that a slowrelease steroid such as Ozurdex (Allergan) or Illuvien (Alimera Sciences) might be useful in such a situation. In a related presentation Ramin Tadayoni MD, Lariboisiere University Hospital, Paris, discussed the border between pharmacology and surgery in the treatment of diabetic retinopathy. “This is a highly indistinct border. For example, slow-release drugs implanted in the vitreous: is this surgery or pharmacology? And pre-surgery treatment with anti-VEGF: does this represent two different modalities, or is the pre-treatment actually part of the operation?”

Experience of surgeon Dr Tadayoni also cited the example of microplasmin, which is a drug that is used to achieve a surgical result, namely the separation of the vitreous from the retina. In the end, the main dividing line is the skills-based difference between pharmacology and surgery. The success of surgery is highly dependent on the skills and experience of the surgeon, said Dr Tadayoni, whereas prescribing and injecting anti-VEGF is relatively straightforward. “But,” Dr Tadayoni added, “with the introduction of more and more ‘surgical drugs’ like r-tPA, enzymatic vitreolytics and anti-PVR antibodies, the dividing line between surgery and pharmacology will continue to blur.”

contacts Anat Loewenstein – anatlow@tasmc.health.gov.il Ramin Tadayoni –ramin.tadayoni@lrb.aphp.fr

Update

ocular

Want a perfect cut? Not all trephines are the same

work ETHICS

A careful approach can distinguish the ophthalmologist learning a new technique by Howard Larkin in Chicago

echnology advances continuously challenge ophthalmologists to learn new skills throughout their careers. Professional ethics require that surgeons take sufficient time and effort to master new skills before performing new procedures, Roberto Pineda MD of the AAO Ethics Committee reminded the American Academy of Ophthalmology annual meeting cornea subspecialty day. “When a decision is made to incorporate new techniques or new technology into a practice, we recommend a formal course of study,” said Dr Pineda, who also is on faculty at Harvard Medical School, Boston, Massachusetts, US. However, the type and extent of training depend on previous experience and existing skill sets, he added. For example, a skilled cataract surgeon may need little more than a brief course and a little hands-on experience with new phaco machines and smaller instruments to adopt microincision surgery. However, developing an unfamiliar skill, such as implanting glaucoma drainage devices or adding laser-assisted cataract surgery, requires a much more comprehensive planning and learning process, Dr Pineda said. Whether a new skill will help patients, and whether there is sufficient volume potential to maintain competence are key questions, Dr Pineda said. The process should start with a thorough analysis of the evidence, or lack thereof, including the potential biases of information sources, about a procedure. Any training required for you and your staff should be planned, as should acquisition of all necessary equipment and supplies. Dr Pineda outlined the steps an American colleague took to learn corneal crosslinking, which is not yet approved in the US. He started his research by reading magazines such as EuroTimes, and peerreviewed articles. He spoke to colleagues outside the US at scientific meetings and arranged to see postoperative patients from outside the US. He began referring patients to Canada for treatment, and followed them afterward. Finally, he performed proctored cases outside the US. “This is a very reasonable approach to acquiring a new technique,” Dr Pineda said.

EUROTIMES | Volume 18 | Issue 4

“

When a decision is made to incorporate new techniques or new technology into a practice, we recommend a formal course of study Roberto Pineda MD

Preparing for the first case Beyond adequate training and required equipment, patient selection is important in preparing for the first case, Dr Pineda said. Starting with uncomplicated cases builds skill and confidence while patients with anxiety or demanding styles may not be suitable. He also recommends making a dry run before the first case, and allowing plenty of time to deal with possible complications in early cases. Also consider a proctor, he advised. Informed consent may also need to be modified, Dr Pineda said. Be open with patients about the new procedure, how it relates to your previous skills and what role, if any, a company representative or proctor will play in the procedure. Do not misrepresent your experience, skill or training in any way, he stressed. Also, make sure you have malpractice coverage and comply with any hospital, health plan or local requirements for adding a new procedure. “Most hospitals will require formal training and supervision by senior staff,” Dr Pineda said. Afterward, honestly examine outcomes and investigate the causes of any complications. These will help improve performance, Dr Pineda said. “A careful, honest, ethical approach distinguishes the competent ophthalmologist learning a new technique.”

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Update

ocular

EDUCATION IS NOT THE

FILLING OF A PAIL, BUT THE

LIGHTING

COGNITIVE IMPAIRMENT

Understanding the links between cataracts and dementia by Priscilla Lynch in Brighton

OF A

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phthalmologists need to be aware of the link between dementia and visual decline, and the potential for overlap and misdiagnosis of both, Joanna Jefferis MD told delegates attending the XXXVI UKISCRS Congress. Cataracts and cognitive impairment are both common age-related problems, and ophthalmologists are increasingly likely to encounter patients who have either, both, or forms of dementia that incorporate visual impairment, said Dr Jefferis, Claremont Wing Eye Department, Royal Victoria Infirmary, Newcastle, UK. As dementia patients who display early visual issues can frequently present first to ophthalmology services, Dr Jefferis said it is important that ophthalmologists familiarise themselves with the types of cognitive conditions that have visual elements or mimic symptoms. “Visual symptoms can be the presenting feature of dementia, and can be either complex or simple, such as having difficulty reading, blurring of vision, recognising objects and visual acuity,” she explained. The most common forms of dementia are Alzheimer’s and dementia with Lewy bodies, which presents with prominent visual features such as hallucinations and visuospatial dysfunction. Parkinson’s disease dementia and the very rare Creutzfeldt-Jakob disease also have visual elements, she elaborated. “Also, posterior cortical atrophy, a form of Alzheimer’s which affects the posterior and visual part of the brain, is a reasonably newly recognised problem which presents invariably first to eye care providers. It causes progressive reading and visuospatial problems. For example, they are able to perceive individual elements of a scene but not a whole scene at once,” Dr Jefferis commented. She noted that as dementia and cataracts both share similar symptoms, they can frequently be misdiagnosed as each other. Common symptoms of both cataracts and cognitive issues include difficulties in negotiating steps, reading and recognising faces, blurred vision and glare while driving. So there is plenty of scope for misdiagnosis. When these patients have coexisting cataracts, it may be even more difficult to distinguish visual complaints due to cataract from those due to dementia. “We may more commonly be getting the problem of cataracts muddled with cognitive impairment. This could lead to unnecessary surgeries,” she said quoting a number of research and case studies that backed this assertion up. One retrospective study of 22 patients (Cooper 2005) with the Heidenhain variant of sporadic CJD (sCJD) showed that 77 per cent had initially presented to ophthalmology services, and two of these patients had cataract extraction before the diagnosis of sCJD was made. The study noted that as ocular intervention carries with it the risk of onward transmission, awareness of this condition among ophthalmologists is important. She also cited a separate case study of a 77-year-old female with visual issues including past history of retinal

detachment, reporting seeing white lines and flowers, with a VA of 6/9 in the right eye and 6/12 in the left eye who was diagnosed with mild to moderate cataracts. However, Dr Jefferis said following cataract surgery on the patient's left there was no real improvement in her symptoms and she reported visual hallucinations. “Following a number of cognitive tests, including Montreal Cognitive Assessment, which has a lot of visuospatial aspects, we were able to diagnose this patient as having dementia with Lewy bodies, and that had been the reason for the visual symptoms she had been experiencing,” she explained.

