EuroTimes Vol. 19 - Issue 11 by EUROTIMES

SPECIAL FOCUS CATARACT & REFRACTIVE CORNEA

GOOGLE’S SMART CONTACT LENSES HERALD NEW AGE IN HEALTH MONITORING Nov 2014 | Vol 19 Issue 11

PAEDIATRIC OPHTHALMOLOGY

SEVERE MYOPIA EPIDEMIC TRIGGERED BY MANY YEARS SPENT IN EDUCATION

The Future of Cataract Surgery

The Essence of Perfection

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Conor Ward Senior Designer Janice Robb Designer Lara Fitzgibbon Circulation Manager Angela Morrissey Contributing Editors Howard Larkin Dermot McGrath Roibeard Ó hÉineacháin Contributors Maryalicia Post Leigh Spielberg Pippa Wysong Gearóid Tuohy Priscilla Lynch Soosan Jacob Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

CONTENTS SPECIAL FOCUS

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2013 and 31 December 2013 is 40,878.

GLAUCOMA

CATARACT & REFRACTIVE 4 Cover Story: With more advances in technology, where will cataract surgery be in 30 years?

8 A lot done, a lot more still to do

P.20

20 Is vascular disease

playing a role in normaltension glaucoma?

21 Cerebrospinal fluid

pressure could be a critical parameter

22 The 10-10-10 Challenge – potential for major worldwide impact

10 IOLs with innovative

designs now in clinical tests

24 New indicators may

help detection and monitoring of disease

12 Award-winning essay

gazes into the future of ophthalmology

13 Nomograms can reduce laser energy, but diagnostics are crucial

RETINA

REGULARS

25 Surgeon demonstrates

33 JCRS update

technique to avoid dangerous complication

27 Patients report positive

FEATURES

12-month results for subretinal implant

CORNEA 15 New therapies possible for a wide range of corneal diseases

OCULAR 29 Clinical results prove

16 Endothelial cell loss data may be giving an unclear picture

31 Education and behaviour

a health mission with smart contact lenses

driving myopia epidemic, claims study

19 Study highlights need for

34 Eye on History 35 Industry News 36 Review 39 Book Reviews 40 Calendar

encouraging for uveal melanoma

PAEDIATRIC

18 Tech giant Google on

same-day evaluations due to surgical risks

™

32 Management of the

posterior capsule crucial in cataract cases

Included with this issue... Bayer HealthCare and Laboratoires Théa supplements

CORRECTION: In EuroTimes Volume 19 Issue 6, June 2014, page 47, in an article titled 'Control And Tame', Dr Soosan Jacob discussed how the capsulorhexis should always be well controlled. In her article, Dr Jacob stated: "AC is deepened with cohesive OVD and the flap unfolded and laid flat. A forceps grasps the flap at the very root of the tear and pulls centrally to redirect the tear inwards." The article should have stated: "AC is deepened with cohesive OVD and the flap unfolded and laid flat. A forceps grasps the flap at the very root of the tear and pulls first backwards and then centrally to redirect the tear inwards." We thank Mr Steven Naylor, FRCOphth, for his correspondence pointing this out.

EUROTIMES | NOVEMBER 2014

EDITORIAL A WORD FROM ROBERTO BELLUCCI MD

PAST, PRESENT & FUTURE European ophthalmologists must learn from the achievements of their colleagues in the past to help them build for the future

he recent Congress of the ESCRS held in London As a society, we are very lucky to have not only many was attended by 8,132 delegates, the biggest ever experienced ophthalmologists giving us their time to help attendance in the history of the Society, and I would us develop an excellent scientific programme every year, but like to thank every single doctor and colleague who we are also very fortunate to have so many talented young took part in it. ophthalmologists taking part in our activities. As I stated in my address at the opening One of these young ophthalmologists, Dr Lampros ceremony, our community gathers at home once a year – and Lamprogiannis, was the winner of the 2014 John Henahan the name of this home is the ESCRS. Like every home, we are Prize for his essay ‘How Do I See Cataract Surgery in 30 constantly looking for improvements and the strength of our years?’ and in this month’s EuroTimes you can share Dr society is that we have continued to renovate and refurbish. Lamprogiannis’s vision of the future. I am very proud to be the president of such a great Our Cover Story also addresses this theme and it includes organisation that uses past knowledge to build a brighter some fascinating insights into how our specialty might develop future for our profession and for our young delegates. in the future. And this month’s EuroTimes gives a perfect example of My personal view is that the cataract procedure will be more the ESCRS’s role in bridging past and future. To stress this automated and the surgeon will act partially as a consultant, point, Dr Günther Grabner’s Ridley Medal lecture explaining options to patients and in London has shown us how much can change over overseeing procedures carried out I am very proud to be the 40 years. largely by machines. This does not president of such a great Dr Grabner paid tribute to early pioneers at the mean that we will no longer need 2nd University Eye Clinic in Vienna, where he skilled practitioners. As my colleague organisation that uses trained, such as Eduard Jaeger, Karl Koller and Oliver Findl points out, patients will past knowledge to build Ernst Fuchs, personal mentors such as Prof Hans still want personal care and to be a brighter future for our Slezak, Dennis Shepard MD, Santa Maria, and his taken care of in a personal fashion. teachers at the FI Proctor Foundation, UCSF, such as However, the increasing role of profession and for our Dick O’Connor, Gil Smolin MD and Mitch machinery in helping the surgeon’s young delegates Friedlaender MD. hand and of the Internet in helping the He also reflected on the visionary accomplishment surgeon’s brain and memory cannot of Harold Ridley, the inventor of the intraocular lens (IOL). be neglected. Once more we are living in a time of change, a time Dr Grabner finished his lecture by pointing out that it was of opportunity, and an exciting time of enthusiasm. important never to lose sight of the everyday wonder of a profession that could do so much good for so many people. “We need to remember the words of Sir Harold Ridley that ‘even when a miracle becomes routine, it still remains a miracle’,” he said. I echo those comments and I hope in the next 30 years we will be able to reflect on the achievements of a new generation * Roberto Bellucci MD is president of the ESCRS of innovators.

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), 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), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

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COVER STORY: CATARACT & REFRACTIVE

LONG-TERM LENS STABILITY CURVILINEAR CAPSULORHEXIS FOLDABLE INTRAOCULAR LENS (IOL) SURGEON-ADJUSTABLE VACUUM

FEMTOSECOND LASERS LASER TECHNOLOGY 3-D IMAGING

FULLY ACCOMMODATING LENS

1984

ROBOTIC SURGERY

CATARACT SURGERY 2044 Technology and technique will change the procedure – but not the need for surgeons. Howard Larkin reports

... The emulsification was done in the anterior chamber. Healon is shown to have a protective effect on the cornea as judged by corneal thickness measurements and by endothelial cell counts. … [N]o attempt was made to remove Healon from anterior chamber at the end of surgery. It cannot be excluded that Healon may occasionally cause increased intraocular EUROTIMES | NOVEMBER 2014

pressure...”– Holmberg AS, Philipson BT. Ophthalmology. 1984 Jan;91(1):53-9. Three decades ago, ophthalmology stood at the threshold of modern smallincision cataract surgery. Most of the technologies and techniques that make the procedure so reliable and repeatable today were in place at least in embryo, or about to emerge.

COVER STORY: CATARACT & REFRACTIVE In 1984 phaco machines with surgeonadjustable vacuum and flow were available, as were early viscoelastics. 1984 also saw the first commercial foldable intraocular lenses (IOLs) – the innovation that finally made it possible to take full advantage of the 3.0mm or less incisions provided by phaco technology for more than a decade. Within a year the seminal paper outlining the benefits of capsular bag IOL placement by David J Apple MD and colleagues would be published (J Am Intraocul Implant Soc. 1985 Jan;11(1):44-63). The continuous curvilinear capsulorhexis, which all but eliminated previously ubiquitous anterior capsular tears, also would be described independently, by Thomas Neuhann MD, Howard Gimbel MD, John Graether MD and Calvin Fercho MD. Along with IOLs featuring posteriorly-angled compressible haptics, these innovations in technique enabled greater refractive predictability and long-term lens stability. The confluence of advances in technology and technique proved irresistible. Phaco use jumped from 12 per cent of ophthalmic surgeons responding to the first ASCRS member survey in 1985 to more than half in 1990, according to David Leaming MD. By the end of the century, phaco with foldable IOLs placed in the bag was standard of care throughout the developed world, and is now widely practised in much of the developing world as well. Today cataract surgery again stands at the threshold of a technology revolution. Femtosecond lasers, 3-D intraoperative imaging and aberrometry, and robotic surgery hold out the tantalising prospect of precision and predictability far beyond what can be achieved manually. New IOLs, both mechanical and electrooptical, hold promise for truly restoring accommodation. And medical advances that may delay or even reverse cataract formation might obviate the need for surgery in many cases. Ophthalmology is routinely an area of technology innovation, said industry consultant Brad Fundingsland, Santa Ana, California. In a recent survey of 1,500 ASCRS surgeons, supported by his organisation, nine per cent considered themselves as “first to adopt” new technology, while 51 per cent considered themselves “early adopters”. Where these and other unknown developments will take cataract surgery is anyone’s guess. EuroTimes asked several ophthalmology leaders where cataract surgery might be in 30 years, and how it might affect surgeons’ roles and practice opportunities.

SURGICAL TECHNOLOGY One trend that appears inevitable is increased automation of the cataract procedure. “Laser surgery will spread

Laser surgery will spread rapidly, and new devices allowing the patient to remain seated during the procedure will probably be developed Roberto Bellucci MD rapidly, and new devices allowing the patient to remain seated during the procedure will probably be developed. The technician’s role will be more important, as surgery will be semiautomated,” said ESCRS President Roberto Bellucci MD, Verona, Italy. He sees the surgeons acting partially as a consultant, explaining options to patients and overseeing procedures carried out largely by machines. Laser technology will likely advance quickly to the point that lens removal will involve only aspiration, said Douglas Koch MD, Houston, US, former co-editor of the Journal of Cataract and Refractive Surgery. “The procedure may be highly automated and not require a surgeon’s presence,” he said. He also sees a growing role for corneal procedures to improve visual outcomes. 3-D imaging will also play a growing role, said researcher Pablo Artal PhD, Murcia, Spain. “We get in real time beautiful images of the eye, guiding whatever type of surgery,” he said. He sees automation as good for patients since it could eliminate performance variations due to surgeon fatigue or state of mind. Many surgeons believe automated laser procedures will eventually become the norm, said Brad Fundingsland. In the most recent survey of 1,500 ASCRS members his organisation supported in 2014, 91 per cent believed they will be doing laser cataract surgery in 10 years. However, only 37 per cent believe they will do it on a majority of their patients. “The survey data demonstrates that while many are very enthusiastic about the future of laser cataract technology, the most significant barrier to adoption remains the ability to make this a financially viable part of their practice,” notes Mr Fundingsland.

LENS TECHNOLOGY A fully accommodating lens is the holy grail of cataract surgery, and some believe it will be available within 30 years.

Dr Bellucci believes future surgeons will probably be able to replace the crystalline lens with a fully accommodating artificial lens in a matter of minutes. He believes the availability of such lenses will expand indications for lens surgery to patients with large refractive errors. As technology improves, Dr Koch predicts the incorporation of some kind of accommodating lens into standard cataract care. He also sees routine intervention for presbyopia as patients reach their late 30s or early 40s. What form such lenses might take is a matter of debate. José Güell MD, Barcelona, Spain, sees much potential in biomechanical designs that accommodate by changing shape or moving bioptic lenses. However, late complications such as fibrosis and capsular bag shrinkage must be addressed to make these work for the long-term, noted Oliver Findl, Vienna, Austria. Dr Artal suggested that getting a biomechanical lens tight may prove too difficult. A lens that moves too easily is difficult to control, whereas a lens that requires too much effort may not accommodate at all. He believes that electro-optical lenses may be the solution for true accommodation. Dr Artal also believes that current approaches, including multifocal and extended depth of focus, will continue to play a big role. New technology including adaptive optics and adjustable power lenses will allow these lenses to be truly customised, which will greatly improve their performance, he said.

MEDICAL TREATMENT OF CATARACT While current trends suggest an everlarger need for cataract surgery, medical advances could reduce the need, Dr Koch said. “We will have better ways to modulate cataract progression and to maintain flexibility of the crystalline lens that may delay the onset of presbyopia and visually significant cataract. That may come through medication or some form of genetic therapy.”

