EuroTimes Vol. 19 - Issue 6 by EUROTIMES

special focus Glaucoma review

A complete guide to controlling the capsulorhexis June 2014 | Vol 19 Issue 6

RETINA

Stem cell treatment for retinal disease a possibility in the future

glaucoma

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Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Angela Sweetman Advertising Executive Mairin Condon Senior Designer Janice Robb

Contents

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 ESCRS, Temple House, Temple Road, Blackrock, Co. Dublin, Ireland. Tel: 353 1 209 1100 Fax: 353 1 209 1112 email: escrs@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

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.

SPECIAL FOCUS

15 Postoperative eye

Glaucoma 3 4 5 7 8 9

Could nanoparticles represent the medicine of the future? Range of techniques set to revolutionise glaucoma treatment Study shows huge reduction in glaucomaassociate blindness Nanodiamond-embedded contact lenses may aid treatment of glaucoma Researchers investigate promotion of retinal ganglion cell survival Recognising problems ahead of time could improve cataract surgery in glaucoma patients

™

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25 26 27

drops may be replaced by nanotechnology technique Study findings show good quality of vision with aspheric IOL Meta-analyses indicate potential benefits of CME prevention guidelines Forward thinking ensures optimal outcomes for femtosecond assisted cataract procedures Triplet optical design could provide a wide range of accommodation Study results show good outcomes for high myopes Adaptive optics could one day optimise monovision strategies

FEATURES

Cornea

Cataract & Refractive

28 Experts discuss

10 Adherence to safe

principles of bilateral cataract surgery reduces risk of endophthalmitis 11 Restoring accommodation in presbyopic patients may be effective with laser 12 Is femto-cataract surgery a better option for your patient? 13 Excellent safety profile experienced with light adjustable lens implant 14 Virtual eye surgery can provide novel training for surgeons

p.32 retina 32 Researchers hopeful stem cell technology will be used for retinal repair

Paediatric 36 Talented artist proves her ability despite having low vision

Ocular 37 Colour vision can be affected by ageing

how progression of keratoconus should be measured 31 Matching the cornea’s natural asphericity key to good outcomes

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Meeting Report 38 News from the ASCRS meeting in Boston

REGULARS 39 Ophthalmologica update 40 Travel 41 Book Reviews 43 Industry News 44 JCRS Highlights 45 Product close-up 46 Review 48 Calendar Eurotimes | june 2014

editorial A Word from clive peckar MSc, FRCS, FRCOphth

GLAUCOMA UPDATE A look at some of the latest developments in the treatment and management of glaucoma

n this issue we feature articles on some of the latest developments in glaucoma: Prof Dean Ho at the UCLA School of Dentistry, (page 7) describes a new drug delivery system utilising nanoparticles embedded onto a contact lens which releases timolol, from the contact lens, when it comes into contact with tear film lysozyme. Prof Ho also points out that other drugs, or binding mechanisms, could potentially be utilised, resulting in sustained drug delivery, for example, in patients with co-existing ocular surface disease; the nanoparticles acting as slow release matrices. It is hoped that this new technology may improve the pharmacological treatment of eye disease while reducing complications from local and systemic toxicity. The article on the experimental work by Jeffrey Goldberg, at UCSD, (page 8) describes their use of ‘ciliary neurotrophic factor implants’ to promote retinal ganglion cell survival and optic nerve regeneration, as part of their research into neuroprotective agents. Unfortunately this study demonstrated no improvement in function and, therefore, reminds us of the value of early intervention in open-angle glaucoma (OAG) before significant damage occurs. In 1968 Cairns first described the concept of ‘trabeculectomy’, as a method of restoring physiological outflow by removing the juxta-canalicular trabecular meshwork, allowing direct access of aqueous, from the anterior chamber, into Schlemm’s canal and its collector channel network. Unfortunately, this early attempt at internal drainage failed as there was no method of preventing the cut and crushed edges of the canal from closing; however, this surgical dissection survived, due to the leaking superficial sclerectomy flap, as a “sub-conjunctival ‘bleb-dependant’ fistularising procedure”, with the misnomer ‘trabeculectomy’. Today, 46 years on, trabeculectomy, a procedure that destroys part of Schlemm’s canal, with or without Mitomycin C (an antineoplastic alkylating agent which destroys local collector channels) is the most widely performed surgical procedure for OAG.

surgical and long-term risks. He discusses the new ‘micro-invasive glaucoma surgery (MIGS)’ procedures for Ab-Interno Schlemm’s Canal Surgery and predicts the demise of trabeculectomy as the standard surgical procedure in OAG, promoting the concept of early surgical intervention, as these procedures have reduced surgical risk, compared with trabeculectomy. This renewed interest in Schlemm’s canal surgery follows the pioneering work of Prof Robert Stegmann, from the Medical University of South Africa, first published in 1999, in which Schlemm’s Canal is approached ab-externo and opened and dilated, utilising high-viscosity sodium hyaluronate, creating ‘blebindependent’ internal physiological drainage, via the ‘collector channel network’; the ab-externo procedures of ‘viscocanalostomy’ and ‘canaloplasty’ (with and without the use of ‘intra-canalicular stenting’ using tension sutures or implants). Whilst these ab-externo techniques have an established track record they have only been adopted, as the main surgical procedure for OAG, in a limited number of surgical centres in Europe. This is due to the time taken to perform these procedures, and the relatively long learning curve and technical difficulties of the ab-externo surgical dissection and tight sclerectomy closure. I hope that one or more of these early MIGS procedures will prove to be a safe and successful treatment for OAG (not just ‘mild glaucoma’), without the necessity for the meticulous dissection, visco-dilatation and closure, currently required in ab-externo Schlemm’s canal surgery. Perhaps there is still hope that during my lifetime I may see the demise of trabeculectomy, and its bleb, as the so-called ‘gold-standard’ glaucoma procedure, in favour of ‘bleb-independent’ procedures which re-establish internal physiological drainage. In the meantime I, and my other canaloplasty colleagues, practising in Europe, South Africa and America, will continue working our way along Schlemm’s canal taking the ab-externo route.

Pioneering work Ike Ahmed, assistant professor at the University of Toronto, in his ASCRS Binkhorst Medal Lecture (page 4), points out that historically, glaucoma surgery was reserved for advanced cases largely because trabeculectomy and tube shunts involve significant

ClivePeckar@PremierEyeClinic.co.uk

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 | june 2014

special focus: glaucoma

NANOMEDICINE Tiny particles can pack a punch in the delivery of ophthalmic medicine. Roibeard O’hEineachain reports

anoparticles may represent the medicine of the future and are already showing promise in some ophthalmological applications, said Eduardo D Silva MD, PhD, University Hospital, Coimbra, Portugal. “The aim of nanomedicine is the comprehensive monitoring, control, construction, repair, defence and improvement of human biological systems at the molecular level using engineered nanodevices and nanostructures operating massively in parallel at the single cell level ultimately to achieve a medical benefit,” said Dr Silva at a joint symposium of the European Paediatric Ophthalmology Society (EPOS) and the World Society of Paediatric Ophthalmology and Strabismus (WSPOS), held at the XXXI Congress of the ESCRS in Amsterdam. He noted that the nanoparticles most likely to be used first in medicine would be solid colloidal particles composed of macromolecular particles and ranging in size from 10 to 100 nm. The earliest uses of nanomedicine will likely come in the form of drug delivery devices. The types of nanoparticles under investigation for clinical use include nanospheres, nanogels, nanoliposomes, nanomicelles and nanosuspensions, each with their theoretical advantages and disadvantages. For example, nano liposomes have good drug loading properties, but are unstable. Nanogels, meanwhile, are very good at delivering oligonucleotides to target cells, but they represent an expensive technology. There are a growing number of reports in the literature supporting the use of nanoparticles in ophthalmic medicine. For example, in one recent study laboratory Eduardo D Silva MD, PhD experiments indicated that contact lenses loaded with nanoparticles, used as an extended release carrier for timolol would deliver timolol at therapeutic doses for about a month at room temperature, with a minimal impact on critical lens properties. Moreover, in preliminary animal experiments with dogs wearing the drug and nanoparticle-treated contact lenses there was a reduction in IOP (Jung HJ. J Control Release. 2013 Jan 10;165(1):82-9).

Topical Administration Another study investigated the use of nanoparticles to enhance delivery of pilocarpine through the cornea when administered topically. A corneal permeation study revealed that the apparent permeability coefficient of pilocarpine/ nanoparticle-loaded drops was more than twice as high as that of commercial eye drops (Li et al., Int J Pharm. 2013; 15;455(12):75-84). Nanomedicine might also be used in the form of tissue regeneration scaffolds and implantable nano-devices with biomolecular machinery, which would perform such functions as genetic testing and IOP-monitoring, Dr Silva noted. “Some of the obstacles that remain to the use of nanoparticles include the persistence of nanoparticles, the need for safe manufacturing techniques and the possibility of unintended consequences,” he added. Eduardo D Silva: Esilva2579@hotmail.com Eurotimes | june 2014

special focus: glaucoma

MIGS FUTURE BRIGHT Microinvasive Glaucoma Surgery enables earlier, safer, more effective glaucoma intervention. Howard Larkin reports

ASCRS 2014 Programme Chair Edward J Holland MD (left) presented the Binkhorst Medal to Dr Ike Ahmed in Boston

range of ab-interno devices and techniques that provide moderate to excellent intraocular pressure (IOP) control with much less risk than traditional filtration or tube surgery are set to revolutionise glaucoma treatment, Iqbal “Ike” K Ahmed told the 2014 Symposium & Congress of the American Society of Cataract and Refractive Surgery (ASCRS) in Boston. Collectively known as Microinvasive Glaucoma Surgery (MIGS), these include implants and instruments for enhancing physiological outflow, such as microstents and the trabectome, as well as shunts that open suprachoroidal channels or create scleral subconjunctival blebs. Together they fill the historical treatment gap between less effective but safe topical medications and lasers and effective but risky trabeculectomy and tube surgery, which typically are seen as treatments of last resort, Dr Ahmed said in the 2014 ASCRS Binkhorst Lecture. “The promise of MIGS is that you can intervene early in the disease, reducing the morbidity of progression. This hopefully will reduce the need to expose ourselves and our patients to more aggressive surgical options when we are already too late in the disease process,” said Dr Ahmed, who is assistant professor at the University of Toronto where he also directs research, and clinical assistant professor at the University of Utah. The effectiveness of some devices now in clinical tests rivals trabeculectomy, the current gold-standard for controlling IOP, without the long-term infection Eurotimes | june 2014

risk. If proven effective long-term these minimally invasive techniques could replace trabeculectomy altogether, he said. “I hope this will happen sooner rather than later. There is no reason why an ab-interno bleb cannot do just as well as an external bleb.”