Can surgery improve cognition? Dr Jefferis examined the hypothesis of whether cognitive function can be improved through cataract surgery in dementia patients. “We know that cognition gets worse with time and vision gets worse with time, and can be related to each other. So if we can improve vision, can we therefore improve cognition?” she asked. Looking at international research on the issue, Dr Jefferis said that there are studies that support a yes and a no answer. However, upon careful analysis and looking at whether there were control groups involved in the studies, she said her opinion is that no, there is not currently sufficient evidence that cataract surgery can lead to a notable improvement in cognitive function. She also looked at the separate question as to whether cognitive function influences the visual outcomes of cataract surgery. While there is increasing evidence that cortical factors have a role to play in declining visual function with advancing age, Dr Jefferis said cognitively impaired patients appear to have equal visual outcomes to non-cognitively impaired patients following cataract surgery. Quoting her own research on the results of cataract surgery in 100 patients aged 75 years and over with varying levels of cognition, she reported that those with the lowest levels of cognition had the poorest levels of visual acuity pre-surgery. Postoperatively, her early research findings suggest that the visual results are not significantly different between the three cognitively defined patient groups. Dr Jefferis acknowledged the challenges in differentiating dementia and cataract symptoms in elderly patients and encouraged ophthalmologists to be cautiously thorough in diagnosing and electing to treat cataracts in this cohort. Speaking to EuroTimes following her presentation, she said a multidisciplinary approach with ophthalmic, neurological and psychiatric input is an effective way to diagnose and manage complex visual problems in older people.

contact Joanna Jefferis – Joanna.jefferis@ncl.ac.uk

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Cognitively impaired patients should have regular eye tests and screening by Priscilla Lynch in Brighton

urgeons should choose the most minimally invasive and pain free approach to removing cataracts in cognitively impaired patients, recommends Paul Ursell FRCOphth, Sutton Eye Unit, UK. Dr Ursell detailed his extensive experience of performing cataract surgery in patients with learning disabilities and dementia in a talk at the XXXVI UKISCRS Congress. He noted that patients with learning difficulties have a much higher incidence of visual impairment, with approximately 60 per cent needing glasses. However, because of their cognitive impairment, many of these patients may not be able to communicate their vision issues, thus regular eye tests and screening are very important. Dr Ursell advised early treatment for any patients with impaired cognitive function diagnosed with cataracts, as the impact of vision loss can be more difficult for them to deal with and they will have a better physical and psychological recovery when treated early. When considering cataract surgery for this cohort surgeons should consider that near vision is often more important than distance vision to patients with learning disabilities, he said. If surgery is to be performed, Dr Ursell advised removing cataracts in the “easier” eye first. Local anaesthetic can be used for many dementia patients undergoing cataract surgery but general anaesthetic is also acceptable, and can be particularly useful in agitated patients, he said. “In the past people wouldn’t use general anaesthetic on these patients as they believed it would make their dementia worse, but modern cataract surgery is quite short and it is known now that anaesthetic does not have a detrimental effect on their dementia,” he explained. If biometry cannot be performed before surgery, it is possible to do it when the patient is on the table under anaesthetic, Dr Ursell noted. He recommending contact immersion biometry for determining the axial length and hand held corneal keratometry readings, followed by Perkins tonometry to help determine the best implant choice for the patient. Dr Ursell expressed a preference for a square-edged intraocular lens with a low posterior capsule opacification profile.

EUROTIMES | Volume 18 | Issue 4

“

Cataract surgery in patients with dementia or learning difficulties is a very important and rewarding surgical procedure and has a very big impact on the quality of people’s lives Paul Ursell FRCOphth

“This is because you don’t want them to need YAG capsulotomy, because that is hard work in patients with dementia.” Additionally, surgeons should avoid sutures where possible and use nontoothed forceps, meaning the eye is as comfortable as possible post-surgery to minimise eye rubbing. “Particularly in patients that can be difficult to handle, your surgical technique should be geared towards causing no postoperative pain,” he maintained. Postoperative care should be as straightforward as possible, and planned beforehand, Dr Ursell said. The patient should be involved in the decision on postoperative treatment care as much as possible and the plan should be fully discussed with their care group – carers, GP, nurse, etc. If the patient’s family/carers don’t think they will be able to put eye drops in the patient’s eye, Dr Ursell recommended using steroid injections or subconjunctival antibiotics while the patient is still under anaesthetic. “Cataract surgery in patients with dementia or learning difficulties is a very important and rewarding surgical procedure and has a very big impact on the quality of people’s lives. Also remember if you can improve their vision, it can often help their cognitive function too,” he concluded. n

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21.02.2013 07:36:36

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Update

GLOBAL OPHTHALMOLOGY

James Wawrzynski – jrw77@cam.ac.uk

EYE ON INDIA

Can European ophthalmologists learn from the model of eye care practised at the Aravind eye hospitals in India? by James Wawrzynski BA (Cantab)

“ Courtesy of James Wawrzynski BA

Today, Aravind has expanded to five self-sustaining eye hospitals in Southern India and 33 primary eye care centres seeing 1.4 million outpatients and performing 200,000 sight-restoring operations each year, two-thirds of which are free to the patient James Wawrzynski BA

A community clinic set up for one day in a community hall. Patients arrived in the morning and are waiting to be seen

ndia has one of the highest rates of preventable blindness in the world. Of the 12 million blind people in India, 50 per cent could have their sight restored with a simple cataract operation. A further 17 per cent simply need an adequate prescription for glasses. In 1976, Dr G Venkataswamy, a retired ophthalmic surgeon from Southern India set about creating his first eye hospital in Madurai, Southern India. He would fund a free eye hospital for poor people by offering a for-profit eye care service to the wealthy. His hospital would concern itself mainly with the removal of cataracts. Central to Aravind’s success has been ruthless cost-cutting. Each cataract operation in the UK costs the National Health Service (NHS) £932. The cost to Aravind of removing a cataract in its ‘free’ section is just £10. How can such a dramatic reduction be achieved? Partly this is a reflection of the system’s efficiency; surgeon, nurse and operating room time is used to full capacity. It is also because salaries are lower in India and surgeons save time (at least in the free section of Aravind) by removing cataracts via the ‘Small Incision Cataract Surgery’ method

At the make-shift community clinic: measuring intraocular pressure using a tonometer

(similar to traditional extracapsular surgery) rather than the more sophisticated minimally invasive method of phacoemulsification. However, much of the cost reduction lies in the low cost of their intraocular lenses (IOLs) and surgical equipment.

Aurolab manufacturing facility Recognising the high cost of such equipment sold by multinational American and European companies, Aravind set up its own manufacturing plant in 1992 – the Aurolab. Through the same principles of efficiency and a diligent work ethic that is central to their hospitals, this facility has developed into an international business over the last 20 years. It now sells world-class IOLs and other surgical equipment to many countries around the globe, including to Europe and America. Due to this success it has recently moved to a large newlybuilt facility and as it is growing so quickly it has deliberately left the third and fourth floors empty for further expansion. In addition to cost, Dr Venkataswamy realised that another major barrier to his goal was the lack of ophthalmologists in India. In the UK, we have nearly 100

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ophthalmologists per million population. In India, this number is between four and 25 per million. Therefore, key to the success of his healthcare system was to maximise the use of his most scarce resource, the ophthalmologists’ time. In order to achieve this, there had to be a considerable amount of careful time management to ensure that the ophthalmologists never had to wait for a patient, a set of notes, their instruments etc. Today, Aravind has expanded to five self-sustaining eye hospitals in Southern India and 33 primary eye care centres seeing 1.4 million outpatients and performing 200,000 sight-restoring operations each year, two-thirds of which are free to the patient. As such, it is the largest eye care provider in the world. Although Dr Venkataswamy died in 2006, his founding principles are still strongly evident throughout Aravind.