We get in real time beautiful images of the eye, guiding whatever type of surgery Pablo Artal PhD EUROTIMES | NOVEMBER 2014

COVER STORY: CATARACT & REFRACTIVE Such medical non-surgical approaches might increase the age of presbyopia onset and the need for lens removal, which may be good given that patients are living longer, Dr Güell said. “I definitely expect some drugs will be available to be used topically or systemically to reduce the speed of crystalline lens sclerosis. Presbyopia symptoms that are significant today for those older than 40-55 will probably come much later, at 75, 80 or 85.” But advances in lens technology may offset that, Dr Koch said. “It will be an interesting tug of war between advances in technology for delaying presbyopia and cataract, and the spectacular technology we will have on hand for insertion of lenses and the improved quality of vision they may provide.” Others believe that medicine won’t make much difference. “I do not think drugs preventing or reverting cataract formation will play an important role: people prefer rapid surgery to the prolonged care required to avoid it,” Dr Bellucci said. Dr Findl agreed. “Prophylactically you would have to take medicines for years or decades. The side effects could be worse than the procedure.”

THE SURGEON’S ROLE Technological advances will likely reduce the need for surgeons to perform all aspects of surgery – but not the need for surgeons. “It’s possible in the foreseeable future that you may see robotic surgery in straightforward cases without risk factors. But you will still need a surgeon to survey what is happening. If things don’t go as planned you need a surgeon to rectify things,” Dr Findl said. Dr Koch agrees. “Some procedures may be highly automated, and ancillary personnel may do these. Surgery will still require an ophthalmologist, and there will still be all the complications we see today – loose zonules, white cataracts.” While automation may reduce the number of surgeons required, this might be offset by people living longer and requiring more high-skill late services, such as removing dislocated lenses. Still, the growing scarcity of ophthalmic surgeons could result in some procedures being taken over by non-surgeons, Dr Findl said. Local culture and law will likely have a big effect on who does what. But the surgeon will always have a place.

IMPACT ON TRAINING Automation of cataract surgery will likely create training challenges. Without a large volume of uncomplicated cataract patients, surgeons will lose the opportunity to develop and maintain basic microsurgical skills needed to perform more complex procedures, Dr Güell noted. Already, since the advent of phaco, many young surgeons cannot do an extracapsular or intracapsular extraction, or even manage sutures. Advanced simulators may take up some of the slack. Current simulators help develop spatial skills and manual dexterity, and help students get used to using a microscope, said Sonia Manning MD, a resident in training in Dublin, Ireland. “Simulators are very helpful at the beginning, but they are less helpful later on,” she commented. The biggest drawback is a lack of tactile feedback, she said. However, newer simulators add this feature and may be more effective. Though she has not yet used a laser system, Dr Manning believes that if they are adopted, they could limit hands-on training, leaving surgeons unprepared should an emergency arise. Dr Koch suggested that it may become necessary to separate trainees into two groups, those who do routine procedures and those groomed for more complex manual procedures. “We will have to figure out a way to train at least a small cadre of students to do more complex procedures,” he said.

PRACTICE OPPORTUNITIES Automation also may influence practice opportunities. Dr Manning is convinced that the cost of new technology will make it nearly impossible for ophthalmologists to enter solo practice. She sees most of her colleagues going to public, hospital or private group practice. “The number of machines needed to assess patients properly today and the cost is mind-boggling.” As presbyopia treatments become more accurate and repeatable, Dr Findl expects that more public and private insurance plans will cover them. However, he still sees a lot of demand for private practice and premium refractive procedures. “People still want personal care and to be taken care of in a personal fashion.” Dr Bellucci sees public hospitals continuing to offer basic cataract services,

I definitely expect some drugs will be available to be used topically or systemically... José Güell MD EUROTIMES | NOVEMBER 2014

You should never say never. Things that seem impossible now might be the norm in 30 years’ time Sonia Manning MD

with private practices offering a higher standard of care for those who want to be spectacle-independent while having little or no cataract. Private surgeons will be compelled to join forces to afford equipment and learn from each other, but opportunity will be plentiful. “Owing to the reduction in the number of ophthalmologists that is foreseen in Europe, I still see a bright future for those young people who want to undertake this career,” he said. However, technology may not advance as quickly as most anticipate. Dr Artal notes that many technologies, such as liquid injectable lens materials, have been in development for more than two decades. “We are too optimistic. We are playing with new things, new toys, but the reality takes much longer in general.” But no one really knows, Dr Manning said. “You should never say never. Things that seem impossible now might be the norm in 30 years’ time.” Sonia Manning: sonia.sofia1@gmail.com Roberto Belllucci: robbell@tin.it Brad Fundingsland: brad@tfgeducation.com Oliver Findl: oliver@findl.at José Güell: guell@imo.es Douglas Koch: dkoch@bcm.edu Pablo Artal: pablo@um.es

SPECIAL FOCUS: CATARACT & REFRACTIVE

MAJOR ADVANCES Dr Günther Grabner’s Ridley Medal lecture encompassed the entire span of modern ophthalmology. Dermot McGrath reports

hile the past 40 years have produced major advances in cataract surgery leading to enhanced safety and excellent visual outcomes for most patients, there is still some unfinished business, according to Günther Grabner MD, who delivered the Ridley Medal Lecture at the XXXII ESCRS Congress in London. As one of the renowned innovators in the field of cataract surgery, Dr Grabner’s wide-ranging lecture encompassed the entire span of modern ophthalmology, paying tribute to early pioneers at the 2nd University Eye Clinic in Vienna, where he trained, such as Eduard Jaeger, Karl Koller and Ernst Fuchs, personal mentors such as Prof Hans Slezak, Dennis Shepard MD, Santa Maria, and his teachers at the FI Proctor Foundation, UCSF, such as Dick O'Connor, Gil Smolin MD, Mitch Friedlaender MD and the visionary accomplishment of Harold Ridley, the inventor of the intraocular lens (IOL). Looking back to the early days of his residency training, Dr Grabner said that cataract surgery as practised then was radically different to today’s procedures. “I was taught the fundamentals of intracapsular cataract extraction (ICCE) and it was basically the same technique for many years. We used retrobulbar anaesthesia and neural block of lids, 10 minutes of oculopression, and no gloves or microscopes as surgery was carried out using loupes. We performed a 180-degree incision with a big scissors, followed by cryoextraction and no IOL implantation, with one to seven silk sutures to seal the wound and the patient was typically hospitalised for five to seven days,” he said.

KEY QUESTIONS Dr Grabner said his lecture would seek to answer four key questions in relation to cataract surgery over the last 40 years. Addressing the question of safety in cataract surgery, Dr Grabner said that issues such as aphakia, endothelial cell loss, aqueous loss, vitreous loss and postoperative infection all posed potential problems for surgeons operating in the 1970s and 1980s. “Aphakia, for instance, was terrible,” said Dr Grabner. “We rendered 100 per cent of our patients aphakic, sometimes only in one eye, and kept them some time before the second eye was done. They usually had very low optical quality and a lot of patients suffered from falls as a result of their aphakia that was corrected with thick spectacles.” Typical rates of endothelial cell loss were about 20 per cent after ICCE surgery and vitreous loss rates were up to 10 per cent, said Dr Grabner. The most feared complication, however, was postoperative endophthalmitis. In this respect, Dr Grabner said he was proud to have played a part in the landmark ESCRS endophthalmitis study, which helped to establish important guidelines for the prevention of this sight-threatening condition. Overall, Dr Grabner said there was no doubt that safety has significantly improved over the past 40 years.

FULL VISUAL FUNCTION In terms of restoring full visual function, Dr Grabner said that a lot of progress has been made in terms of biometry, reduction of PCO formation, astigmatism control and presbyopia, but that unresolved issues remained to be tackled. EUROTIMES | NOVEMBER 2014

Courtesy of Günther Grabner MD

While around 90-95 per cent of patients have sufficiently precise biometry to be happy, some outliers still exist. He said the concept of adjustable IOLs is intriguing, but that the practical difficulties of asking people to return to the clinic for “lock-in” procedures and to wear dark glasses between treatments might pose an obvious obstacle to widespread adoption. For astigmatism control, Dr Grabner said that today’s toric lenses and advanced eye trackers deliver excellent results. “I think astigmatism above 0.5 D should be treated and yet not all of these potential patients are treated. There is quite low patient request because they are used to spectacles, we need additional chair time, it costs more and it needs surgery time and special equipment to be performed properly,” he said.

UNFINISHED BUSINESS While some progress has also been made on PCO formation, Dr Grabner said that this was still “unfinished business” and that new IOL materials and designs should help to reduce the risk in the future. In terms of presbyopia solutions, Dr Grabner said that many approaches have been tried over the years, including accommodating and special IOLs simulating intracorneal inlays, but that the mission is not yet completed in terms of finding a universally accepted solution to the problem. Turning to the introduction of the femtosecond laser into cataract surgery, Dr Grabner said it represents a significant surgical advance for the patient in terms of safety, with over 99.6 per cent of capsulotomies successfully completed in over 1,600 cases in his own surgery, and more interesting options such as intrastromal arcuate keratotomy (ISAK) to be finetuned for widespread use. In terms of rapid visual rehabilitation, he made a plea for more widespread use of immediate sequential bilateral surgery. Dr Grabner finished his lecture with an emotional tribute to his colleagues and family and said that it was important never to lose sight of the everyday wonder of a profession that could do so much good for so many people. “We need to remember the words of Sir Harold Ridley that ‘even when a miracle becomes routine, it still remains a miracle’,” he said. Günther Grabner: g.grabner@salk.at

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SPECIAL FOCUS: CATARACT & REFRACTIVE

FS-CATARACT LENSES Designs use precise capsulotomy for stability, dysphotopsia reduction. Howard Larkin reports

ntraocular lenses (IOLs) designed to snap into the precise capsulotomies made possible with femtosecond laser-assisted cataract surgery are now in clinical tests, presenters told the XXXII ESCRS Congress in London. Capturing the capsulotomy in a peripheral groove may make these lenses more stable and their position more predictable, and could eliminate negative dysphotopsias associated with in-the-bag IOL placement. Ludger Hanneken MD, Cologne, Germany, reported on his experience with the Oculentis Lentis, of which he has implanted three in the first round of human tests. The lens has a special rhexis clip design which fixes the IOL

within the capsulotomy. Two large haptics longitudinal and two smaller haptics transversal on the anterior ensure the lens remains firmly in place after fixation in the capsulotomy. The aspheric lens is designed to be aberration neutral with an optic of 5.7mm diameter, and total posterior haptic diameter of 10.5mm. Potential advantages include precise lens centration, as well as greater resistance to dislocation, tilt and rotation, Dr Hanneken said. These may result in better predictability and stability of lens placement, potentially improving refractive outcomes. The stability and precise positioning may enhance the performance of multifocal, toric and enhanced depth-offocus lenses.

The lens was inserted through a 2.2mm incision and required some manipulation to position the haptics inside and outside the capsular bag, Dr Hanneken said. While this sounds and even looks complicated on video, it was not difficult to position the lens, he added. Perfect centration was achieved with all three lenses, Dr Hanneken said. No intraoperative complications were experienced, and the lens should have a short learning curve. He cautioned, however, that all OVD must be removed from the bag before the lens is inserted as the lens completely seals the capsule. An open-label prospective multicentre international trial of the Lentis lens is now under way, with Gerd Auffarth MD, Heidelberg, Germany, as principal investigator.

Courtesy of Ludger Hanneken MD

ANTI-DYSPHOTOPIC IOL

One-piece posterior chamber lens with aspherical surface for laser assisted cataract surgery and easy fixation in the capsulorhexis

EUROTIMES | NOVEMBER 2014

In a related presentation, Samuel Masket MD, Los Angeles, US, described an IOL designed to prevent negative dysphotopsias. Sometimes likened to horse blinders, these shadows have been reported in up to 15 per cent of patients immediately after surgery and persist indefinitely in one to three per cent of cases. They may be the leading cause of patient complaints after what seems to be perfect surgery, he said. In Dr Masketâ&#x20AC;&#x2122;s clinical experience, negative dysphotopsias can be treated in most cases by overlapping the edge of the IOL over the edge of the anterior capsulotomy, either by raising the edge of the IOL optic out of the bag or implanting a piggyback lens or sulcus supported lens. In contrast, changing lenses implanted completely in the bag seldom eliminates dysphotopsias, leading Dr Masket to conclude the overlap of the capsule over the lens edge is involved.

Dr Masket’s design features a groove around the periphery of the anterior optic that would allow the lens optic to snap into and overlap the edge of a preciselysized anterior capsulotomy. This feature has been incorporated into the Morcher 90S hydrophobic acrylic lens, which has now been implanted in 12 human eyes, Dr Masket said. Burkhard Dick MD, PhD, Bochum, Germany, implanted six lenses using a Catalys femtosecond laser system (AMO)

Courtesy of Prof Oliver Findl

Figure 1: Overview of Morcher 90S (Masket TM) IOL

to cut 4.9mm capsulotomies, inserting the lens through a 2.4mm corneal incision, Dr Masket said. But while the design is “perfectly matched” to femtosecond laser-cut capsulotomies, the lens also can be implanted in measured manual capsulorhexis, he added. Oliver Findl MD, PhD, Vienna, Austria, has successfully implanted six lenses using a Zeiss Callisto system to guide creation of the manual capsulorhexis. Three months after surgery, none of the 12 eyes reported any dysphotopsia, and no iris chafe was observed, Dr Masket reported. “Clinical experience and peer reviewed literature say that negative dysphotopsia can be prevented or relieved if the optic edge overrides the capsulotomy. The Morcher 90S IOL does that.”

