EuroTimes Vol. 19 - Issue 12 | Vol. 20 - Issue 1 by EUROTIMES

SPECIAL FOCUS RETINA CORNEA

BRILLOUIN OPTICAL MICROSCOPY GENERATES EXCITEMENT Dec 2014 | Vol 19 Issue 12 Jan 2015 | Vol 20 Issue 1

NEW ERA FOR RETINAL DIAGNOSTICS

GLAUCOMA

HOW RISK FACTORS FOR ONSET AND PROGRESSION CAN GUIDE STRATEGY

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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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS RETINA 4 Cover Story: Combining old and new imaging techniques to diagnose retinal problems

8 Crowdsourcing could

be useful for screening diabetic retinopathy

9 Comparing treatments

used for patients with DME

10 Two vitreoretinal surgeons debate the role of surgery in treating AMD

12 What is the most

effective course of action for submacular haemorrhage?

FEATURES CATARACT & REFRACTIVE 14 Femtosecond laser is

surgeons’ preferred option for flap creation

CORNEA 19 Brillouin optical

microscopy technology is generating major interest

20 Safe and successful

technique for treating recurrent corneal erosion

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22 One cornea specialist

outlines the decision to adopt DMEK in his practice

REGULARS

25 Eyelid warming device

31 Ophthalmologica update 32 Resident’s Diary 33 Industry News 34 ESCRS and Charities 35 JCRS update 36 Eye on Technology 39 Book Reviews 40 Calendar

offers treatment for Meibomian Gland Dysfunction

GLAUCOMA 28 Will technology replace doctors in diagnosing and monitoring?

29 Alternative techniques for

reducing IOP in eyes with open-angle glaucoma

30 Knowing the risk factors

for onset and progression can guide strategy with a patient

Cover image shows Dr Szilard Kiss and his research fellow standing inside the CAVE visual environment at Weill Cornell Medical College.

15 Customised laser

Courtesy of Dr Szilard Kiss, Weill Cornell Medical College

treatments for irregular corneas complement each other

16 Some exciting digital

developments showcased at AAO meeting

17 ESCRS-sponsored 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.

online registry now available for reporting endophthalmitis cases

18 Momentum grows behind immediately sequential bilateral cataract surgery

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Included with this issue... Oraya Therapeutics, Inc. Supplement

EUROTIMES | DECEMBER 2014/JANUARY 2015

EDITORIAL A WORD FROM FRANCESCO BANDELLO MD, FEBO

A BUSY YEAR AHEAD

Work has already started on preparing for the 15th EURETINA Congress in Nice, France

s president of EURETINA, it gives me great The Winter Meeting will focus on retinal research, pleasure to write the editorial for the December/ to provide an opportunity for interaction between January issue of EuroTimes. distinguished scientists and clinicians working in the field of I am delighted to say that our 14th EURETINA translational research. Congress in London was the most successful in The themes that will be of focus during the sessions the history of the society, with 5,411 delegates include retinal gene therapy, stem cells, advanced imaging attending the meeting. techniques and sight restorative therapies. The Society continues to go from strength to strength A report on the meeting will be included in a future and this is largely due to the excellent work of our issue of EuroTimes and once again I would like to thank Programme Committee, whose members delivered the magazine for its excellent an outstanding scientific programme. reports, not only on EURETINA The Winter Meeting There were many highlights at the meeting, meetings but on other major will focus on retinal including the Kreissig Lecture delivered by Dr retina meetings from around research, to provide an Johanna Seddon, “Understanding the mechanisms the world. and etiology of macular degeneration – genetics and Every year provides us with new opportunity for interaction modifiable factors”. challenges and I am confident that between distinguished We were also honoured with the contribution 2015 will be another successful scientists and clinicians of Professor Robert McLaren, who delivered the one for our Society. working in the field of EURETINA Lecture on “Gene Therapy for Retinal This issue of EuroTimes is a Disease – What Lies Ahead”. double issue for December 2014 translational research In London we also had the opportunity to combine and January 2015 and the next forces with the ESCRS and EuCornea, and the issue will appear in February. Let overlapping meetings gave us the opportunity to meet and me conclude by wishing all of my friends and colleagues and exchange views with our colleagues in different specialties. readers of EuroTimes a very happy Christmas and also best The 15th EURETINA Congress will be held in Nice, France, wishes for the New Year that lies ahead. from 17-20 September 2015 and already our Programme Committee is hard at work on preparing what promises to be another excellent scientific programme. This will be a busy year and, as well as preparing for the September Congress, we are also holding the 5th EURETINA Winter Meeting in The TS Elliot Lecture Theatre, Merton College, Oxford, UK on Saturday 24 January 2015. This is a smaller and more intimate meeting than our annual Congress, with participation limited to 150 delegates, and we are privileged to be able to hold the meeting in one of * Prof Francesco Bandello is president of EURETINA Europe’s great seats of learning.

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)

EUROTIMES | DECEMBER 2014/JANUARY 2015

FOUR EVENTS

ONE VENUE Fira Gran Via, Barcelona, Spain

XXXIII Congress of the ESCRS

6th EuCornea Congress

5–9 September www.escrs.org

4–5 September www.eucornea.org

WSPOS

3rd World Congress of Paediatric Ophthalmology and Strabismus

The 7th International Conference on Ocular Infections

4–6 September www.wspos.org

3–4 September www.ocularinfections.com

COVER STORY: RETINA

Szilard Kiss and his research fellow standing inside the CAVE visual environment at Weill Cornell Medical College. Dr Kiss explained: “We are looking at a 3D reconstruction of a patient with large pigment epithelial detachments due to chronic central serous choroidopathy. Each of us has on active 3D glasses. In my right hand I have a remote control that moves the image. In addition, the glasses that I am wearing are radio tracked such that as I move my head the image moves accordingly, giving the impression of this virtual reality world”

A NEW ERA FOR RETINAL DIAGNOSTICS Imaging techniques for diagnosing retinal problems have moved on. Sean Henahan looks at mixing old and new methods

he recently published EURETINA guidelines (Schmidt-Erfurth et al, BJO 2014; 98: 1144-1167) provide comprehensive recommendations for the diagnosis and management of neovascular age-related macular degeneration (AMD). This includes a comprehensive discussion of diagnostic procedures, including fluorescein angiography, autofluorescence imaging and optical coherence tomography (OCT). “Retinology and vitreoretinal surgery are some of the most exciting fields in medicine. The progress in these sub-specialties in the last few years has been immense, particularly in the treatment of macular degeneration, venous occlusion, diabetic retinopathy and inflammation. Therefore it is EUROTIMES | DECEMBER 2014/JANUARY 2015

necessary to establish a catalogue of guidelines and recommendations to help the ophthalmologist provide the best treatments for patients,” Gisbert Richard MD, founding president of EURETINA, told EuroTimes. But science does not live in a vacuum, noted Dr Richard, Chairman of the Department of Ophthalmology, University Eye Clinic Hamburg-Eppendorf, Germany. Costly new treatments come at a time when health care systems are under enormous pressure to economise. The advice from

an international independent society like EURETINA has an important role to play not only in determining the best treatment, but also in reimbursement decisions. The EURETINA guidelines remind clinicians that fluorescein angiography continues to be the first step in confirming a suspected case of AMD. Angiography is still considered the primary basis for clinical classification and initiation of therapy. The guidelines also note that fluorescein angiography may still prove useful

Retinology and vitreoretinal surgery are some of the most exciting fields in medicine Gisbert Richard MD

Courtesy of Dr Szilard Kiss, Weill Cornell Medical College

COVER STORY: RETINA for monitoring anti-VEGF therapy in patients with high myopia, extrafoveal lesions and in cases of fresh choroidal neovascularization (CNV) reactivation at the borders of a fibrotic lesion. Fluorescein angiography and indocyanine green angiography are also recommended when there is sudden worsening of clinical symptoms, haemorrhage or pigment epithelial detachment. Fluorescein angiography is a tried and true tool in ophthalmology, but it is not without potential problems. It is invasive and can be uncomfortable for patients. Adverse effects, although rare, include nausea, hives, hypotension and anaphylaxis. A new approach, high-speed sweptsource OCT angiography could eliminate those risks, while providing additional diagnostic information. David Huang MD, PhD and colleagues at the Casey Eye Institute, Oregon Health & Science University, Portland, US, have reported promising results in imaging the optic nerve head and CNV with this technique. Besides avoiding systemic complications that can occur with conventional angiography, OCT offers the advantages of three-dimensional imaging, and allowing separation of disc, retinal and choroidal circulations. It can distinguish CNV above or below the retinal pigment epithelium. It can also provide sections and projections along any plane. Current disadvantages include a small field of view, but this is expected to improve with higher speed scanning. Also, while OCT angiography can visualise fluid space and retinal thickening, it does not provide visualisation of leakage. “OCT angiography can distinguish normal retinal circulation in the inner retinal layer, CNV in the outer retinal layer, and choroidal circulation,” he told EuroTimes, adding that he can foresee a time when the initial fluorescein angiography would be replaced completely by OCT angiography. Dr Huang’s team has begun recruiting patients for an NIH-supported study (PI: Yali Jia and Steven Bailey) using highspeed OCT angiography in AMD. The primary goals of the OCT Angiography

EURETINA guidelines for management of neovascular AMD

Spectral-domain OCT is perfectly adequate for treating some of the things we are treating Alex Hunyor MD

in Neovascular Age-Related Macular Degeneration study are to use OCT angiography to diagnose the presence of abnormal new blood vessels and to evaluate patients undergoing treatment for CNV. The study also seeks to determine if reduced flow to the choroid is a risk factor for developing wet AMD. “OCT angiography is able to quantify CNV area which appears to be a leading indicator for the reduction and re-emergence of CNV after anti-VEGF treatment. So monitoring of CNV OCT angiography may provide more timely treatment strategies, compared to relying on visualisation of fluid accumulation on structural OCT, or assessing changes in visual acuity,” said Dr Huang. However, for the time being, fluorescein angiography will remain the first step in the diagnosis of macular degeneration. Once angiography confirms a diagnosis of AMD, diabetic macular oedema (DME) or other retinal disease, clinicians rely on OCT to monitor the disease. OCT has become the mainstay in monitoring retinal disease, favoured for its ability to non-invasively visualise optical structures instantly at high resolution. Since it first appeared some 20 years ago following work by James Fujimoto PhD, David Huang, Carmen Puliafito MD and colleagues, OCT has evolved rapidly, with ongoing improvements in scanning speed, sensitivity and resolution. OCT relies on low-coherence interferometry and tomography to generate high-resolution images of ocular structures. The first commercially available OCT systems were time domain based. This was followed by the development of Fourier-domain OCT, which could be either based on a spectrometer (spectraldomain OCT) or a rapidly tuned laser (swept-source OCT). Fourier-domain OCT systems now available for clinical use can provide high-speed retina scanning with complete coverage of macular area and the creation of 3D retinal images. Indeed, with OCT imaging widely available, and awareness of importance value of prompt treatment with antiVEGF agents, retina specialists now advocate a ‘zero tolerance’ attitude of close monitoring with OCT and prompt therapeutic response. With so many systems available, which tool is useful for what application? The EURETINA guidelines suggest monitoring disease activity with spectral domain OCT on a monthly basis or whenever administering anti-VEGF treatments.

ROLE OF SWEPT-SOURCE OCT Swept-source OCT is generating a lot of excitement among retina specialists, but the debate continues on how best to use it. This was the subject of a discussion at the annual meeting of the American Society of Retina Specialists in San Diego recently. “The difference between time domain and spectral domain was huge, but the difference between spectral and swept-source is much smaller. You get better visualisation of deep structures with spectral domain, it is faster, and you can look at more tissue in the same amount of time. “Once we have more FDA approved devices on the market, swept-source makes sense. Do you go out and throw away your spectral domain machine? No, because it is such a functional technology with a good track record and normative data,” commented Alex Hunyor MD, Director of Vitreoretinal Services at the Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. “Spectral-domain OCT is perfectly adequate for treating some of the things we are treating. However, sweptsource OCT does provide much better choroidal visualisation, faster speed, and better quality images,” concurred Nadia Waheed MD, Assistant Professor of Ophthalmology, Tufts University School of Medicine, Boston, US. She added that there is not enough data out there at present on the optimal clinical applications of swept-source OCT. She noted that swept-source might find an important place in OCT angiography. “We have been able to obtain excellent OCT angiography images with both spectral and swept-source OCT systems. The 840nm wavelength spectral OCT appears to provide better retinal vascular details, while the 1050nm wavelength swept-source OCT provides more consistent visualisation of central retinal vessels in the optic nerve head. But there is no essential difference for clinical applications,” said David Huang. Carmen Puliafito, currently Dean of the School of Medicine at the University of Southern California in Los Angeles, was a pioneer in the development of OCT imaging in ophthalmology. He expressed a wait-and-see viewpoint on swept-source OCT for general clinical use. “The way to evaluate OCT is a clinical decision-making tool. We were pretty good with the OCT that was built at Tufts in 1992. The Stratus wasn’t bad, and current EUROTIMES | DECEMBER 2014/JANUARY 2015

COVER STORY: RETINA systems are great. So as a clinical decisionmaking tool we are really doing very well with what we have. When we are asking research oriented questions in patients with retinal degeneration, and asking why doesn’t this patient see better, then having higher resolution really does make sense. However, swept-source is a buzzword, and it not at all clear that this is the thing that will enable OCT in the future,” he said. OCT imaging technology is evolving rapidly. Most systems now available include multiple capabilities. Newer capabilities include fundus autofluorescence, enhanced depth imaging, ultra-wide field imaging and en face OCT. Future systems will likely employ adaptive optics to further enhance imaging. Perhaps one of the most visually interesting developments in OCT has to be full-room 3D OCT. Szilard Kiss MD and colleagues at Weill Cornell Medical College in New York are developing an imaging system that would let clinicians and researchers walk around inside the virtual retinal vasculature. They have combined OCT imaging with volumetric reconstruction within a computer assisted virtual environment (CAVE). The viewer enters a 12 x 12ft (3.6m x 3.6m) space, and dons special 3D glasses to view 3D retinal images projected in high resolution on three walls and the floor of the room. While this system is not likely to become mainstream anytime soon, the researchers believe it could be very useful for surgical planning, and for training young surgeons.