Another world I was fortunate to visit Aravind for an internship in the summer of 2011. It was like entering another world. Everything was noticeably more orderly. Even the way the clinics are set up is designed to maximise

VISIT OUR WEBSITE FOR INDIAN DOCTORS

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Operating theatre: two surgeons are operating, with two tables each. There is one microscope per surgeon situated between the two beds

efficiency. Patients formed neat queues whilst they waited in silence to go through a well-designed series of stations progressing from registration to sight tests to eye examinations and finally counselling if an operation was required. Whilst waiting to be seen, patients are asked to stand immediately outside the consultation booths to ensure a quick transition as soon as the previous patient has finished so that the doctors’ time at work is never wasted. Doctors may see as many as 100 patients in a day. They work solidly from 7.30am to 6pm with just two 15-minute coffee breaks and a half hour lunch break during the day. The managers have even removed the chairs from the coffee room to encourage doctors to return quickly back to work rather than sitting down and socialising. The same principles of efficiency extend to the operating theatres. Instead of having just one table per operating theatre, they have two. This allows the nursing staff to prepare the next patient whilst the previous is still being operated. Each time the surgeon finishes a case, he simply moves his microscope across and immediately starts on the next. In the UK surgeons may frequently wait half an hour or more between operations before the next patient is ready for them; at Aravind they have managed to reduce this time to less than one minute and are frequently able to complete 15 cases per hour. Could the West learn from Aravind’s example? Concerns about patient safety are often raised when new measures to increase efficiency are discussed. However, it is important to remember that improving efficiency need not jeopardise patient safety. In fact, increasing efficiency can often go together with improved patient safety. For example, at Aravind they use dedicated operating rooms for each type of surgery; all cataract operations are done in Room 1, all cornea surgery in Room 2 etc. This streamlines the process and in addition decreases the chance of clinical incidents such as the wrong operation being performed or the wrong sets being prepared for surgery. EUROTIMES | Volume 18 | Issue 4

PAEDIATRIC SUB SPECIALTY DAY WEDNESDAY 9 OCTOBER 2013 Taking place during XXXI Congress of the ESCRS 5–9 October 2013 Amsterdam RAI, Amsterdam, The Netherlands Immediately preceding The 39th Meeting of EPOS in Leiden, The Netherlands from 11–12 October 2013.

Examination booths in the Outpatient Department for paying patients

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Torches and eye drops for basic examination of the eyes at the make-shift community clinic

So why does the NHS cataract service continue to be inefficient? Perhaps the pressure of the mounting cataract burden in the UK is not yet high enough to make streamlining of the service a priority. However, I wonder if the answer could also lie in the unique position occupied by the NHS in the UK healthcare market. Unlike private providers, which make a greater profit if they carry out more procedures, the NHS makes a greater loss the more procedures they fund. Mounting waiting lists result in more people turning to the private sector, which is a short-sighted way for the government to save money in the immediate future.

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eye on technology

THE MALYUGIN RING The leading driving force of innovation is the necessity to solve a problem

Courtesy of Soosan Jacob MS, FRCS, DNB

by Soosan Jacob MS, FRCS, DNB

Figures 2A, B: The Agarwal modification of the Malyugin Ring for use in eyes with small pupil and posterior capsular rupture

Courtesy of Boris Malyugin MD

Figure 1A: The T-26 model IOL with closed-loop haptics: the inspiration for the Malyugin Ring; Figure 1B: The haptic element catches the iris/anterior capsule during implantation

EUROTIMES | Volume 18 | Issue 4

ecognition of the intraoperative floppy iris syndrome (IFIS) by Chang and Campbell has allowed the surgeon to be forewarned in many cases regarding the possibility of intra-operative iris billowing, iris prolapse and progressive miosis. Of the many solutions available for tackling the small pupil secondary to IFIS and other causes, the Malyugin Ring (MicroSurgical Technology) has proven to be very popular. This is a transitory, square shaped implant, made of polypropylene with four circular scrolls that engage the pupillary margin at equidistant points providing a balanced stretch. It is implanted and explanted through an injector. Designed by Boris Malyugin MD (Cataract and Implant Surgery Department chief, deputy director (R&D, Edu) at the S.Fyodorov Eye Microsurgery Complex, Moscow), the Malyugin Ring has several advantages over traditional iris retractor hooks and other pupil dilating devices. Implantation and explantation are performed with an injector and are relatively simple. As the device is implanted through the main port, additional incisions are not required making the procedure less traumatic and easier. It can be inserted through regular incisions as well as through the 1.6-1.8mm microincisions used in MICS with a woundassisted technique of insertion and removal. The unique design of the device provides eight points of pupillary margin fixation equating it to eight iris hooks. It gives a

uniform, gentle dilatation to the pupil with lack of excessive stress at localised points, resulting in a better postoperative appearance of the pupil. The ring has a reliable clamping mechanism keeping the position of the ring stable throughout the procedure. “The main concept of the ring is the paper clip iris margin fixation. The idea for this design did not come from the real paper clip but from the haptic design of the T-26 model IOL which has two closed-loop haptics made from polypropylene (Figures 1A, B). Polypropylene is quite flexible as opposed to PMMA. To add some rigidity to the haptic, the loop at the centre of each haptic element was created. This IOL was the first IOL with yellow-tinted PMMA optics, that was designed back in the mid 90s. To date more than 1,000,000 of these lenses have been implanted in Russia and surrounding countries (ex-SU). In some cases, during implantation (positive pressure from the posterior segment, AC shallowing, etc), I experienced the problem of catching the anterior lens capsule and sometimes the iris. At some point of time, the idea of using this loop as a basis for the pupil expanding device occurred,” says Dr Malyugin. How did this innovation happen? Dr Malyugin answered, “The leading driving force of innovation, at least in my case, was the necessity to solve the problem. Like all other innovations, time just came to the point when it was necessary to take the step forward. This was so with the wheel which

was invented to solve the problem of high friction occurring with the sledge; and was so with oblique sails invented to increase manoeuvrability of the ships on the seas, enhancing ability to sail against the wind. There are also many other examples...” The Malyugin Ring is manufactured in two sizes – 6.25mm and 7.0mm – the smaller one being universal for almost any case with small pupil. The larger one is useful in IFIS. It may also be preferred by surgeons using the phaco flip technique for nucleus as well as when implanting an IOL with 6.5mm optic. On surgical pointers in insertion and removal techniques, Dr Malyugin advises: “Before inserting the ring it is better not to overfill the anterior chamber with viscoelastic to avoid pushing the iris against the anterior lens capsule. If posterior synechiae exist, they should be lysed first. With very small pupils, it is advisable to enlarge it to 3-3.5mm by stretching with two instruments and then inject the ring. The injector should be placed at the centre of the anterior chamber and the ring is expelled from it by pressing on the thumb button. As soon as the distal scroll is engaged with the iris, I prefer to start retracting the inserter while simultaneously injecting the ring. “Before removing the ring I prefer to disengage both proximal and distal scrolls, leaving the two lateral scrolls in place. While engaging the proximal scroll (curl) with the inserter hook, the second instrument is introduced through the paracentesis to lift this scroll above the iris and help position it on the injector plate. I think there are no major problems in insertion and removal.” The ring can also be used in cases with posterior capsular rupture without fear of dropping into the vitreous cavity by using the Agarwal modification proposed by Prof Amar Agarwal (Figures 2A, B). “We tie a 6-0 polyglactin vicryl suture to the leading scroll of the ring before implantation to secure a hold on the ring throughout the surgery. This prevents the expander device from inadvertently dropping into the vitreous during intra-operative manipulation,” says Prof Agarwal. Other advantages of the Malyugin Ring include lack of any sharp or pointed ends which can damage intraocular tissue, equidistant loops which give just the required dilatation without causing overstretching of the pupil, retention of iris tissue in the right plane without forward bunching thus giving adequate anterior chamber space for performing phaco manoeuvres and the balanced stretch and stabilisation of iris tissue provided in cases with IFIS. * Dr Soosan Jacob is a senior consultant ophthalmologist at Prof Agarwal’s Eye Hospital, Chennai, India – dr_soosanj@hotmail.com.