Figure 2: Callisto (Zeiss) projected anterior capsulotomy

Ludger Hanneken: hanneken@sehkraft.de Samuel Masket: avcmasket@aol.com

Potential advantages include precise lens centration, as well as greater resistance to dislocation, tilt and rotation Ludger Hanneken MD

Courtesy of Prof Burkhard Dick and Dr Tim Schultz

Courtesy of Samuel Masket MD

SPECIAL FOCUS: CATARACT & REFRACTIVE

Figure 3: Postoperative view of Morcher 90S (Masket TM) IOL. Note the peripheral groove and excellent centration

6th EuCornea Congress

BARCELONA 4-5 September 2015 Fira Gran Via, Spain

www.eucornea.org

EUROTIMES | NOVEMBER 2014

SPECIAL FOCUS: CATARACT & REFRACTIVE

ENDURING VALUES

Lampros Lamprogiannis won the 2014 John Henahan Prize

for young ophthalmologists for this essay with a vision for the future

is flight would soon come to an end. In a few minutes’ time, his personal air taxi would land in London. He felt quite satisfied with his decision to watch the Congress in person, although most ophthalmologists at his age would prefer the virtual environment option the Society had implemented 10 years previously. It is not every year that an anterior segment surgeon has the chance to commemorate Sir Harold Ridley’s great discovery and the LXVII annual Congress of the ESCRS, held in London to honour the pioneer of cataract surgery, was a great opportunity. As he was approaching the landing spot, his thoughts went back to the first ESCRS Congress he had attended as a resident ophthalmologist, 35 years ago, also held in London. A stunning experience for a young physician, reflecting, however, a completely different era in ophthalmology. He was grateful to have been a part of the breathtaking advances that had taken place in the last three decades in the fields of cataract and refractive surgery, redefining common beliefs and leading to better surgical results.

HOLOGRAPHIC ADVERTISEMENTS The congress hall was decorated with holographic advertisements, depicting smiling patients in their mid-30s. New-era intraocular lenses (IOLs), capable of preserving accommodation, had changed cataract surgery drastically. Clear lens extraction was now the rule and young patients had the choice to correct refractive errors, preserving the integrity of their cornea and avoiding cataract completely. Corneal refractive surgery was now reserved for a minority of patients. There was even a heated argument among Society members regarding its name, as many thought that ESLS (European Society of Lens Surgeons) was better related to their everyday practice, and a vote was to be held during the congress. The exhibition room was impressive, with its central spots reserved by companies presenting their integrated, laser-assisted phacoemulsification devices. With the use of integrated systems, preoperative control and surgery were easily combined, with the patients remaining in a single position throughout the entire process. Only a small part of the operation was still performed manually and uneventful operations seldom lasted more than a few minutes. The rate of complications was constantly declining.

ROBOTIC ASSISTANTS The question whether there was still a necessity for skilled surgeons kept troubling him, but he was comforted by the thought that challenging cases which rendered human surgical skill and experience necessary would always come up. A robotic assistant offered him a synthetic refreshment, vaguely reminiscent of an orange juice, disrupting his thoughts. While he EUROTIMES | NOVEMBER 2014

was strolling through the exhibition, he was amazed by the variety of custom made IOLs. A multitude of companies was now offering IOLs especially designed and fabricated for each individual patient. Anterior segment surgeons were not only able to define the refractive power, but also the size and the coating of the lens. Naturally, postoperative use of eye drops was dramatically reduced, as new generation IOLs eluted the necessary drugs for the desired period of time, overcoming all problems related to drop instillation. He had the chance to test some of them in virtual reality “wet labs” and the results were more than satisfactory. Education had always been a vital part of the Society’s activities and, as expected, a special session was devoted to young surgeons’ new training methods. New-era simulators and technological advances led to a shorter learning curve, meaning that resident ophthalmologists were ready to perform unassisted surgery within a few months. Courtesy of Eoin Coveney

TRAINING DAYS His thoughts went back to his training days and his first operations. He couldn’t help but feel a little envious of his young colleagues who avoided the stress he had to undergo while training, but he also recalled his feelings after a successful operation and this memory put a smile on his face. The Orbis and Oxfam projects grabbed his attention with their impressive presentations of their work. With cataract becoming the primary reason of loss of sight in developing countries, these initiatives devoted a great share of their resources to its treatment. Although state-of-the-art methods such as those presented in the Congress remained out of reach for developing countries, previous generation equipment provided a decent, cost-effective alternative and allowed thousands of patients to achieve a better quality of vision. Supported by technological advances in the fields of communications and transportation, a great number of volunteers worked constantly towards improving global eye health. As he had expected, the Congress turned out to be a rewarding experience. Indeed, a lot had changed in ophthalmology during the last decades and treatment of cataract was one of the fields that had undergone the most drastic changes, in terms of demographics, methods, equipment and training. He felt grateful to have witnessed them. However, it was equally obvious that the values of the ophthalmological community had remained the same. Ophthalmologists around the world continued devoting their work, and often their life, to restoring their patients’ eyesight and, as a result, their quality of life. It was safe to predict that this effort would continue in the years to come. * Dr Lampos Lamprogiannis is a resident ophthalmologist in the 4th Ophthalmology Department of AHEPA Hospital in Thessaloniki, Greece

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FRAGMENTATION RESULTS However, the fragmentation results were difficult to evaluate because precise numeric values for lens opacity were not identified, Dr Bellucci said. “The LOCS classification appeared of limited help in adjusting the laser energy for lens fragmentation. “To develop a better lens fragmentation laser energy nomogram we need more precise evaluation of lens opacity, better consideration of lens density and a more precise method to evaluate results. I think we are not there at the moment,” Dr Bellucci concluded.

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inimising energy dissipated in the eye during cataract surgery, whether ultrasonic or laser, may lower the risk of damaging delicate intraocular tissues. But while current phaco systems allow continuous ultrasonic energy control during surgery, femtosecond (FS) laser systems do not. However, total laser energy delivered during FS laserassisted cataract surgery can be reduced by lowering the pre-set power of individual laser pulses, Roberto Bellucci MD, Verona, Italy, told the 2014 ESCRS Congress in London. Because laser energy is sensitive to light scatter, the minimum pulse power required to produce photodisruption in target tissues should vary with the transparency of tissues between the laser and target, with clearer corneas and lenses requiring less energy, he reasoned. Dr Bellucci presented results of two nomograms for adjusting FS pulse power in cataract surgery that he developed based on this principle. For capsulotomy, Dr Bellucci adjusted pulse power based on a gross evaluation of corneal transparency. Overall, the reduction in energy in clearer corneas was slight. Adjustments varied from 7,100 to 7,400 Roberto Bellucci nanojoules (nJ), with two-thirds of 79 eyes treated at 7,200nJ. He concluded that energy settings for capsulotomy are not very critical. Potentially more significant are power adjustments for lens fragmentation, which requires much more energy delivered deeper in the eye. Dr Bellucci adjusted lens fragmentation power based on corneal and lens opacity, and lens hardness. Lens opacity was graded using the LOCS III system at the slit lamp under mydriasis, and pulse power adjusted over a range of 1,200nJ, from 7,500nJ to 8,700nJ based on total opacity. The actual study treatment range was narrower, with 67 of 79 eyes treated with 7,600 to 8,200nJ pulses, two each at 7,500, 8,500 and 8,600nJ, and none at the maximum 8,700nJ, Dr Bellucci reported. Fragmentation effectiveness was also rated. The 6.3 per cent of eyes that subsequently required nucleus chopping were rated “poor”; 61 per cent with easily separated nuclear fragments rated “good”; and 32.7 per cent with fragments completely separated before phaco rated “excellent”. Phaco energy was not considered because cataract hardness varied.

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CORNEA

BIOENGINEERED CORNEAS Corneal stromal stem cells offer new therapeutic possibilities. Dermot McGrath reports

orneal stromal stem cells can now be isolated reliably from long-term stored organ culture corneas, opening up the possibility to develop cell- and tissue-based therapies for a wide range of corneal diseases, according to Alvena Kureshi PhD. “We can now differentiate these corneal stromal stem cells into keratocytes which is a useful cell population for bioengineering a corneal stroma or perhaps a cell therapy for corneal scarring,” Dr Kureshi, of University College London, told delegates attending the 5th EuCornea Congress in London. Corneal blindness remains a leading cause of treatable vision loss worldwide, noted Dr Kureshi, with widespread donor shortages and problems with immune rejection spurring major research efforts to find viable alternatives. “Currently the most common approach to restoring vision in scarred corneas is to surgically replace the stromal (stroma??) with allogeneic donor cornea tissue. However, there is a decreasing supply of donor corneas worldwide and this is expected to further reduce due to recent advances in corrective eye surgery, which unfortunately renders corneas unsuitable for transplantation,” she said. Dr Kureshi's research, carried out in collaboration with Prof Jim Funderburgh from the University of Pittsburgh, focuses on using stem cell therapy technologies that are capable of repairing or replacing the scarred corneal stroma. “The key to this is to use cells that are native to the corneal stroma, so we really wanted to find out which would be the ideal cells to use for this purpose,” she added.

For the delivery system, Dr Kureshi proposed utilising a refined system of compressed collagen gels fabricated by a process known as Real Architecture for 3D Tissues (RAFT, TAP Biosystems). To produce 3D cell cultures, a mix of collagen, cells and other reagents is pipetted into the wells of a plate and incubated for 15 minutes to form a collagen hydrogel. The RAFT plate, with its set of biocompatible absorbers, is then placed on top of the gels and over a 15-minute period a controlled amount of liquid is removed from the hydrogel leaving cells “encapsulated” in collagen and evenly distributed in the culture. Dr Kureshi noted that while the initial RAFT process was quite inconsistent and not very reproducible, collaboration with TAP Biosystems has resulted in a modified approach to make the well plate carrier system more robust, more reproducible and, critically, more compatible with good manufacturing practice, she said. “We have further evolved the RAFT system for increased clinical applicability and it is now commercially available as a kit with type I collagen and neutralising solutions. The initial paper plungers have now been replaced with hydrophilic porous absorbers which have much less particle shedding and hence are much more appropriate for use in an environment such as a clean room for eventual transplantation to a patient,” she concluded. Alvena Kureshi: a.kureshi@ucl.ac.uk

PROGENITOR CELLS Stromal stem cells have been identified as the progenitor cells of keratocytes and also support human limbal epithelial stem cells (LESCs), essential for the maintenance of the ocular surface, said Dr Kureshi. “Keratocytes are the main population of cells responsible for synthesising and maintaining the organised ultrastructure of the stroma which is key to its transparency,” she said. These stromal stem cells hold great therapeutic potential, said Dr Kureshi. “Unlike keratocytes which can be difficult to culture in vitro as they quickly become fibroblasts when you try to expand them, corneal stromal stem cells replicate without loss of differentiation potential. This means that we would potentially be able to culture these cells in large quantities and then differentiate them into keratocytes which would be a useful cell population for bioengineering the corneal stroma,” she said. The cells could also be potentially used as direct cell-based therapy for corneal scarring, said Dr Kureshi. “Recent studies using a mouse scar model have shown that these cells have the ability to restore collagen fibril organisation and transparency when injected into the corneal stroma of lumicandeficient mice without immune rejection,” she added. After learning to isolate and culture the corneal stromal stem cells, Dr Kureshi established that the cells could also potentially survive long-term storage conditions and be successfully differentiated into keratocytes.

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CORNEA

ENDOTHELIAL CELL LOSS Decreases in ECD likely overestimated due to limitations in measurement techniques. Cheryl Guttman Krader reports

ndothelial cell loss is an important outcome parameter for corneal transplantation procedures as it is used both as a measure of success and for predicting survival of the transplanted tissue. However, interpretations of data on endothelial cell loss following different keratoplasty techniques should consider that there are a number of limitations affecting the accuracy of the determinations, according to Isabel Dapena MD, PhD. Speaking in London at the 5th EuCornea Congress during a symposium on new trends in endothelial transplantation, Dr Dapena reviewed the factors that may be confounding measurements of endothelial cell density (ECD). She concluded that the reported data on ECD changes after descemet membrane endothelial keratoplasty (DMEK) and other endothelial keratoplasty procedures may overestimate the true loss. “Since endothelial cell loss after endothelial keratoplasty has generally been attributed to donor tissue manipulation during surgery, when DMEK became available as a standardised ‘no touch’ technique, we expected to find that it was associated with a lower endothelial cell loss rate than descemet stripping endothelial keratoplasty. “To our surprise, however, we found in our DMEK series that the ECD loss after six months was between 30 and 34 per cent, which is within the range reported for other endothelial keratoplasty techniques. Therefore, we considered there must

be factors other than surgical handling that were affecting our measurements and could explain these results,” said Dr Dapena, cornea specialist, Melles Cornea Clinic, Netherlands Institute for Innovative Ocular Surgery, Rotterdam, Netherlands.