HOME MONITORING Even as device companies roll out better and more expensive OCT imaging tools, efforts are also under way to develop portable affordable monitoring systems, some of which are now being used for home monitoring retinal disease. One such device, the Foresee Home device, was evaluated in the Home Monitoring of the Eye (HOME) study, a collaborative effort from investigators of the AREDS2 study. After in-office training, patients self administer the preferential hyperacuity perimetry (PHP) test, in which stimuli are successively flashed in various locations of the visual field. The patients identify waves or distortions on the screen and that information is transferred to a central server for analysis. Any abnormality triggers an alert, which is forwarded to the patient’s doctor.

Courtesy of Dr David Huang, Casey Eye Institute

Composite en face OCT angiogram (3 × 3mm2) of an eye with age-related macular degeneration, showing inner retinal blood flow (blue), choroidal neovascularizaiton (yellow) and choroidal vessels (red)

The HOME study results, reported at the 14th EURETINA Congress in London by Usha Chakravarthy MD, Professor of Ophthalmology and Vision Sciences, Queen’s University Belfast, Northern Ireland, showed that the device did help detect CNV in high-risk patients at better levels of vision compared to standard care methods. “This approach is clearly useful for home monitoring of persons at high risk of developing neovascular AMD,” she told EuroTimes. The FORESEE home testing device is intended for use by almost any patient diagnosed with intermediate AMD. The device requires patients to have stable fixation, visual acuity of 20/60 or better, and functional cognitive and physical ability.

iMACULA The number of useful monitoring apps for patients and doctors with smartphones and tablets continues to increase. On the home monitoring front, the SightBook app from DigiSight Technologies gives retina patients many options for home vision testing.

This approach is clearly useful for home monitoring of persons at high risk of developing neovascular AMD Usha Chakravarthy MD EUROTIMES | DECEMBER 2014/JANUARY 2015

The tests include Snellen visual acuity, Amsler grid, contrast sensitivity, colour discrimination and low light acuity and contrast. Patients can work with their physicians to plan a sequence of tests that can be performed on a regular schedule. These results are stored on a server that is available to the patient and the physician. The system issues an alert to the designated physician in the event of any significant change in the test results. Another home monitoring system, myVisionTrack, developed by the Vital Art and Science company, recently became the first retina screening app to receive US FDA approval. Available only by prescription, the app is designed to have patients with degenerative eye disease regularly self test with a proprietary shape discrimination test. The results are stored online and compared with previous test results. As with other systems, the physician is alerted in the event of any sudden change in vision. This system is expected to be employed for monitoring patients during clinical trials. David Huang: davidhuang@alum.mit.edu Alex Hunyor: aphunyor@retina.com.au Nadia Waheed: nwaheed@tuftsmedicalcenter.org Carmen Puliafito: cpuliafito@usc.edu Usha Chakravarthy: u.chakravarthy@qub.ac.uk Szilard Kiss: szk7001@med.cornell.edu

NICE 15th EURETINA Congress

17â&#x20AC;&#x201C;20 September 2015 Acropolis, Nice, France

Abstract Submission Deadline 15 March 2015

www.euretina.org /EURETINA

@EURETINA

EURETINA

SPECIAL FOCUS: RETINA

RETINOPATHY SCREENING Crowdsourcing recruits public to grade fundus images. Sean Henahan reports

rowdsourcing, now used for everything from designing T-shirts to funding biotech start-ups, could also be a useful tool for screening diabetic retinopathy, Christopher Brady MD told a session of the annual conference of the American Society of Retina Specialists in San Diego, California. “We know we are not screening enough patients with diabetes for diabetic retinopathy. To do better will take a significant increase in human resources. In some areas, telemedicine is going to be part of the answer. Using computers and artificial intelligence to interpret fundus photos should also help reduce the human resources burden. But there is room for other novel methods such as crowdsourcing,” said Dr Brady, of Wilmer Eye Institute, Baltimore, Maryland, US. He was inspired in part by a Spanish/ South African collaboration that used the crowdsourcing approach to screen slides for signs of the malaria plasmodium parasite. The developers created a fun game interface and encouraged the public to zap parasites by clicking on them in sample slides. The results gathered from the game help public health officials screen for malaria. The game, which can be found at malariaspot.org, can be played on any computer, iOS or Android platform.

LABOUR INTENSIVE “You may remember from medical school that this is an incredibly labour intensive skill, requiring processing of huge amounts of data to screen large populations. Not only did people do very well, the developers saw additional benefits as young participants were developing into citizen scientists,” Dr Brady said. For assistance, Dr Brady turned to tech giant Amazon, which has a crowdsourcing tool known as the Mechanical Turk (www.mturk.org). It enables researchers in any field to coordinate the use of human intelligence to perform tasks that computers are currently unable to do. Dr Brady and colleagues used this platform to test the hypothesis that members of the public could be enlisted to help screen fundus photographs. In the first phase of the study, anonymous graders were paid $0.10US to evaluate 19 fundus photos, of which 12 were abnormal and seven were normal. Participants underwent training in plain English during which they learned the basic terminology, and how to identify signs of retinopathy. EUROTIMES | DECEMBER 2014/JANUARY 2015

Courtesy of EyeWire

The EyeWire online game, created at Massachusetts Institute of Technology, uses crowdsourcing to create a 3D map of the neurons in the retina

It took 10 anonymous graders 25 seconds to grade each image, or less than two hours for the entire task. The average individual grader was correct 81.5 per cent of the time. The accuracy improved to 90 per cent when all graders results were combined. There were no false negative grades. “I get asked why anyone would go online and take $0.10US to participate, marking images with little idea what they are. But if you multiply it out, that amounts to $14 per hour, above the minimum wage in the US, and better than other Amazon crowdsourcing tasks,” he noted. Based on the initial study, the researchers then tweaked the system and improved the interface based in part on user feedback. They then expanded the task to have graders mark four levels of retinopathy from normal to severe, based on UK screening guidelines. At first the graders did no better than chance, but with feedback and experience their accuracy and specificity improved considerably. As in the first study, graders tended to over call the cases, so sensitivity was 100 per cent. “We heard from people all over the world. People enjoyed the work and they liked learning about diabetes. We saw more engagement than we anticipated. With minimal training this scalable around-the-clock workforce can rapidly determine whether these images are normal or abnormal. We believe this could prove to be a useful way to screen for diabetic retinopathy.” The reach of such an approach is global. It would be possible to recruit graders from whatever region was being studied. This would have the added advantage of keeping some money in the local economy, he added.

British researchers recently reported promising results using a very similar approach. A study sponsored by the UK Biobank Eye and Vision Consortium reported that crowdsourcing provided “an accurate, rapid and cost-effective method of retinal image analysis” (Mitry et al, PLOS1, “Crowdsourcing as a Novel Technique for Retinal Fundus Photography Classification”, DOI: 10.1371/journal.pone.0071154). Another research group is already using crowdsourcing to create a 3D map of the neurons in the retina. Dr Sebastian Seung and colleagues at the Massachusetts Institute of Technology have created an online game called EyeWire (eyewire.org) that has already recruited more than 140,000 players from more than 140 countries. Participants complete a one-hour tutorial, then compete with others to see who can map the most cubes per week. Players compete for personal glory and unique prizes such as the right to name new neuron discoveries. The neuroscientists benefit from the game players’ enthusiasm as these efforts help develop advanced artificial intelligence tools and computational technologies for mapping the connectome, the structural map of all neural connections. * Dr Brady’s study was recently published at: Brady CJ et al, “Rapid grading of fundus photographs for diabetic retinopathy using crowdsourcing”, J Med Internet Res. 2014 Oct 30;16(10):e233. doi: 10.2196/ jmir.3807. PMID: 25356929 Christopher J Brady: christopherjbrady@gmail.com

SPECIAL FOCUS: RETINA

TREATMENT & DIABETES Study looks at best treatment for patients with DME. Sean Henahan reports

oth intravitreal bevacizumab and triamcinolone appear to improve outcomes in patients with diabetic macular oedema (DME) undergoing cataract surgery, with little difference seen between the two agents, reported Salmaan Al-Qureshi MBBS, FRANZCO at the annual meeting of the American Society of Retina Specialists in San Diego, California. Dr Al-Qureshi provided an update on the latest results from the prospective randomised trial of intravitreal bevacizumab versus triamcinolone for patients with DME at the time of cataract surgery (DiMECAT study). “We know cataract and diabetes co-exist and both are common causes of vision loss. The outcome of cataract surgery in diabetics is unpredictable, with poorest outcomes seen in patients who have DME at the time of cataract surgery. Yet, despite advances in surgery there is little evidence regarding use of anti-VEGF agents or triamcinolone in this setting,” he said. The lack of any prospective studies looking at this question prompted Dr Al-Qureshi and colleagues at the University of Melbourne, Australia to design a single masked prospective randomised trial. All patients participating in the trial had to have visually significant cataracts, with co-existing DME not amenable to laser treatment. The patients were randomised to receive either intravitreal triamcinolone or bevacizumab following cataract surgery. The primary endpoint was best-corrected visual acuity at one, six and 12 months. Researchers also looked at macular thickness, the number of re-treatments and adverse effects. Dr Al-Qureshi presented interim results for 46 patients available for follow-up at six months. At three months, both treatment groups showed significant improvement in visual acuity, with triamcinolone recipients gaining an average of 21 letters and bevacizumab patients gaining 14 letters. Patients receiving triamcinolone, but not those receiving bevacizumab, also showed a slight decrease in central macular thickness. This pattern continued at six months. However, these differences did not reach statistical significance. Re-treatments were done monthly if there was an increase in central macular thickness of 50 microns or more, or decrease of five letters or more. At six months the re-treatment rate was 0.19 in the triamcinolone group, compared with 1.93 in the bavacizumab group. Adverse events were rare, with one case of an intraocular pressure (IOP) spike following treatment with triamcinolone. This was controlled effectively with topical agents. “The discussion really is that there are few studies of DME and cataract surgery. Intravitreal triamcinolone acetonide has been advocated by some as best treatment for DME. Cataract surgery appears to be an inflammatory insult to the diabetic eye. While anti-VEGF agents work only via one modality, triamcinolone will work in both an anti-inflammatory mode and with anti-VEGF action. The early clinical experience supports this premise,” said DrAl-Qureshi. Meanwhile, the ESCRS has announced the launch of the PREvention of Macular EDema after cataract surgery (PREMED) study, which has now enrolled its first patients. Salmaan Al-Qureshi: shq@unimelb.edu.au EUROTIMES | DECEMBER 2014/JANUARY 2015

SPECIAL FOCUS: RETINA

EXPERTS DEBATE RETINAL SURGERY Does surgery still have a role in AMD? Leigh Spielberg reports

wo vitreoretinal surgeons debated the role of surgery in the treatment of agerelated macular degeneration (AMD) during the Amsterdam Retina Debate at the 14th EURETINA Congress in London. Dr Marco Mura MD, University of Amsterdam, The Netherlands, made the case for operating as a last resort in patients with severe visual loss due to AMD. Dr Frank Holz MD, University of Bonn, Germany, presented the case against surgery. “I agree with you, Dr Holz, that surgery has a limited role in AMD. Surgery can be complex. The results are variable and centre-dependent. Further, it is a great burden for a large component of the target population,” said Dr Mura. “But I believe it remains an option for a select group of patients,” he said, admitting that most trials show that surgery does not improve upon the natural history, and that anti-VEGF treatment has changed EUROTIMES | DECEMBER 2014/JANUARY 2015

the landscape forever in favour of a pharmacological approach. “Why bother to defend surgery?” asked Dr Mura. “What if anti-VEGF doesn’t work? What if this is an active and healthy patient’s only eye?” he asked. “Clearly, there are obvious indications for surgery, such as submacular haemorrhages, RPE rips and non-response to medical treatment. “In the case of a massive submacular haemorrhage, the natural history has a very poor prognosis,” said Dr Mura. “Surgery is really the only option, and it works quite well. Submacular rTPA improves the prognosis in 68 per cent of patients as compared to no treatment.”