News

research

PATIENT OUTCOMES ESCRS research project will benefit both patients and surgeons by Dermot McGrath

n ambitious project which seeks to add patient-reported outcomes to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) database will shortly get under way thanks to funding from the ESCRS. This ESCRS project is the brainchild of Swedish ophthalmologist Mats Lundström MD, PhD, who led the initial development of EUREQUO, and Konrad Pesudovs MD, PhD, based at the Department of Optometry and Vision Science at Flinders University and Flinders Medical Centre, Adelaide, Australia. As Dr Lundstrom points out, EUREQUO has been very successful in collecting data on cataract surgery outcomes, with more than 1,000,000 cataract extractions having been reported to the database over the past three and a half years. However, the registry is still missing a vital part of the jigsaw in order to make the database truly comprehensive – patient-reported outcomes. “The concept of cataract surgery outcomes includes four different areas: visual outcome, refractive outcome, complications and patient-reported outcomes,” said Dr Lundstrom. “While the existing EUREQUO database includes the first three areas there is no data on patient-reported outcomes. This is a vital missing part which needs to be included if the purpose of the EUREQUO project is to completely reflect cataract surgery outcomes,” he added. The refractive surgery database has been slower in growth, but data is being entered in increasing volume, notes Dr Lundstrom. However, as with the cataract registry, patient-reported outcome remains a key missing ingredient of the database. “We were extremely happy with the adoption of our research project by the ESCRS. This essentially means that the ESCRS, a society very oriented towards technical issues within ophthalmic surgery, also recognises the importance of patientreported outcomes,” said Dr Lundstrom. The key to making the project work, explained Dr Lundstrom, is to ensure that the questionnaires that form the basis of the patient-reported outcomes have been developed and tested to the highest levels of validity. “In terms of content, a cataract surgery outcome questionnaire should evaluate activity limitations in daily life due to visual loss caused by cataract. The EUROTIMES | Volume 18 | Issue 4

“

We were extremely happy with the adoption of our research project by the ESCRS Mats Lundström MD, PhD

For reFractive and cataract Surgery

questionnaire should also be short and suitable for patients’ self-administration to streamline implementation. Patients need to fill in the questionnaire before surgery and three months after surgery. The questionnaire should be scored using Rasch analysis to provide legitimate interval scoring and constructed and validated by modern psychometric techniques,” he said.

Quality of life Dr Lundstrom said that a recent publication evaluating different available questionnaires identified the Catquest-9SF as the ideal questionnaire for cataract surgery and the Quality of Life Impact of Refractive Correction (QIRC) for refractive surgery. “Our aim is to offer the possibility for all surgeons and scientists to include patient-reported outcomes in their outcome studies and clinical practice. The project aims at performing translations and validation studies of these two questionnaires in a number of European languages. We hope to be able to offer the translated questionnaires as a free benefit for anyone who wants to use them in clinical practice. Our conviction is that tools for quality assurance in clinical practice should not be limited by licenses or copyrights.” Once the project is up and running, clinics or surgeons participating in the EUREQUO database will have the opportunity to connect the patient questionnaire to their data collection of outcomes for a limited period of time. This will enable surgeons to compare with other clinics on what disability level their patients are operated on and the magnitude of improvement after surgery. “Collecting data on patient-reported outcomes will also generate new information about patient satisfaction with vision and indications for cataract surgery. This will benefit both patients and surgeons,” concluded Dr Lundstrom.

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28.02.13 14:58

News

obituary

PROF JOSEPH COLIN

(1949-2013)

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EUROTIMES | Volume 18 | Issue 4

or the Romans, the manner of a person’s death was the most telling indication of their true character. Courage and dignity have been the landmarks of Joseph Colin’s last months. He was surrounded by beloved and loving children, with the permanent help and love of his wife Florence, and of his whole family. Till his last weeks he held meetings with his staff, even in his hospital room, to ensure continuity of his work. Joseph Colin was born in 1949 on the island of Ouessant, at the extreme west of France. From his birthplace he listened for his lifetime to the call of the sea and of new territories to search. He was one of these travelling islanders, taking back home the innovation seeds. His first master in ophthalmology was Doctor Renard from Brest who foresaw a brilliant career for his gifted and hardworking resident. During his residency Joseph came to Nantes, a stronghold in French ophthalmology. He made friends with many colleagues there, and especially with Georges Baikoff. Their friendship lasted ever since and induced emulation and mutual help between them. A very young professor at the age of 32 in Brest he also became head of the university Eye Department. He immediately used this position to create a dynamic and innovative school of ophthalmology. One of the first pioneers of refractive surgery, a world expert on corneal herpes, he developed our knowledge on cornea and anterior segment . When he left Brest for Bordeaux in 2000 he had created an ophthalmology light house at the extreme end of Brittany. He carefully prepared his succession and left the department in the hands of a smart and hard working chairperson, Béatrice Cochener, to follow the trail. In Bordeaux he continued a highly international educative and innovative life, together with many commitments in the ESCRS Board and several committees, as chair and Board member of the Société Francaise D’ophtalmologie (SFO), as chair of SAFIR (French implant and refractive surgery society). He also served the ISRS, and the ISCRS committee of the American Academy of Ophthalmology; he was involved in many post-graduate educational programmes in France and abroad. In his country he was made Chevalier de la Légion d’Honneur.

Joseph Colin

There is not enough room here to fully cite his awards, contributions and achievements. In the ESCRS we shall remember Joseph for his original thinking, for many tasks he successfully carried out, for his continuous dedication to creation and to education. Different societies, in France and worldwide, will pay the specific tribute they owe him. His personal creativity covered many different fields, from his initial work on corneal herpes to recent new laser applications in anterior segment surgery. Joseph was extremely motivated by this new approach, conducted with David Touboul. With his brilliant team in Bordeaux he developed a special programme on keratoconus, with the help of Florence Malet, his wife and an internationally renowned contact lens specialist. His work on intra-corneal rings is a landmark of corneal knowledge and corneal diseases treatment. To his family, to his children, to Florence we express our deepest sympathy and love. Their father and husband was one of our first rank companions. We shall badly miss his bright, active and enthusiastic personality. To us he is – and will stay -a smiling, creative, team leader, ophthalmologist and friend. Au revoir Joseph. Philippe Sourdille

News

john henahan

YO WRITING PRIZE

Entries are invited for the John Henahan writing competition

Oliver Findl, chairman of the Young Ophthalmologists Committee with Sorcha Ní Dhubhghaill, winner of the 2012 John Henahan Prize and Emanuel Rosen, chairman of the ESCRS Publications Committee

he theme for this year's John Henahan Prize for Young Ophthalmologists is “Recollections of My First Intraocular Surgery”. Young ophthalmologists, who must be members of the ESCRS and aged 40 years or under, are invited to submit entries. The winner of the prize will receive a €1,000 travel bursary to the XXXI ESCRS Congress in Amsterdam, The Netherlands, which takes place from 5-9 October 2013 and a specially commissioned trophy. Entries should be 900-1000 words and should be sent to Colin Kerr, executive editor, EuroTimes at colin@eurotimes.org. The closing date for entries is Friday 21 June 2013. The judges are Emanuel Rosen, chairman ESCRS Publications Committee; Jose Guell, EuroTimes medical editor; Oliver Findl, chairman ESCRS Young Ophthalmologists Committee; Sean Henahan, editor EuroTimes; Paul McGinn, editor EuroTimes; and Robert Henahan, contributing editor EuroTimes. The prize is named in honour of the late John Henahan who edited the magazine from 1996 to 2001.