MEASUREMENT TECHNIQUES Discussing the possible contributors, Dr Dapena noted that there are limitations introduced by the measurement techniques. The baseline measurement determined by eye bank analysis of the donor tissue is generally overestimated by the cell counting techniques that are used. Introducing further sources for error, the postoperative measurement is performed in vivo by a different observer using different methodology and different instrumentation. Another issue to consider is that endothelial cell count determinations focus on the centre of the cornea. However, there may be field migration of the endothelial cells post-transplantation from the central region towards the periphery, and that shift would result in an overestimation of endothelial cell loss in the centre. Change in hydration of the cornea after transplantation could also lead to overestimation of endothelial cell loss as the result of an increase in host posterior corneal surface area when the cornea de-swells. Dr Dapena explained that the posterior stroma is more easily hydrated than the anterior layers, and as the posterior layers thicken, the posterior surface of the cornea flattens.

To our surprise, we found in our DMEK series that the ECD loss after six months was between 30 and 34 per cent...

As the cornea de-swells posttransplantation, the posterior surface steepens, resulting in an increase in arc length from limbus to limbus and in the posterior surface area. Since the transplant is attached to the posterior surface of the cornea, the cells are stretched outside the fixed area of the specular microscope’s measurement window. Therefore, fewer cells are counted using specular microscopy even though their total number is actually unchanged. (Figure 1) Dr Dapena and colleagues recently published a paper in which they developed a mathematical model to investigate how corneal deturgescence after DMEK affects posterior corneal surface area and determinations of endothelial cell loss (Quilendrino R et al, Curr Eye Res. 2013;38(2):260-5). The model was created based on data from 25 eyes that underwent DMEK, including measurements of central corneal thickness, ECD, and pachymetry through follow-up to six months. The analyses showed that de-swelling of the cornea resulted in an 8.6 per cent increase in total posterior corneal surface area that could account for about 25 per cent of the observed average 34 per cent decrease in ECD over the first six months following surgery. “According to these findings, the increase in posterior corneal surface area resulting from postoperative de-swelling of the cornea might lead to an eight per cent overestimation of the actual loss of endothelial cells,” Dr Dapena said. Isabel Dapena: dapena@niios.com

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Isabel Dapena MD, PhD

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CORNEA

GOOGLE OPHTHALMOLOGY Smart contact lenses target the eye as new frontier in health monitoring. Dermot McGrath reports

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of which are independently challenging to duplicate,” said Jeffrey hen Google and Novartis announced a Anshel OD, FAAO, an optometrist in private practice in Carlsbad, partnership earlier this year to develop a range California, and President of the Ocular Nutrition Society. of smart contact lenses to improve vision and The specific problem for a glucose-sensing lens is that diabetics monitor health, the widespread media coverage frequently show deficient tear levels, so are contraindicated to wear was predictably upbeat. “traditional” contact lenses, he added. “Sweet solution for diabetics”, “Smart “Unless newer materials are developed that are more contact lens promises to revolutionise diabetes biocompatible with these reduced bio-tissues, complications may treatment” and “Smart lenses eyed as medical breakthrough” were subvert the success of this technology,” he said. just three typical headlines welcoming the announcement. While diabetes and presbyopia are the initial targets for the The professed aim of the collaboration is to develop contact lenses contact lens technology, other targeting two massive health markets: first diabetes, with a lens ocular and systemic indications capable of monitoring glucose levels, and second presbyopia, are sure to follow. with an autofocusing lens that will dispense with the need Glaucoma, for instance, for reading glasses. with an estimated Jeff George, division head of Alcon, the second 60 million patients largest unit within Novartis that will be charged worldwide, represents with developing the smart lenses, spoke of another potentially unlocking “a new frontier to jointly address the huge opportunity unmet medical needs of millions of eye care for smart contact patients around the world”. lens technology. This new frontier is a place where Dr Anshel miniaturised technology and human also noted that biology intersect, with wearable and the tear layer does implantable technologies giving people the have the ability opportunity to proactively take charge of their to express several own health management. bodily functions, so “I believe that the product holds a lot of promise, the possibilities of smart and with Novartis collaborating on the project, contact lenses might be there is the willpower to push through with it,” said expanded to tear testing. Chloe Wu, an analyst at market research provider A prototype of the new smart contact lens Unlike diabetes and Euromonitor International. presbyopia, however, the Nevertheless, significant hurdles will have to be overcome contact lens technology to monitor if the promise of a smart contact lens is to become a commercial intraocular pressure (IOP) is not wishful thinking for the future, reality, she warned. but is already here and commercially available. “With a large proportion of diabetes diagnoses coming from The Swiss company Sensimed AG has stolen a march on its lower-income groups, the immediate question that comes to potential rivals by developing Triggerfish®, a contact lens used mind relates to the cost and practicality of the to automatically record both volume change and IOP over a glucose-sensing contact lenses. In addition, there 24-hour period. are reports that suggest that diabetic Kaweh Mansouri MD, MPH, a glaucoma specialist at Geneva patients may be particularly susceptible University Hospital, Switzerland, who was involved in the clinical to developing ocular complications trials of the Triggerfish®, told EuroTimes that the contact lens from contact lens wear,” she said. technology has been largely perfected by Sensimed. The biocompatibility issue is certainly “The measurements have been shown to be extremely repeatable one that will engage the and reliable. Over the 24-hour measurement period the contact creative energies of Alcon’s lens is generally well tolerated by patients. The key challenge is engineers in the coming therefore interpretation of the resultant data to guide clinicians on months. Lens technology ways to improve the treatment of their glaucoma patients,” he said. which incorporates nonAlthough some companies might understandably see a threat invasive sensors, microchips in Google’s ambitions for the healthcare industry, Dr Mansouri and other miniaturized believes that the Google-Novartis partnership is actually a “huge electronics will also need positive” for everyone involved in developing contact lens to find a way to allow vital sensing technology. nutrients to reach the cornea “It further demonstrates the pivotal role of the visual organ in and maintain a healthy the future of eMedicine. As our understanding of the molecular ocular surface. mechanisms of disease improves in line with advances in micro“We have to remember that and nano-technology, a multipurpose diagnostic and therapeutic the cornea is an extremely contact lens should not be considered pure science fiction,” he said. unique tissue that combines the unlikely features of Jeffrey Anshel: jeffanshel@gmail.com optical clarity, hydrophila Jeffrey Anshel OD, FAAO Kaweh Mansouri: kawehm@yahoo.com and structural integrity, all Co

We have to remember that the cornea is an extremely unique tissue that combines the unlikely features of optical clarity...

EUROTIMES | NOVEMBER 2014

CORNEA

PUPIL BLOCK AFTER DMEK Study suggests up to 10 per cent of patients have potential for block, so same-day evaluation is necessary. Howard Larkin reports

WATCH THE BUBBLE Dr Feng noted that air is injected into the anterior chamber at the end of DMEK to hold the graft in place until donor endothelial cell function suctions it up against the recipient stroma. To ensure the graft is held firmly even when the patient sits up, the target is an air fill that leaves a small 360-degree fluid meniscus when supine. This corresponds to an 80-90 per cent air fill in most eyes, which leaves enough fluid over a patent PI to allow aqueous flow and circumvent pupillary block. (see Figure) With DSEK and DSAEK, large bubbles have been shown to carry a risk of pupillary block (Lee JS et al, Cornea. 2009 Jul;28(6):652-6), with reported rates ranging from 0.3 (Terry MA et al, Ophthalmology. 2008 Jul;115(7):117986) to as high as 30 per cent for phakic patients (Tsui JYM et al, Cornea. 2011;30(3):291-295), Dr Feng noted.

Immediate postoperative slit lamp photo, demonstrating an 85 per cent air fill that completely covers the DMEK graft even when the patient is upright while still leaving a fluid meniscus over a patent inferior PI, shown here at 6:30 o’clock

“How is it then that in the English literature the published rate (for DMEK, which usually uses a larger bubble) is zero per cent?” he asked. To better characterise pupillary block risk in DMEK, Dr Feng and colleagues conducted a retrospective interventional cohort study of 351 consecutive eyes over a one-year period that underwent DMEK procedures, with or without cataract surgery, for Fuchs', corneal edema or failed grafts. Only eyes with previous glaucoma surgery were excluded. Outcomes included bubble size after surgery, IOP and management required. Sub analyses were conducted by whether a single or triple DMEK was performed and the status of the PI, posterior capsule and vitreous. One hour after surgery, 74 eyes (or 21 per cent) had a full air fill rather than the intended 80-90 per cent. Of these, 57 per cent (or 12 per cent overall) spontaneously resolved under observation. However, 43 per cent (or nine per cent overall) required intervention in the form of air removal, and these are the eyes Dr Feng believes are at risk of pupillary block. No eyes experienced pupillary block after discharge. Statistically significant factors associated with full air fills at one hour were PI obstruction, high same-day postoperative IOP and DMEK triple procedure. Dr Feng believes newly pseudophakic eyes may be at higher risk because a

flexible IOL-iris diaphragm allows for more air to be pumped into the anterior chamber. Eyes requiring intervention had a higher incidence of IOP over 30mm Hg or PI obstruction than those that resolved spontaneously.

HAVE A PLAN Dr Feng recommended adopting a management algorithm for patients with full air fills one hour postoperatively. For those with an obstructed PI, IOP above 30mm Hg, or rising IOP with symptoms of pupillary block, he advised shrinking the air bubble to 50-60 per cent and dilating. For those with high IOP and a potentially patent PI (eg obvious PI in an area of iriscorneal touch from air behind iris), he suggested shrinking air to 80 per cent. Air fill patients with a patent PI and lower IOP should be observed hourly but generally resolve spontaneously, he said.

AIR REMOVAL Eyes that underwent air removal achieved similar three-month visual results (median 20/25) and endothelial cell counts (median 2100-2200 cells/mm2) as those that resolved with observation, Dr Feng said. At three per cent, the air removal eyes actually had lower re-bubble rates than the 17 per cent seen in observation eyes, but the difference just missed significance (P = 0.06), he added. Matthew Feng: mattfeng@pricevisiongroup.net EUROTIMES | NOVEMBER 2014

Courtesy of Matthew T Feng MD

s many as 10 per cent of patients undergoing descemet membrane endothelial keratoplasty (DMEK) are at risk of pupillary block after surgery if the problem is not detected and managed, Matthew T Feng MD told the 2014 American Society of Cataract and Refractive Surgery symposium in Boston. The 10 per cent rate suggested by a study Dr Feng and colleagues conducted at Price Vision Group, Indianapolis, US, is within the range reported for descemet stripping automated endothelial keratoplasty (DSAEK), he said. Dr Feng’s study found that patients undergoing DMEK combined with cataract surgery and intraocular lens (IOL) implantation are at higher risk. Dr Feng recommended examining all DMEK patients one hour after surgery for signs of pupil block. These include the anterior chamber remaining full of air, high intraocular pressure (IOP) and obstructed peripheral iridotomy (PI). Patients with signs of potential pupil block should be observed further. Those with full air fills that do not spontaneously resolve or develop symptoms of pupil block should be dilated and have some air removed, Dr Feng said. “In our practice, the pupil block rate is zero because we actively screen for and prevent it,” he added.

GLAUCOMA

NORMAL-TENSION RISKS Vascular factors increase risk of progression. Roibeard O’hEineachain reports

part from having a normal intraocular pressure (IOP), there is as yet no known diagnostic feature of normaltension glaucoma (NTG) that separates it from hightension glaucoma. However, some research suggests that vascular disease may play a direct or indirect role in some patients with the condition, said Antonio Fea MD, PhD, University Eye Hospital, Torino, Italy. “There are two families of low-tension glaucoma, one which is probably more atherosclerotic and which has a slower pace of progression but which at the same time does not respond very well to IOP reduction, and another family that has a more vasospastic type of disease and responds better to IOP-lowering therapy,” Dr Fea told a session of the 11th European Glaucoma Society Congress in Nice. He noted that optic nerve head pathology of both high- and normal-tension glaucoma share the same characteristic features. However, some features, like disc haemorrhages, pits and notches, occur more commonly in NTG. In terms of visual field loss, again there are no diagnostic features to distinguish normal-tension from high-tension glaucoma, although as a rule, visual field loss in NTG tends to be more localised, denser in the superior quadrant and more prominent in the lower hemifield.

LOCALISED DETERIORATION In addition, visual field loss in NTG tends to progress more slowly than high-tension glaucoma. A study into the natural history of the disease showed that after seven years only half of the cases had a confirmed localised deterioration. However, the rate of progression varied significantly between patients, ranging from -0.2dB to -2dB. Although IOP is at normal levels in NTG, IOP is nonetheless an important factor in the disease. Research has shown that NTG patients in whom treatment brings about a 30 per cent reduction in IOP will have a better preservation of their visual field than untreated patients (Am J Ophthalmol. Jan 1999;127(1):120). The more recent LowPressure Glaucoma Treatment Study (LOGTS) yielded similar results and showed that risk factors for progression included lower mean ocular perfusion pressure and the use of systemic antihypertensive agents (Krupin, Am J Ophthalmol. April Antonio Fea MD, PhD 2011;151(4):671-681).