Referring to published studies on surgery for AMD, as well as a retrospective analysis of different surgical techniques he and his team recently submitted to the BJO, Dr Mura outlined his standard protocol for the treatment of submacular haemorrhages, which included subretinal rTPA injection; subretinal blood removal with the placement of an RPE-choroid patch; and subretinal blood removal followed by macular translocation. Dr Mura then showed several compelling videos of his procedures, restoring useful vision to otherwise hopeless patients, primarily in those who had long since lost vision in one eye and had recently suffered a dramatic decrease in visual acuity in the other. “I have patients who are desperate for an operation, having grown tired of monthly anti-VEGF with no visual improvement. These are the patients that we should focus on,” concluded Dr Mura. Dr Holz began his argument by stating that the rare patient might experience some improvement in visual acuity, but he added that this is science, not storytelling. “We need numbers, we need proof and we need studies to support the case for surgery,” said Dr Holz. He referred to a Cochrane meta-analysis, which indicated insufficient evidence for macular translocation surgery. “Complications permanently impairing functional outcome occur with relatively high frequency after complex surgical interventions such as RPE-choroid patch translocations. These include patch fibrosis and PVR-induced retinal detachment. Stable VA maintenance is possible in some cases, but the majority lose vision over four-seven years.

... surgery has a limited role in AMD. Surgery can be complex. The results are variable and centre-dependent Marco Mura MD

SPECIAL FOCUS: RETINA

Courtesy of Marco Mura MD

... the focus remains squarely on pharmacotherapy for the disease. In a recent 20-chapter book on AMD, only one was devoted to surgical therapy

Frank Holz MD “We have learned so much about the genetics, complement pathways, and biology of the disease, and have thus multiple cytokines involved including developed effective, pathway-targeted VEGF and PDGF. interventions,” concluded Dr Holz. He admitted that there were unmet “The best approach to improve care for needs in AMD, such as dry AMD, RPE our patients is to follow the biology,” he said, tears, subretinal haemorrhages and longquoting a review article by Dr Joan W Miller. term treatment with anti-VEGF. Dr Holz proceeded to outline the highly He described what he envisioned as complex nature of the disease, including being the future role of so-called “minor” choroidal in innovative AMD SOE 2015neovascularizations, 130 x 178 Eurotimeshighlighting advert_Layout 1surgery 20/11/2014 16:25 Page 1 treatments.

These included delivery of long-acting drugs; stem cell therapy; and subretinal gene therapy. “But the focus remains squarely on pharmacotherapy for the disease. In a recent 20-chapter book on AMD, only one was devoted to surgical therapy,” he noted. Frank Holz: Frank.Holz@ukb.uni-bonn.de Marco Mura: drmmura@yahoo.com

SE E YOU IN V IEN NA! www.soe2015.org

Abstract submission now open. Closing date 28 January 2015. Visit www.soe2015.org to submit an abstract. EUROTIMES | DECEMBER 2014/JANUARY 2015

SPECIAL FOCUS: RETINA

ACUTE HAEMORRHAGE Rapid treatment essential, but which is best? Leigh Spielberg reports

apid treatment of a submacular haemorrhage is crucial, as progressive retinal damage begins within 24 hours, Elsbeth JT van Zeeburg MD, PhD, of the Rotterdam Eye Hospital, told delegates at the 14th EURETINA Congress in London. But which treatment is most effective? Dr van Zeeburg described the results of her team’s single-centre, prospective, randomised, controlled study of treatment of acute submacular haemorrhage due to AMD. Twenty-four patients were randomised to either minimal invasive treatmentintravitreal injections of rtPA plus bevacizumab plus C3F8, or maximal invasive treatment vitrectomy plus subretinal rtPA plus C3F8 gas plus intravitreal bevacizumab. All patients also received intravitreal anti-VEGF treatment at five and 10 weeks thereafter. “There is a current trend towards vitrectomy with submacular administration of rtPA, as this seems to be a more controlled administration route for surgeons. However, the literature does not yet indicate any difference in safety or efficacy of either method,” she noted. Intravitreal injection of rtPA with a gas tamponade seems to be a very effective method and can be performed in an office setting. Because no operating theatre is required, it can be planned and performed quickly, minimising the time between the onset of haemorrhage and treatment. Dr van Zeeburg noted that rtPA administration is also a good treatment option for patients with a submacular haemorrhage due to a retinal

Courtesy of Elsbeth JT van Zeeburg MD, PhD

Preoperative and four weeks postoperative AF image of a patient with a submacular haemorrhage, treated with intravitreal rtPA and bevacizumab injection, and a C3F8 gas tamponade

macroaneurysm. As these patients do not have underlying macular pathology, the potential visual acuity gain from early haemorrhage displacement in this patient group is significant. The goal of the current study was to compare the displacement of the subretinal haemorrhage, subretinal fluid and subRPE volume away from a 1.0mm3 and a 2.2mm3 cylinder around the macula, as measured on SD-OCT. Because of this quantitative, detailed volumetric analysis, only haemorrhages with a thickness of 750μm or less were included. “Intravitreal rtPA injection seems as effective in displacing the subretinal haemorrhage and subretinal fluid as vitrectomy with submacular administration,” said Dr van Zeeburg. Visual acuity results are both favourable and comparable in the two groups. Total

There is a current trend towards vitrectomy with submacular administration of rtPA... Elsbeth JT van Zeeburg MD, PhD

displacement of subretinal haemorrhage and fluid occurred in a majority of patients in both groups. However, total displacement of sub-RPE volume was more difficult to achieve, with a relative volume reduction of less than 30 per cent in both groups, but the total volume of this sub-RPE volume is relatively minimal compared to the subretinal volume. Complications occurred in both groups. Patients in the submacular group suffered retinal detachment (two) and new submacular haemorrhage (one). Those in the intravitreal group experienced one retinal detachment, one new submacular haemorrhage, two vitreous haemorrhages and one intraocular pressure spike above 50mmHg within four hours after the injection. “Increased IOP can be avoided by injecting 0.2ml C3F8 gas the day of the rtPA administration, and an additional 0.2ml the day after,” said Dr van Zeeburg. “As the results seem comparable, whilst the intravitreal injection is less invasive, simpler to perform and does not require access to an operating theatre, we will soon compare intravitreal rtPA with anti-VEGF agents in a larger, multi-centre controlled trial,” said Dr van Zeeburg.

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CATARACT & REFRACTIVE

FEMTO FLAPS & BEYOND From flap creation to a new LASIK alternative. Roibeard O’hEineachain reports

lthough similar to modern microkeratomes in terms of visual outcomes and complication rates, the femtosecond laser’s high precision and ease-of-use make it the preferred instrument for flap creation for most surgeons who have used them, according to Beatrice Cochener MD, CHU Brest, Brest, France. “There is still a learning curve and certainly you need to perform at least 10 procedures to master the technology. But now there is no need to adjust the parameters, since everything is already set with a very high degree of safety,” Prof Cochener said at the 18th ESCRS Winter Meeting in Ljubljana. She noted that femtosecond laser systems have undergone a rapid and steady evolution since first introduced as an alternative to the microkeratome for creating LASIK flaps in the early years of this millennium. The improvements in the lasers used in refractive surgery include smaller, more tightly-packed cavitation bubbles that can produce an almost continuous cut. They are therefore free of the mechanicallyresistant tissue bridges which could make flaps harder to lift.

MECAHNICAL LIBERATION “The femtosecond laser is in fact a reproducible laser scalpel that provides us with an easy flap removal thanks to the spontaneous mechanical liberation of the tissue bridges,” she said. Other refinements include new algorithms for the creation of elliptical flaps or reversed edges designed for the mechanical reinforcement, and thinner flaps and interfaces with lower suction and vacuum pressure. There are currently five femtosecond lasers for LASIK flap creation on the market. They are the latest version of the original femtosecond laser the Intralase® iFS (AMO), the LDV® (Ziemer), the Wavelight® FS 200, the Visumax® (Zeiss) and the Victus® (Technolas Perfect Vision). One question that is still debated is whether the benefits of femtosecond lasers justify the higher cost. One of their main selling points is their higher predictability. Studies show that the thickness of LASIK flaps created with femtosecond lasers tends to vary from EUROTIMES | DECEMBER 2014/JANUARY 2015

target values by only around 10 to 15 microns, compared to around 30 microns for the microkeratomes. “In terms of the predictability, the femto-cut appears to be more uniform, more precise and more reproducible than that achieved with a microkeratome,” Prof Cochener said. However, the bulk of evidence from published studies to date suggests that the femtosecond laser’s improved accuracy in flap creation does not have a significant impact on visual outcomes, she noted. She cited two studies where there was no difference in mean refractive predictability and uncorrected visual acuity between those with flaps created with the latest generation of microkeratomes and those created with femtosecond lasers (Munoz et al, J Cat Refract Surg 2010; 36:934-44, Patel et al, Ophthalmology 2007; 114:1482-1490). However, in another comparative study involving a total of 2,000 eyes, the femtosecond laser group had more rapid visual recovery and better uncorrected visual acuity than the microkeratome group (Tanna et al, J Refract Surg 2009 Jul; 25(7 Suppl):S668-71). Studies also indicate that LASIK-treated eyes with femtosecond laser-created flaps have statistically similar results in terms of induced aberrations. Complication rates with the two technologies are also very similar, although intraoperative complications are more common with microkeratomes and postoperative complications are more common with femtosecond lasers. For example, in one comparative study the overall rate of flap complications was 14.2 per cent among eyes with microkeratome-created flaps and 15.2 per cent among eyes with femtosecond lasercreated flaps (P = 0.5437). However, the rate of intraoperative complications was significantly higher in the microkeratome group, at 5.3 per cent, than in the femtosecond laser group at 2.9 per cent (P = .0111), and the postoperative flap complication rate was significantly lower in the microkeratome group, 8.9

per cent versus 12.3 per cent seen with femtosecond laser (P = .0201). The most common postoperative complication in both groups was diffuse lamellar keratitis (DLK), which occurred in 6.0 per cent of eyes in the microkeratome group, compared to 10.6 per cent of eyes in the femtosecond laser (P = .0002), (Moshirfar et al. J Cat Refract Surg 2010; 1925-1933).

FEMTO REFRACTIVE Having proved their worth in LASIK-flap creation, femtosecond lasers now look set to enter a new era where they will be used as an alternative to excimer lasers in a potentially LASIK-beating corneal refractive surgery procedure called SMILE (small incision lenticule extraction). The technique involves the cutting of a lenticule within the stroma with the femtosecond laser and then removing it through a small incision. The technique offers the potential to leave the anterior 40 per cent of the stroma intact. The anterior stroma has a resistance to deformation that is twice that of the posterior stroma. As a result, eyes undergoing the SMILE procedure should be less prone to regression and ectasia. “The potential advantages of the SMILE procedure suggest you may be able to safely correct higher amounts of refractive error than we can with the excimer laser, with less thermal effect and with better respect of corneal architecture and better postoperative comfort. In addition, you have one laser for doing everything,” Prof Cochener said. However, she added some words of caution about the SMILE procedure. “All the assumed potential and promising advantages of this concept (specifically patented by Zeiss laboratory on its Visumax platform) need to be demonstrated by long follow-up studies of a larger series.” Beatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr

... the femto-cut appears to be more uniform, more precise and more reproducible than that achieved with a microkeratome Beatrice Cochener MD

CATARACT & REFRACTIVE

IRREGULAR CORNEAS Topography- and wavefront-guided ablations can work well together.

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opography-guided and wavefront-guided customised laser treatments complement each other well in the customised treatment of irregular corneas, according to Michael C Knorz MD, University Hospital Mannheim, Germany. “Topography-guided ablations perform best in the regularisation of highly irregular surfaces, and wavefront-guided ablations perform best in the correction of smaller irregularities and in the fine-tuning of the refractive result,” Dr Knorz told the XXXII Congress of the ESCRS in London. He noted that the customised laser treatment of irregular corneas traces its origins from the early pre-topography days of LASIK. At that time the surgeon had to painstakingly and individually plan each treatment in such cases. The advent of topography-guided treatment helped provide a greater standardisation of the technique. There followed the introduction of the more scientifically-based wavefrontguided ablations. Topography-guided ablations have the advantage of being based on the surface irregularities that are causing the visual disturbance, he said. They are typically used for large errors and for grossly irregular corneas. Their most reliably beneficial effect is in eyes with decentred ablations and those undergoing the treatment for the enlargement of small optical zones. “There is typically a lot of variability in the outcome, but you do improve the topography, although you do not typically achieve a very good refractive result. And obviously a lot of re-treatments are necessary and you have a lot of regression, but again, these are patients who really need our help and we really need these techniques to improve their vision,” Dr Knorz noted. In contrast to topography, aberrometry measures the aberrations of the eye’s total optical system. As a result, the refractive outcomes of wavefront-guided ablations are typically much better than those of topography-guided ablations. However, aberrometry provides no information on the treated surface and cannot measure irregular corneas reliably. “Grossly irregular corneas cannot be treated with wavefront-guided ablations because you don’t really have a measurement with which to plan the treatment. Therefore, a wavefront-guided ablation is typically more for the smaller areas or for fine-tuning the refraction. In a grossly irregular case, we typically use a topography-guided treatment first, followed about six months later with a wavefront-guided retreatment to get rid of the refractive error,” he added. Causes of unpredictability in customised topographyor wavefront-guided surgery in irregular corneas include the cornea’s healing and biomechanical responses to the ablations. “These limitations could help explain why not too many people are really enthusiastic about customised ablations. However, the treatments can provide meaningful improvements in patients with decentrations and other problems,” he added.