High standard “The two main criteria for consideration by the judges are the clinical content of the story and the writing style, punctuation and grammar which should reflect the high standard of material EUROTIMES | Volume 18 | Issue 4

published in EuroTimes,” said Dr Rosen. Last year’s winner was Sorcha Ni Dhubhghaill, a third-year basic trainee at St Vincent's University Hospital, Dublin, Ireland. Dr Rosen said the standard was extremely high and the winning essay captured the essence of the practice of medicine. “Every physician must always be aware of the big picture not just an ophthalmic complaint,” said Dr Rosen. “History taking is the fundamental requirement of being a good doctor and then every doctor must have an ability to observe clinical details – in this case a patient with AMD who developed a stroke not at first obvious and easily missed for assumed tired inattention,” he said. As an undergraduate in Trinity College Dublin, Ireland, Sorcha became interested in ophthalmology after an attachment in the Royal Victoria Eye and Ear Hospital in Dublin. After graduating in 2005, she did her PhD in age-related macular degeneration with Prof Humphries in the Genetics Department in Trinity College where she also worked as clinical tutor for the medical students in the Eye and Ear Hospital. She returned to clinical ophthalmology in 2010 and has since worked to further her clinical and surgical skills. In her spare time she is a competitive archer and is learning Dutch to give her the mobility to gain experience in other European centres of excellence. ad-half page vertical-Eurotimes-ENG EyeCee-1303v01 pva.indd 1

06.03.13 12:15

Amsterdam

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Feature

RESIDENT’s DIARY

OLDEST RESIDENT

In the emergency room it’s about keeping many balls in the air – and keeping the circus outside

ust about halfway through our residency it happens, abruptly, unexpectedly. On a given morning, sometime during the third year of training, our schedule indicates that we’re the chief resident in the Emergency Room of the Rotterdam Eye Hospital. In our hospital, the chief resident in the ER is referred to as “De Oudste,” which literally means “The Oldest.” This is a relative term, since we’re only older than the other residents working in the ER that morning, but it sounds good. When we make the sudden transition from junior resident to Oudste, our tasks multiply. Although patient care remains our most important job, we’re also there to assist the four junior residents, manage patient flow and serve as a gateway for tertiary referrals. The Dutch are highly organised, efficient workers who hate chaos, so the Oudste is also expected to manage and motivate the whole ER team. Having internalised this mentality, I remind myself: “It’s not a circus; it’s an ER. Make sure it stays that way.” That’s easier said than done. The four other residents can come to ask for advice regarding any patient they see. Nurses from the inpatient ward wait outside our exam room door, requesting clarification of patient care instructions prescribed by other doctors. Nurses from the patient phone hotline drop by for prescription refills for patients who have run out of eye drops. General practitioners call to discuss patients who are sitting before them in their examination room. General ophthalmologists call to ask whether they can refer their patients immediately, which of course they can. Subspecialists in our own hospital refer patients who need to be fast-tracked to the inpatient ward or to the operating room. And all the while, there’s a medical student sitting next to us on a little stool, trying to find a manageable way to both learn as much as possible and stay out of the way. While I’m examining a retinal detachment, Itsje, a junior resident, walks into my exam room. “My patient’s IOP won’t decrease. I’ve already administered all the standard meds. What next?” she asks, looking at me as though I’ve been an ophthalmologist for 25 years. I try to play the part. “What’s the etiology? Uveitis? Steroid response? PosnerSchlossman? Closed angle? Neovascularisation?” I ask. “Um, I’m not sure,” she responds. “I’ll take another look.” “Okay, report back to me when you have some more information.” Assisting the juniors is my favorite aspect of being the Oudste. It’s a study of contrasts: at every moment, I am lifted by the realisation that I have learned so much during the past 2½ years while being confronted by the fact that we all have so much to learn before we graduate. As a first- and second-year resident, I always found it fantastic to be able to discuss a patient with the Oudste. They seemed to know so much, to have an answer for every question, a solution for nearly every problem. But not for everything. What I now realise is that a great deal of what I am unsure about cannot be found in the literature. Instead, we have to rely on judgment and feeling that can only come with experience. So, I don’t hesitate to refer junior residents and their

EUROTIMES | Volume 18 | Issue 4

patients to the senior subspecialists, with instructions to tell me what the answer was. Antje, a nurse from the inpatient ward, is waiting to ask me something. “Do you think Dr Bootsma really meant hourly eye drops, day and night?” She shows me the patient’s record. The instructions seem clear to me. “Yes, acanthamoeba is nasty and painful and terrible. Hourly drops.” A general practitioner calls regarding a patient sitting before him. “She has a red, painful left eye. No contact lenses. Unknown herpes simplex status. No history of uveitis. No trauma. Possible visual loss.” There’s only one appropriate response in this case. “Okay, well, send her in. We’ll be here all day.” Meanwhile, my patient with the retinal detachment is waiting. While I’m completing the documentation for surgery, one of our secretaries interrupts. “A general ophthalmologist called regarding a wheelchair-bound patient who was referred from the nursing home with a huge corneal ulcer in her best eye. Are we willing to assume responsibility for her care?” “Yes.” Another phone call, this time from a senior subspecialist. “Hi, this is Dr van Dijk from glaucoma. My patient has a superior retinal detachment in his best eye – can you make sure he makes it to the operating room, today?” Oh yes, and there are also about 80 ER patients who would like to be seen before the nightfall. Ideally, each patient should be treated before the end of normal clinic hours, so that the other 20 residents in the hospital don’t need to come assist after having finished their own specialist clinics or

Image by Eoin Coveney

by Leigh Spielberg MD

surgical cases. The other residents call before they come to the ER. “Do you need any help?” they ask, hoping that the answer will be, “Nope, we’ve got it all under control here!” But it takes a while before a new ER Oudste can say that with reliability. The first few times that anyone is the Oudste, the waiting room is still overflowing at the end of clinic hours. The patients get restless, the secretaries become unhappy and the younger residents get stressed out. Time-management, multi-tasking, and delegating responsibility become the keys to success, and it takes quite a while to learn it all. After all, we’re all just young docs with book smarts, a few years out of medical school and still new to many of the realities of busy practical work.