There are two families of lowtension glaucoma, one which is probably more atherosclerotic and which has a slower pace of progression...

Localised optic nerve cupping and optic nerve haemorrhages, although more frequent of NTG, can occur both in high-pressure and low-pressure glaucoma

The LOGTS study also famously demonstrated that there was less progression among patients receiving brimonidine than in those receiving timolol, despite both groups achieving the same IOP reduction, suggesting that brimonidine may have a neuroprotective effect. Dr Fea noted that several studies have shown that glaucoma patients have a lower cerebral spinal fluid pressure and a higher trans-lamina cribrosa pressure difference when compared to those without glaucoma. “The cerebrospinal fluid is correlated to blood pressure, so it might be that in some way some of the circulatory issues that we are seeing in NTG are related to this parameter more than the circulation itself,” he added. Dr Fea also highlighted that, although it is not included in the guidelines for the diagnosis of NTG, progression should be considered essential in the diagnosis of the disease because several other entities may mimic both the visual field defect and the optic nerve appearance. Antonio Fea: antoniofea@interfree.it

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Courtesy of Antonio Fea MD, PhD

GLAUCOMA

CSF PRESSURE IS CRITICAL Imbalance of fluid pressures lies at the heart of open-angle glaucoma. Roibeard O’hEineachain reports

he cerebrospinal fluid (CSF) pressure is a potentially critical parameter in the pathology of primary open-angle glaucoma, a finding with possible implications for research, reports Jost B Jonas MD, University Eye Clinic, Mannheim, Germany. “Physiological relations in the dynamics of the change in intraocular pressure (IOP) and orbital cerebrospinal fluid pressure may play a role in the onset and progression of glaucomatous optic neuropathy,” he told the 11th Congress of the European Glaucoma Society in Nice. Previous population-based, clinical and laboratory studies point to a positive correlation between CSF pressure, blood pressure and IOP. However, the research also shows that, although arterial hypertension is significantly associated with elevated IOP, it is not associated with glaucoma. Like IOP, CSF pressure is also elevated in people with hypertension, but both blood pressure and CSF pressure tend to be low in patients with normal tension glaucoma. What the findings suggest is that glaucoma may result from some sort of malfunction in the body’s normal mechanisms for maintaining the equilibrium between the fluid pressures of the intraocular space, the systemic circulation and the brain, Dr Jonas said.

PREVENT DAMAGE He noted that in patients without glaucoma, the CSF pressure rises to match that of the IOP and so is able to counter the IOP and prevent damage to the optic nerve. In an eye with primary open-angle glaucoma, on the other hand, the IOP exceeds the CSF by such a degree that it creates an abnormal pressure gradient on the lamina cribrosa that in turn influences the physiology of optic nerve fibres and their axoplasmic flow. Evidence supporting that theory comes from the Beijing Eye study and the Central India Eye and Medical Study which showed that, in patients with angle glaucoma, a smaller rim and thinner retinal nerve fibre layer was associated with a higher trans-lamina cribrosa pressure difference but not with a higher IOP. Dr Jonas added that on that basis there could be several scenarios where glaucomatous damage to the optic nerve is likely to occur. They include patients with high IOP but normal CSF, those with normal IOP but low CSF and those with arterial hypotension in whom cyclical reductions in CSF pressure exceed those of IOP. Another implication of the research is that many situations where IOP is elevated pose no threat to the optic nerve head in healthy individuals. For example, a trumpet player may have high IOP while in performance, but will not be vulnerable to optic nerve head damage because the brain pressure is also increased. The same may be true when a person stands on their head or is in a supine position, Dr Jonas added. Jost B Jonas: Jost.Jonas@augen.ma.uni-heidelberg.de EUROTIMES | NOVEMBER 2014

GLAUCOMA

GLAUCOMA RESEARCH 10mmHg in 10 minutes? The 10-10-10 Challenge for glaucoma. Sean Henahan reports ir Peng Tee Khaw is an optimist. He foresees a time in the not too distant future when patients with glaucoma can receive a treatment that takes 10 minutes, lowers intraocular pressure (IOP) to 10mmHg, and lasts for 10 years. This would have an enormous impact on the management of glaucoma worldwide if it could be achieved. Dr Khaw, Professor of Glaucoma and Ocular Healing at the UCL Institute of Ophthalmology and Consultant Ophthalmic Surgeon at Moorfields Eye Hospital, London, UK, outlined progress in glaucoma treatment that may help get to that goal during a talk at the World Ophthalmology Congress in Tokyo. “We are still far from this goal. In the 21st Century, whatever surgery you are doing, whether in the suprachoroidal space, subconjunctival, or anywhere else, they all rely on tissue scarring. And they all fail because of tissue scarring, particularly when you fail to achieve a low pressure,” he noted. What is needed is nothing less than perfect surgical technique, along with perfect healing. Fortunately, there has been

considerable progress on both fronts. The traditional problems of glaucoma surgery of hypotony and complications are both occurring less frequently with better surgical techniques. He cited as an example a success story involving a young patient with advanced congenital glaucoma.. Following successful surgery in this particularly challenging condition, she has maintained an IOP of 10mmHg for the past 10 years. “She scored us 10/10 because she has had a good life. The important thing is to get the pressure low, and I mean to around 10mmHg if you can do this safely. If you keep the pressure low for most patients over a prolonged period of five to 10 years, most of them don’t progress. It is very important to get this right,” he emphasised. (Image 1: Long-term diffuse non-cystic bleb, pressure 10mmHg) Recent years have seen incremental improvements in surgical technique that are already making a difference. For example, simple changes in trabeculectomy have made the use of antimetabolites safer, and are producing better looking blebs compared with before. Hypervascularity and leakage are problems linked with poor outcomes. Treatments that take this into consideration could make a difference.

Image 1: Long-term diffuse non-cystic bleb, IOP 10mmHg

Courtesy of Prof Peng T Khaw

Image 2: Red bleb, Grade 5, Moorfieds grading system

EUROTIMES | NOVEMBER 2014

GLAUCOMA “We see in the clinic that people are very different. You see the same surgeon using the same device, and same anti-scarring agent, yet the outcomes are very different. We have seen that hypervascularity is a very bad sign. A patient with a very red eye post-op on the Moorfields scale at two weeks has a hazard ratio of 2.89; if still very red at 6 weeks, the hazard ratio is six. There are not many things in medicine that have a hazard ratio of six.” (Image 2: Severely inflamed bleb - Grade 5, Moorfields bleb grading at week 6. This eye is six times more likely to fail. http://www.blebs.net )

Courtesy of A Khalili

But in the meantime, we continue to use more anti-inflammatory agents than in the past.” Anti-VEGF antagonists like bevacizumab (Avastin) are also likely to have an important role in treatment. High-resolution angiography imaging studies show that it is leakage that is the problem, not neovascularisation. VEGF inhibition tends to stabilise the leakage, which is important from the point of view of wound healing. (Image 3: High-resolution angiography showing bleb leakage rather than neovascularisation) Another line of approach involves pain control. Better pain control reduces leakage and VASCULAR LEAKAGE the release of cytokines and the Vascular leakage can negate cascade of fibroblasts and other the effects of intraoperative Image 3 : High-resolution angiography showing bleb leakage rather inflammatory factors. Simple pain than neovascularisation mitomycin-C and other agents control may provide significant used at the time of surgery. It may anti-scarring effects. be necessary to deploy these agents in the longer term, otherwise the “We all learn in medical school - calor dolor, rubor. That is, surgery could fail, or pressures will not be as good as they should be. heat, pain, and redness in inflammation. We are sticking needles “We are finding in laboratory research that inflammation is in people’s eyes, and it hurts. I always use local anaesthetic in the very important. We tend to use steroids, or non-steroidal antiinjection when giving postoperative agents. Patients like it, and inflammatory drugs if steroids are not sufficient. What we really when they come back for a second injection, they are not jumping need is a new generation of anti-inflammatory agents without up the wall. You may also be improving their outcome as well by the troubling side effects. preventing scarring,” said Dr Khaw. “We are seeing signs in translational research of new agents that do not have the side effects of steroids. We are very excited. Peng Tee Khaw: p.khaw@ucl.ac.uk

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EUROTIMES | NOVEMBER 2014

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GLAUCOMA

DETECTING CHANGES

New detectable biomarkers and bio-signatures for glaucoma show promise. Roibeard O’hEineachain reports

s research continues to define the pathological characteristics of glaucoma, new diagnostic and prognostic indicators are being discovered which could help in the detection and monitoring of the disease, according to presenters speaking at the 11th Congress of the European Society of Glaucoma in Nice. “Although at this point we don’t have one specific biomarker that is consistently measurable and helpful, there are a number of new potential biomarkers that are being studied and some of these are beginning to show some potential,” said M Roy Wilson MD, MS, Wayne State University, Detroit, US. Dr Wilson said that, although some authors use the term biomarkers in a much broader sense, he prefers to restrict the term to molecules that are involved with a function that influences the disease. Another important characteristic of biomarkers is that they should be highly specific. Therefore, for example, enhanced expression of neuronal thread protein is not a clinically important biomarker for glaucoma because it also occurs in Alzheimer’s disease and some other neurodegenerative disorders. He noted that, in the case of primary open-angle glaucoma, various pathophysiological mechanisms have been suggested for the neurodegeneration that defines the disease. They include ischaemia and hypoxia, as well as aberrant immunity, autoimmunity, inflammatory cytokines and effects on the lamina cribrosa that in turn result in a blockade of neurotrophins. Among the cytokines, TGF β2, the major transforming growth factor in the eye, may have some potential not only as a biomarker but as a treatment target at well. The growth factor is elevated in the eyes of patients with glaucoma and has the effect of increasing the fibrosis material in the trabecular meshwork.

“Theoretically, if one could minimise TGF β2 one could possibly delay the ageing process of the trabecular meshwork in glaucoma patients,” Dr Wilson said. He added that there is now some evidence that auto-antibodies may increase the susceptibility of the optic nerve to damage by changing the properties of the vasculature in the lamina cribrosa, which also increases the intraocular pressure (IOP) as a by-product. Research suggests that serum antibodies against neuron-specific enolase are present in 20 per cent of glaucoma patients, he said. Those glaucoma patients with the auto-antibody also appear to have lower maximum IOP than those without it, and its presence and its levels may provide an additional gauge of disease progression. Auto-antibodies for the detoxification enzyme, glutathione s-transferase, are also increased in open-angle glaucoma patients and may represent a response to tissue damage, he continued. Another potential immunological biomarker is H pylori immunoglobulin, levels of which are increased in the aqueous humour in open-angle glaucoma patients. Higher titres of the protein appear to correlate with the severity of glaucomatous damage

BIO-SIGNATURES Neeru Gupta MD, PhD, MBA suggested that a broader grouping of risk factors and biomarkers and surrogate outcomes, which she termed “bio-signatures”, could be useful in clinical practice. “By bio-signatures, I mean something that you can use to distinguish suspects from disease, that will help us predict treatment outcomes, and the course of disease,” said Dr Gupta, Professor and Dorothy Pitts Chair of Ophthalmology and Vision Science, St Michael’s Hospital, University of Toronto, Canada. The classic bio-signature of glaucoma is damage to the optic nerve head. However, the correlation between damage to the optic nerve, as currently

We need to pay much more attention to what is changing for the patient from a visual point of view... Neeru Gupta MD, PhD, MBA EUROTIMES | NOVEMBER 2014

measured, and visual field test results tends to be inconsistent. The same is true of IOP, which has a complex and as yet not fully understood role in pathology, although 24-hour monitoring may help clarify its role, she said. “Our signatures aren't always as good as they can be and the problem is that if we use them to follow and monitor our patients clinically, it takes a really long time,” she added.