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Michael Knorz: knorz@eyes.de EUROTIMES | DECEMBER 2014/JANUARY 2015

CATARACT & REFRACTIVE

DIGITAL INNOVATIONS

AAO showcases iPhone imaging devices and 3D printing for ocular prostheses. Howard Larkin reports

igital technology that promises to expand access to ophthalmic services with devices that lower costs and expand practice beyond the well-equipped office was on display at the 2014 AAO meeting held in conjunction with SOE 2014 in Chicago. The D-Eye is a compact adapter that attaches to an iPhone to create a portable ophthalmoscope. Developed by researchers from the University of Brescia, University of Molise and ‘Federico II’ University of Naples, Italy, it produces retinal images suitable for grading diabetic retinopathy. Comparing results from the D-Eye with conventional slit-lamp biomicroscopy in 120 patients with diabetes, exact agreement was found in 85 per cent of eyes and agreement within one step in 96.7 per cent. In most one- and two-step disagreements, severity was graded higher by biomicroscopy. Nine eyes were not gradable based on D-Eye images, compared with four for biomicroscopy. While not perfect, the D-Eye can be carried in a pocket and costs a fraction of an office slit-lamp, noted lead researcher Andrea Russo MD. “The affordability of this option could make it much easier to bring eye care to non-hospital remote or rural settings, which often lack ophthalmic medical personnel,” he said.

GLAUCOMA SCREENING Researchers from the University of Iowa, the University of Maryland, Johns Hopkins University, the University of Michigan, US and the Tilganga Eye Institute in Nepal used a free peripheral vision assessment app to screen approximately 200 patients in Nepal for glaucoma using an iPad. Results from the Visual Fields Easy app were compared with those from a Humphrey SITA Standard 24-2. The two tests agreed between 51-79 per cent of the time. Agreement was best among patients with moderate or advanced visual field

Courtesy of Andrea Russo MD

The D-Eye acquisition process with the stitching algorithm (beta version, still under development) for panoramic retina view

loss. False positives among normal controls were an issue. While the app is not precise enough for general vision screening, it may be useful with high-risk populations, said Chris A Johnson PhD, director of the Visual Field Reading Centre at the University of Iowa. “Although not perfect, the tablet glaucoma screening method could make a significant difference in remote locations where populations would not otherwise receive screening at all,” he said.

3D PRINTED PROSTHESES Creating a facial prostheses for a patient with an exenterated eye takes weeks of effort by an ocularist skilled in matching skin and eye colours at a cost of €10,000 or more. A 3D printing device cuts that to half a day at a fraction of the cost.

The affordability of this option could make it much easier to bring eye care to non-hospital remote or rural settings... Andrea Russo MD EUROTIMES | DECEMBER 2014/JANUARY 2015

Patients are scanned on both sides of their face using a mobile scanner. Software meshes the two to create a 3D facial image. The topographical information then goes to a 3D printer, which translates the data into a mask formed out of injection-molded rubber suffused with coloured pigments matching the patient's skin tone. Developed by researchers at Bascom Palmer Eye Institute, Florida, US, the device uses nanoclay infused with pigment, potentially making the prosthesis more resistant to surface wear, said David Tse MD, who collaborated with engineers at the University of Miami to develop the technology. Andrea Russo: dott.andrea.russo@gmail.com Chris Johnson: chris-a-johnson@uiowa.edu David Tse: dtse@med.miami.edu

Please find a video showing the D-Eye acquisition procedure at: https://www.dropbox.com/ s/6kw80j5udmdq1t8/d-eye%20 prototype%20presentation.mov?dl=0

CATARACT & REFRACTIVE

REPORTING INFECTIONS Endophthalmitis registry is now online. Howard Larkin reports

n online registry sponsored by ESCRS is now available for reporting endophthalmitis cases throughout Europe, Peter Barry FRCS, FRCOphth, FRCSI told EuroTimes. The registry can be found at www.endophthalmitisregistry.com. Intended to help identify and track patterns of infectious organisms and antimicrobial resistance, the registry is available free of charge for reporting suspected infections after cataract surgery or intravitreal injections, said Dr Barry, principal investigator in the landmark ESCRS Endophthalmitis Study that established the efficacy of prophylactic intracameral antibiotics. “In Europe, with the widespread adoption of intracameral antibiotic prophylaxis in cataract surgery, the number of endophthalmitis cases everywhere is going dramatically down, but it is still there. To get some meaningful information on it we decided we would open up an ESCRS endophthalmitis registry, and cover endophthalmitis in association with intraocular injections as well,” Dr Barry said. Indeed, injections may present the greater risk for patients. While the incidence of endophthalmitis per procedure is similar between cataract surgery and intraocular injections, the incidence per patient is much higher with injections at about 1:500 because they receive multiple injections, Dr Barry noted. To report a suspected case, log on, select cataract surgery or injection, and enter information on the patient. The registry then assigns a unique identifying number to the case to maintain patient and surgeon confidentiality. After 90 days, the registry automatically queries the reporting surgeon in confidence about the case, asking if it was confirmed as endophthalmitis. If the answer is yes, a series of further questions are asked, including: • What was the infectious organism? • How was the agent identified: Gram stain, culture, PCR or some combination? • For cataract cases, were intracameral antibiotics used? If so, which one? • Were topical antibiotics used? If so, which one? • For intravitreal injections, how many injections had the patient had previously? • Were topical antibiotics used before or after the injection? If so, which ones, and for how long? • Which antiseptic was applied before injection, povidone iodine or chlorhexidine, and how long was the exposure time: less than one minute, one to three minutes, more than three minutes? This data may be useful not only for tracking infectious organisms, but also for developing protocols for intravitreal injections that reduce the risk of infection and development of resistant organisms, Dr Barry said. The proper use of topical antibiotics in patients receiving frequent injections is uncertain, Dr Barry said. Antiseptic practice is also uncertain, he added. Evidence-based cataract surgery protocols call for povidone iodine solution to be left in place for at least three minutes before commencing incisions. Registry data may help guide development of standard intraocular injection protocols, he said.

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CATARACT & REFRACTIVE

SEQUENTIAL SURGERY Debate weighs pros and cons of same-day bilateral cataract surgery. Dermot McGrath reports

he momentum behind immediately sequential bilateral cataract surgery (ISBCS) seems to be growing worldwide, with no strong scientific rationale currently existing to rule out this approach in terms of safety and efficacy for routine cataract cases, according to both speakers in a debate at the JCRS Symposium held during the XXXII Congress of the ESCRS in London. Both Steve A Arshinoff MD and José Guell MD agreed that there are no demonstrated drawbacks, and several clear advantages, to performing ISBCS for routine cataract cases. Nevertheless, Dr Guell noted that while he does perform some same-day bilateral cataract surgery, his preference remains sequential unilateral cataract surgery. “The patient demand is definitely there, particularly younger cataract and refractive lens exchange patients with active lifestyles who want to get back to their routine as quickly as possible after surgery. However, I think simultaneous bilateral surgery encourages the patient to minimise the significance of the surgery and that is something I prefer to avoid,” he said. Dr Guell emphasised that this was more a question of personal choice rather than a firm conviction based on any conviction that ISBCS might pose an increased risk for complications or poorer visual outcomes. “If we just take account of the scientific literature there are no statistically significant differences in complication rates and visual outcomes between simultaneous and sequential cataract surgery, so it certainly makes sense to consider it for the majority of noncomplicated cataract cases.

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“And there are benefits for simultaneous surgery in terms of higher refractive predictability and final patient satisfaction because of the binocular refraction attained, although at the same time, some better refractive predictability for the second eye surgery is still defended by some of us,” said Dr Guell. While routine cases might well be considered for ISBCS, Dr Guell reminded delegates that there is still a subset of patients, those with concomitant ocular disease or systemic conditions such as diabetic or immunocompromised patients for instance, for whom simultaneous surgery is contraindicated. Making the case for ISBCS, Dr Arshinoff said that of the 11, 579 cataract procedures he has performed from 1996 to 2014, about 80 per cent were bilateral cataract surgery. For surgeons interested in finding out more about immediately sequential bilateral surgery, he said that ISBCS.org was a good starting point. “We have a very simple rule in the society which states: ‘If any unresolved complication occurs with the first eye, then the operation on the second eye should be deferred.’ That is a very important guiding principle. “However, everyone who does bilateral surgery finds out after a very short time that the best time to operate on the second eye is immediately after gaining the experience of the individual peculiarities of the first eye. The second eye is always easier, both for the surgeon and for the patient,” he said.

GUIDING PRINCIPLES Surveying the guiding principles for ISBCS, Dr Arshinoff said that the complexity of the case should always be within the surgeon’s competence. Moreover, it is advisable to record the intraocular lens (IOL) powers and astigmatism for both eyes and put them on a board visible to everyone in the operating room. “Every member of staff has to be familiar with bilateral surgery, everybody who hands the IOL or its package must be able to review calculations for accuracy and announce agreement with the chosen IOL to avoid any possible mistakes. “We also insist on complete aseptic separation of right and left eye procedures with nothing going from one table to the other. We also make systematic use of intracameral antibiotics and we recommend if there is any complication that it should be resolved with the first eye before proceeding to the second eye,” he said. The advantages of ISBCS are multiple, said Dr Arshinoff. “It avoids the issue of fear for patients who had a problem with the first eye operation. There is greater visual improvement after second eye surgery, as patients do better with binocular vision, and immediate rehabilitation of the visual system. “It also allows better planning of the refractive result, with no period of anisometropia. Furthermore, there are significant cost savings to health systems using such an approach,” he said. Summing up, Dr Arshinoff said that when given the choice 80 per cent of patients choose to have ISBCS. “ISBCS is rapidly gaining in popularity throughout the world. About 10 per cent of ESCRS members now perform bilateral cataract surgery and over half of all cataract cases in Finland are done this way. “We have a large membership in the UK and over 80 per cent of cases on the Canary Islands are done as bilateral surgery. The trend is also upwards in other parts of the world,” he said. José Guell: guell@imo.es Steve A Arshinoff: ifix2is@sympatico.ca

EUROTIMES | DECEMBER 2014/JANUARY 2015

CORNEA

BRILLOUIN TECHNOLOGY New tool for evaluating tissue biomechanics holds promise for CXL. Cheryl Guttman Krader reports

EVALUATING THE EFFECTS OF CXL Dr Mrochen reported that findings from ex vivo studies conducted by Scarcelli et al and by Avedro researchers demonstrated that Brillouin optical microscopy was sensitive enough to detect differences between porcine corneas treated using different CXL protocols. The results showed there was a linear relationship between increasing the UVA energy dose and the measured increase in Brillouin modulus after crosslinking. Scarcelli et al also reported using Brillouin optical microscopy for in vivo evaluation of the human eye and identified differences between keratoconic and normal corneas, as well as within and outside the area of the cone in the keratoconic specimens. Although more research is certainly needed to establish the clinical role of Brillouin optical microscopy in various applications, Dr Mrochen said that one goal would be to integrate the information it provides with that of corneal topography to design a customised CXL treatment plan for eyes with keratoconus.

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rillouin optical microscopy, a novel technology for non-contact in vivo measurement of tissue biomechanical properties, is generating considerable excitement because of its possible utility in numerous applications in ophthalmology. Speaking in London at the 5th EuCornea Congress, Michael Mrochen PhD discussed the promise of Brillouin optical microscopy for understanding and improving outcomes of corneal crosslinking (CXL). “A variety of tools have been developed for in vivo evaluation of corneal biomechanics. However, as a limitation, they all involve application of a mechanical force which itself induces a change in the highly viscoelastic cornea that confounds the ability to determine the properties of the tissue in its physiological state,” said Dr Mrochen, IROC Science, Zurich, Switzerland. “Brillouin optical microscopy does not cause mechanical deformation and holds promise to fulfil an unmet medical need by providing more accurate quantitative biomechanical measurements of the cornea and other ocular tissues.” Brillouin scattering is a phenomenon that arises from the interaction between incident light and acoustic phonons present within the illuminated material. The Brillouin-scattered light is characterised by a frequency shift that is related to the material’s elastic modulus and depends on the mass density, the optical wavelength and the refractive index. In Brillouin optical microscopy, Brillouinscattered light is captured with a spectrometer and the Brillouin spectrum is analysed by custom software to determine the Brillouin frequency shift. Now, after obtaining exclusive licence to commercialise scientific patents created at the University of Rostock, Germany, Avedro (Waltham, Massachusetts, US) is developing a Brillouin optical microscopy system for clinical use. A beta version is expected to be available in the middle of 2015.