Journal Watch High rates of visual problems among veterans A majority of soldiers who suffer traumatic brain injuries following explosive blasts will manifest vision problems. A new study compared visual symptoms and function in two groups, patients whose brain injury was associated with a blast wave and those whose injury was associated with direct head trauma associated with the blast. Vision dysfunction occurred after all severities of traumatic brain injury. However, visual acuity remained normal in most of these patients and was not a reliable predictor of visual outcome after brain injury. The mechanism of injury, blast or non-blast, generally did not appear to result in different frequencies or types of visual dysfunction. However, the investigators did observe higher frequencies of light sensitivity in the blast-related traumatic brain group. Patients in the nonblast-related group appeared to have a higher rate of saccadic dysfunction. The reasons for these differences

are not known. The high rates of vision complaints and oculomotor defects in both groups of patients highlight a need for a thorough eye examination for any patient with a history of traumatic injury of any severity, the researchers conclude. n GL Goodrich et al., Optometry & Vision Science, “Mechanisms of TBI and Visual Consequences in Military and Veteran Populations”, February 2013 Volume 90 - Issue 2 - p 105–112.

Feature

industry news

Recent developments in the vision care industry

Safer surface ablation option

Laser cataract surgery patent

Digital retinal camera

Canon Europe has announced an addition to its range of digital retinal cameras with the launch of the CR-2 Plus AF, a Non Mydriatic retinal camera that includes automatic functions and Fundus Autofluorescence (FAF). “The new device will allow medical staff and optometrists to provide improved retinal disease diagnosis in an efficient and noninvasive way,” said a company spokeswoman. “The CR-2 Plus AF builds on Canon’s existing portfolio of cameras that include FAF imaging technology, with the addition of automated functions to improve the usability of its various modes. The new device will improve the efficiency of medical workflows thanks to autofocusing, auto shot and auto exposure modes that eliminate the need for constant manual adjustments by medical staff,” she said. n www.canon-europe.com/medical

Orca Surgical, developer of EBK, a new treatment procedure for surface epithelium removal, has announced positive results of a clinical study José L Güell on the safety and efficacy conducted by Dr José L Güell at the IMO Center in Barcelona. Dr Güell is an associate professor of ophthalmology at the Autonoma University of Barcelona since 1991. The study, in which Orca Surgical’s the Epi-Clear™ device was used, suggests that doctors should take into consideration treatment bed condition and risk of corneal trauma when performing surface ablation. “The Epi-Clear is an excellent device for de-epithelisation in PRK, CXL and epithelial biopsies,” says Dr Güell. “The rate of re-epithelisation is much faster than with other methods.” n www.orcasurgical.com

OptiMedica has announced that the US Patent & Trademark Office (USPTO) has granted the company a patent relating to the fundamental technology underlying laser cataract surgery. The OptiMedica patent contains broad claims and describes a 3-D image-based femtosecond laser system for performing anterior capsulotomy and lens fragmentation during the cataract procedure. “We are gratified to see the USPTO recognise the novelty of our invention and its practical realisation in OptiMedica’s Catalys Precision Laser System,” said Dr Mark Blumenkranz, professor and chairman of the Department of Ophthalmology at Stanford University and an OptiMedica Board member. “Laser cataract surgery is an exciting new breakthrough in ophthalmology, and it has been an honor to be at the forefront of its advance,” said Dr Blumenkranz. n www.optimedica.com

Ophthalmic surgical devices

ALSANZA, a German manufacturer of medical and pharmaceutical liquids since 1960, is now extending its activities to ophthalmology, and focus on producing ophthalmic surgical devices . “ALSANZA has expertise in innovation, development, manufacturing and distribution,” said a company spokeswoman. “With experienced specialists on board, different sites of manufacturing and supportive investment, ALSANZA is a new partner of choice, offering high-quality innovative ophthalmic products for patient satisfaction,” she said. n www.alsanza.com

Seamless vitrectomy

A series of support instruments around the Uno Colorline Trocar system will help to ease work procedures in seamless vitrectomy, according to Geuder. Three instruments have been developed in cooperation with Prof Dr med Lars-Olof Hattenbach, Ludwigshafen. The “Shark” bulb retaining ring is a ringshaped instrument reinforced with small “shark teeth” which fixates the eyeball during the insertion of the trocars without damaging the conjunctiva. The “Triangle” scleral depressor can be used for careful denting and secure holding without provoking rupture to the conjunctiva. With the “Horse Shoe” instrument, a lightning-quick extraction of the trocars is possible. Further accessories are available including the seam-aid model “Bonn”, for easy stitching without opening the conjunctiva as well as the Bartz-Schmidt trocar occlusion forceps. “This is suitable for the removal of trocars, for trocar occlusion with liquid-air-exchange and for bulb rotation,” said a company spokeswoman. n www.geuder.com

From the Archive Improved options for presbyopes in the near and distant future

ontinuing advances in IOL design are bringing the day closer when virtually all ametropes, presbyopes and cataract patients will be able to achieve complete and uncompromised spectacle independence through refractive EUROTIMES | Volume 18 | Issue 4

lens exchange, said I Howard Fine MD, Casey Eye Institute, Oregon Health and Science University, Eugene, Oregon. The recent availability of new multifocal and accommodative IOLs together with improvements in the

techniques and technology of cataract extraction have already transformed what was once a treatment for advanced cataracts into a procedure that can now be used electively in the early stages of presbyopia, according to Dr Fine. “Cataract surgery has had improved outcomes through lower energy, smaller incisions and adjunctive astigmatic techniques. As a result of its increased accuracy and safety it has undergone a natural evolution into refractive surgery,” he said.

From EuroTimes, Volume 13, Issue 4, April 2008, p10

Review

JCRS Highlights Journal of Cataract and Refractive Surgery

Biometry in high myopia High myopes are more likely to develop cataract, glaucoma, myopic maculopathy and retinal detachment. Therefore, accurate biometric measurements in highly myopic eyes are of crucial importance for assessing the severity, progression and associated pathologic changes as well as for calculating IOL power. But which method is the most reliable? Researchers compared the repeatability and accuracy of optical biometry (Lenstar LS900 optical low-coherence reflectometry [OLCR] and IOLMaster partial coherence interferometry [PCI]) and applanation ultrasound biometry in 33 highly myopic eyes. The mean SE was −11.20 D ± 4.65. The coefficient of variations for repeated axial length measurements using OLCR, PCI and applanation ultrasound were 0.06 per cent, 0.07 per cent, and 0.20 per cent, respectively. The limits of agreement for axial length were 0.11mm between OLCR and PCI, 1.01mm between OLCR and applanation ultrasound, and 1.03mm between PCI and ultrasound. The ACD values were 0.29mm, 0.53mm, and 0.51mm, respectively. These repeatability and agreement results were comparable in eyes with extreme myopia or posterior staphyloma. The mean radius of corneal curvature was similar between OLCR and PCI (7.66 ± 0.24mm versus 7.64 ± 0.25mm). The researchers conclude that optical biometry provided more repeatable and precise measurements of biometric parameters, including axial length and anterior chamber depth, than applanation ultrasound biometry in highly myopic eyes. n P

Shen et al., JCRS, “Biometric measurements in highly myopic eyes”, Volume 39, Number 2, pp 180-7.

Age and refractive outcome Previous studies suggest that age may play a role in the outcomes of refractive surgery, with older patients achieving more refractive change for the same attempted dioptric correction. Researchers in The Netherlands performed a study to evaluate the influence of patient age on postoperative clinical outcomes in a large population of consecutive moderate to high myopic LASIK treatments of −5.00 D or more of spherical equivalent using the Schwind Amaris laser system. The study of 612 eyes indicated that patient age affected postoperative outcomes in a subtle, yet significant manner. The researchers suggest that an age-dependent adjustment toward greater attempted correction in younger EUROTIMES | Volume 18 | Issue 4

patients and less intended correction in older patients may help optimise refractive outcomes. n M

Luger et al., JCRS, “Influence of patient age on high myopic correction in corneal laser refractive surgery”, Volume 39, Number 2 204-210.