Big role for cataract surgeons That the Binkhorst Lecture, which usually examines cataract and refractive surgery, this year focused on glaucoma reflects the growing role for cataract surgeons in glaucoma treatment. About 15 per cent to 20 per cent of patients undergoing cataract surgery also have glaucoma, Dr Ahmed noted. Phacoemulsification and lens extraction by itself often lowers IOP significantly and reduces the need for topical medications to control pressure. Adding MIGS technologies, such as the iStent (Glaukos) and Trabectome (NeoMedix), further reduces post-op IOP and medication needs, and these can be done with cataract surgery with very little additional risk. “Any patient with glaucoma going to cataract surgery I think needs a really hard look for possibly combining [MIGS] with phaco. You’ve heard of a zero-sum game. This is a zero-loss game. We have very little to lose by trying an implant that does not preclude future [glaucoma] surgery, particularly in mild to moderate patients,” Dr Ahmed said. The iStent is among the most studied of MIGS technologies and the first approved

by the US FDA. Trials have shown that two iStents work better than one. Newer Schlemm’s bypass devices include the injectable iStent, which resembles a rivet and is delivered through the clear cornea with a 26-gauge injector. The Hydrus (Ivantis), a scaffolding device inserted in Schlemm’scanal, also has been shown to reduce IOP and greatly reduce medication use when placed in combination with phaco compared with phaco alone. Studies also show that placing the iStent closer to a major collection channel further improves performance. Dr Ahmed recommended that surgeons interested in implanting Schlemm’s canal bypass devices familiarise themselves with the anatomy of aqueous veins and how to locate them in patients’ eyes, and place devices close to major outflow channels to maximise effectiveness. Familiarity with gonioscopy and visualising the angle are also essential skills for placing any type of outflow stent. Focal blood reflux after placing a Schlemm’s bypass stent is usually a good sign that it is properly placed close to an aqueous vein. Suprachoroidal micro-stents create a channel from the angle to the suprachoidal space, taking advantage of the pressure gradient to drain aqueous into a collector lake, where it is resorbed. Early trials of the CyPass (Transcend) show it is effective in lowering IOP in patients with pre-op levels exceeding 21 mmHg. The iStent Supra also targets the suprachoroidal outflow channel. The Xen implant (AqueSys) is an ab-interno device that creates an external subconjunctival bleb. But since it is delivered through an injector through a clear corneal incision, no external dissection is required, reducing long-term infection risk. Combined with an intraoperative injection of mytomycin C, Xen has been shown to reduce IOP by about 40 per cent over nine months, performance comparable to trabeculectomy. Dr Ahmed sees Schlemm’s canal and suprachoroidal stents as low-risk options for mild to moderate glaucoma, with subconjunctival approaches possibly useful for full-spectrum disease. However, more data is needed to further support such indications. He is confident that MIGS will alter the traditional treatment algorithm. In addition to routine use in cataract surgery, the safety of MIGS will allow MIGS solo procedures, and possibly multiple MIGS procedures before resorting to trab or tubes. Ike Ahmed: ike.ahmed@utoronto.ca

special focus: glaucoma

ENCOURAGING RESULTS

OCULUS Centerfield® and Easyfield®

Long-term risk of glaucoma blindness drops by half

large-scale long-term research project indicates that as the diagnosis and treatment of the disease has improved, the incidence of glaucoma-associated blindness has dropped by nearly 50 per cent. In a large retrospective, populationbased cohort study, researchers reviewed all cases diagnosed with glaucoma between 1981 and 2000 among residents of Olmsted County, Minnesota, age 40 or above. They then identified all cases that progressed to blindness, defined as visual acuity ≤20/200 or visual field constriction to ≤20° in at least one eye. The study compared blindness rates for patients diagnosed in the period from 1965 to1980 with rates for patients between 1981 and 2000. Statistical analysis revealed that while the incidence of glaucoma remained similar, the 20-year probability and the incidence of blindness associated with open-angle glaucoma (OAG) decreased from 25.8 per cent for patients in the earlier group to 13.5 per cent for those diagnosed between 1981 and 2000. The population incidence of blindness within 10 years of diagnosis was found to have declined from 8.7 per 100,000 to 5.5 per 100,000 for those groups, respectively. Higher age at diagnosis was one factor associated with a statistically significant increased risk of progression to blindness. “These results are extremely encouraging for both those suffering from glaucoma and the doctors who care for them, and suggest that the improvements in the diagnosis and treatment have played a key role in improving outcomes,” said Arthur J Sit MD, associate professor of ophthalmology at the Mayo Clinic College of Medicine and lead researcher for the study. However, enthusiasm for the study results should be tempered by the finding that nearly 15 per cent of the patients diagnosed in the more contemporary group did progress to blindness, he noted. “Despite this good news, the rate at which people continue to go blind due to open-angle glaucoma is still unacceptably high. This is likely due to late diagnosis and our incomplete understanding of glaucoma, so it is critical that research into this devastating disease continues, and all eye care providers be vigilant in looking for early signs of glaucoma during routine exams.”

Using Threshold Noiseless Trend (TNT) for efficient progression analysis

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The study appeared in the journal Ophthalmology, M Malihi et al., “Long-Term Trends in Glaucoma-Related Blindness in Olmsted County, Minnesota”, Vol. 121, Issue 1, 134-141.

• SPARK strategy for fast and

• Automated glaucoma staging systems • Threshold Noiseless Trend (TNT) for

high sensitivity progression analysis

reliable examinations

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Eurotimes | june 2014

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special focus: glaucoma

NANODIAMONDS Nanodiamond-embedded contact lenses may improve glaucoma treatment. Dermot McGrath reports

Drawbacks

Courtesy of UCLA School of Dentistry

iny nanoparticles may offer a solution to one of the biggest problems in glaucoma treatment – poor patient compliance. A new drug delivery system using nanoparticles embedded onto a contact lens may represent a major step forward in improving the management of glaucoma, suggest researchers at the University of California, Los Angeles (UCLA) School of Dentistry who created the new system. The glaucoma drugs are released into the eye when they interact with the patient’s tears. Researchers believe that their approach may entail less severe side effects than traditional glaucoma medication and improve patients’ ability to comply with their prescribed treatments. In a recent study published in the journal ACS Nano, the new technology showed great promise for sustained glaucoma treatment and, as a side benefit, the nanodiamond-drug compound even improved the contact lenses’ durability, said lead author of the report Dean Ho PhD, MS, professor of oral biology and medicine and co-director of the Jane and Jerry Weintraub Center for Reconstructive Biotechnology at the UCLA School of Dentistry. To deliver a steady release of medication into the eye, the UCLA researchers combined nanodiamonds with timolol maleate, which is commonly used in eye drops to manage glaucoma. When applied to the nanodiamond-embedded lenses, timolol is released when it comes into contact with lysozyme, an enzyme that is abundant in tears. Prof Ho told EuroTimes that the study highlighted several advantages in using nanoparticles for drug delivery in glaucoma.

Nanodiamond-embedded contact lens, developed by Dr Dean Ho and researchers from the UCLA School of Dentistry

“The integration of nanodiamonds into the contact lens resulted in lysozymetriggered drug release, improved mechanical robustness of the device, preserved water contact which is important for lysozyme access to mediate drug release and wear comfort, and practical clarity levels. In addition, the nanodiamonds are byproducts of conventional mining/ refining processes and as such are sustainable nanomaterials,” he said.

A drawback of traditional timolol maleate drops is that as little as five per cent of the drug reaches the intended site. Another disadvantage is burst release, where a majority of the drug is delivered too quickly, which can cause large amounts of the drug to spill out of the eye and, in serious cases, can cause complications such as an irregular heartbeat. Drops also can be uncomfortable to administer, which leads many patients to stop using their medication. For patients with ocular surface disease, dry eye or other tear deficiencies which often co-exist in glaucoma patients, Prof Ho said the system could be potentially adapted to take account of individual patient characteristics. “Under these circumstances, other drugs or binding mechanisms could potentially be utilised that results in sustained drug delivery, where the nanodiamonds can be used as slow release matrices. We have previously harnessed potent nanodiamond-drug binding for sustained therapy against cancer,” he said. After completion of initial preclinical studies within the next year or two, Prof Ho said that the next steps would be large animal validation studies followed by the first clinical studies in humans. Dean Ho: dho@dentistry.ucla.edu

The integration of nanodiamonds into the contact lens resulted in lysozymetriggered drug release... Dean Ho PhD, MS

TRABECULAS

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Eurotimes | june 2014

special focus: glaucoma

RCG REGENERATION

Early results from the first clinical trial to use CNTF in patients with glaucoma. Sean Henahan reports

laucoma treatment strategies are starting to shift from only treating increased intraocular pressure (IOP), to treating the underlying damage to the retina and optic nerve. Current efforts to stimulate retinal ganglion cell regeneration were described by Jeffrey L Goldberg MD, PhD, professor and director of research, Shiley Eye Center, UCSD, San Diego, US, at the World Ophthalmology Congress in Tokyo. “While we now mostly focus on controlling the pressure in the front of the eye, the damage is happening in the back of the eye. The fundamental problem we have with vision loss and vision restoration in glaucoma is that there is no retinal ganglion cell regeneration after optic nerve injury. The cells die and there is no endogenous replacement,” he noted. Researchers are looking at treatment strategies that might approach retinal ganglion cell loss at different stages in the disease process. Intervention during the early stages of disease would attempt to keep existing retinal ganglion cells alive through the use of neuroprotective agents. A related approach would involve introducing neurotrophic factors and growth factors that could help the cells regenerate. The most recently tested approach involves introducing one such factor, ciliary neurotrophic factor (CNTF) in an attempt to promote both retinal ganglion cell survival and optic nerve regeneration. Studies have recently been conducted in patients with glaucoma, as well as with retinitis pigmentosa, macular telangiectasia and geographic atrophy. In a previous multicentre Phase II study, patients with advanced geographic atrophy associated with non-neovascular age-related macular degeneration showed promising results on visual acuity when treated with CNTF in a proprietary approach known as encapsulated cell therapy (NT-501, Neurotech). This involves implanting eyes with a small immunologically neutral capsule designed to release CNTF. The 1.0 x 6.0mm implant contains an RPEderived cell line engineered to continuously produce CNTF for extended periods in humans. It is a relatively simple surgical procedure, implanting the device at the pars plana via a small incision and securing it with a single suture. It is placed outside of the main visual axis. That study confirmed the utility of the implant for safe, long-term delivery of biological agents. While no improvement Eurotimes | june 2014

NT-501 used in glaucoma, geographic atrophy, RP and MacTel studies releases CNTF

NT-503 for wet-AMD releases soluble VEGF receptor showing confluent cell attachment to internal scaffold matrix Courtesy of Neurotech

in visual acuity was noted, there was a trend towards visual stabilisation which was statistically significant among patients with better vision at baseline. Investigators also reported a dose-dependent, statistically significant increase in retinal thickness as measured by optical coherence tomography (OCT). Dr Goldberg presented early results from the first clinical trial to use CNTF in patients with glaucoma. One of two openlabel studies he conducted enrolled eleven patients with primary open-angle glaucoma (POAG) starting in February 2012; the second study enrolled patients with nonarteritic ischaemic optic neuropathy, but the results are not yet available. For inclusion in the study patients were required to have clinical evidence of progressive retinal ganglion cell dysfunction demonstrated by functional and structural testing. Patients also had to have failed maximal IOPlowering therapy, or have visual defects affecting quality of life.