GLAUCOMA AND THE BRAIN Meanwhile, there is accumulating evidence that glaucomatous neurodegeneration extends beyond the optic nerve, through thelateral geniculate nucleus, and all the way through to the optic nerve. Structural changes in these areas could prove to be useful prognostic indicators regarding disease progression and treatment response. For example, Dr Gupta's team in collaboration with Dr Yeni Yucel has shown that in human glaucoma there is significant neural degeneration in the pre-chiasmal optic nerve, the lateral geniculate nucleus and visual cortex (Gupta et al, Br J Ophthalmol. 2006;90:6 674-78). In addition, other MRI studies she and her associates conducted in glaucoma patients have shown significant atrophy of the lateral geniculate nucleus in human disease (Gupta et al, Br J Ophthalmol. 2009;93(1): 56–60). Moreover, glaucomatous neurodegeneration likeley extends to the non-retino-geniculo-cortical visual pathway. That includes changes in the superior colliculus that may cause detectable changes in the behaviour of a patient’s visual system. She noted that in a recent study she and her associates conducted, that saccadic eye movements were significantly delayed in patients with glaucoma (Kanjee et al, Eye and Brain. 2012;4:63-68). “This raises the question of whether there are other vision tasks that we should be looking for that might help us clinically. We need to pay much more attention to what is changing for the patient from a visual point of view and how it affects their quality of life - other than the routinely used visual field,” Dr Gupta added. M Roy Wilson: president@wayne.edu Neeru Gupta: guptan@smh.ca

RETINA

PROGRESS IN SURGERY New technique allows endoscopic retinal repair with no PFCL. Leigh Spielberg reports

ubretinal perfluorocarbon liquid (PFCL) migration is a rare but serious complication associated with retinal detachment repair, primarily due to the potential for toxic effects of the liquid. Intraoperative removal is the ideal solution, but this can be difficult, and retained PFCL is easily missed, to be detected only later during follow-up visits. “When you’re treating cases with giant retinal tear with slipped and rolled retina, it is essentially impossible to avoid subretinal perfluorocarbon liquid migration in every case. So I developed a technique that I believe can eliminate this problem while still achieving good surgical results,” reported Tatsushi Kaga MD, PhD, of Nagoya, Japan, at the 14th annual EURETINA Congress in London. Using an endoscope and successively tilting the patient’s head and eye in order to control the movement of subretinal fluid, Dr Kaga demonstrated his method of flattening and unrolling the retina without the use of PFCL. “In this manner, it’s really not so difficult to flatten the retina,” he explained. Step 1 is to use a flute needle to drain as much of the subretinal fluid as possible. Employing the endoscope to maintain visualisation of the peripheral tear, the patient’s head and eye are tilted so that the tear is positioned at the lowest position of the eye (Step 2). “The subretinal fluid moves down towards the inferior part of the eye and gathers around the retinal tear because of gravity and surface tension,” said Dr Kaga.

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FLUTE NEEDLE Dr Kaga showed an endoscopic video of Step 3, in which the retina is flattened using a silicone-covered flute needle, “as if being swept by a broom”, he said. This step can be repeated until the retina is flat. Once the subretinal fluid has been removed to the surgeon’s satisfaction, the patient’s head and eye are tilted so that the peripheral tear is positioned higher in the eye. End laser retinal photocoagulation can then be performed (Step 4). This step is also performed using the endoscope for visualisation. “The endoscope provides a highly magnified image, so you can perform the photocoagulation with great certainty,” he said. “Endoscopic techniques are different from microscopic techniques and are not easy to perform, even in the hands of skilled surgeons.” Dr Kaga cautioned that there is a definite learning curve involved in the use of the endoscope. However, he believes the benefits are worth the effort. An endoscope provides stable visibility during fluid-air exchange. The fundus can be seen in any position, even if the eye is highly tilted, and it’s possible to see from oblique angles with magnification. Tatsushi Kaga: kaga@chukyogroup.jp

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RETINA

PATIENTS SEE THE BENEFITS 12-month results promising for subretinal implant for retinitis pigmentosa. Leigh Spielberg reports

n increasing amount of clinical data support the use of electronic subretinal implants for the restoration of some useful, functional vision in patients blinded by retinitis pigmentosa, according to Dr Eberhart Zrenner MD, of the University of Tübingen in Germany. “Patients described being able to see things like their granddaughter in a little white dress, the silhouette of Tübingen town-hall, fireworks, blooming flowers in the garden, a goose swimming in a pond, and being able to differentiate between red and white wine,” Dr Zrenner told the 14th EURETINA Congress in London. Dr Zrenner presented the 12-month visual and safety outcomes of a prospective, multi-centre clinical trial on the safety and efficacy of subretinal implants for partial restoration of vision in 29 patients who had lost all vision due to retinitis pigmentosa. Research teams from Germany, England, Singapore, Hungary and Hong Kong participated in the study. “Electronic implants are presently the only possibility for these patients to regain some vision, which can currently reach 20/550,” he said. The Alpha IMS subretinal implants (Retina Implant AG, Reutlingen, Germany) were positioned beneath the foveal region. Each of the 1,500 photodiodes, which represent one pixel each, controls an amplifier that, depending on the strength of the light, emits currents to stimulate overlying bipolar cells. Power and control signals are supplied inductively via a subdermal, retroauricular coil from which a subdermal cable leads to the eye. Detection, localisation and recognition of shapes and objects in activities of daily life were significantly better with implant power switched on than off during the first three months. The patients, who were on average 53 years old, had on average lost the ability to read 17 years ago. However, after implantation, four patients (14 per cent) could read letters 4-8cm in size. Thirteen patients (45 per cent) reported useful visual experiences, including recognition of shapes or details in daily life and eight patients (28 per cent) could localise objects in daily life. Four patients gained no light perception. The presentation was highlighted by several videos of patients using their devices. One video showed a patient identifying and accurately grasping tableware objects. “Psychophysical testing and self-reported outcomes show restoration of useful vision in a majority of patients,” said Dr Zrenner. Of the 29 patients, six reported “very good visual experiences”, seven reported “useful visual experiences” and eight described being able to localise light sources, albeit without shape or details. Eight patients reported no useful visual experiences in daily life. Technically, there is room for improvement for use in daily life, said Dr Zrenner, referring to improvements in visual resolution, visual field and practicability. Besides two serious but treatable adverse events there were no safety concerns. Eberhart Zrenner: ezrenner@uni-tuebingen.de EUROTIMES | NOVEMBER 2014

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OCULAR

UVEAL MELANOMA MEK inhibition shows benefit as monotherapy; now being looked at as platform for combination strategies. Cheryl Guttman Krader reports

Courtesy of Kun-Liang Guan PhD

ecent discoveries about the genetics and molecular biology of uveal melanoma are providing a foundation for developing targeted therapy, and with that step have come some encouraging clinical results. In a paper published in the June 18, 2014 issue of JAMA (JAMA. 2014;311(23):2397405), investigators in a Phase II clinical trial reported that treatment with oral selumetinib (AstraZeneca), an investigational MEK1/2 inhibitor, improved clinical outcomes compared to chemotherapy in patients with advanced uveal melanoma. Richard D Carvajal MD, director of the Developmental Therapeutics Program and member of the Melanoma and Immunotherapeutics of Memorial Sloan Kettering Cancer Center, New York, is the lead author of the JAMA article. He told EuroTimes: “This is the first randomised comparative study to show that a systemic therapy provides significant clinical benefit for patients with advanced uveal melanoma. We consider it an important step forward for this patient population that currently has a poor prognosis and very limited treatment options.” He noted that an international Phase III study [Selumetinib in Metastatic Uveal Melanoma (SUMIT)] is now under way comparing selumetinib plus dacarbazine versus chemotherapy alone. “SUMIT is the first study with registration intent to be conducted for patients with advanced uveal melanoma, and we hope that it will confirm the efficacy of MEK inhibition observed in our Phase II trial,” Dr Carvajal said. The Phase II study randomised 101 chemotherapy-naïve patients with metastatic uveal melanoma to selumetinib 75mg twice daily or chemotherapy using oral temozolomide (Temodar, Merck) or intravenous dacarbazine. Median treatment duration was 16.1 weeks for selumetinib and eight weeks for the control group.

(14 per cent). Selumetinib also improved overall survival compared to chemotherapy (median 11.8 vs 9.1 months). Although the difference between groups did not achieve statistical significance, the investigators noted that determination of a survival benefit for selumetinib may have been confounded by the fact that 86 per cent of the control patients crossed over to selumetinib after experiencing disease progression while on chemotherapy. Almost all patients experienced treatment-related adverse events in the selumetinib group. Consistent with the safety profile of other MEK inhibitors, the most common adverse events were acneiform rash, creatine kinase elevation, fatigue and liver enzyme elevations. The selumetinib dose was reduced for management of an adverse event in 37 per cent of patients and six per cent of patients discontinued treatment because of an adverse event. The rationale for investigating selumetinib as a treatment for metastatic uveal melanoma derives from understanding that about 80 per cent of patients with uveal melanoma harbour oncogenic mutations in GNAQ or GNA11 leading to activation of the mitogen-activated protein kinase (MAPK) pathway. MEK is a key enzyme in the MAPK pathway, and previous studies

conducted using uveal melanoma cell lines demonstrated an anti-tumour effect of MEK inhibition. Dr Carvajal noted that in addition to SUMIT, two Phase II clinical trials are under way investigating MEK inhibition as a platform for novel combinatorial therapeutic strategies. One study is comparing a commercially available MEK inhibitor trametinib (Mekinist, GSK) with or without an investigational AKT inhibitor (GSK2141795). “These studies are based on preclinical data indicating that it may be possible to build upon the efficacy observed with single agent MEK inhibition through the addition of AKT or PKC inhibition,” Dr Carvajal said. In another recent paper (Cancer Cell. 2014;25(6):822-30), Kun-Liang Guan PhD and colleagues reported that GNAQ/GNA11 mutations drive uveal melanoma tumorigenesis by activating the Yes-associated protein (YAP). Based on that information and evidence that verteporfin (Visudyne, Valeant) acts as a YAP inhibitor, they tested the anti-tumour efficacy of the commercially available photosensitizer and found that it slowed uveal melanoma growth both in cell culture and in vivo in an animal model. Richard D Carvajal: carvajar@mskcc.org Kun-Liang Guan: kuguan@ucsd.edu

ENDPOINT ANALYSIS The primary endpoint analysis showed selumetinib significantly prolonged progression-free survival compared to chemotherapy (15.9 vs seven weeks). In addition, only selumetinib-treated patients achieved tumour regression (49 per cent) or an objective radiographic response

SUMIT is the first study... to be conducted for patients with advanced uveal melanoma... Richard D Carvajal MD EUROTIMES | NOVEMBER 2014

World Society of Paediatric Ophthalmology and Strabismus

World Congress of Paediatric Ophthalmology and Strabismus Fira Gran Via, Barcelona, Spain 4â&#x20AC;&#x201C;6 September 2015 Abstract Submission Deadline: 18 January 2015

www.wspos.org

Expertise Does Not Reside in Only One Part of the World

PAEDIATRIC OPHTHALMOLOGY

MYOPIA EPIDEMIC The condition increases with level of education and longer schooling.

s levels of myopia continue to rise to epidemic proportions in China and other parts of East and Southeast Asia, there is growing evidence that education and behaviour may have a greater impact on the development of nearsightedness than do genetic factors. With each school year completed a person becomes more near-sighted, and the higher the level of education completed, the more severe the impairment of vision, according to the results of a major population-based cohort study of myopia carried out at Mainz University Medical Centre, Germany. While nearsightedness is widespread, it has become more prevalent around the world in recent years and presents a growing global health and economic concern, said Professor Norbert Pfeiffer who led the research along with Dr Alireza Mirshahi. To analyse the possible correlation between myopia development and education, researchers at the Mainz University Medical Centre examined myopia in 4,658 persons from mid-western Germany aged 35 to 74 years, excluding those who had undergone cataract or refractive surgery. Undertaken as part of the Gutenberg Health Study, the results demonstrate that myopia becomes more prevalent with a higher level of education. Only 27 per cent without any school graduation were myopic, while 51 per cent of high school graduates were nearsighted. In contrast, no less than 53 per cent of university graduates were nearsighted. In addition to education levels completed, the Mainz-based researchers found that people who spent more years in school tended to be more myopic, with nearsightedness worsening for each year of school. The researchers also looked at the effects of 45 genetic markers, but found that these have a much lower impact on the severity of nearsightedness compared to the level of education achieved.