Femto KAMRA Many refractive surgical solutions are appearing for the treatment of presbyopia, the most common refractive error, affecting more than two billion people worldwide. Technological advances include femtosecond laser technology and corneal inlays as a removable non-lensbased surgical approach for the corneal compensation of presbyopia. A recent study looked at the two-year postoperative safety and efficacy outcomes after monocular Kamra corneal inlay implantation in femtosecond laser–created corneal pockets of 24 emmetropic presbyopic patients to improve near and intermediate vision. After 24 months, the mean binocular UNVA improved from 20/50 to 20/25; 20 patients (83 per cent) had a UNVA of 20/25 or better. The mean binocular UIVA was 20/20. The mean UDVA was 20/20 in the surgical eye and 20/16 binocularly after 24 months. Contrast sensitivity under photopic and mesopic conditions remained in the range of the normal population. No patient had detectable central visual field defect. No inlay was explanted. No inflammatory reactions were observed. The ECC and CCT remained stable. The researchers conclude that corneal inlay implanted in femtosecond laser–created pockets was effective and safe for the corneal compensation of presbyopia in emmetropic patients after 24 months. Seyeddain et al., JCRS, “Femtosecond laser-assisted small-aperture corneal inlay implantation for corneal compensation of presbyopia: Two-year follow-up”, Volume 39, Number 2, 234-41.

JCRS SYMPOSIUM Focus on Technique:

What the Anterior Segment Surgeon Needs to Know in 2013

Monday, April 22, 2013 1:00–2:30 PM

Moderators: William J. Dupps Jr, MD, PhD, Nick Mamalis, MD • Femtosecond Laser–Assisted Cataract Surgery:

Tales from the Learning Curve Jason J. Jones, MD, William B. Trattler, MD

n O

• Microincision Glaucoma Devices: Who Should Use Them and When? Reay H. Brown, MD, Steven D. Vold, MD • DMEK Versus DSAEK Francis W. Price Jr, MD, Mark A. Terry, MD • Collagen Crosslinking Technique: What Does the Evidence Support and Where Are We Headed? Peter S. Hersh, MD, Theo Seiler, MD, PhD

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

During the ASCRS Symposium on Cataract, IOL and Refractive Surgery San Francisco, California, USA

The latest clinical education at my fingertips www.ascrs.org

What do you want for your career? ASCRS has it. • In-depth educational programming • Web seminars, clinical reports, daily discussions, podcasts, and the IOL calculator • Subscription to EyeWorld magazine, Ophthalmology Business magazine, and the Journal of Cataract & Refractive Surgery

• Hundreds of surgical videos, online symposia, and paper sessions in the ASCRS MediaCenter • Unique access to the latest techniques and technologies in ophthalmic surgery

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Additional Programming Cornea Day ASCRS Glaucoma Day ASOA Workshops Technicians & Nurses Program

Book Early for the Best Rates

Housing Opens Friday, April 19, 2013

Feature

EYE ON TRAVEL

on the water

Hamburg exudes spa-like atmosphere of relaxation and understated elegance by Maryalicia Post

Town Hall

elegates travelling to Hamburg for the 13th EURETINA Congress in September will have the chance to enjoy one of Germany’s most stylish – yet relaxed – cities. Hamburg exudes such an atmosphere of well-being, of understated elegance, that the capital of the Free and Hanseatic State of Hamburg could be mistaken for a spa town. Jungfernstieg, the broad boulevard overlooking the inner Alster Lake, is where affluent families once strolled on Sunday with their daughters (Jungfern). Today it is where the most exquisite boutiques cluster around a luxurious department store, the Alsterhaus. From the terrace opposite the Alsterhaus, sturdy-looking sightseeing boats depart to explore the inner and outer Alster Lakes, the historic warehouse district, the Elbe River, and Hafen City, Hamburg’s ambitious new residential and business quarter. EUROTIMES | Volume 18 | Issue 4

Alster boat tour

It’s no coincidence that so much of Hamburg can be viewed from the water. Hamburg’s wealth – and it is Germany’s wealthiest city – began with the sea. In the Middle Ages, its convenient port made it one of Europe’s most important trading centres. Presently, the port is Europe’s second most important (after Rotterdam) and the waterways still offer the best tourist experiences in the city.

Hamburg sightseeing highlights:

Boat tour: A one-hour boat tour of the Alster is the best way to appreciate Hamburg's picturesque skyline. There are few skyscrapers, but its church spires and the tower of the neo-renaissance Town Hall give it shape. The view is especially lovely at sunset. If you have more time and are there between April and early October, take the cruise that runs from the Jungfernstieg to

Winterhuder Fahrhaus. It criss-crosses the Alster, offering glimpses of the east and west banks of the lake. You can hop off at any of nine stops along the way to sightsee or have a coffee in one of the waterside cafes. Hop aboard the next boat to resume your voyage. (This tour runs only from 31 March until 6 October 2013). For details, visit: www.alstertouristik.de. Hafen City: Europe’s biggest building site, this waterfront development project has been under construction since the master plan was approved in 2000. Completion is expected in 2025. This immense undertaking will almost double the size of Hamburg's business and residential quarters. In a welter of innovative buildings, the star is the new concert hall, the Elbphilharmonie by the Swiss architects Herzog & de Meuron. Built on top of an abandoned brick warehouse, the glass superstructure is 12 stories high on one side and 18 on the other. It looks like an enormous wave or a ghostly ship in full sail. It's run considerably over time and over budget, but the building is now scheduled for completion in 2014. Best views of it are from the 13-metre high information tower on site, but the glimpses from the water and the hop-on, hop-off bus tour will give you an idea of the scale of the work. Town Hall: You can’t miss seeing the facade of the flamboyant Town Hall that stands in a lively square a block back from the Alster lakefront. The building is said to have 647 rooms; however, as a room in the tower was only discovered by accident in 1971, there may be more. The Town Hall is the seat of Hamburg’s government – its Parliament and Senate – but the ornate lobby is open to the public. St Michaelis Church: One of Hamburg's five Protestant churches, this is the city's best loved icon. Since its completion in 1667 it has been destroyed by lightening, fire and World War II bombings, but restored each time. Another church, St Nicolai, has also been destroyed and rebuilt several times in its long history but was left in ruins after World War II as a reminder of the consequences of war. In 2005 a lift was installed to take visitors to a 75.3 metre-high platform inside the spire from which to enjoy a view over Hamburg and particularly of the nearby Speicherstadt, literally the “city of warehouses.” Hier wohnte: Keep an eye out, as you walk in Hamburg, for the glint of what looks like a brass cobblestone set in the pavement. It will be a “stolpersteine,” a memorial stone for an individual victim of the Holocaust. Installed in front of the victim’s last known residence, the inscription begins with “Here lived,” followed by the person's birth date, the name of the camp in which he or she perished and, if known, the date of death. Often stolpersteine are in groups

Shopping in Hamburg

representing whole families. To date, well over 2,000 of these individual memorial stones have been installed in Hamburg. Many of them can be seen in the University district. More than 30,000 stolpersteine have already been laid in European cities and towns and the work of tracing the victims is ongoing. While the vast majority of the stones commemorate Jews who perished in the Holocaust, others are in memory of homosexual, political or religious victims. Gunter Demnig, the artist who conceived and carries out this project, hammered the first memory blocks into the pavement in Berlin in 1996. For details, visit: www.stolpersteine-hamburg.de.