No serious adverse events All patients completed the study. There were no surgery or implant-related serious adverse events. Patients did experience minor postoperative events including irritation and redness which resolved in the first month. There were also reports of anisocoria associated with the implant that has previously been described with CNTF and is known to be reversible. “Early conclusions from current research suggest that CNTF appears to be safe in humans. There was also some indication of biological effect with a marked increase in

the retinal nerve fibre layer demonstrated by both OCT and GDX.” The approaches now being investigated reflect an improved understanding of the underlying pathology of glaucoma. The first step is characterised by axon transport failure following increased IOP. The resulting axonal damage manifests as axonal thinning and dendritic changes leading to retinal ganglion cell death later in the process. CNTF is a member of the IL-6 cytokine category. It is released by retinal glial cells in response to injury. Many years of laboratory research have shown that CNTF promotes retinal ganglion cell survival, protects retinal ganglion cells from degeneration and promotes optic nerve regeneration. Dr Goldberg also reported promising animal studies in which implanted retinal ganglion cells showed evidence of growing both dendrites into the retina and axons along the retinal nerve fibre layer and across the optic chiasm. This suggests that it may be possible to transplant RGC cells even in the very late stages of glaucoma, he said. Implantable devices for sustained drug delivery are becoming a new wave of treatments for eye disease. Neurotech, the company that makes the NT-501 CNTF implant is also developing another product, NT-503, that is being evaluated for intraocular delivery of a VEGF receptor fusion protein for treatment of macular disease. A Phase II study in wet AMD is under way that shows control of macular oedema for at least 12 months. A Genentech scientist also reported at the conference that his company is developing an implant for slow release of anti-VEGF therapy.

special focus: glaucoma

CATARACTS IN GLAUCOMA PATIENTS Extra-gentle surgery necessary when performing phaco in glaucomatous eyes. Roibeard O'hEineachain reports

ost of the problems associated with cataract surgery in glaucoma patients cease to be problems when recognised ahead of time and appropriate precautions are taken, said Khiun Tjia MD, Zwolle, The Netherlands. It is not thinking about the problem and not identifying the problem which leads to the actual problem, Dr Tjia said at a Glaucoma Day session at the XXXI ESCRS Congress in Amsterdam. The typical difficulties surgeons are likely to encounter include shallow anterior chambers, narrow pupils, posterior and anterior synechiae, cystic and very thin filtration blebs and weak zonules. Furthermore, eyes with advanced glaucoma risk losing what they have left of their visual field if they have extreme peaks of IOP postoperatively.

Surgical instruments Injection of a viscoelastic prior to making the second incision will help establish a sufficiently deep anterior chamber for cataract surgery and greatly facilitate the entry of surgical instruments into the eye, Dr Tjia said. He recommended using dispersive viscoelastic for that purpose, because a small residual amount left in the eye is unlikely to induce high postoperative peaks of IOP. When a patient’s pupil is smaller than the surgeon feels confident working through, a Malyugin ring is a very useful option, he noted. In some glaucomatous eyes the laxity of the zonule and the resulting folds in the capsule are such that a forced capsulotomy may cause

sections of the zonule to be torn away from the ciliary body. For that reason, a sharp capsulotomy made with a knife is usually the best option. Using a low fluidic strategy can be very advantageous in many glaucoma cases, Dr Tjia said. It minimises the iris movement and is therefore essential in eyes with floppy Iris syndrome. It also does not aspirate dispersive viscoelastic, which is best left in place during the procedure in order to protect the corneal endothelium and deepen the angle. The slower pace of surgery with a low-flow approach also gives the surgeon much more control overall. “The lower the flow, the lower the opportunity for any inadvertent movement of the iris or capsule towards the tip. It will take a little bit more time to take the lens out with this very low flow strategy. But you're not in a hurry, so that is not a problem, and the extra time taken for the surgery will not have that much impact on the patient's outcome,” Dr Tjia added. He noted that in the most severe cases he lowers the bottle 40cm, to provide an irrigation pressure of 47mm, and reduces aspiration pressure to the very minimum which is 12 mmHg.

Classic technique When removing a cataract from a glaucoma patient, he prefers the classic divide-and-conquer technique. That is because it does not require reaching out to the periphery of the lens, where visibility is often very poor. He uses high vacuum in a special chop step to move the first quadrant to the middle to facilitate nucleus removal. He recommended use of a cohesive viscoelastic when

I have been extremely excited to be involved in the development of this system and I think it will help surgeons in the future Khiun Tjia MD

implanting the IOL because it is the only type of viscoelastic that is easy to remove completely from the eye. He added that a closed system is very important in some cases. It is therefore a good idea to create a very small side port through which to manipulate one’s second instrument. Bimanual irrigation and aspiration with very tight dedicated small incisions also creates more control in a closed anterior chamber system, he said.

Stable IOP A new technology that offers special advantages in glaucoma patients is the Centurion® Vision System phacoemulsification machine from Alcon. It allows surgeons to set a certain target IOP which it then maintains throughout surgery and at the same time also maintains an extremely stable IOP, Dr Tjia said. He presented a video demonstrating how in a routine cataract case, even with very high 500 mmHg vacuum settings, neither the pupillary edge of the iris nor the posterior capsule appeared to be drawn to the phaco tip during occlusion break. “This is truly groundbreaking technology. It gives us the opportunity do surgery in a very well-controlled manner with lower IOP than was possible previously. I have been extremely excited to be involved in the development of this system and I think it will help surgeons in the future,” Dr Tjia said. Dr Tjia noted that Alcon also recently introduced disposable bimanual I/A handpieces with polymer tips. The tips have an extremely smooth surface and large aspiration opening (0.3mm) which reduces the risk of capsular damage when polishing the posterior capsule. “It really gives you the option of doing bimanual irrigation and aspiration with very smooth aspiration control and without any risk of capsular tear of any sort. It really has improved safety a lot,” he said. Khiun Tjia: kftjia@planet.nl Eurotimes | june 2014

Cataract & refractive

BILATERAL SURGERY Proponents address fear of simultaneous bilateral endophthalmitis with realistic risk estimates. By Cheryl Guttman Krader

imultaneous bilateral endophthalmitis resulting in bilateral blindness is probably the most feared risk of immediate simultaneous bilateral cataract surgery (ISBCS). However, surgeons who cite this complication as the reason not to operate on both eyes at the same session should rethink their stance based on what is considered to be the best available evidence, according to a study presented at the XXXI ESCRS Congress in Amsterdam. Olivia Li MD presented data estimating the risk of simultaneous bilateral endophthalmitis (SBE) after ISBCS and its visual prognosis. Risk was calculated using data on unilateral endophthalmitis from two large studies. Assuming adherence to principles of safe surgery, including use of intracameral antibiotics and full segregation of each procedure, it was estimated that SBE might occur in just one patient per 3.9 million ISBCS cases or more optimistically, in just one patient per 206 million cases of ISBCS. The information on visual outcome was derived from a recent analysis of data collected in the Swedish National Cataract Register [J Cataract Refract Surg. 2013;39(1):15-21]. In the Swedish National study, there were 135 cases of postoperative endophthalmitis occurring over a six-year period, and 32.5 per cent of the eyes had a final distance BCVA of 20/40 or better. Integrating these data with the estimated risk of SBE, the chance of having bilateral BCVA worse than 20/40 after ISBCS would be approximately one in over nine million, said Dr Li, specialist trainee in ophthalmic surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK. “Practical and procedural advances are continually being made to reduce complications from cataract surgery and we believe ISBCS has many benefits for patients, surgeons and healthcare budgets,” she said. “There are other concerns about ISBCS that may still need to be addressed. However, we urge all cataract surgeons to consider the available information on the risks and merits of ISBCS, look beyond the rhetoric on SBE and offer their patients an informed discussion about immediate simultaneous procedures.” In evaluating the risk of SBE following ISBCS, Dr Li noted that a review of the literature identified only four published cases. “Importantly, details from these cases revealed that in each, there was breach of the aseptic protocols recommended by the Royal College of Ophthalmologists (RCO) in the UK and by the International Society of Bilateral Cataract Surgeons (iSBCS),” said Dr Li. Due to the paucity of data on SBE, its risk was estimated by translating information on unilateral endophthalmitis risk. The two sources used were the ESCRS Postoperative Endophthalmitis study [J Cataract Refract Surg. 2007;33(6):978-88], in which the risk of unilateral endophthalmitis in eyes receiving intracameral

cefuroxime was 0.05 per cent, and a report analysing the experience of iSBCS members, where the risk was only 0.007 per cent (a single case of endophthalmitis among 14,352 operated eyes) [J Cataract Refract Surg. 2011;37(12):2105-14]. Dr Li explained that assuming surgeons would follow guidelines from the iSBCS and the UK RCO to ensure that the bilateral surgeries were performed as completely separate procedures, the risk of both eyes becoming infected would be random events. Therefore, the risk of SBE could be calculated from unilateral risk data by taking the inverse of the squared value of the unilateral SBE rate [1/ (0.00050582)2 = 1 case per 3.9 million ISBCS] using the ESCRS data and 1/(0.007)2 = 1 case per 206 million ISBCS procedures using the iSBSC data]. Dr Li compared the risk estimates for SBE and bilateral blindness after SBE with data showing a one in 100,000 risk of death following use of a general anaesthetic. “Some patients choose to undergo cataract surgery using general anaesthesia, even in the absence of medical indications for its use,” said Dr Li, noting that ISBSCS also halves the risks of general anaesthesia.