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Michael Mrochen: michael.mrochen@irocscience.com EUROTIMES | DECEMBER 2014/JANUARY 2015

CORNEA

TREATING RECURRENT CORNEAL EROSION Alcohol delamination offers a simple, safe and successful technique. Cheryl Guttman Krader reports

he treatment algorithm for recurrent corneal erosion syndrome (RCES) begins with conservative measures, including use of topical lubricants, then oral tetracyclines, and application of a bandage contact lens. When those modalities fail or if symptom relief is short-lived, clinicians can intervene with a variety of surgical options. Speaking at the 5th EuCornea Congress in London, renowned cornea specialist Harminder S Dua MD, PhD, said the list of interventions for recalcitrant RCES includes botulinum toxin injection into the lid margin, mechanical debridement, diamond burr polishing, anterior stromal puncture with a needle or Nd:YAG laser, and phototherapeutic keratectomy (PTK). Noting that he has experience with several of those techniques and that they all offer success, Dr Dua also highlighted their limitations and discussed why alcohol delamination of the damaged corneal epithelium is his preferred procedure. “Alcohol delamination is a safe and effective alternative. Unlike anterior stromal puncture, it does not cause corneal haze or scarring. “In contrast to diamond burr polishing, alcohol delamination provides tissue for histological analysis, and compared with PTK, alcohol delamination is relatively inexpensive and will not induce a hyperopic shift,” said Dr Dua, Professor of Ophthalmology and Visual Sciences, University of Nottingham, UK. Dr Dua and colleagues described the utility of alcohol delamination as

Courtesy of Harminder S Dua MD, PhD

Figure 1: Top left - Slit lamp diffuse view of the eye of a patient with symptom of recurrent corneal erosion syndrome. Top right - Slit lamp diffuse view with fluorescein stain, showing late positive staining and tiny areas of negative staining of the affected area. Bottom left - The same area highlighted to show the lesions causing RCES. Bottom right - The cornea after alcohol delamination, stained with fluorescein showing the delaminated area

a treatment for recalcitrant RCES in papers published in 2006 and 2007 (Dua HS et al. Alcohol delamination of the corneal epithelium: an alternative in the management of recurrent corneal erosions. Ophthalmology. 2006;113:404-11. Singh RP et al. Alcohol Delamination of the Corneal Epithelium for Recalcitrant Recurrent Corneal Erosion Syndrome. Br J Ophthalmol. 2007;91:908-11). The findings from those case series showed the treatment resulted in dramatic and persistent relief of symptoms without

Alcohol delamination is a safe and effective alternative. Unlike anterior stromal puncture, it does not cause corneal haze or scarring Harminder S Dua MD, PhD EUROTIMES | DECEMBER 2014/JANUARY 2015

any deleterious effects during an average follow-up of 24 months. He told attendees that more recently a follow-up questionnaire was sent to 20 patients whose follow-up duration now extends to 10 years. Fifteen patients responded, of whom 14 reported having no symptoms since undergoing alcohol delamination. Dr Dua also noted that his centre’s positive experience with alcohol delamination is corroborated by two studies that reported outcomes for the procedure compared with PTK (Chan E et al. A randomised controlled trial of alcohol delamination and phototherapeutic keratectomy for the treatment of recurrent corneal erosion syndrome. Br J Ophthalmol. 2014;98:166-71).

ALCOHOL DELAMINATION In his presentation, Dr Dua also described his technique for alcohol

CORNEA delamination and for preparing the removed tissue for histological examination. Using an optical zone marker, the treatment area is defined and covered with four to five drops of 20 per cent alcohol. After waiting 30 to 40 seconds, the alcohol is removed with a dry swab, and the epithelium peeled off as a sheet. (Figure 1) Then the eye is covered with a bandage contact lens and treated with topical chloramphenicol. “Exerting a little downward pressure with the optical zone marker will create a seal and prevent spillage of the alcohol. Therefore, it is possible to get close to the limbus with this technique,” Dr Dua said. The tissue is prepared for histology by laying it on a piece of paper, covering it with a few drops of water, and gently teasing it flat with two forceps. To settle the tissue flat on the paper, a dry swab is applied at the periphery of the water bubble to absorb it. Then the fixative is added, and after 10 to 15 minutes the specimen is ready for further handling. Dr Dua theorised that the efficacy of alcohol delamination for treating RCES lies in its ability to clear away collagenous debris, leaving a smooth surface that enables firm attachment of the new epithelium to the basement membrane. He explained that microscopic evaluation of debrided sheets of epithelium from eyes treated for RCES show abnormal hemidesmosomes in the basal epithelium

Figure 2: Transmission electron micrograph of an epithelial sheet removed by alcohol delamination for recurrent corneal erosion syndrome. Arrow head: intercellular space through much of the alcohol seeps down to the basement membrane. Arrow: abnormal hemidesmosomes between basal epithelial cells and underlying collagenous debris (star). Bar = 4 microns

along with presence of collagenous debris between the basal epithelium and basement membrane. (Figure 2) These features prohibit the anchoring filaments from forming firm attachments and therefore enable the epithelium to easily strip away. The alcohol that is applied percolates down between cells (leaving 30-70 per

cent of epithelial cells viable) and below the subepithelial debris. “Once the epithelium and debris are removed, the smooth clean surface left behind allows for better, stronger adhesion when the new cells grow,” Dr Dua said. Harminder S Dua: harminder.dua@nottingham.ac.uk

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EUROTIMES | DECEMBER 2014/JANUARY 2015

CORNEA

STEP UP TO DMEK Cornea specialist details the anatomy of the decision. Cheryl Guttman Krader reports

ompared with the rapid adoption of DSAEK (Descemet stripping automated endothelial keratoplasty), corneal surgeons are still struggling with the decision of whether or not to adopt DMEK (Descemet membrane endothelial keratoplasty). Speaking at the 5th EuCornea Congress in London, Sadeer B Hannush MD described how he finally decided to include DMEK in his practice. He told attendees that he and colleagues are relative latecomers to the community of academic cornea specialists performing DMEK. He explained that they first introduced DMEK in February 2014, and did so only after undertaking an 18-month period of investigation and analysis to gather evidence supporting the decision and to guide their surgical protocol. “We were early adopters of DSAEK because we were certain it would improve patients’ lives compared with penetrating keratoplasty. However, DMEK brings technical challenges and we were not convinced at first that it offered significant advantages over a well-performed DSAEK with a thin lenticule, less than 100 microns,” said Dr Hannush, Attending Surgeon, Cornea Service, Wills Eye Hospital, Department of Ophthalmology, Sidney Kimmel Medical College at Jefferson University in Philadelphia, US. “The length of time I spent researching and preparing for DMEK is far longer than that for any other new procedure I incorporated in my practice in the last 26 years since I finished training.” Ultimately, Dr Hannush and his colleagues concluded that at least for certain patients and in the hands of skilled surgeons, a well-performed DMEK offers significantly faster visual rehabilitation

patients with corneal disease, he felt it was important to be able to choose from the entire armamentarium of keratoplasty procedures in order to offer the best option for each and every patient.

TECHNICAL DECISIONS

Figure 1: Insertion of the Trypan Blue stained scrolled DMEK graft into the anterior chamber

Figure 2: The DMEK graft apposed to the host cornea with a 20 per cent SF6 bubble

than DSAEK. As another advantage compared with DSAEK, it seemed that DMEK grafts behave consistently once they attach and the cornea clears. “The DMEK outcome is predictable once a surgeon gets through the learning curve. Unlike DSAEK, it is not a function of graft thickness or architecture, but simply of good apposition and cell count at the end of the procedure,” Dr Hannush said. In addition, Dr Hannush said he was satisfied that the DMEK procedure could be standardised and therefore could be taught well to trainees. Finally, as Wills Eye Hospital is a centre providing consultative services to colleagues for their

Aiming to develop a surgical protocol that would minimise the technical challenges of the procedure and optimise outcomes, Dr Hannush and colleagues looked at available evidence and spoke to experts to guide their decisions. In particular, they investigated the following issues: Who should prepare the graft? How should it be inserted and unscrolled? And what should be used for tamponade? Dr Hannush noted that he needed to review these issues/challenges from the dual perspective of being both a corneal surgeon and medical director of the Lions Eye Bank of Delaware Valley. “The methods we chose are not necessarily the right ones for everyone, but they seemed to be best for our situation,” he said. The answer to the question of whether the surgeon or eye bank should prepare the donor tissue came easily – it would be done by a trained and certified eye bank technician using the technique developed by Gerrit Melles MD, PhD, Rotterdam, The Netherlands. “We could not see the surgeon or the institution being responsible for tissue wastage, and so we created a special process for the eye bank to prepare pre-stripped DMEK tissue,” Dr Hannush explained. While concern over wastage was the major determinant, Dr Hannush told EuroTimes that after a decade of experience as a surgeon performing endothelial keratoplasty, he is also convinced that a well-trained eye bank technician could potentially prepare the graft better and in

Figure 3: Post-op anterior segment OCT revealing complete adherence of the graft

EUROTIMES | DECEMBER 2014/JANUARY 2015

CORNEA

less time than Dr Hannush could. “Using pre-stripped tissue makes the surgeon’s component of the procedure shorter and less stressful,” Dr Hannush said, adding that he still believes there is value for surgeons to learn the stripping technique themselves. Dr Hannush and colleagues chose to use a modified glass tube (Straiko-Jones) rather than a modified intraocular lens cartridge for introducing the graft into the anterior chamber. He explained that this decision took into account what would be most compatible with the surgical environment

Figure 5: One month post DMEK surgery with the contour of the graft barely visible

at his centre in terms of the personnel involved (nurses, scrubs, residents and fellows) as well as ease of skills transfer in teaching trainees. For graft unscrolling, the anterior chamber shallowing technique with corneal

Using pre-stripped tissue makes the surgeon’s component of the procedure shorter and less stressful

tapping was selected instead of a small air bubble assisted technique. Also, based on a gut feeling and personal communications, including advice from José Güell MD, Barcelona, Spain, use of an isoexpansile concentration of SF6 (20 per cent) rather than air was chosen for tamponade. “We wanted to ensure graft adherence with the fewest number of rebubbling procedures, and so it made sense to choose the tamponade technique that would provide graft support for the longest period of time,” Dr Hannush told EuroTimes.

Sadeer B Hannush MD

Sadeer B Hannush: sbhannush@gmail.com

EYE CONTACT

STUDIO INTERVIEWS with leading ophthalmologists at the XXXII Congress of the ESCRS EXCLUSIVE TO EUROTIMES!

Retinopathy of Prematurity David Granet MD interviews Wagih Aclimandos Available at www.eurotimes.org/eyecontact and the EuroTimes App

EUROTIMES | DECEMBER 2014/JANUARY 2015

Courtesy of Sadeer B Hannush MD

Figure 4: One month post-op DMEK surgery with a clear cornea. “S” mark may be seen on the Descemet side of the graft

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Bags under the eyes, a good thing. Priscilla Lynch reports

n innovative eyelid warming device offers a simple and effective treatment of Meibomian Gland Dysfunction (MGD), a study published in the British Journal of Ophthalmology suggests. Eyelid warming therapy is considered the mainstay of treating MGD. Currently, however, there are no standardised eyelid warming procedures described in the scientific literature. Significant patient compliance issues relate to insufficient heating, duration and frequency of treatment, and there have been a number of attempts to develop a commercial device to provide a stable warming temperature and ease of use. The incidence of dry eye is very significant and is on the rise, largely due to increased ‘screen time’ and less blinking. However, despite the discomfort it causes patients, dry eye is not being adequately addressed by the ophthalmic community, Teifi James FRCOphth, consultant ophthalmologist and surgeon, West Yorkshire, England, and creator of the MGDRx EyeBag®, told EuroTimes. Twenty-five patients with confirmed MGD-related evaporative dry eye were enrolled in a randomised, single masked, contralateral clinical trial. Test eyes received a heated device - the MGDRx EyeBag®, and control eyes used a nonheated device for five minutes, twice a day for two weeks. Efficacy (ocular symptomology, non-invasive break-up time, lipid layer thickness, osmolarity, Meibomian gland dropout and function) and safety (visual acuity, corneal topography, conjunctival hyperaemia and staining) measurements were taken at baseline and follow-up. Subsequent patient device usage and ocular comfort was ascertained at six months. After two weeks, statistically significant improvements occurred in all efficacy measurements in test eyes (p<0.05). Visual acuity and corneal topography were unaffected. All patients maintained higher ocular comfort after six months, although the benefit was greater in those who continued usage of the MGDRx EyeBag® one to eight times a month. The study found that the subjective benefit of the MGDRx EyeBag® lasted at least six months, aided by occasional retreatment. Thus, the device appears to offer an effective and standardised solution to dry eye that is easy for patients to use, with high compliance, the authors conclude. Dr James said these results show the MGDRx EyeBag® provides safe effective relief without using any eye drops at all. “Dry eye really is a significant quality-of-life issue for people who suffer from it. This is the first self-administered device that truly treats the condition as opposed to other treatments such as eye drops which just treat the symptoms,” he told EuroTimes. He added that a separate study of 40 patients with Sjogren’s Syndrome who used the MGDRx EyeBag® found that 90 per cent reported a significant benefit because they have MGD too. The EyeBag® is a reusable compress with one side made of thin pure silk and the other side made from 100 per cent thick brushed cotton ‘moleskin’. A typical treatment course would be five to ten minutes twice a day for two weeks, and then three or four times a week as symptoms dictate. * The clinical study information is available online at: http://bjo.bmj.com/cgi/content/full/bjophthalmol-2014305220?ijkey=S3Lz6LYaNsNot8u&keytype=ref. Teifi James: eyebags@mac.com

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GLAUCOMA

DOCTORS VS MACHINES Can new diagnostic technologies replace experienced glaucoma specialists? Roibeard O’hEineachain reports

ill advances in technology render ophthalmologists obsolete in the diagnosis and monitoring of glaucoma? Two noted glaucoma specialists debated the question during a session of the 11th Congress of the European Glaucoma Society in Nice. Taking up the argument that machines will replace doctors, was Francisco Goni MD, PhD, Barcelona, Spain. “With the increasing number of patients in our healthcare systems we really need time-saving, effective, reliable, reproducible, and standardised methodology for disease diagnosis and follow-up,” he said. He noted that although diagnosis by physicians remains the current gold standard, even experienced glaucoma specialists disagree on whether or not an eye has developed glaucomatous damage or if damage that is already present has worsened. Dr Goni also noted that automated diagnosis is already in use by most glaucoma specialists in the form of computerised perimetry, with both diagnosis and progression analysis software. In fact, the European Glaucoma Society guidelines currently recommend the use of automated progression algorithms. “Many doctors are making direct clinical decisions based on perimetric diagnostic indicators, like hemifield test or pattern standard deviation, statistical tools that help us separate patients as likely normal or abnormal. Similarly, progression algorithms allow us to detect and measure change in an objective manner. Clinical criteria developed from studies have shown a good sensitivity/ specificity balance,” he said. The automation of the detection of the structural abnormalities that characterise glaucoma has kept pace with functional testing. The past decade has seen rapid development in technologies such as scanning laser polarimetry, confocal scanning laser ophthalmoscopy and optical coherence tomography. “These imaging devices have similar or even better diagnostic performance than clinical assessment by doctors. Their measurements are quantitative and show a high reproducibility, allowing the detection of change with strong confidence contrary to the qualitative, subjective evaluation of progression performed in a classic doctor's clinical examination. Thus nowadays an increasing number of doctors rely only on imaging devices to detect and measure structural progression,” he said.