SPECIAL SPECTACLES The researchers note that attempts to slow the progression of myopia with special spectacles or contact lenses have proved unsuccessful or impractical to date. And while some studies have shown low-dose atropine eye drops to be effective in controlling myopic progression, issues of compliance, cost and concerns about possible long-term side effects may limit their widespread adoption. One possible solution, however, may be simply to encourage children to spend more time outdoors, with a number of large-scale studies now showing that the risk of the development of myopia may be less with spending more time outdoors and, thus, by greater exposure to sunlight and greater time looking at the far. Around 15 hours per week appears advisable, according to the Mainz University press release, while at the same time the eyes should not be used for close-up activities such as reading or using computers and smartphones for more than 30 hours per week. The findings of the Mainz University research broadly echo two separate landmark studies in recent years, in which Donald Mutti

Kathy Rose and I challenged the dogma that myopia was genetic... Ian G Morgan

Courtesy of Qianyun Chen, Zhongshan Ophthalmic Centre

Dermot McGrath reports

Primary school children sleeping in the dark at lunchtime on a school day in China

and colleagues at Ohio State University and an Australian group led by Kathryn A Rose and Ian G Morgan from the University of Sydney and the Australian National University first highlighted the link between environmental factors and myopia development. “Kathy Rose and I challenged the dogma that myopia was genetic in a major review published back in 2005,” Prof Morgan, Research School of Biology at the Australian National University, Canberra, told EuroTimes. “In 2008 we reported on the data we had been collecting on time outdoors as a protective factor. I have to say that we are happy that the evidence since then has increasingly confirmed our, at the time, quite heretical hypotheses. This new paper by Mirshahi and colleagues gives the importance of environmental factors very strong support,” he said. Prof Morgan noted that while the prevalence of myopia does appear to be increasing in Europe, it is still quite a bit lower than in East Asia, where young adults are now 80-90 per cent myopic, and where the level of high myopia is now of the order of 20 per cent, compared to around one to three per cent in Europe. “The detailed genetic studies that have been carried out have so far not found any genetic factors to be associated with the much higher prevalence of myopia in East Asia. But we now know of two factors that are important in generating the difference. The first is the massive educational demands on children in East Asia, who effectively start studying for competitive university entrance from the beginning of primary school, if not earlier. The other factor is the amount of time that children spend outdoors, which appears to prevent the development of myopia,” he said. Prof Morgan said that the available survey data suggest that children in East Asia spend remarkably little time outdoors compared to children in Europe, North America or Australia. The evidence is finally prompting health authorities and governments in the countries most affected by the upsurge in myopia to take action to counteract the phenomenon, said Prof Morgan. Singapore, for instance, has officially adopted more time outdoors as its myopia prevention strategy, but is approaching this by attempting to influence parental choices through information campaigns. The Chinese government is also currently discussing whether to severely limit the amount of homework given to children in kindergartens and primary schools. Alireza Mirshahi: alireza.mirshahi@unimedizin-mainz.de Norbert Pfeiffer: pfeiffer@augen.klinik.uni-mainz.de Ian Morgan: ian.morgan@anu.edu.au EUROTIMES | NOVEMBER 2014

PAEDIATRIC OPHTHALMOLOGY

CATARACT Posterior capsule management tips.

KR-800S AUTO KERATOREFRACTOMETER WITH “SUBJECTIVE” FUNCTIONS · Accurate objective measurement (REF, KRT, R/K) · Subjective measurement for far & near · Glare test · Contrast test · Grid test · Pre- and post-cataract screening

Leigh Spielberg reports

n paediatric cataract cases, management of the posterior capsule is crucial, Abhay R Vasavada MD emphasised at the Combined Symposium of Cataract & Refractive Societies on “Cataract Surgery in Difficult Eyes” at the annual meeting of the ESCRS in London in September. “Management of the posterior capsule significantly affects the outcome of paediatric cataract surgery,” stressed Dr Vasavada, Iladevi Cataract & IOL Research Centre, Raghudeep Eye Hospital, Ahmedabad, India. (Figure 1) This is primarily because visual axis obscuration (VAO) is rapid and virtually inevitable in very young children when the posterior capsule is left intact. In paediatric cataract, primary posterior capsulotomy and vitrectomy are considered routine surgical steps, although there are many variations in technique. Dr Vasavada described his preferred method of posterior capsulorhexis, which he performs after insertion of the intraocular lens (IOL) into the capsular bag. “I find this technique to be easier, particularly in very small infant eyes, since the IOL maintains a certain capsular stability, far more so than when the bag is empty,” said Dr Vasavada.

ANTERIOR APPROACH Of course, this isn’t possible via an anterior approach, so Dr Vasavada explained how he does it via the pars plicata. “This technique can be used to create a posterior capsulectomy of the desired size in a controlled manner, in order to avoid later destabilisation of the IOL,” he said, referring to a study he and his team published in the Journal of Cataract & Refractive Surgery. This procedure should be followed by an anterior vitrectomy with the use of triamcinolone, he added. The posterior approach to procedure can also be used for lentiglobus (previously referred to as lenticonus), with the creation of a posterior capsulorhexis via a pars plana approach. Dr Vasavada and his team have published a prospective study in which intracameral injection of preservative-free

www.topcon-medical.eu

Figure 1: Anterior and posterior capsulorhexis in a paediatric eye along with an in-the-bag IOL. Posterior capsulorhexis is essential to retard development of visual axis opacification

triamcinolone acetonide was shown to improve visualisation of the vitreous during paediatric cataract surgery. Triamcinolone was injected three times: once after the capsulorhexis, once after anterior vitrectomy and for a third time after IOL implantation. This is useful to detect any residual vitreous strands left behind following anterior vitrectomy through the limbal or pars plicata approach. Dr Vasavada also has experience with femtosecond capsulorhexis in paediatric cases. “This is quite effective, but it requires two docking sessions, one for the anterior capsule and one for the posterior capsule. This makes it expensive to use, and it also raises concerns about infection, since the incisions have been made prior to the second docking session and the pressure suction can cause potential influx of ocular surface contamination.” The delegates and panel members asked several questions. Asked what his opinion was of one-piece IOLs in paediatric cases, Dr Vasavada responded: “My routine choice is a one-piece hydrophobic acrylic IOL, specifically Acrysof. However, if the bag is damaged I’m reluctant to use a one-piece, because if one haptic escapes it’s a disaster. It’s also very difficult and dangerous to implant both haptics of a one-piece lens in the sulcus.” Abhay R Vasavada: icirc@abhayvasavada.com

Management of the posterior capsule significantly affects the outcome of paediatric cataract surgery Abhay R Vasavada MD

EUROTIMES | NOVEMBER 2014

Courtesy of Abhay R Vasavada MD

JCRS

Corneal Transplant

JCRS

Automated

HIGHLIGHTS

VOL: 40 ISSUE: 10 MONTH: OCTOBER 2014

ASTIGMATIC OUTCOMES WITH TORIC IOLS The management of pre-existing corneal astigmatism has become clinically more important with the advent of improved IOLs and surgical techniques. Japanese researchers conducted a large prospective study of long-term astigmatic outcomes and rotational stability of the Acrysof IQ toric SN6AT IOL in 378 eyes. Using serial digital photographic analysis of anterior segment landmarks to assess absolute and relative rotational alignment, the authors documented a mean rotational misalignment of 4.1 degrees ± 3.0 (SD) at two years with an overall reduction in refractive astigmatism from 1.92 ± 1.45 dioptres to 0.67 ± 0.9 D. The mean IOL rotation was greatest by postoperative day one (4.5 ± 4.9 degrees) and changed little in the subsequent two years. Six eyes demonstrated more than 20 degrees of rotation, and all these eyes had axial eye lengths greater than 25 mm, with-the-rule astigmatism, and early postoperative rotation. This suggests that misalignment is still an important source of postoperative residual astigmatism. T Miyake et al, JCRS, “Long-term clinical outcomes of toric intraocular lens implantation in cataract cases with pre-existing astigmatism”, Volume 40, No 10, 1654-60.

New

ASTIGMATIC OUTCOME WITH CORNEAL RELAXING INCISIONS Corneal relaxing incisions present an entirely different intraoperative challenge with respect to astigmatic outcomes. Unlike toric IOLs, relaxing incisions maintain a fixed rotational alignment once placed. However, the magnitude of astigmatic effect is less predictable and standard nomograms are notoriously imprecise in eyes with altered corneal biomechanical states owing to previous corneal surgery, ectatic disease, or keratoplasty. A three year follow-up study of 20 eyes of 20 patients that underwent small incision cataract surgery concludes that manual peripheral corneal relaxing incision effects are more limited in range and take longer to stabilise. R Lim et al, JCRS, "Long-term stability of keratometric astigmatism after limbal relaxing incisions", Volume 40, No 10, 1676-81.

• Performance independent of user variation • Consistent reproducibility for thin lamellae • Wide range of single-use heads: from 110 µm to 450 µm

BEST ANALGESIA AFTER PRK? PRK is less popular than LASIK, primarily due to problems of slower visual recovery and discomfort in the immediate post-op period. Numerous drugs are used to provide pain relief for PRK patients. A new review surveyed 23 prospective, randomised trials in an attempt to determine which approach provided the most pain relief. The studies found that although the efficacy of drugs tended to be similar, tetracaine one per cent and nepafenac 0.1 per cent tended to have the most analgesic effect. E Faktorovich et al, JCRS, “Efficacy and safety of pain relief medications after photorefractive keratectomy: Review of prospective randomised trials”, Volume 40, No 10, 1716-30.

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

THOMAS KOHNEN European editor of JCRS

Become a member of ESCRS to receive a copy of EuroTimes and JCRS journal

EUROTIMES | NOVEMBER 2014

EYE ON HISTORY

THE TURKISH INNOVATORS AT THE INTERSECTION OF IDEAS AND IMPLEMENTATION. FEBRUARY 12–15, 2015 TURNBERRY ISLE MIAMI, AVENTURA, FLORIDA

PHYSICIANS PROGRAM (Subject to Change) Don’t miss this new opportunity to receive step-by-step guidance on how to immediately deploy what you learn. PROGRAM CHAIRS Edward J. Holland, MD Stephen S. Lane, MD Roger F. Steinert, MD

THURSDAY, FEBRUARY 12 Meet the Experts Roundtable Welcome Networking Reception

Ahead of the 19th ESCRS Winter Meeting, Dr Andrzej Grzybowski looks at major Turkish influences

erefeddin Sabuncuoğlu (1385-1468), who lived in the city of Amasya in central Anatolia, wrote the first illustrated surgical textbook in Turkish-Islamic medical literature, namely Cerrahiyyetü’l-Haniyye (Imperial Surgery), in 1465. The book included descriptions and illustrations of many surgical procedures, incisional techniques and instruments. Only three handwritten copies are preserved which are deposited in Paris and Istanbul. The book consists of three chapters and is divided into 193 sections. The book reviewed Greek, Roman, Arabic and Turkish surgical techniques and is based on the author’s experiences. Among the ophthalmic procedures he described were cataract couching, eyelid operations of warts, chalazion, metaplastic lashes, symblepharon, entropion, ectropion and ptosis, ocular surface surgeries of pterygium and pannus, and an operation of creating a fistula into the nose through the skin near to the eye.

FRIDAY, FEBRUARY 13 ’Stigmatism

Courtesy of Millet Library, Istanbul

Glaucoma Therapy in 2015: MIGS, MEDS, and Beyond Hands-on Workshops (non-CME) Side Bar Session

SATURDAY, FEBRUARY 14 Corneal Issues in Cataract Surgery Cataract Surgery Challenges and Complications Hands-on Workshops (non-CME) Side Bar Session Attendee Dinner

SUNDAY, FEBRUARY 15 Evolving Technology in Cataract Surgery Retinal Injections Hands-on Workshops (non-CME)

JANUARY 13—EARLY BIRD REGISTRATION AND HOUSING DEADLINE

sideXside.ascrs.org EUROTIMES | NOVEMBER 2014

A figure depicting a physician during a treatment from Serefeddin Sabuncuoglu’s book Cerrahiyyetü’l-Haniyye

BEHÇET DISEASE Hulusi Behçet (1889-1948) was born in Istanbul on February 20, 1889. He graduated from medicine at Gülhane Military Medical Academy and specialised in dermatology and venereal disease. He worked as a consultant dermatologist in the Edirne Military Hospital until 1918 when he moved to work at departments of dermatology and syphilis, first in Budapest and then in Berlin. Later he moved to Istanbul Vakžf Guraba Hospital and became a professor and director of the Istanbul University department of dermatology and venereal diseases in 1933. In the years 1924-1925 he made his first observations on the disease later named after him. The first observation started with a patient who had been examined because of eye disturbances, recurrent oral and genital ulcers. Behçet, who continued to examine the patient after his loss of vision, thought that the causative agent was a virus. The second patient was a woman with oral and genital ulcers and eye redness who presented in 1930, but could not be diagnosed until 1935. Behçet reported his idea of the new entity in 193637. Later it was named Behçet Disease. * Dr Andrzej Grzybowski, Department of Ophthalmology, Poznan City Hospital, Poland; Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland

INDUSTRY NEWS

INDUSTRY

NEWS

NEW INJECTOR Rayner Intraocular Lenses Limited has launched the company’s new injector, RaySert PLUS, in the US market after receiving 510(k) clearance from the US Food and Drug Administration (FDA). “RaySert PLUS is designed for safe and effective implantation of the C-flex Aspheric IOL and simple and controlled IOL delivery through a wound assisted 2.2mm clear cornea mini-incision,” said a company spokesman. www.rayner.com

LANDMARK STUDY

TOTAL CORNEAL ASTIGMATISM FUNCTIONALITY I-Optics has announced new Cassini Corneal Analysis functionality designed to measure both anterior and posterior astigmatism, providing refractive-cataract and cornea surgeons with a Total Corneal Astigmatism (TCA) measurement. “Previous clinical studies have demonstrated that posterior corneal astigmatism could be a factor in generating unexpected postoperative outcomes,” said a company spokesman. “Cassini provides critical information to properly select the power and position of Toric IOLs.” www.i-optics.com