data analysis

Eurotimes | june 2014

Risk minimisation strategies As underscored by the experiences in the four published reports of SBE, the development of endophthalmitis in both eyes after simultaneous surgery likely does not represent independent events. Rather, there are surgeon-related factors as well as patientrelated features that link the two complications and attention to all of these issues is critical. “Prevention is better than cure, and so with an aim to prevent endophthalmitis, surgeons must recognise the importance of careful case selection and adherence to the principles of safe ISBCS,” Dr Li said. Patient features that increase susceptibility to infection include blepharitis, external colonisation by commensal organisms, compromised immune status and certain anatomical characteristics. These factors largely remain even if the patient undergoes delayed sequential surgery, where bilateral endophthalmitis remains a risk, though rarely considered. In all cases, any preexisting pathologies that predispose to infection should be managed preoperatively. Cases that are anticipated as being difficult with an increased chance for intraoperative complications that might increase the risk for endophthalmitis should generally be excluded from ISBCS, as well as anaesthesia that demands postoperative patching. And, when ISBCS is planned, patients should be counselled preoperatively that if any unexpected events occur during the first eye procedure, the second eye operation would be delayed. Olivia Li MD: mail@olivia-li.com

Cataract & refractive

SMOOTH MICRO CUTS Trials under way for novel femtosecond laser treatment for presbyopia. Dermot McGrath reports

sing a femtosecond laser to create smooth micro cuts inside the crystalline lens may provide a quick, effective and safe means of treating the loss of accommodation in presbyopic patients. “We have been trying to restore the elasticity of the natural lens of the eye by generating sliding planes in the crystalline lens using a femtosecond laser (ROWIAK GmbH). These micro cuts reduce the inner friction inside the crystalline lens and help to restore its flexibility. The advantage of this procedure is that we do not have to open the eye and therefore we do not need a sterile operating room and can perform this as an in-office procedure,” Holger Lubatschowski PhD told the XXXI ESCRS Congress in Amsterdam. There is a strong rationale for using ultrafast laser pulses to try to restore accommodation, Prof Lubatschowski said. “Presbyopia leads to loss of near focusing ability and we know that the ciliary muscle continues to contract in presbyopic eyes. Secondly the lens capsule stays elastic with age and we now know that lens stiffness is the single key factor that limits the accommodative amplitude at any age and ultimately leads to a complete age-related loss of accommodation,” he said. Ex vivo studies initially demonstrated proof of concept of the lentotomy procedure, showing that the use of appropriately selected cutting parameters could generate significantly enhanced flexibility in the human lens. In terms of safety, subsequent studies in animal eyes showed no evidence of cataract induction arising from the creation of sliding planes in the crystalline lens, said Prof Lubatschowski. He noted that a pilot clinical trial in humans has commenced at two German sites: the University Eye Hospital of Rostock and Augenklinik am Neumarkt in Cologne. This phase I safety study will be carried out on 30 cataract eyes in patients aged between 50 to 65 years. The study eye will receive femtosecond lentotomy with no capsulorhexis, followed one week later by conventional cataract surgery, while the fellow eye will be treated with conventional cataract surgery alone. Prof Lubatschowski said that a lot of the initial research focused on determining the optimal laser settings for generating smooth cuts with minimal creation of gas bubbles that might result in unwanted light scattering. “That is why we use an ultrafast femtosecond laser with a shorter pulse duration than other commercially available devices. Using the right parameters, the lesions generated can be confined and localised to a range of just a few microns. We need to use the correct laser energy and pulse spacing in order to obtain the desired outcome,” he said. Using a docking procedure similar to femtosecond cataract procedures, the entire lentotomy procedure takes just 30 to 60 seconds depending on the size of the sliding planes being generated. “We remarked in these few first eyes that the laser lesions are clearing off quite rapidly in a matter of hours to a few days. The distance vision seems to be unchanged, which means that with the right pattern we do not induce aberrations,” he said. Holger Lubatschowski: h.lubatschowski@rowiak.de

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Cataract & refractive

Pause for thought Is femto-cataract better for the patient?

Dermot McGrath reports

he seemingly inexorable rise of femtosecond laserassisted cataract surgery (FLACS) seems to owe more to the powerful marketing potential of laser surgery than to any proven benefit to the patient in terms of surgical outcomes, according to Rupert Menapace MD, FEBO. “Laser surgery is a big seller and it is easy to convince the patient of the magic of laser cataract surgery. Skilled manual surgery with modern instrumentation is as good as femtosecond laser-assisted cataract surgery. It saves lots of money and preserves the independence of the surgeon. It is not only ethically correct but also simply fair to inform the patient about the facts when discussing the option of femto-laser cataract,” Dr Menapace told delegates attending the JCRS Symposium at the XXXI Congress of the ESCRS in Amsterdam. The key questions which need to be answered in relation to FLACS, added Dr Menapace, are whether it is more effective and safer than manual surgery and, if so, whether it is worth the additional cost. While not minimising the capability of the femtosecond laser to create perfect corneal cuts of any desired architecture and location, Dr Menapace noted that modern ultrathin steel microkeratomes can also create excellent incisions in a variety of geometries. “The differences in incision quality, if at all present, are marginal and will be nullified by oar locking and distension of the incision due to manipulation of the phaco and i&A probes and the lens injector tip during IOL insertion. In fact a recent study found exactly the same topographical changes with 2.75mm clear corneal incisions made with a steel blade and a femtosecond laser,” he said. The perfectly-shaped capsulotomies created by the femtosecond laser are often cited as a major advantage over manual techniques, but the key issue is actually the centration of the capsulotomy to guarantee circumferential capsule-optic overlap, said Dr Menapace. “The larger the capsulotomy the more precisely it must coincide with the anatomical centre of the capsular bag. This, however, is still a guess since the imaging tools of lasers cannot reach out to the lens equator. The centre of the limbus or pupil or even visual axis can considerably deviate from the anatomical centre of the lens. Using these features as landmarks can be very misleading. A capsulotomy, even when perfectly shaped, misses its target when not perfectly concentric with the IOL optic,” he said. By contrast, simple and Rupert Menapace MD, FEBO straightforward techniques

Laser surgery is a big seller and it is easy to convince the patient of the magic of laser cataract surgery

Eurotimes | june 2014

exist to ensure proper sizing and centration of a manual capsulorhexis, said Dr Menapace, adding that this can be achieved by simply following a circle mirrored in the surgical microscope. Likewise, secondary capsulorhexis reshaping is possible using a manual approach in situations where a large eye or an extremely wide pupil make judgement of the correct size and centration difficult, he added. For cataract removal, femtosecond lasers can pre-fragment the nucleus and save phaco time and ultrasound energy, said Dr Menapace, but the key benefits stop there. “The laser must stop at least 1.0mm above the posterior capsule as a safety distance to avoid inadvertently cutting into it and it does not create a groove. The resulting posterior hinge and the difficulty to insert the phaco tip and spatula between the closely attached sectors make cracking of the nucleus more difficult. Alternatively cutting the central lens material in small cubes may cause them to spin off and be difficult to visualise and retrieve when they settle in the chamber angle or ciliary sulcus,” he said. The femtosecond laser is also redundant when it comes to extremely hard black cataracts since the laser cannot penetrate into the deeper layers, added Dr Menapace. Cortical clean-up is also rendered more complicated by using the femtosecond laser, he said. In terms of safety, Dr Menapace said while the femtosecond laser can create clear corneal incisions, its inability to create limbal or posterior limbal incisions limits its utility. “Both limbal and posterior limbal incisions have been shown to be significantly superior to clear corneal incisions with regard to astigmatic neutrality and deformation stability. While a 3.0mm clear corneal incision still induces significant sectorial flattening, a posterior limbal incision does not up to a width of 4.0mm. Because of the reduced self-sealing ability and deformation stability, the use of clear corneal instead of scleral corneal incisions increases the risk of endophthalmitis to a similar extent as when not using intracameral cefuroxime prophylaxis,” he said. While femtosecond lasers can reduce phaco energy and ultrasound power consumption, studies thus far have failed to demonstrate a concomitant reduction in endothelial cell loss, said Dr Menapace. Improvement of refractive outcomes with the femtosecond laser has also not been corroborated by independent studies nor has it been shown to reduce the incidence of posterior capsule opacification, added Dr Menapace. The expense of femtosecond laser technology should also give surgeons pause for thought, he said. Rupert Menapace: rupert.menapace@meduniwien.ac.at

Cataract & refractive

LENS TECHNOLOGY Positive series of results with light adjustable IOL. Dermot McGrath reports

Courtesy of Tobias Neuhann MD,

he light adjustable lens (LAL, Calhoun Vision) implant offers a unique technology which allows customised and changeable postoperative refractions with a high degree of predictability and an excellent safety profile, according to speakers at the XXXI Congress of the ESCRS in Amsterdam. “Although the implant is currently only used in a handful of centres in the UK, the LAL is gaining popularity with cataract and refractive surgeons worldwide as it offers the possibility of non-invasively addressing postoperative errors of refraction and gives us the ability to use the implanted refractive outcome as a guide to how presbyopic correction is suited to the individual’s needs,” said Hasan A Usmani FRCOphth, Blackpool Victoria Hospital, UK. He said that the lens offers the possibility of making non-invasive sphero-cylindrical adjustments postoperatively, thereby negating the risk of refractive surprises that can occur with conventional IOLs. Dr Usmani’s retrospective study included data for 36 eyes of 22 patients who underwent cataract and refractive lens exchange and opted for monovision as their preferred method of presbyopic correction. All patients underwent uncomplicated standard phacoemulsification, with UV protection for up to 14 days post implantation of the lens. Where possible the dominant eye was implanted first, aiming for emmetropia. The non-dominant eye was implanted approximately one month later for near with a refractive target of -1.25 D. Refraction was undertaken at each adjustment visit and adjustments continued up to a maximum of three times until customisation of near vision by individual patients was achieved, and the lens power was then locked in with a final treatment. The mean patient age was 55.2 years and preoperative spectacle spherical equivalent ranged from -16.00 to +6.50. The mean follow up was six months with a range of four to 18 months. Looking at the results, Dr Usmani noted that most of the cases ended up slightly myopic, giving them excellent near vision. Overall, 92 per cent of patients were within 0.50 D and 75 per cent within 0.25 D of the desired refractive target. Binocular near vision of N8 or better was achieved in 91 per cent and N6 in 86 per cent of patients, with binocular distance vision of 6/6 or better in 83 per cent of patients.