DOCTORS STILL NEEDED Taking the opposing view, Anton Hommer MD,

If the visual field in the same patient stays normal it is probably justified to start medical therapy...

EUROTIMES | DECEMBER 2014/JANUARY 2015

Anton Hommer MD

Vienna, Austria, agreed that computerised perimetry is here to stay, but without the supervision of a trained physician the automated tests are still prone to error because of fixation loss, and other diseases that can affect visual fields. Furthermore, structural features detected by some of the newer imaging technologies can also be misleading, not only because changes similar to those that occur in glaucoma can also occur in other optic neuropathies, but also because there is so much variation in the optic nerve head and retinal nerve fibre layer among individuals without any disease at all. For example, in the normal population the retinal nerve fibre layer thickness at the optic nerve head can vary by between 800,000 and 1.6 million nerve fibres. Similar differences exist in the normal population regarding the size of the optic nerve head and cup/disc ratios and the degree of asymmetry between the two eyes. In addition, all of the current technologies have certain shortcomings. For example, the accuracy of early diagnosis with both the GDx-VCC scanning laser polarimeter (Carl Zeiss Meditec) and the HRT II confocal scanning laser ophthalmoscope (Heidelberg Engineering) is dependent on the disc size of the eye being examined. The GDx-VCC is more sensitive with small discs and the HRT II is more sensitive with large discs. Spectral domain OCT with the Spectralis® system (Heidelberg Engineering), for its part, is limited by the size of its normative database, which includes only 246 eyes of 123 patients, all of whom were Caucasian and between the ages of 20 and 87 years. Normative database is limited in all machines/OCTs, Dr Hommer pointed out. However the new imaging technologies have much to offer in the detection of progression, Dr Hommer said. He suggested using a two-step approach. “We know that with the available techniques nowadays structural changes are more likely to be detected at the early stage of glaucoma and functional examination is superior in advanced stages for detecting progression. Structural deviation from normal does not automatically mean that there is a disease. “But if we have confirmed change in OHT or early glaucoma with the structural measurements (not only one follow-up picture) it may be justified to start or change treatment. If the visual field in the same patient stays normal it is probably justified to start medical therapy, but not to perform surgery, because of more potential severe complications for a patient that had no loss in QoL before. If we have on the other side confirmed visual field progression due to glaucoma, but structure stays unchanged, because of advanced damage yet and the measurements are not providing useful information, then the functional tests are more valuable,” he said. “Therefore, all these high tech measurements are good for follow-up, but we always have to consider the patient individually as a whole, and this cannot be done by machines,” he said. Francisco Goni: francisgoni@yahoo.com Anton Hommer: a.hommer@aon.at

GLAUCOMA

THE BLEB AND BEYOND

leb-dependent filtration surgery remains the gold standard for reducing intraocular pressure (IOP) in eyes with open-angle glaucoma, but there are a range of alternative techniques for eyes in which the procedure is unsuitable, according to speakers at the European Glaucoma Congress in Nice. Trabeculectomy does not appear to work equally well in all eyes and there is evidence suggesting that differences in the conjunctival tissue of the bleb may explain some of the variations in the technique’s efficacy, said Christophe Baudouin MD, PhD, QuinzeVingts National Ophthalmology Hospital, Paris, France. “We know that bleb formation is extremely important for the outcome of surgery and if we can understand how it works then we will also get a better idea of why it doesn’t work in some cases,” he added. Dr Baudouin noted that his own research shows that the functionality of the bleb appears to correlate with the density of microcysts in the bleb’s conjunctival tissue, as detected by scanning laser microscopy. The microcysts’ density in turn appears to correlate with the concentration of goblet cells, which in the functioning blebs appear to contain aqueous humour instead of mucin, as is usually the case. (see Figure 1) A more recent study they conducted using en face optical coherence tomography (OCT) appeared to confirm the correlation between the density of microcysts (see Figure 2) and the functionality of blebs, Dr Baudouin said. It also showed an inverse correlation between the amount of IOP reduction achieved Figure 2

Figure 1

preoperatively and the number of years a patient had received preservative-containing eye drops preoperatively. Meanwhile, several new techniques have been developed over the years that use nonconjunctival routes to improve outflow of the aqueous from the anterior chamber. “The question for the future will be whether it is better to improve glaucoma surgery with blebs, with its problems related to bleb formation and anti-metabolites, or whether blebless surgery will replace or partly replace bleb-dependent surgery,” said Dr Baudouin.

ENDOSCOPIC PHOTOCOAGULATION An older form of minimally invasive glaucoma surgery that is undergoing renewed evaluation is endoscopic cyclophotocoagulation (ECP), a 15-year-old technique which aims to reduce IOP by both reducing aqueous production and increasing aqueous outflow, said Pavi Agrawal MD, Nottingham University Hospital, Nottingham, UK. The ECP procedure involves the use of an 18-gauge endoscopic diode laser probe placed through a 1.5mm limbal incision to provide a visually targeted delivery of energy to the ciliary processes. The result is a coagulative shrinkage and necrosis of the pigmented epithelium. The technique also increases uveoscleral outflow through the inflammatory effects of the laser. “The beauty of this technique is that it can be combined with phacoemulsification in elderly patients, hopefully avoiding the need for filtration surgery in some cases,” Dr Agrawal said. ECP can achieve good reductions in IOP in many cases where medication and filtration surgery has failed. Success rates with the technique reported in the literature range from 75-90 per cent, varying on the

Courtesy of Christophe Baudouin MD, PhD

Research could improve patient selection for filtration surgery; other surgical approaches showing promise. Roibeard O’hEineachain reports definition of success. ECP can achieve up to a 40 per cent reduction in IOP, which is not far off the IOP reductions of 45-55 per cent achievable with filtration surgery. The typical indications for cyclophotocoagulation include eyes in which previous medical and surgical therapy have failed and also patients who have a painful blind eye. However, there are several other types of cases in which the treatment has special advantages. They include eyes with acute angleclosure crisis unresponsive to intravenous Diamox and iridotomy, and cases where the patient is pregnant, in whom antimetabolites are therefore contraindicated. Moreover, research suggests that the adverse effect on vision which some attribute to cyclophotocoagulation may actually be a result of the more advanced stage of glaucoma that is present in patients who undergo the treatment. The main complication of ECP is cataract progression, but when combined with phacoemulsification the main complications are an IOP spike and a fibrinous inflammatory reaction. “Endoscopic photocoagulation is not a replacement for filtration surgery, but it is an important part of the glaucoma surgeon’s armamentarium. It has promising outcome data in terms of its effect on visual acuity, intraocular pressure and rate of complications,” Dr Agrawal added.

DEFINING SUCCESS While many years of research are needed to accurately assess the therapeutic value of any given surgical technique in glaucoma, one thing that could be achieved much more readily is a consensus as to what is meant by the “success” of the treatment, said Tarek Shaarawy MD, glaucoma sector head, Geneva University Hospitals, Switzerland. “We need to ask their surgeons to adhere to a strict definition of success that we will agree on so that we can all speak the same language. We definitely need to include not only intraocular pressure reduction but also the amount of complications in our definition of success. We also definitely need to include visual function as outcome measures. There’s no use saying that the operation was a success when the patient went blind,” he added. Christophe Baudouin: baudoin@quinze-vingts.fr Pavi Agrawal: pagrawal@doctors.org.uk Tarek Shaarawy: Tarek.shaarawy@hcuge.ch EUROTIMES | DECEMBER 2014/JANUARY 2015

GLAUCOMA

RISK FACTORS Predictors of onset and progression provide treatment clues. Roibeard O’hEineachain reports

nowledge of risk factors for primary open-angle glaucoma onset and progression can be helpful when deciding on a management strategy in individual patients, according to some noted glaucoma experts who spoke at the 11th European Glaucoma Society Congress in Nice. “Knowing the risk factors for glaucoma onset won’t tell us with certainty which individual will one day develop glaucoma, however it can help you estimate the possibility,” said Anne L Coleman MD, PhD, Fran and Ray Stark Professor of Ophthalmology, Vice Chair of Academic Affairs in Ophthalmology and Professor of Epidemiology, University of California, Los Angeles, US. Intraocular pressure (IOP) is the most well-established risk factor for the onset of glaucoma and it is the only risk factor that current therapies attempt to modify, Dr Coleman said. Population-based studies, as well as large prospective and retrospective studies, have shown that patients with a higher IOP have a higher incidence of glaucoma. IOP also appears to be closely linked to glaucoma’s pathological mechanisms. For example, it is a common clinical observation that, in patients with asymmetric disease, it is the eye with higher IOP that will progress more rapidly. Moreover, in non-human primates, artificially increasing the IOP causes damage to the optic nerve that is very similar to that which occurs in glaucoma. Other risk factors identified in the literature include many that are not modifiable, such as age, race, certain genes, family history, central corneal thickness and myopia. However, some of the other identified risk factors are potentially modifiable. They include lower socioeconomic status, high body mass index, low intake of antioxidants and high intake of fats, poor exercise habits and sleep apnoea. “It is important to emphasise that a lot of the risk factors are chosen from statistical analyses. Therefore, a risk factor may cause

or induce glaucoma, but it could also be that the glaucoma is inducing the risk factor. In addition, it could be that the risk factor and glaucoma are related to another underlying condition and really have nothing to do with each other,” Dr C o l e m a n added.

PROGRESSION

FA K IS

Anders Heijl MD EUROTIMES | DECEMBER 2014/JANUARY 2015

R O T C

In eyes with established primary open-angle glaucoma, progression of the disease has its own set of risk factors, each with its own fairly welldefined impact on the likely outcome in a particular patient, said Anders Heijl MD, Skåne University Hospital Malmö, Sweden. “In patients with risk factors we may need to modify our management strategy. For example we may need to aim for a lower target IOP. And more importantly, patients with risk factors for progression need to be followed more frequently,” Dr Heijl said. He noted that many factors which figure strongly in glaucoma onset appear to have no influence on disease progression. Evidence is weak for any association between glaucoma progression and central corneal thickness, refractive error, and ocular perfusion pressure, although there is good evidence for all those factors and glaucoma onset. Elevated IOP is a risk factor for both onset and progression. Several large randomised trials, including the Early Manifest Glaucoma Treatment study (EMGT) and the Advanced Glaucoma Intervention Study (AGIS) have shown a clear association between elevated IOP and disease progression. In contrast, there is no evidence that broad IOP fluctuation is an independent risk factor for glaucoma progression. Advanced age is another risk factor shown in the studies. In the EMGT it doubled the risk of progression. Disc

There is no evidence that any lifestyle factors influence the risk of glaucoma progression

haemorrhage is also a clear marker for increased risk glaucoma progression in eyes with established disease, but an even better marker in suspect glaucoma. The strongest predictor of future progression is the amount of progression occurring in previous years. He added that, apart from adhering to their IOP-lowering regimens, there unfortunately does not appear to be a lot that glaucoma patients themselves can do to reduce their risk of glaucoma progression, Dr Heijl said. “There is no evidence that any lifestyle factors influence the risk of glaucoma progression. General health factors are often discussed in the literature, but there’s really no clear-cut scientific evidence,” he added.