Topcon Medical Laser Systems has announced the publication of a study affirming the clinical safety and efficacy of non-damaging photo-thermal therapy for the treatment of chronic Central Serous Retinopathy (CSR) using a PAtternSCAnning Laser (PASCAL) with Endpoint ManagementTM (EpM) software. The study, authored by Daniel Lavinsky MD (Federal University, Rio Grande do Sul) and Daniel Palanker PhD (Stanford University), titled “Non-damaging Photothermal Therapy of the Retina: Initial Clinical Experience with Chronic Central Serous Retinopathy”, was published in Retina, ePub ahead of print, where the study and authors demonstrated that PASCAL with EpM was safe. www.topconmedical.com

THE SWISS TROCAR SYSTEM FOR PRECISE AND SAFE VITREO-RETINAL SURGERY 23G and 25G models with MVR blade and self-sealing cap for 1-step techniques

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EUROTIMES | NOVEMBER 2014

REVIEW

PHACO FOCUS

Everything you ever wanted to know about phaco power and its modulation. Dr Soosan Jacob reports

ver since Charles Kelman and Anton Banko introduced phacoemulsification in 1967, phaco machines have continued to evolve, giving greater precision, effectiveness, safety and speed. With continuing advances and newer power modulations, surgeons need to keep abreast of technology. This article discusses terminologies that need to be understood with regard to phaco power. Nucleus emulsification is achieved using ultrasound energy by applying an electrical field to a piezoelectric crystal causing it to oscillate. These oscillatory movements are transmitted to the phaco tip causing it to vibrate back and forth. Back and forth movement of the phaco tip creates jackhammer and cavitation effects as well as acoustic and fluid waves. The transient cavitation effect creates small air bubbles that implode releasing large amounts of energy. This together with the jackhammer effect causes breakdown of nuclear fragments. Phaco power is used to emulsify the nucleus. Frequency and stroke length contribute to phaco power. Frequency is fixed and ranges from 27 to 50kHz for most machines. Stroke length is the length of movement of the needle and ranges between 2-4 mil. Though the back and forth movement emulsifies nucleus, the forward movement of the tip also causes lens material to be pushed away, thereby decreasing followability. Phaco power modulation is important to increase followability and to decrease chatter and heat production. Excess phaco power can cause wound burn and endothelial loss. Tuning the phaco machine prior to using it is important to make sure that the electronic circuits are working well. This is of importance to increase efficiency while decreasing thermal effects.

PHACO POWER DELIVERY Continuous Mode phaco: Continuous delivery of ultrasound occurs with no time in-between for cooling the tip or for nuclear fragments to move back towards the tip. This results in decreased followability and increased heat generation, thereby decreasing efficiency and safety. Non-continuous modes of phaco have on and off periods of ultrasound energy. During the off period, the pieces get attracted to the tip again, thereby increasing followability and decreasing energy delivered. Pulse mode phaco delivers phaco in pulses with on and off times. Duty cycle refers to percentage of phaco-on to total phaco time and default value set is 50 per cent. EUROTIMES | NOVEMBER 2014

Cycle time refers to time taken for one phaco pulse and its subsequent off period. The cycle time determines pulses per second and can generally go up to 20pps. The total energy delivered can be changed by changing duty cycle but not by changing cycle time. Hyperpulse mode can go up to 120pps. Using very high pulse rates gives the same efficiency as continuous phaco but with less energy delivered. Burst mode phaco gives bursts of phaco energy at fixed power but variable control of burst period to as low as 80 milliseconds. On depressing the foot pedal, the bursts come closer together at the fixed phaco power setting till at the bottom of the foot pedal excursion, it is continuous phaco. A minimum interval or endpoint duty cycle may be programmed to prevent continuous phaco and overheating at the lowest foot pedal depression. Single and multiple bursts are also possible. Hyperburst mode can go as low as four milliseconds. These modulations also result in less total energy used and less heat build up. Maximum phaco power is preset by the surgeon. In linear phaco delivery, with depression of the foot pedal, increasing levels of energy are delivered up to the preset level at the bottom of the foot pedal. This can be set in both continuous and pulse phaco. Panel controlled phaco delivery delivers the full preset phaco power as soon as the pedal is depressed into foot position 3. Actual phaco power in linear mode denotes the actual power being delivered at that instant. Phaco time refers to the time that phaco is used. EPT refers to effective phaco time at 100 per cent power and equals the product of phaco time and average phaco power. Normally, power level delivered in each pulse or burst starts directly at the full level proportionate to the foot pedal position. A gradual rising up of the power level in individual pulse or burst allows a variable rise time. This decreases the power used

...the forward movement of the tip also causes lens material to be pushed away... Soosan Jacob MS, FRCS, DNB

protectalon_eurotimes2.pdf

Figure A: Panel mode continuous phaco B: Panel mode pulse phaco at 50 per cent duty cycle decreases power used C: Panel mode pulse phaco at 25 per cent duty cycle further decreases total power used D: Linear mode continuous phaco E: Linear mode pulse phaco at 50 per cent duty cycle decreases power used F: Linear mode pulse phaco at 25 per cent duty cycle decreases total power used G: Burst mode phaco gives bursts of phaco at preset level with interval between bursts decreasing as foot pedal 3 is pushed down. The longer intervals shown in between are at foot pedal 2

28/10/14

16:32

REVIEW

for phaco, decreases chatter and also increases efficiency. A variable duty cycle similarly prevents continuous phaco energy even with maximum foot pedal depression. CY

CMY

LONGITUDINAL AND NON-LONGITUDINAL PHACOEMULSIFICATION

Phacoemulsification can be done using traditional longitudinal ultrasound or the newer torsional and transversal ultrasound modes. In longitudinal phaco, the needle tip moves back and forth in a longitudinal direction coring the nucleus and decreasing followability. Non-longitudinal modes have better followability, generate less heat, are safer and more effective and act by shaving nuclear material. However, when wanting to impale the nucleus as for phaco chop, longitudinal phaco offers a better grab of the nucleus than non-longitudinal modes. In torsional phaco, the phaco tip oscillates around its axis. With an angled Kelman phaco tip, significant movement of the end of the tip is attained. It shaves nuclear material effectively and decreases repulsion of nuclear material from the tip that occurs with longitudinal phaco. By virtue of the bent tip, it also has the advantage of achieving a longer stroke path at its tip while the movement within the corneal tunnel is much less, thereby decreasing chances of wound burn. In transversal phaco, an elliptical lateral movement is used. Straight and curved tips may be used. The Stellaris (Bausch & Lomb) has longitudinal power mode, Infiniti (Alcon) has both longitudinal and torsional modes, whereas Whitestar Signature (AMO ) has both longitudinal and transversal modes. * Dr Soosan Jacob is a Senior Consultant Ophthalmologist at Dr Agarwal's Eye Hospital, Chennai, India, and can be reached at dr_soosanj@hotmail.com EUROTIMES | NOVEMBER 2014

19 ESCRS WINTER MEETING ISTANBUL TH

In conjunction with

Turkish Ophthalmology Society Cataract & Refractive Surgery Section

20â&#x20AC;&#x201C;22 February 2015

Hilton Istanbul Bosphorus, Turkey

Preliminary Programme, Hotels & Registration Available

www.escrs.org

BOOK REVIEWS

GRACEFUL ACCOUNT It must have been a dream come true for ophthalmologists worldwide, the announcement that a successful technique for treating retinal detachments had been developed. It was 1930 and Jules Gonin had been refining his methods for the past decade. Nearly 80 years had passed since the first PUBLICATION ophthalmoscope had allowed GOOD NEWS FROM SWITZERLAND: visualisation of the ocular A HISTORY OF RETINAL fundus, but the intervening time REATTACHMENT SURGERY had not brought meaningful therapeutic advances. AUTHORS: PETER LEAVER AND RICHARD KEELER This began to change upon the widespread acceptance of PUBLISHED BY RSM PRESS Gonin’s method of locating and sealing retinal breaks. The story of this remarkable development, and the vitreoretinal advances that have followed since, is elegantly told in Good News from Switzerland: A History of Retinal Reattachment Surgery (RSM Press). Written by Peter Leaver and Richard Keeler, this book takes a graceful walk through the evolution of retinal surgery. “The history of retinal reattachment is defined by three great inventions: the ophthalmoscope, [Gonin’s] successful operation to repair a torn retina, and a method for safely removing the vitreous gel,” reads the preface. The text itself fills in the details, providing both the context in which each of the major developments were made and interesting background information about the surgeons who generated them. Richly illustrated with early surgical drawings and photographs of 19th Century pioneers and their equipment, Good News from Switzerland brings this history to life and is highly recommended for all those retinal surgeons whose high rates of surgical success owe a great deal to those who are described herein.

BOOK

REVIEWS

CORNEAL TOPOGRAPHY Zooming forward to a highly technical, computerised age, the Atlas and Clinical Reference Guide for Corneal Topography (Slack) provides an efficient way to find characteristic topographic maps and practise recognising them. “Corneal topography has become essentially a pattern recognition trade, best learned by viewing multiple images of representative patterns,” declare the authors, Ming Wang and Lance Kugler. In order to facilitate this learning and recognition, the atlas has been divided into three sections. Section I illustrates the differences between the two major types of corneal topographers: placido-disk and elevation-based topography. Once the reader understands these differences, (s)he is ready for Section II, which demonstrates a map-based approach, organised by the type of map. Section III takes a reverse approach by organising the maps based on the disease. The atlas is intended for the busy clinician in need of quick reference and is appropriate for anyone who uses a corneal topographer.

SAN DIEGO APRIL 17–21

THE LARGEST U.S. MEETING DEDICATED TO THE ANTERIOR SEGMENT SPECIALIST THE LEADING PRACTICE MANAGEMENT PROGRAM IN OPHTHALMOLOGY ASCRS GLAUCOMA DAY ASOA WORKSHOPS TECHNICIANS & NURSES PROGRAM

AnnualMeeting.ascrs.org All programming will be held in the San Diego Convention Center.

A joint meeting with

LEIGH SPIELBERG Books Editor

If you have a book you would like to have reviewed please send it to: EuroTimes, Temple House, Temple Road, Blackrock, Co Dublin, Ireland

EUROTIMES | NOVEMBER 2014

CALENDAR

JUNE

DECEMBER

SOE 2015 Congress

6th Amsterdam Retina Debate 12 December Amsterdam, The Netherlands www.amc.nl/retinadebate

↙

JANUARY 2015

LAST CALL

NOVEMBER 2014 Femto Congress 2014

7–9 November Budapest, Hungary www.femtocongress2014.hu

94th SOI National Congress 21–24 November Rome, Italy www.congressisoi.com

27th APACRS Annual Meeting 13–16 November Jaipur, India www.apacrs2014.org

Joint Irish/UKISCRS Refractive Surgery Meeting 21 November Dublin, Ireland Email: hmurphy@materprivate.ie

9th International Congress ‘Macula of Paris’

6–9 June Vienna, Austria www.soe2015.org

SEPTEMBER

International Conference on Ocular Infections (ICOI) 3–4 September Barcelona, Spain www.ocularinfections.com

9 January Paris, France www.maculaofparis.org

6th EuCornea Congress 4–5 September Barcelona, Spain www.eucornea.org

5th EURETINA Winter Meeting 24 January Oxford, UK www.euretina.org

3rd World Congress of Paediatric Ophthalmology and Strabismus

FEBRUARY

4–6 September Barcelona, Spain www.wspos.org

73rd Annual Conference of AIOS 5–8 February New Delhi, India www.aios.org

Inaugural Asia-Australia Congress on Controversies in Ophthalmology (COPHy A2)

5–8 February Ho Chi Minh City, Vietnam www.comtecmed.com/cophy/aa/2015/

19th ESCRS Winter Meeting 20–22 February Istanbul, Turkey www.escrs.org

NEW ENTRY 29th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery 26 February–1 March Athens, Greece www.hsioirs.org/index.php/en/

APRIL

XXXIII Congress of the ESCRS

15–17 April San Diego, US http://corneacongress.org/

15th EURETINA Congress

NEW ENTRY World Cornea Congress VII (WCCVII)

NEW ENTRY Barcelona Oculoplastics Meeting

5–9 September Barcelona, Spain www.escrs.org

17–20 September Nice, France www.euretina.org

17–18 April Barcelona, Spain www.imo.es/barcelonaoculoplastics

ASCRS.ASOA Symposium and Congress

17–21 April San Diego, CA, USA www.ascrs.org/meetings-and-events

MAY

6th Baltic Congress

MARCH

1–3 May Kiel, Germany www.baltic-congress.de

6th World Congress on Controversies in Ophthalmology (COPHy)

26–29 March Sorrento, Italy www.comtecmed.com/cophy/2015/

ARVO Annual Meeting 3–7 May Denver, Colorado, USA www.arvo.org

Nice

th EURETINA

Winter Meeting Saturday 24 January 2015

T.S. Elliot Lecture Theatre, Merton College, University of Oxford, UK www.euretina.org

Recognize both. Recommend AcrySof IQ Toric IOL. 速

Recommend the AcrySof 速 IQ Toric IOL for your astigmatic cataract patients.

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