LAL - Light adjustable lens after second lock-in

Over 86 per cent of patients achieved both uncorrected binocular 6/9 distance vision and near vision of N6 or better.

Positive assessment The LAL also received a positive assessment in a separate study presented by Tobias Neuhann MD, Marienplatz Eye Clinic, Munich, Germany. Dr Neuhann’s study included 98 eyes with a mean patient age of 64. Of the 98 eyes with two years' followup or more, 64 were classified as virgin eyes and 34 as complicated eyes – 23 were post-LASIK, four eyes had undetected keratoconus that was spotted during the preoperative evaluation, seven eyes had no reliable IOL Master axis measurement. “Posterior pole cataracts are often very difficult to measure and for these patients I like to use the LAL because I am not sure exactly where to go and which dioptre of lens to implant,” he said. Some eyes had a slight over-correction and practically no under-corrections after the surgery, said Dr Neuhann. He said that the astigmatic correction was particularly impressive in this series of patients. “The postoperative cylinder is almost always below 1.0 D after the surgery and more often it is 0.5 D or less. This is something that I cannot achieve with a normal toric lens because the small cylinders between 0.5 D and 2.0 D are very difficult to measure and all our measurement devices are not precise enough. With the LAL, we

can adjust the astigmatism corrections after the subjective refraction and it gives very impressive results in the low dioptre toric range,” he said. The refractive results were stable over the two-year follow-up period, noted Dr Neuhann and the predictability data was also first rate. “Around 64 per cent of patients were within 0.25 D of target refraction, 86 per cent were within 0.5 D and 100 per cent were within 1.0 D – this is something which is hard to achieve with the current formulas,” he said. In terms of side effects, Dr Neuhann said that most patients experienced transitory erythropsia after UV treatment, with the first lock-in treatment typically producing the strongest erythropsic effect. Two patients recorded a loss in visual acuity from 20/20 to 20/200 in one of their treated eyes after the first lock-in procedure. OCT scans of these eyes showed inflammation of the photoreceptor layers and rehabilitation of visual acuity took up to six months. One patient had fibrin in the anterior chamber, which resolved after tissue plasminogen activator treatment, and two other patients had cystoid macular oedema, one before the treatment and one after lock-in treatment. Dr Neuhann said that the results showed good reliability, stability and efficacy for the LAL, both in virgin and difficult eyes such as post-LASIK and keratoconic cases. Tobias Neuhann: dr.neuhann@email.de Hasan A Usmani: hasan.usmani@gmail.com Eurotimes | june 2014

Cataract & refractive Left image: Virtual reality Simulation Centre with EYESi Cataract-Simulator on the right and EYESi Vitroretinal-Simulator on the left. Faculty of Medicine, University of Maribor, Slovenia Below image: EYESi Vitreoretinal simulator screen

Courtesy of Dušica Pahor MD

VIRTUAL REALITY Device provides realistic surgical experience and objective measurement of skill. Roibeard O’hEineachain reports

irtual eye surgery with the EYEsi system allows surgeons in training to practise their surgical techniques free of anxiety and provides them with encouraging feedback as their skills improve, said Dušica Pahor MD, Faculty of Medicine, University of Maribor, Slovenia, Department of Ophthalmology, University Medical Centre Maribor, Slovenia “The technical difficulties involved in modern ophthalmological procedures have increased the need to perform training outside the operating theatre. Surgeons must learn to control the psychological stress during surgery. Ophthalmic virtual reality simulators represent a satisfactory response to this need, she said at a symposium of the Slovenian Society of Ophthalmology, at the 18th ESCRS Winter Meeting in Ljubljana. She noted that her department has adopted the VRMagic EYESi Ophthalmic Surgical Simulator for surgical training purposes. The device is one of the most well-developed simulators available and provides trainee surgeons with repeated measurements of standardised surgical tasks performed in a virtual environment. It also provides feedback on the achievement of surgical goals, surgical efficiency and surgical errors.

Only with an integrated approach can we move from the old model of practising on real patients

the anterior chamber and place them in a basket in a different place in the anterior chamber. As the training progresses, the surgeon moves to new levels where the task becomes increasingly difficult. “This task is for teaching the surgeon the skills required to grasp the edge of a capsulorhexis flap, keeping the eye centred and avoiding injury to the lens or cornea,” Dr Pahor said. For each attempt the surgeon makes the score can vary from zero to 100. The simulator gives points for the percentage of the task completed, but subtracts points for reduced efficiency and errors such as excessive time taken and injuries to intraocular structures and tissues. Simulation technology should become a standard feature of ophthalmic surgical training programmes, Dr Pahor said. It can improve patient safety for surgical procedures such as vitreoretinal and cataract surgery in modern surgical education. “Virtual reality simulation offers a new approach for surgical training. Results of previous studies revealed a positive transfer of skills from the simulation environment to initial operating room procedures,” she said. She added that a structured curriculum with a virtual reality training programme teaching the basic skills should be the first step in a procedure-based training curriculum for ophthalmic surgery. “A standardised approach to surgical training is needed. Only with an integrated approach can we move from the old model of practising on real patients. Virtual reality simulation can be made available to trainees any time and any place and does not require any additional supplies or animal tissue. It is the ideal training tool,” Dr Pahor concluded.

Dušica Pahor MD

Dušica Pahor: d.pahor@ukc-mb.si

Eurotimes | june 2014

The simulator consists of a mannequin head with a rotatable electronic eye. It also includes a virtual operating microscope, complete with zoom/focus foot pedal, that provides stereoscopic images of the eye and instruments to the surgeon. To use the device the trainee surgeon first logs in and configures the settings for the eye and instrumentation on a touch screen control panel. When performing a virtual procedure, the surgeon inserts a special set of hand-held instruments into the electronic eye. The device simulates instrument interaction with the ocular tissues and ocular structures, which the trainee can observe through the virtual microscope. There is a range of training modules available for the EYESi simulator. The modules range in difficulty from the relatively simple to very complicated tasks. It also allows the surgeon to practise each part of a procedure in isolation until they have fully mastered it. There are courses on capsulorhexis, hydrodissection and phacoemulsification. “Each course combines training of basic skills with training of actual surgical procedures in structured course design, leading students step-by-step to expert performance,” Dr Pahor said. The modules have a game-type structure. An example is the anterior segment forceps module. It requires the surgeon to grasp objects from an area in the periphery of

Cataract & refractive

DRUGELUTING IOLs Thin film technology may eliminate need for eye drops after cataract surgery. Roibeard O’hEineachain reports

new nanotechnology technique, using a thin film coating as a vehicle for pharmaceutical substances, is showing promise and could be applied to IOLs, thereby eliminating the need for postoperative eye drops, said Lampros Lamprogiannis MD, MSc, Aristotle University of Thessaloniki, Thessaloniki, Greece. “The thin film was transparent and demonstrated a smooth release of the test drug. In previous research, the thinfilm technology has shown excellent biocompatibility, and the films leave no toxic by-products as they decompose,” he told the XXXI Congress of the ESCRS in Amsterdam. He presented his findings from a study in which he and his associates in the Laboratory for Thin Films - Nanosystems & Nanometrology, Department of Physics, Aristotle University of Thessaloniki, headed by Prof Stergios Logothetidis, prepared four groups of thin films on a silicone substrate using the spincoating method. The technique involves depositing a small amount of the polymers mixed with the test drug, in this case dexamethasone, on the substrate, which rotates very fast. Part of the mixture is allowed to evaporate, leaving a thin film on the substrate. Organic polymers served as a matrix for the films and each group had a different amount of dexamethasone. There were two groups with two film layers, one of which had a two-to-one ratio Lampros Lamprogiannis of matrix to dexamethasone, the other had a three-to-one ratio. The remaining two groups had one layer of film, with matrix-to-dexamethasone ratios corresponding to those of the other two groups. Atomic force microscopy showed that in the two dual-layer groups the dexamethasone tended to aggregate but in the two monolayer groups the film was speckled with nanopores which apparently contained dexamethasone. Ellipsometry showed that the film reduced the transparency of the silicone substrate to light in the near-to-ultraviolet wavelengths. The film’s maximal level of reflectivity refractivity is in the green light wavelengths. In a further investigation they tested the rate of release of the drug into an aqueous-like liquid over a 10-week period. They found that with all the films the release of dexamethasone was most rapid during the first two weeks, with 60 per cent released by one month and the rest released in a gradually tapering fashion over the following two weeks. “We are currently working, under the supervision of assistant professor of ophthalmology Ioannis Tsinopoulos, on the development of thin films to be deposited directly on the surface of IOLs which we plan to test in vitro and possibly in an in vivo study. Our ultimate goal is to combine more than one pharmaceutical substance in the film so that patients with coated intraocular lenses will not require further postoperative application of eye drops,” Dr Lamprogiannis concluded. Further developments will be presented by Dr Athanassios Karamitsos MD, PhD, at the XXXII ESCRS Congress in London. Lampros Lamprogiannis: lamproslamprogiannis@hotmail.com

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13.00 – 14.00 Laser Vitreolysis and Retinal Rejuvenation Therapy (2RT) for Early AMD & DME: Two Revolutions in Nanopulse Lasers Moderator: M.J. Tassignon BELGIUM C. Van der Windt THE NETHERLANDS W. Heriot AUSTRALIA M.J. Tassignon BELGUIM Sponsored by

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Cataract & refractive

ABERRATION-FREE IOL Aspheric lens provides promising early results. Roibeard O’hEineachain reports

Courtesy of Florian Niklas Auerbach MD

He presented the preliminary results of a prospective study involving 20 eyes of 14 cataract patients with a median age of 63 years who underwent implantation of the MicroCryl IOL. The patients had a median preoperative sphere of +0.25 D, and a median preoperative cylinder of -0.38 D. All underwent phacoemulsification and implantation of the IOL with a median power of +21.5 D and values ranging from +16.5 D to -29.5 D. IOL power was calculated with the Holladay I formula. At a follow-up of two to four months after surgery, the median achieved refraction was +0.13 D. The median difference between achieved and intended spherical equivalent was +0.46 D, with values ranging from -0.57 D to +1.08 D. In addition, 25 per cent were within 0.25 D of target refraction and 50 per cent were within 0.5 D and 90 per cent were within 0.75 D.