TREATMENT HAS ITS OWN RISKS Among the many factors to keep in mind when assessing how to treat a patient who presents with glaucoma is the patient’s own view of whether the risks of treatment outweigh the risks of non-treatment, said Norbert Pfeiffer MD, University of Mainz, Germany. For example, topical medications carry the risk of side effects, such as hyperemia and allergic reactions. In addition, in certain rare instances, patients can have a severe cardiovascular reaction to topical beta blockers. Surgical treatments, for their part, carry the risk of complications that can have an immediate effect on vision, Prof Pfeiffer noted. Even successful and uncomplicated surgery can leave a patient unhappy, as was the case with a patient of his who became very self-conscious when a partially visible bleb formed at the junction the limbus. “You have to keep weighing the risks, and please keep in mind that your risk assessment may be greatly different from your patient's risk assessment and their quality-of-life is not ours,” he concluded. Anne L Coleman: colemana@ucla.edu Anders Heijl: anders.heijl@med.lu.se Norbert Pfeiffer: pfeiffer@Augen.klinik.uni-mainz.de

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 232 ISSUE: 3 MONTH: NOVEMBER 2014

FOR REFRACTIVE AND CATARACT SURGERY

INFLAMMATORY FACTORS INVOLVED IN DME DISEASE PROCESS Inflammatory factors that affect vascular permeability may play a role in the aetiology of diabetic macular oedema (DME), a new study’s findings suggest. In 36 patients with DME, enzymelinked immunosorbent assay showed significantly higher vitreous fluid levels of vascular endothelial growth factor (VEGF), soluble VEGF receptor (sVEGFR)-2, soluble intercellular adhesion molecule (sICAM)-1, monocyte chemotactic protein (MCP)-1 and pentraxin 3 (PTX3) than was present in 15 patients with macular hole. In addition, the patients’ aqueous flare values correlated significantly with their vitreous fluid levels of the inflammatory factors. H Noma et al, “Role of Inflammation in Diabetic Macular Edema”, Ophthalmologica 2014; Volume 232, No 3 (DOI:10.1159/000364955).

DEXAMETHASONE IMPLANT SHOWS RAPID AND SUSTAINED EFFECT In patients with macular oedema secondary to retinal vein occlusion, the intravitreal erodible 700-μg dexamethasone implant Ozurdex provides rapid reductions in central retinal thickness and improvements in BCVA that are sustained throughout the first 90 days following implantation, according to the results of a prospective study. In 19 eyes of 18 patients, mean central retinal thickness decreased rapidly after treatment (p < 0.0001) from 503μm at baseline to 288μm at one day and 199μm at three months. There was an average gain in BCVA of six ETDRS letters at one day and 11 letters at 90 days. D Veritti et al, “Early Effects of Dexamethasone Implant on Macular Morphology and Visual Function in Patients with Macular Edema Secondary to Retinal Vein Occlusion”, Ophthalmologica 2014; Volume 232, No 3 (DOI:10.1159/000366232).

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LOSS OF ACUITY AFTER SWITCHING ANTI-VEGF AGENTS Switching AMD patients from ranibizumab to bevacizumab may slightly negate the initial gains achieved with ranibizumab, according to authors of a retrospective study. In 110 eyes with AMD that underwent treatment with ranibizumab on a PRN basis for a mean of 18.1 months, mean BCVA decreased from 54.8 letters to 51.7 letters (p < 0.001) after being switched to bevacizumab for a mean of 12.2 months . However, the authors noted that the natural history of wet AMD could explain the small reduction in visual acuity. J Pinheiro-Costa et al, “Switch from Intravitreal Ranibizumab to Bevacizumab for the Treatment of Neovascular Age-Related Macular Degeneration: Clinical Comparison”, Ophthalmologica 2014; Volume 232, No 3 (DOI:10.1159/000363422).

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TRUST YOURSELF

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believing in your own abilities

“

K, so I’ll go ahead any given time, and since it’s and plan your always a resident with four years cataract surgery,” I of experience, we are allowed a said to my patient, a great deal of autonomy. friendly woman of This autonomy, however, about 75 years old. is paired with its ever-present She nodded in agreement. siblings: responsibility and “Would you like me to do the respect. This is sharply different operation?” I asked. She looked from the patients’ expectations around the examination room, in my training hospital, which as though she were looking for is a tertiary referral centre someone else. She then looked back staffed by 30 sub-specialists and at me, somewhat surprised. “Yes, of 20 residents. course, who else?” Some patients have been Good point, I thought. Who sent here by their primary else? It was the first day of my ophthalmologist for difficultsix-month general ophthalmology to-manage conditions, which rotation in Saint Francis Hospital, often require multidisciplinary a large community hospital serving ophthalmic care. northwest Rotterdam. Others have been treated by I had not yet gotten used to the the same sub-specialist for 10 context in which I was working. years and are not inclined to trust In my teaching hospital, the their ocular health to a young, Rotterdam Eye Hospital, residents unknown doctor. are referred to as “assistants”. Yet others have come from a For historical reasons, “doctor’s hundred miles away in search of assistant” is the Dutch term for the “best” care from the “best” “resident in training”. Everyone doctors, and are convinced that in our hospital understands this the professor in the next exam outdated term, except the patients room is the best person to treat “All four of us perform cataract themselves, who seem to interpret their blepharitis. surgery. Three are full-time staff this as, “Assistant? This person is As a young resident, I was often ophthalmologists, and I’m in training” not qualified to operate on my eye.” either frustrated or intimidated In the community hospital, it’s by these patients, but as my quite different. Despite being a training progressed, this seemed teaching hospital, with residents in every department, the vast to become less and less of a problem. majority of the doctors are full-time staff members. “Who else?” my 75-year-old patient repeated. “Who else But for patients, there is no obvious difference between residents would do it if you didn’t?” I snapped out of my dreamland. and staff doctors; we’re all referred to as “doctors”. “Well, there are four doctors who work in this department,” I Although I always introduce myself as “Leigh Spielberg, answered, starting my standard cataract-surgery-planning-story. ophthalmologist in training”, my patients simply regard me as their “All four of us perform cataract surgery. Three are full-time ophthalmologist. staff ophthalmologists, and I’m in training. I’ve done this This trust is supported by Dr Gan, the coordinator of ophthalmic operation hundreds of times, but I haven’t yet received my eye resident training in Saint Francis, who is always prepared to doctor’s diploma. However...” strengthen this confidence in his trainees. “I trust you,” she said, interrupting me. “Thank you,” I said. So when I asked my patient whether she would like me to perform “I do too.” her cataract operation, it was an unexpected question for her. I wasn’t sure whether this was fully true. How could I know For patients in a community hospital, this is their hospital, where for sure? Patients generally seem to trust us, but they don’t really they’ve come their entire lives. Their children were born here; their have a choice. husbands were operated on here. But we have to make this decision for ourselves. We have to All their medical records are stored on the hospital’s files. They take this leap of faith, to jump from the resident’s mindset to that have a deep-rooted and age-old trust in everything that happens here. of the ophthalmologist. Their hospital-printed appointment card says: “You have At a certain point, a trainee like me has to get used to the idea an appointment with Dr Spielberg on July 23rd at 14:20.” This that I’m the one to whom people are coming for help. I have to trust is thus immediately transferred to me, whether I have my develop faith in myself as a doctor, and then I know my patients ophthalmologist’s diploma yet or not. will, too. Ernest Hemingway once wrote, “The best way to find out if you can trust somebody is to trust them.” In our context as RESPONSIBILITY AND RESPECT ophthalmologists, “The best way to allow patients to trust you is The ophthalmology department at Saint Francis is used to to trust yourself.” this. Since there’s only one resident in the department at Courtesy of Eoin Coveney

EUROTIMES | DECEMBER 2014/JANUARY 2015

INDUSTRY NEWS

E E R IP F R EA RSH EES 3 Y BE AIN EM TR M OR F

Become an ESCRS Member Integral to your continuing education INDUSTRY

NEWS

PUPILLARY DISTANCE METER NIDEK has launched the Pupillary Distance Meter PM-700. “It is designed to fit comfortably in the operator’s hands,” said a Nidek spokesman. “The vertical marker with 0.25mm increments has been included, allowing easier alignment with the corneal reflection point. The scale can be corresponded to 0.5mm increments, same as the previous model, the PM-600. Measurement value of pupil distance is presented in 0.5 or 0.1mm increments. Many of the measurement settings can be modified depending upon the situation,” said the spokesman. www.nidek.co.jp

INTRAOPERATIVE OCT SYSTEM Haag-Streit Surgical says that new technical features will enhance the intraoperative OCT system. “A number of recent innovations have made handling easier and simplified the surgical workflow,” said a HaagStreit spokesman. “The intraoperative optical coherence tomography (or iOCT TM) allows the surgeon to directly assess structures within the tissue while performing the surgical operation. “As of late, these iOCT images can be displayed synchronically using the microscope overview,” he said. www.haag-streitsurgical.com

QUICK TRANSITION Medicel AG has introduced its first singleuse screw-type injector ACCUJECTTM SCREW. “The new ACCUJECTTM SCREW injection system allows a quick transition of the lens from the loading chamber using the well-proven pushmechanism and a smooth and controlled lens injection via the screw advancement,” said a company spokeswoman. “Our backloaded technology has been applied to the ACCUJECTTM SCREW injection systems and also to the standard ACCUJECTTM Injection Systems (syringe).” www.medicel.com

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EUROTIMES | DECEMBER 2014/JANUARY 2015

CHARITIES

RENEWING COMMITMENT ESCRS continues to support Orbis and OXFAM

SCRS President Roberto Bellucci has renewed the commitment of the ESCRS to continue supporting the work of the Society’s two charities Orbis and Oxfam in 2015. Representatives from both charities shared a booth at the XXXII Congress of the ESCRS in London, where they explained the work being carried out with the Society’s funding.

OXFAM WASH PROGRAMME Courtesy of Orbis

Oxfam’s Water, Sanitation and Hygiene Promotion (also known as WASH) programme is supporting communities in the conflict-affected region of North Kivu in the Democratic Republic of the Congo (DRC). One of Africa’s largest countries with a population of 65 million people, DRC is ranked in the bottom 10 countries worldwide on the Human Development Index, despite its vast potential wealth. Over 20 years of conflict in the country have created one of the world’s worst humanitarian crises. An estimated 5.4 million lives have been lost (many from preventable diseases) since 1998 alone. The primary objective of the project funded by the ESCRS is to improve the health and well-being of conflict-affected communities in five villages in the Mweso Health Zone and 10 villages in the Masisi Health Zone. This is being done through a number of measures: • Limiting the risks of water contamination and water bornediseases in households by improving water quality and longterm water management by communities themselves; • Improving availability and use of sanitation facilities; • Improving knowledge of good hygiene practices and protection measures against health risks.

A group of patients queuing for screening in Addis Ababa, Ethiopia

ORBIS GONDAR PROJECT

Courtesy of OXFAM

A 60,000-litre capacity water reservoir under construction in Buporo, DRC. In the background is the village of Buporo, one of the two villages to which it will provide water

Ethiopia has one of the highest blindness rates in the world, with levels double those of other developing countries. Out of a population of 82 million people, 1.2 million Ethiopians are blind, and 72,000 of these are children. Orbis, with the support of ESCRS, is partnering with the Gondar University Hospital to establish the country’s third Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia. This programme will provide children with access to high-quality eye care, which in turn will contribute to a decrease in childhood blindness and low vision in North West Ethiopia. Before Orbis began this programme in 2011, only two limitedcapacity CEHTFs existed in the entire country. The World Health Organisation recommends that there is a minimum of one CEHTF facility per 10 million people. With a population of approximately 91.7 million people, the need for Child Eye Health services in Ethiopia is great. With substantial support from ESCRS, Orbis is well on its way to staffing and equipping the third of these facilities at Gondar. It will have capacity to reach 14 million people within its catchment area. Through sponsoring the Fellowship and Hospital Based Programme (HBP) training, ESCRS has allowed the CEHTF to be staffed by a team who have received world class training, enhancing their ability to treat greater numbers of children and provide them with a brighter future. Following three years of substantial support, the ESCRSfunded sub-speciality training for Dr Mulusew Asferaw and Dr Asamere Tsegaw has taken place at Gondar University Hospital, Tanzania, India and the UK. This training has formed an integral part of the Orbis-led programme to substantially reduce the number of children living with blindness and visual impairment in North West Ethiopia.

РОССИЙСКИЙ ВЫПУСК Visit: www.eurotimesrussian.org EUROTIMES | DECEMBER 2014/JANUARY 2015

RUSSIAN LANGUAGE EDITION NOW ONLINE

protectalon_eurotimes2.pdf

28/10/14

16:32

JCRS

JCRS HIGHLIGHTS

VOL: 40 ISSUE: 11 MONTH: NOVEMBER 2014

SPHERICAL EFFECTS OF ASTIGMATIC TREATMENTS Coupling, a term used to describe the relative corneal steepening that occurs 90 degrees from the primary corneal flattening induced by corneal incisions, is a clinically significant phenomenon that affects the visual outcomes of incisional and ablative procedures. Better quantification of coupling would help a surgeon better anticipate the spherical effect of astigmatic effects of surgery. To this end, Alpins and colleagues developed a coupling paradigm that is valid for all forms of incisional and ablative astigmatism treatments. They have created a calculator that determines the coupling effect when sphero-cylindrical treatments are performed. They report that, by using this approach, they are able to reliably estimate the amount of coupling caused by any type of astigmatism treatment. In the case of laser ablation, the resulting coupling adjustment can be incorporated into future surgical plans for sphere to improve the accuracy of visual outcomes. N Alpins et al, JCRS, “Corneal coupling of astigmatism applied to incisional and C ablative surgery”, Volume 40, Issue 11, 1813-27. M

POOR EYEDROP TECHNIQUE COMMON

The inability of patients to instil eyedrops properly after cataract MY surgery is well known, and has implications for postoperative recovery. Just how bad are patients when it comes to eyedrop CY use? Canadian researchers conducted a prospective, crossCMY sectional study to find out. They collected data from 54 K eyedrop-naïve patients after cataract surgery. This included questionnaires, chart reviews and videos of patients. The vast majority of patients demonstrated poor instillation technique, failing to wash hands, contaminating bottle tips, missing the eye, and using an incorrect amount of drops. Most patients tended to overestimate how well they were doing. JA An et al, JCRS, “Evaluation of eye drop administration by inexperienced patients after cataract surgery”, Volume 40, Issue 11, 1857-61.