Day out to Lubeck An UNESCO Heritage Site, Lubeck is only an hour from Hamburg by train or car. Worth visiting for its Old City, medieval gate, Gothic city hall, the St Marien Church and Buddenbrook Haus, childhood home of the writers Heinrich and Thomas Mann. Readers of Thomas Mann's Nobel Prize winning novel, Buddenbrooks, will recognise the house as the setting for the book. In 1991, the Mann house became a museum. Best souvenir of Lubeck? Chocolate-covered marzipan from Niederegger, the long-established cafe and shop opposite the town hall. For details, visit: www.buddenbrookhaus.de.

Hamburg’s new quarter

E R IP FR EA SH ES 3 Y BER INE A EM R M RT FO

ESCRS

Review

Book REVIEW

EYE CHAT Exclusive interviews Up to date information Problem solving

Correct power crucial

Best outcomes for refractive surgery patients Dr Oliver Findl talks to refractive surgery pioneer Jack Holladay about things the surgeon can do, and mistakes that can be avoided, in order to get the best outcomes for patients undergoing refractive surgery.

podcast

www.eurotimes.org

Also available on iTunes

EUROTIMES | Volume 18 | Issue 4

Scan this QR code to gain access to EuroTimes podcasts

Patients have long come to expect to dispose of their glasses after cataract surgery. Having good uncorrected distance visual acuity is sometimes even valued more than the improvement in vision caused by the removal of the cataract itself. So, accurately calculating the correct IOL power is a crucial step in the patient’s perception of overall success of cataract surgery. The techniques currently used to calculate the IOL power have been highly refined during the past 30 years. A significant amount of this work was done by Dr Kenneth J Hoffer, who has consolidated all the relevant information into one book, IOL Power, published by Slack Incorporated. Formatted along the lines of the IOL power courses that Dr Hoffer has taught at AAO and ASCRS meetings over the past 36 years, this book is a crucial read for every cataract surgeon – and an excellent way to help avoid unpleasant post-op refractive surprises. Most surgeons are familiar with the frequently used formulas by Hoffer, Holladay and Haigis. These allow for rapid and accurate calculations for the vast majority of eyes. But how did these formulas come to be? And, more importantly in clinical practice, how can they best be used for “non-standard” eyes? Developing a thorough understanding of the background and significance of each measurement helps the clinician avoid the pitfalls that could ultimately lead to a very unhappy patient. IOL Power is divided into two sections. Section I, “Basics and Accurate Biometry,” begins with an admission by the author that “this science is rather dry.” It does indeed seem quite technical to a beginner, although each component is interesting and very useful to the surgeon looking to perfect his or her outcomes. By breaking the process down into manageable components, the author makes it all more accessible. The ultrasound, A-scan biometry, laser interferometry and the IOLMaster, corneal power, automated keratometry, the pentacam and corneal power measurements and IOL position are each discussed in their own chapter(s). For example, following an introduction to axial length measurements with the ultrasound, the important differences between immersion and applanation techniques are discussed. A-scan biometry is explained in detail. This allows the reader to select those aspects of

the procedure of greatest interest, or those in which (s)he needs some fine tuning. Section II, “Formulas and Special Circumstances,” goes further to discuss the calculations in non-standard situations. “It is important to understand the history of IOL power formulas so that one gains an understanding of the vagaries of today’s modern formulas,” begins his section. Since the theoretical beginnings in the late 1960s, five generations of formulas have been introduced, with the later formulas allowing optimisation for both IOL style and surgeon. Further, the use of different formulas is encouraged, depending on the eye’s axial length: for eyes smaller than 24.5mm, use the Hoffer Q; for those 24.5 – 26.0, use the Holladay 1; and for those >26.0mm, the SRK/T should result in the best outcomes. Complicating factors such as the postoperative effective lens position are also discussed. This section continues with discussions of axial length measurement in atypical eyes. The authors are very straightforward about the difficulties that can be encountered. Staphyloma eyes “may be the most frequent condition in which a precise AL measurement may not be obtained.” This book is recommended for residents during their cataract surgery rotation; fellows and young ophthalmologists who are still learning the complexities of the calculations; and more experienced surgeons looking to fine-tune their results.

BOOKS EDITOR Leigh Spielberg PUBLICATION IOL POWER AUTHOR KENNETH J HOFFER PUBLISHED BY SLACK INCORPORATED If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

The Premier Innovative Educational Retreat for Anterior Segment Surgeons and Administrators Make your advance reservation today.

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Reference

cAlENDAR oF EVENTs

Dates for your Diary

April

May

4th World Congress on Controversies in Ophthalmology (COPHy)

ASCRS•ASOA Symposium and Congress

ARVO

www.ascrs.org www.asoa.org

Black Sea Ophthalmology Society & ESCRS Academy Meeting

11th SOI International Congress

2013

4-7 BUDAPEST, HUNGARY

www.comtecmed.com/cophy/2013/

2013

19-23 SAN FRANCISCO, USA

2013

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

15-18 MILAN, ITALY

www.congressisoi.com

24-26 TBILISI, GEORGIA www.bs-os.org

The Visions of Gullstrand – 600 year jubilee

31-2 JUNE LANDSKRONA, SWEDEN www.feinpat.hemsida24.se

June European Society of Ophthalmology (SOE) 2013

2013

June

July

10th Congress SEEOS and 3rd Congress of Macedonian Ophthalmologists

International Meeting on Anterior segment surgery

Indian Intraocular Implant & Refractive Surgery Convention

2013

8-11 COPENHAGEN, DENMARK www.soe2013.org

2013

20-23 OHRID, MACEDONIA

22-23 VERONA, ITALY

6-7 CHENNAI, INDIA

www.femtocongress.com

www.iirsi.com

www.zom.mk

July

September

26th APACRS Annual Meeting

5th World Glaucoma Congress

13th EURETINA Congress

www.apacrs.org

www.worldglaucoma.org

14th International Paediatric Ophthalmology Meeting

2013

11-14 SINGAPORE

2013

17-20 VANCOUVER, CANADA

12-13 DUBLIN, IRELAND

2013

26-29 HAMBURG, GERMANY www.euretina.org

Email: hmurphy@materprivate.ie

October

November

ESCRS Glaucoma Day

XXXI Congress of the ESCRS

AAO Annual Meeting

93rd SOI National Congress

www.escrs.org

www.aao.org

www.congressisoi.com

2013

4 AMSTERDAM, THE NETHERLANDS

4th EuCornea Congress

4-5 AMSTERDAM, THE NETHERLANDS www.eucornea.org

2013

5-9 AMSTERDAM, THE NETHERLANDS

2013

16-19 NEW ORLEANS, USA

2013

27-30 ROME, ITALY

EPOS/WSPOS Paediatric Sub Speciality Day 9 AMSTERDAM, THE NETHERLANDS www.wspos.org

Advertising Directory: Alcon Laboratories: Page: OBC; A.R.C. Laser Ag: Pages: 19, 21; ASCRS/Eyeworld: Pages: 42, 43, 47; Benz Research & Development: Page: IBC; Croma-Pharma GmbH: Pages: 12, 37; D.O.R.C. International BV: Page: 11; Haag Streit Ag: Page: 31; Katena Products Inc.: Page: 29; Maya Idee s.r.l.: Page: 25; Medicel Ag: Page: 17; Medicontur International SA: Page: 7; Moria: Page: 9; Nidek: Page: 15; Oculus Optikgerate GmbH: Page: 16; Oertli Instruments AG: Page: IFC; Schwind: Page: 23; Technolas Perfect Vision: Page: 3; Ziemer Ophthalmic Systems: Page: 35

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