Visual acuity

Implanted MicroCryl IOL

he MicroCryl® aspheric IOL (MC 6125 AS, Human Optics) can provide cataract patients with predictable visual outcomes with a good quality of vision, said Florian Niklas Auerbach MD, University of Heidelberg, Heidelberg, Germany. “Our findings show that implantation of the MicroCryl aspheric IOL provides good and predictable functional results, and stray light does not adversely affect patients’ vision. There is on average, a slight amount of negative spherical

aberration,” Dr Auerbach told the XXXI Congress of the ESCRS in Amsterdam. (Auerbach FN, Fitting A, Khoramnia R, Rabsilber TM, Holzer MP, Auffarth GU).

One-piece design The new aberration-free lens has a one-piece design. It is composed of hydrophilic acrylate material. The IOL has an overall length of 12.5mm, and its optic has a diameter of 6.0mm and a 360-degree square-edge profile. The lens is available in powers from +10.0 to +30.0 D in 0.5 D increments, and from -10.0 D to +50.0 D in 1.0 D increments, Dr Auerbach said.

Our findings show that implantation of the MicroCryl aspheric IOL provides good and predictable functional results... Florian Niklas Auerbach MD Eurotimes | june 2014

With regard to visual outcomes, uncorrected distance visual acuity had a median value of 0.02 logMAR and ranged from 0.34 to -0.12 logMAR. Median corrected distance visual acuity improved from 0.2 logMAR preoperatively to -0.14 logMAR postoperatively, with values ranging from -0.28 to 0.06 logMAR. In terms of visual quality, wavefront analysis performed with the Zywave II aberrometer (Bausch + Lomb) showed that the median total higher order aberration RMS at a pupil size of 6.0mm was +1.14 µm. Spherical aberration had a median value of -0.34 µm and ranged from -0.73 to +0.23 µm. In addition, stray light analysis with the C-Quant (Oculus) and contrast sensitivity testing with the FACT chart showed values within normal range for both parameters. Furthermore, in their responses to a questionnaire, all patients said that they were satisfied with the results of their surgery and that they would recommend this surgery and this IOL to a relative or friend. Gerd U Auffarth MD, FEBO, Florian N Auerbach MD, International Vision Correction Research Centre (IVCRC) Department of Ophthalmology, University of Heidelberg, Germany. IVCRC has received Research grants and travel reimbursements from Dr Schmidt, Inc., Erlangen, Germany. Augenklinik@med.uni-heidelberg.de

Cataract & refractive

MACULAR OEDEMA Meta-analyses highlight need for evidence-based CME prevention guidelines.

Dermot McGrath reports

espite numerous studies, very few firm conclusions can be drawn concerning the optimal treatment and best prevention methods for post phacoemulsification cystoid macular oedema (CME), according to a study presented at the XXXI ESCRS Congress in Amsterdam. “The quality, size and analysis of the clinical trial evidence needs to be taken into account before we can make firm recommendations on the treatment and prevention of CME after cataract surgery,” said Jan Schouten MD, PhD, who noted that many previous studies fell short of the rigorous requirements of evidencebased medicine. After conducting a meta-analysis of the published clinical trials looking at macular oedema, Dr Schouten, University Eye Clinic, Maastricht, The Netherlands, said that some tentative recommendations could be made without taking into account the quality of the studies. “Ketorolac could be helpful for chronic CME post cataract surgery, while an NSAID [non-steroidal anti-inflammatory drug] especially when used in combination with topical prednisolone could be beneficial for acute CME post phaco. For prevention in patients without diabetes, topical NSAIDs could be used. There seems to be an additional effect of the NSAID to a topical corticosteroid but we are still uncertain about the optimal type, timing, dosage and frequency and whether corticosteroids are equivalent to an NSAID,” he said.

Prevention In diabetic patients, NSAIDs or topical corticosteroids are not sufficient, added Dr Schouten, noting that anti-VEGF and corticosteroids are helpful in treating diabetic macular oedema and may also be helpful for prevention. Dr Schouten said that randomised controlled trials are the bedrock for evidence-based medicine, which he defined as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. “First of all we need to compare with a control group to exclude the influence of the natural history. We need to randomise to exclude the influence of baseline differences, of prognostic factors and to avoid confounding by other factors that influence the outcome. We need masking for the intervention and assessment of the outcome to exclude bias. We also need a large study to have an accurate estimate of the effect size and ultimately proper statistical analysis,” he said. Meta-analyses perform a very useful function for busy clinicians, said Dr Schouten. “We do meta-analyses because we have no time to read all articles. We need to approach the literature in a systematic way to avoid bias. We can assess the quality of the research and calculate the magnitude of the effect. We can also study differences between studies in terms of heterogeneity and we need ultimately to reduce practice variation,” he said. Filtering the relevant meta-analyses for post-cataract treatment of diabetic macular oedema, Dr Schouten cited Parravano et al’s 2013 Cochrane library study looking at 11 randomised trials of antiVEGF treatments in DME (not post-cataract) on a total of 1,053 patients. The meta-analysis found an improvement in visual acuity in treated patients, no significant difference between anti-VEGF drugs used and no serious adverse events. Looking at bevacizumab treatment alone in DME (not post-cataract), Goyal’s 2011 study

We do meta-analyses because we have no time to read all articles Jan Schouten MD, PhD analysed four studies of 484 eyes and found an improvement in visual acuity and reduction in retinal thickness for treated eyes. For corticosteroid use in DME (not post-cataract), a Cochrane library study by Grover et al in 2009 looked at seven randomised trials of 632 eyes and found that intravitreal triamcinolone, fluocinolone acetonide implant (FAI) or dexamethasone drug delivery led to improvement in visual acuity and reduction in retinal thickness. Reported adverse events include cataract and IOP increase.

Insufficient evidence In terms of NSAID treatment for CME after cataract, a Cochrane library meta-analysis by Sivaprasad et al in 2012 of seven randomised studies of 266 patients found the evidence insufficient to clearly inform practice for acute CME. Treatment with topical 0.5 per cent ketorolac for chronic CME was found to be effective in two trials. For prevention of CME post cataract surgery, Dr Schouten performed a systematic review of the scientific literature and included a final total of 54 studies. These studies included 18 drugs in total: nine NSAIDs, seven corticosteroids and two anti-VEGF agents. Routes of administration included topical, subconjunctival, sub-Tenon, orbital floor, intravitreal, oral and intravenous. The key findings of the analysis were that topical NSAIDs were better than placebo in CME, that the incidence of oedema was lower in diabetic patients treated with corticosteroids than placebo, that NSAIDs added to corticosteroid treatment may give an additional effect and that anti-VEGF treatment was beneficial in diabetic macular oedema. Going forward, the PREvention of Macular EDema after cataract surgery (PREMED) study, which is being led by Dr Schouten’s colleague Rudy Nuijts at the University Eye Clinic of Maastricht and funded by the ESCRS, will seek to provide evidence-based recommendations for clinical guidelines to prevent the occurrence of CME after cataract surgery in patients with and without diabetes. Jan Schouten: j.schouten@mumc.nl Eurotimes | june 2014

Cataract & refractive

LEARNING CURVE Ensuring a smooth transition to femto-cataract surgery. Dermot McGrath reports

ppropriate preparation and forward thinking can help surgeons avoid the most common pitfalls of introducing a femtosecond laser for cataract surgery into their ophthalmic practices, according to Michael C Knorz MD. “Like every new technology there is a learning curve to be negotiated in introducing a femtosecond laser for cataract surgery. However, with a bit of forward planning the transition can be negotiated smoothly and without too many difficulties,” Prof Knorz told delegates attending the XXXI Congress of the ESCRS in Amsterdam. Based on his own experience in Mannheim, Germany since introducing the LenSx (Alcon) laser in 2011, Prof Knorz said that there are three key steps to obtaining optimal outcomes with femtosecond-assisted cataract procedures: docking, capsulorhexis and hydrodissection. “My advice would be to practise docking as much as possible before doing the first procedure because it is absolutely essential to the success of the surgery. Secondly, confirm that the capsulorhexis is complete. It is very rare that it won’t be, especially with the modern lasers we use today, but it is still safer to inject viscoelastic and confirm that it is fully complete to maintain the significant advantage of the perfect capsulorhexis created by the laser. Finally, I would advise using a modified hydrodissection technique to ensure that there is no excessive build-up of pressure inside the capsular bag that might cause capsular blow-out problems,” he said. In terms of workflow, Prof Knorz said that he opted to place the femtosecond laser inside the main operating room along with the surgical microscope and the Alcon EX 500 excimer laser. All three machines are connected by a moving bed, which has three programmable stops. “I prefer to have all the machines in the one operating room as I think this enhances patient comfort. There are also other advantages. Since the eye has been draped in a sterile environment the surgery can start with an intraocular procedure – for example, pupil expansion rings in small pupil cases before moving the patient Michael C Knorz MD under the laser. The laser may

My advice would be to practise docking as much as possible before doing the first procedure...