MRSA CHALLENGES Ophthalmologists are in the front lines in the war against Methicillin-resistant Staphylococcus aureus (MRSA). Mah and colleagues did a comprehensive review of the current medical literature and describe many of the challenges of ocular MRSA infections, and also recommend ways to identify, treat and reduce the overall problems associated with MRSA. They emphasise that clinicians must remove transient microorganisms from hands by using hand washing or hand antisepsis between all patient contacts. Eye-lane surfaces and hand instruments should be cleaned periodically. They also emphasise the importance of working with local infectious disease specialists to plan treatment. F Mah et al, JCRS, “Current knowledge about and recommendations for ocular methicillinresistant Staphylococcus aureus”, Volume 40, Issue 11, 1894-1908.

THOMAS KOHNEN European editor of JCRS

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EUROTIMES | DECEMBER 2014/JANUARY 2015

EYE ON TECHNOLOGY

PDEK BUBBLE CHALLENGES

PDEK bubble challenges can be overcome. It can also be easily performed in combination with phaco in Fuchs’ dystrophy. Dr Soosan Jacob reports

DEK (Pre-Descemet’s endothelial keratoplasty) is a new endothelial keratoplasty technique described by Professors Amar Agarwal and Harminder S Dua referring to transplantation of Pre-Descemet’s layer (PDL; Dua’s layer), Descemet’s membrane (DM) and endothelium. As discussed in EuroTimes Vol 19, Issue 5, p36, the big bubble formed on injecting air into donor cornea can be either Type 1 – the PDEK graft (well circumscribed, central dome-shaped elevation expanding towards the periphery; tough and resistant to tears and achieving a size of between 7 to 8.5mm); Type 2 – the Descemet membrane endothelial keratoplasty (DMEK) graft (poorly circumscribed bubble starting in periphery and expanding towards centre, achieving a size up to 10.5mm and thin-walled and delicate); or Type 3 – mixed, with both types forming. This article discusses challenges and solutions for creating a good Type 1 bubble. Some personal techniques to avoid complications in bubble creation are described below. Uncontrolled sudden expansion of the bubble should be avoided to prevent bubble rupture. Multiple, small, well-defined, discrete bubbles are indicative of a Type 1 bubble forming. These are expanded very slowly and carefully by either slow injection of air or by exchanging the air-filled syringe with one filled with storage medium/ viscoelastic while retaining the needle in its position, followed by slow, controlled injection. (Figure A) Expansion should be done with care beyond 7mm and grafts larger than 8.5mm should not be attempted. With central endothelial perforation, a more viscous material is needed to prevent leakage from perforation and therefore viscoelastic (HPMC 2%) is preferred. (Figure B) Older donors are more likely to form a Type 2 bubble. If a Type 2 bubble forms

EUROTIMES | DECEMBER 2014/JANUARY 2015

Figure A: PDEK bubble is enlarged using corneal storage medium

Figure B: Endothelial perforation is occluded with pressure and bubble expanded using 2% HPMC

instead of Type 1, it can be prevented from expanding further by puncturing it and allowing air to escape. A small Type 2 bubble at the periphery can be sequestered from an expanding central Type 1 by applying pressure between the two with a thin blunt instrument and not allowing the Type 1 to meet it. (Figure C) This prevents a split graft which can be very challenging to handle. A split graft generally occurs in older corneas and generally starts at one edge. With large splits, it may be more preferable to separate a DMEK graft and proceed with DMEK. (Figure D) Bubble enlargement is directed towards the desired side by linear pressure on the endothelium on opposite side during expansion. Only endothelium beyond intended graft should be touched. Mark Soper’s technique of first scoring the donor rim as for DMEK before injecting air also prevents Type 2 bubble formation. PDEK graft preparation has advantages of not requiring special instruments unlike DSAEK (Descemet stripping automated endothelial keratoplasty). PDEK does not induce hyperopia as stroma is not transplanted. It has advantages over DMEK in being able to use younger donor tissues with higher cell counts. DMEK graft preparation is difficult in donor eyes younger than 50 because of

firm attachment of DM to PDL, however PDEK graft is possible in young donors of any age as air cleaves the plane between stroma and PDL. PDEK graft is also tougher and more resistant to tears than DMEK. It is therefore easy to centre under pressurised air infusion with a reverse Sinskey hook after floating it without causing wrinkling or graft tears. Disadvantages of PDEK are similar to DMEK and include the learning curve for preparing, unfolding and floating the graft. In the author's experience, there is also greater likelihood of Type 2 bubble forming in older corneas as compared to younger ones. Long-term results still need to be evaluated as well as the incidence of haze and rejection as compared to DMEK. PDEK can be easily performed in combination with phaco in Fuchs’ dystrophy. Cataract surgery with intraocular lens (IOL) implantation is performed first. Care should be taken to avoid a posterior capsular rent as a vitrectomised, soft eye may not provide adequate postoperative air tamponade to support the PDEK graft. It is therefore more preferable to perform all cataract manipulations anteriorly closer to the endothelium than to the posterior capsule. Viscoelastic is completely removed after IOL implantation and this is followed by host Descemet’s stripping and PDEK.

EYE ON TECHNOLOGY It may also be performed for pseudophakic bullous keratopathy with a well-positioned IOL. In cases with widely dilated, atonic or floppy pupil, an iridoplasty may be required to prevent air from going behind the iris. In aphakic eyes, the ideal location of the IOL is in the sulcus with, if possible, an optic capture. My personal second choice is to combine with glued IOL because of less pseudophakodonesis. Sclerotomies for haptic exteriorisation may be made slightly closer to the limbus than normal and an iridoplasty done in order to get a stable iris-IOL diaphragm to allow good postoperative air fill. To determine the need for iridoplasty, the bubble test may be performed after IOL implantation by injecting air into the AC and checking adequacy of air fill. If air goes behind the iris, an iridoplasty should be done. Once the PDEK graft is injected into the AC, my personal technique of endoilluminator assisted PDEK or E-PDEK helps keep all further intraocular manipulations to a minimum. Oblique external illumination from a vitreo-retinal light pipe helps define intraocular structures and the PDEK graft with great clarity and threedimensionality. This helps verify orientation of the graft in a non-touch manner. It also helps during the remainder of surgery by allowing better

World Society of Paediatric Ophthalmology and Strabismus

endothelial keratoplasty and offers distinct advantages over DMEK. Techniques for harvesting the PDEK graft are continuing to evolve in the form of automated graft preparation, femtosecond assisted dissection etc, which will result in increased safety and repeatability. Ready-to-order grafts from eye banks will ultimately make PDEK grafts easily available for the EK surgeon without fear of tissue loss during preparation.

Figure C: Type 2 bubble is sequestered from Type 1 and bubble is enlarged towards opposite direction

* Dr Soosan Jacob is a Senior Consultant Ophthalmologist at Dr Agarwalâ&#x20AC;&#x2122;s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

Figure D: DMEK graft is prepared in a split graft

graft perception, thus making surgery easier and faster. To conclude, PDEK is an effective alternative to DMEK for modern

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World Congress of Paediatric Ophthalmology and Strabismus

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SIDE SIDE AT THE INTERSECTION OF IDEAS AND IMPLEMENTATION

FEBRUARY 12–15, 2015 TURNBERRY ISLE MIAMI, AVENTURA, FLORIDA Don’t miss this new opportunity to receive step-by-step guidance on how to immediately deploy what you learn.

PHYSICIANS PROGRAM CHAIRS

Edward J. Holland, MD

Stephen S. Lane, MD

Roger F. Steinert, MD

PROGRAM OUTLINE (Subject to Change) THURSDAY, FEBRUARY 12

SATURDAY, FEBRUARY 14

Meet the Experts Roundtable

Corneal Issues in Cataract Surgery Moderator: Edward J. Holland, MD

Welcome Networking Reception

FRIDAY, FEBRUARY 13 ’Stigmatism Moderator: Stephen S. Lane, MD

Cataract Surgery Challenges and Complications Moderator: Roger F. Steinert, MD Hands-on Workshops (non-CME)

Glaucoma Therapy in 2015: MIGS, MEDS, and Beyond Moderator: Richard A. Lewis, MD

Side Bar Session

Hands-on Workshops (non-CME)

SUNDAY, FEBRUARY 15

Side Bar Session

Evolving Technology in Cataract Surgery Moderator: Edward J. Holland, MD

Attendee Dinner

Retinal Injections Moderator: Keith A. Warren, MD Hands-on Workshops (non-CME)

JANUARY 13—EARLY BIRD REGISTRATION AND HOUSING DEADLINE

sideXside.ascrs.org

BOOK REVIEWS

METICULOUS & IN-DEPTH For anyone searching for a meticulous, in-depth and highly comprehensive text on cataract surgery, Essentials of Cataract Surgery: Second Edition is what you’re looking for. This is a 370-page book that covers everything from the preoperative evaluation to the management of postoperative PUBLICATION complications. It provides both ESSENTIALS OF CATARACT SURGERY: an overview of the procedure SECOND EDITION and the details needed to refine EDITOR each step. DR BONNIE AN HENDERSON Written and presented more as a textbook than a handbook, PUBLISHED BY SLACK Essentials is predominantly text. This is presumably based on the assumption that drawings and surgical photographs can be illustrative, but a well-written description of a particular procedure or concept might better help the reader understand and especially remember what she or he has read. Particularly interesting and useful are the well-written surgical instructions, described in prose. “The keratome is then placed in the corneal groove with the heel down, flush with the ocular surface, and advanced approximately 2mm anteriorly, dissecting a plane through the corneal stroma. The heel of the blade is subsequently elevated off of the globe so that the tip of the keratome is directed toward the iris opposite the wound.” This type of description allows the reader to imagine each step in his or her mind’s eye, mentally preparing the young surgeon. A full 14 pages are devoted to the capsulorhexis alone. This pocket-sized book is ideal for all ophthalmology residents learning cataract surgery, as well as fellows and early-career ophthalmologists looking to update their phaco knowledge.

BOOK

REVIEWS

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OVERVIEW OF LASER PLATFORMS For those who have mastered traditional phacoemulsification, femtosecond laser-assisted cataract surgery is a potential next step. However, it’s easy to get lost amid the frenzy of activity surrounding the new technology. Femtosecond Cataract Surgery, by Drs Federica & Luca Gualdi (Jaypee Publishing), seeks to clarify the latest developments. The strength of this text lies in its overview of the different laser platforms available: the LenSx (Alcon), the Victus (Bausch & Lomb), the LensAR (Topcon), the Catalys (Abbott) and the LDV Z8 (Ziemer). After a quick overview on femtosecond cataract surgery, each platform is described in its own chapter, entitled “Description of the Device, Procedure and Clinical Experiences”. The following chapter focuses on how to use each laser in challenging cases and how to avoid complications with each one. Generously illustrated with surgical photographs and screen shots of crucial settings and the surgeon’s “personal preferences”, this book is intended for any ophthalmologist interested in the potential possibilities offered by the femtosecond laser. 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

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EUROTIMES | DECEMBER 2014/JANUARY 2015

CALENDAR

SEPTEMBER

FEBRUARY 2015

International Conference on Ocular Infections (ICOI)

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

↙

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

LAST CALL

DECEMBER 2014/ JANUARY 2015

20–22 February Istanbul, Turkey www.escrs.org

DECEMBER 2014

12 December Amsterdam, The Netherlands www.amc.nl/retinadebate

6th World Congress on Controversies in Ophthalmology (COPHy)

6th Amsterdam Retina Debate

JANUARY 2015

9th International Congress ‘Macula of Paris’ 9 January Paris, France www.maculaofparis.org

5th EURETINA Winter Meeting

APRIL

MAY

6th Baltic Congress

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

15th EURETINA Congress 17–20 September Nice, France www.euretina.org

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

JUNE

Vienna

SOE 2015 Congress 6–9 June Vienna, Austria www.soe2015.org

World Cornea Congress VII (WCCVII)

NEW ENTRY Retina in Progress 2015: Present and Future

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

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

11–13 June Florence, Italy www.symposiacongressi.eu

AUGUST

NEW ENTRY 28th APACRS Annual Meeting

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

XXXIII Congress of the ESCRS

ARVO Annual Meeting

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

ASCRS.ASOA Symposium and Congress

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

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

MARCH

6th EuCornea Congress

3rd World Congress of Paediatric Ophthalmology and Strabismus

19th ESCRS Winter Meeting

29th International Congress of the Hellenic Society of Intraocular Implant and Refractive Surgery

3–4 September Barcelona, Spain www.ocularinfections.com 4–5 September Barcelona, Spain www.eucornea.org

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

26 February–1 March Athens, Greece www.hsioirs.org/index.php/en/

24 January Oxford, UK www.euretina.org

↙

5–8 August Kuala Lumpur, Malaysia http://www.apacrs.org

th EURETINA

Winter Meeting Saturday 24 January 2015

Merton College, University of Oxford, UK www.euretina.org

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