INDIA

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also be used again in a later part of the surgery, for a posterior capsulorhexis for example,” he said. The first key step to be mastered is the docking of the eye to the laser, said Prof Knorz. While in the case of the LenSx platform this is achieved by lowering the SoftFit suction piece on the eye directly, other laser systems use a liquid interface to achieve the same effect. “The idea behind both approaches is basically the same – to avoid excessive pressure and corneal folds so the laser action is uninhibited, enabling the laser to deliver more precise cuts and hopefully better outcomes. In all these systems, good central docking is essential and surgeons should practise docking on several patients before they start their first procedure. The eye should not be tilted too much, because excessive tilt may cause decentration in the laser pulses and cause decentration of the capsulorhexis,” he said. The next important step in the transition to femto-cataract is to ensure the integrity of the capsulorhexis. “With modern laser systems, 99.9 per cent of the time we achieve a free-floating capsulorhexis but it is important to verify that the capsulorhexis is complete. If it is not complete, capsular tags may cause anterior capsule rupture, which in turn may lead to posterior capsule rupture,” he said. In order to check the integrity of the capsulorhexis, Prof Knorz said that a blunt spatula can be used to open the side-port incision first, followed by injection of viscoelastic to avoid shallowing of the anterior chamber. “I simply use the phaco tip to check the integrity of the capsulorhexis and should any tags be present, I remove the phaco tip and use a capsulorhexis forceps to complete the capsulorhexis manually,” he said. The third important step is to adopt a modified hydrodissection technique, said Prof Knorz. “The laser creates air bubbles in the capsular bag, which may increase the pressure in the bag, especially if a small capsulorhexis is used. Hydrodissection should therefore be slow and with low volume to avoid a capsular blow-out syndrome by a sudden increase in pressure,” he said. The preferred option is to perform the gas release followed by hydrodissection, said Prof Knorz. “I use the hydrodissection cannula to split the nucleus open because it has been fragmented already. The nucleus may also be split with a chopper, splitter or hook to let the trapped air escape prior to hydrodissection,” he said. Once these three key steps have been managed, the remaining part of the surgery is not different from standard phacoemulsification, concluded Prof Knorz. Michael C Knorz: knorz@eyes.de

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cataract & refractive

change of focus New triplet IOL design closely emulates natural accommodation. Roibeard O’ hEineachain reports

n IOL with a three-layered optic that is responsive to the eye’s physiological accommodative mechanisms could, in theory, provide cataract patients and presbyopes with a wide range of focusing powers, said Pablo Artal PhD, Laboratorio de Optica, Universidad de Murcia, Spain. “Although different accommodative IOLs have been proposed, the current designs only provide a rather modest range of accommodation in the best cases. We are proposing a new triplet optical design which could in theory provide a wide range of potential accommodation and which could be incorporated into an IOL,” Dr Artal told the XXXI Congress of the ESCRS in Amsterdam. Dr Artal noted that accommodating IOLs are based on the use of the eye’s natural physiological accommodation apparatus to exert a force that will induce changes in an IOL’s optical power. However, current designs, which work by the forward and backward movement of the IOL’s optic, or optics, are limited to changes in focus of a few dioptres. In the new lens design Dr Artal and his associate Dr Josua Fernandez are proposing, accommodation depends on changes in convexity in the optic such as occur in the crystalline lens with natural accommodation. Only very small amounts of change in an optic's convexity are necessary Pablo Artal PhD to achieve a broad range of focusing power. The lens design consists of three layers composed of silicone and acrylic materials. Its equatorial diameter and therefore its convexity is sensitive to small amounts of compression. There are currently three designs that the Murcia team has assessed on a theoretical basis. Each design differs in its responsiveness to compression forces based on differences in the thickness and dimensions of each layer. “The triplet-like optical structure we propose can produce gains high as one dioptre per micron of equatorial compression allowing for large range of power changes. The proposed triplet-lens also permits the incorporation of aspheric or toric surfaces for optimising ocular spherical aberration or correcting astigmatism. Chromatic aberration and ghost images analysis shows a similar performance to monofocal standard IOLs, Dr Artal said. The triplet optic will typically have a central thickness of 1.0mm and an optical zone 6.0mm in diameter. Those geometrical dimensions and the structure of the proposed haptics could allow implantation of the lens through a conventional corneal incision of 2.0-3.0mm in diameter. Dr Artal and his associates are also in the process of devising a special intracapsular ring to accurately control the accommodative IOL’s equatorial diameter in response to accommodative effort. “An intraocular triplet lens with a wide variable power as a response to small compression forces has been designed. This new lens, in combination with a capsular ring for the precise control of its equatorial diameter, may provide a large range of accommodation restoration,” he concluded.

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Pablo Artal: pablo@um.es Eurotimes | June 2014

cataract & refractive

HIGH MYOPES Operation for 'long eyes' should be allocated to experienced surgeons whenever possible. Cheryl Guttman Krader reports

ontrary to previous reports, a new study from Moorfields Eye Hospital concludes cataract patients with high myopia might do just as well as average eyes. “Our goal in performing cataract surgery is to improve vision, but we would like patients to have a rapid postoperative rehabilitation and achieve accurate refractive outcomes to limit spectacle dependence. As we know, the rate of capsule complications and percentage of eyes within 1 D of target refraction are important criteria in assessing the quality of cataract surgery,” Gianluca Carifi MD, consultant ophthalmic surgeon at Moorfields Eye Hospital in London, said at the XXXI ESCRS Congress in Amsterdam. “We know that these goals are more difficult to achieve in high myopes, and although they represent less than 10 per cent of cataract surgery patients, hundreds of high myopes may be operated on at large institutions each year, given the size of the cataract surgery population.” The study included 407 eyes (284 patients) with an axial length of at least 26mm. Based on measurements obtained with optical biometry, the group had a mean axial length of 27.81mm with a range up to 34.86mm, and the axial length was greater than 28.50mm in 25 per cent of eyes. Anterior chamber depth ranged from 2.29 to 4.29mm with a mean of 3.49mm. Dr Carifi reported on peri-operative complications with a focus on posterior capsule rupture. The safety analyses included data for all 407 eyes, of which nine per cent were operated on by trainees, 54 per cent by fellows and 37 per cent by consultants. Posterior capsule rupture with or without vitreous loss or zonular dehiscence with vitreous loss occurred in seven (1.7 per cent) eyes. Overall, an intraoperative complication occurred in 19 (4.7 per cent) eyes, including anterior capsule tear, corneal wound burn, iris trauma/prolapse and endothelial touch/trauma. As a benchmark for comparison, Dr Carifi cited data from the Gianluca Carifi MD Cataract National Dataset audit

Our goal in performing cataract surgery is to improve vision...

of 55,567 cataract surgery operations performed at 12 National Health Service Trusts in the UK [Narendran N, et al. Eye (London). 2009;23(1):31-7]. In the latter paper, the rate of posterior capsule rupture or vitreous loss or both was 1.92 per cent; axial length ≥26.0mm and trainee surgeons performing the operation were among the risk factors identified for these events. “In our study of eyes with long axial length, the capsule complication rate was not higher than average. However, we feel the operation for these long eyes should be allocated to experienced surgeons whenever possible: despite the fact that 91 per cent of the procedures were performed by a fellow or a consultant, a complication occurred in nearly one of every 20 cases,” Dr Carifi said. Vasiliki Zygoura MD, FEBO, his colleague at Moorfields Eye Hospital, presented the findings from an analysis of refractive outcomes in a cohort of highly myopic eyes (AL ≥26.0mm). Eyes included had IOL power calculation done using the SRK-T formula and in-the-bag implantation with a one-piece or three-piece hydrophobic acrylic foldable IOL. The analysis excluded eyes that had secondary IOL implantation, previous corneal or refractive surgery, corneal disease affecting keratometry measurement, or any intraoperative or chronic postoperative complication. A total of 315 eyes met all of the eligibility criteria. At the one-month postoperaritve assessment, the achieved spherical equivalent was within 0.5 D of the predicted target in 63.5 per cent of eyes; the refractive outcomes were within 0.75 D and 1.00 D in 79.5 per cent and 89.5 per cent of studied eyes, respectively. Dr Zygoura compared the results with those published by Dr Thomas Olsen who analysed the refractive outcomes in an unselected series of 461 consecutive eyes [Olsen T. Acta Ophthalmol Scand. 2007;85(1):84-7]. Using optical biometry data and modern IOL power calculation formulas incorporating anterior chamber depth algorithms, Dr Olsen reported the refractive outcome was within 0.5 D of that expected in 62.5 per cent while 92.5 per cent of eyes were ±1.00 D of target. “Therefore, the refractive outcomes following modern cataract surgery in our population of high myopes seem to be in line with those achieved in a general population of patients. Our results were also similarly good when comparing eyes implanted with a single-piece or a multi-piece IOL. However, with the use of the SRK-T formula, there was a tendency toward a hyperopic outcome,” Dr Zygoura said. Gianluca Carifi: gianluca.carifi@moorfields.nhs.uk Vasiliki Zygoura: vasiliki.zygoura@moorfields.nhs.uk

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Eurotimes | June 2014

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cataract & refractive

MONOVISION Adaptive optics show spherical aberration can improve binocular vision. Howard Larkin reports

daptive optics may one day be used to optimise monovision strategies in clinical practice, Scott M MacRae MD, of the University of Rochester Medical School, New York, US, told a session of the American Academy of Ophthalmology annual meeting in New Orleans. “In 1965, Campbell and Green noted that two eyes are better than one. As clinicians we assume this, but it is actually a more powerful mechanism than I understood until we looked into it in a little more detail,” he said. Dr MacRae and his colleagues used a binocular adaptive optics system that independently detects and corrects aberrations in each of the test subjects’ eyes using wavefront sensors and deformable mirrors. The device measures visual performance, including visual acuity and contrast sensitivity for each eye and binocularly, as well as stereo acuity, under various correction scenarios. A model of binocular summation developed by Gordon Legge in 1984 showed that two eyes with full distance correction have 40 per cent better binocular contrast sensitivity compared to monocular vision. This improvement in contrast sensitivity is called binocular summation. If the two eyes are in focus at different focal points and the focal point difference is too large, then binocular inhibition can occur, that is the two eyes perform worse than the eye that has the best visual quality at that point.

Tipping Point As the focal point difference between the two eyes increases, the binocular summation is reduced and it becomes more difficult for the brain to reconcile the two images. The tipping point for monovision where binocular summation no longer occurs is at 1.5 D of near if there is minimal astigmatism and higher order aberrations. Thus at this point,

“two eyes can be worse than one” and the patient may prefer to close the near eye, Dr MacRae noted. The reason? Binocular visual performance follows the visual performance of the best eye’s image quality and suppresses the image of the most blurred eye. When the images are close, the brain can fuse the image easily and contrast is improved. When the images are more different, the brain has to work harder to reconcile the differences of the images and contrast sensitivity and vision is reduced, Dr MacRae said. This also explains why traditional monovision is generally limited to a difference of 1.5 D, Dr MacRae said. Without aberrations, there is a sharp peak in image quality for distance in the distance eye and a sharp peak in image quality for near in the near eye but the intermediate vision image quality is not as good. If we add a modest amount of spherical aberration (positive or negative) in the near eye, this will increase that eye’s depth of focus improving the intermediate vision and even extending the near vision image range to see even closer objects. It essentially increases the range of vision in this eye. It also brings the near eye’s image closer to the distance eye image and improves binocular summation, contrast sensitivity and stereo acuity. Correcting aberrations for both eyes, making the near eye -1.5 D and adding 0.2 microns of positive spherical aberration in the non-dominant eye, slightly flattens the binocular visual acuity curve decreasing the distance vision only slightly while improving the intermediate and near vision range. Modified monovision only minimally decreases distance vision but the advantage is that the patient has a wider range of vision for intermediate and better near vision beyond the 1.5 D near range of traditional monovision, Dr MacRae reported. Scott M MacRae: scott_macrae@urmc.rochester.edu

...two eyes are better than one. As clinicians we assume this, but it is actually a more powerful mechanism... Scott M MacRae MD

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Eurotimes | June 2014

Cornea

KERATOCONUS PROGRESSION Expert meeting tackles the question of what parameters to use. Cheryl Guttman Krader reports

lthough identification of progression is central to the diagnosis and management of keratoconus, the question of how progression should be measured is a matter of debate. As research in this area continues, fuelled in part by the availability of new diagnostic technologies, the consensus of attendees at the Expert Meeting on the Surgical Management of Keratoconus in Amsterdam was that five parameters should be considered. They include keratometry, the full corneal pachymetric map, posterior corneal elevation and two topometric-derived indices of cornea curvature irregularity generated by the Pentacam (Oculus) – index of surface variance (ISV) and index of height decentration (IHD). The group also noted that progression should not be diagnosed based on any single parameter, but rather should be supported by multiple variables, and ultimately, a regression model may be developed using a combination of variables that would offer a sensitive and specific tool. The consensus opinion was derived taking into account the attendees’ expert opinions and evidence presented by Michael Belin MD and A John Kanellopoulos MD. Dr Belin suggested that posterior surface corneal elevation and the full pachymetric map are the best parameters for determining progression. “The full pachymetric map is more sensitive than just a single central thickness reading, which can vary significantly with examination. Unlike central pachymetry, CDVA and anterior surface curvature, posterior elevation is affected minimally if at all by surface treatments such as rigid gas permeable contact

lens wear that is common among patients being looked at for progression,” said Dr Belin, professor of ophthalmology and vision science, University of Arizona, Tucson. He also noted that use of anterior surface curvature for documenting progression is confounded by the fact that it changes with the measurement axis, while CDVA can vary day to day and depending on lighting and pupil size. The use of ISV and IHD was proposed by Dr Kanellopoulos based on research he conducted with George Asimellis PhD, evaluating correlations between multiple parameters and keratoconus severity. After publishing an initial report based on data from 212 eyes with keratoconus [Clin Ophthalmol. 2013;7:1539-48], Drs Kanellopoulos and Asimellis expanded their investigations to a cohort of 1200 keratoconus and suspect eyes.

Index of Surface Variance (ISV) versus Topographic Keratoconus Grading Classification (TKC)

Index of Height Decentration (IHD) versus Topographic Keratoconus Grading Classification (TKC)

KeratOconus Stage They analysed CDVA, keratometry, central pachymetry and seven anterior surface keratometric and topometric indices generated by the Pentacam, including ISV and IHD. When the eyes were categorised using Amsler-Krumeich criteria, only ISV and IHD were predictive of keratoconus diagnosis and stage. “Our findings should clear the myth that CDVA and corneal thickness are useful to identify progression since we found there was significant overlap in their values between groups,” said Dr Kanellopoulos, medical director, Eye Institute, Athens, Greece, and clinical professor of ophthalmology, NYU Medical School, New York, NY. "These parameters may further complement the evaluation of the full pachymetric map mentioned already. The Scheimpflug imaging may be biased by imperfections in cornea clarity and epithelial

Courtesy of A John Kanellopoulos

Eurotimes | June 2014

Cornea irregularities, resulting in falsely positive findings on the posterior corneal surface and possibly on the pachymetric mapping," he said.

Future directions Moderating the discussion, Sheraz Daya MD, consultant and medical director, Centre for Sight, London, UK, observed that the purpose of obtaining a consensus on parameters for measuring progression was to provide a current foundation for guiding clinical practice and research. However, the proposed methodology is subject to change as more information and new techniques emerge. Looking ahead, there was some interest in epithelial thickness. Dr Belin noted this measurement is currently not applicable as a screening tool in clinical practice and that while there is evidence that epithelial irregularity may be a marker of keratoconus, there are no data showing this parameter has utility for detecting progression. Dr Kanellopoulos observed that new anterior segment OCT technology used by his team in Europe over the last two years may enable studies on epithelial thickness as it facilitates the mapping compared to very high frequency ultrasound biomicroscopy. In routine epithelial mapping of all cones in his practice, his research group was able to identify and report on the normal epithelial distribution, dry eye and keratoconus. Especially when evaluating contact lens wearers and/or dry eye patients, the epithelial maps may prove pivotal in establishing the correct diagnosis (or not) of early keratoconus and or progression.

new Device

considered a non-inflammatory disease, several researchers have reported finding increased levels of inflammatory molecules in the tears and corneal tissue of eyes with keratoconus. To further investigate this area, Dr Merayo-LLoves and colleagues undertook a study in which they used x-omics array analysis to determine levels of more than 600 proteins in tear samples from 18 patients. The study subjects included individuals with different grades of keratoconus as well as unaffected controls, and the analyses showed that certain proteins were specific for keratoconus and could be used to discriminate between different disease severity levels. “Based on available data from clinical and laboratory research, we believe keratoconus is a neuroinflammatory disease with rubbing as a major risk factor. Our findings on protein changes in the tears suggest the possibility of having biomarkers to diagnose keratoconus and its progression,” said Dr MerayoLloves, associate professor of ophthalmology, University of Oviedo, and director of research of the Foundation of the Instituto Oftalmológico Fernández-Vega, Oviedo, Spain. “In addition, protein interaction network analysis of data on protein profiles associated with keratoconus may lead us to new understanding on the pathogenesis of this disease.” Michael Belin: mwbelin@aol.com A John Kanellopoulos: ajkmd.lv@gmail.com Sheraz Daya: sdaya@centreforsight.com Jesús Merayo-Lloves: merayo@fia.as

Courtesy of Jesús Merayo-Lloves MD, PhD

He also suggested research should be conducted using a new corneal topography device that uses multi collared LED illumination spots to register reflection topography (Cassini, i-Optics). Potential advantages of this technology that his team has evaluated over the last year appear to be more accurate data in the corneal centre in comparison to traditional Placido topography, and no bias from cornea clarity issues in comparison to Scheimpflug tomography. His team has already reported in several papers the potential advantages in selected cases. He nevertheless pointed out that keratoconus screening and progression assessment may require correlation of all of the technologies mentioned above along with newer modalities such as the developing Brillouin phonon spectrometry of the cornea that may offer objective biomechanical data and status. As a completely different approach for the future, Jesús Merayo-LLoves MD, PhD, presented research suggesting the possibility of using biomarkers to detect keratoconus progression. He explained that even though keratoconus is typically

Best-spectacle Corrected Distance Visual Acuity (CDVA) versus Topographic Keratoconus Grading Classification (TKC) The first two graphs indicate the applicability of the indices ISV and IHD for keratoconus classification; the third graph indicates that visual acuity is not a good correlate to keratoconus severity

Keratoconus tear samples contain proteins and peptides related with pathological condition and disease progression. A: Tear sample collection by capillary. B: Example of progressive expression increase of protein biomarkers according to severity of disease. (For more information contact Tatiana Suárez: tatiana.suarez@bioftalmik.com)

Eurotimes | June 2014

5th EuCornea Congress

LONDON 12-13 September 2014

2 Days. 11 Symposia.

4 Courses. 9 Free Paper Sessions.

CONGRESS HIGHLIGHTS

EuCornea MEDAL LECTURE

Friday 12 September

14.00 – 17.00

17.00 – 18.00 (At the Opening Ceremony)

Eurokeratoconus III

Current controversies and hot topics in keratoconus

Deep Anterior Lamellar: The Best Keratoplasty option in Keratoconic eyes?

J. Güell SPAIN, F. Malecaze FRANCE

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Treating Non-healing Corneal Epithelial Defects

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Cornea

HYPEROPIA CORRECTION Emulating the cornea’s natural asphericity key to good outcomes. Roibeard O'hEineachain reports

hotoablative corneal refractive treatment of hyperopia is best restricted to lower levels of refractive error, Paolo Vinciguerra MD, Istituto Clinico Humanitas, Milan, Italy, told the XXXI Congress of the ESCRS in Amsterdam. Dr Vinciguerra noted that the findings of current peer-reviewed literature indicate that LASIK is the preferred corneal refractive treatment for hyperopic correction and that its complication rate is below three per cent, on average, among eyes treated for hyperopia of less than +3.0 D. However, the complication rate rises among eyes treated for between +3.0 D and +6.0 D, and LASIK has an unacceptably high severe complication rate when used to correct more than +6.0 D of hyperopia. That contrasts sharply with corneal refractive treatments for myopia, where the complication rate remains low among eyes treated with much higher refractive errors, he pointed out. “For hyperopes it's completely different because the amount of space lost in the transition zones of the annular ablation makes it difficult to obtain a reasonable optic zone. In addition, most lasers are not able to track the visual axis properly in many cases because there is frequently a mismatch between the visual axis and the centre of the pupil in hyperopic eyes, that is, the angle Kappa. So you'll commonly have an induced coma and astigmatism and, in higher corrections, a central keratoconus-like shape that does not produce a good visual acuity,” Dr Vinciguerra added. He noted that, unlike LASIK ablations for myopia, which typically make corneas more oblate than they were preoperatively, ablations for hyperopia typically make corneas more prolate. In other words, myopic ablations increase the cornea’s rate of change of curvature from the centre to the periphery, whereas hyperopic ablations

increase the cornea’s rate of change of curvature from the periphery to the centre. The rate of change of curvature from the cornea’s periphery to its centre may be expressed as the “e” value, which is negative in oblate corneas and positive in prolate corneas. Normal e values range from +0.4 to +0.6. When the e value is too high, a frequent result is a whitish corneal apical scar. The apical scars occur not only in eyes that have undergone high hyperopic ablations but also in untreated keratoconic eyes. The scars occur beneath the epithelium after surface ablations PRK and under the flap after LASIK. They are always connected with very high e values, always greater than +1, and they correspond topographically to the point of maximal steepening. “The scar destroys the quality in the centre because it is very close to the maximum curvature. Therefore the visual acuity can drop four or five lines easily and this becomes very difficult to manage,” Dr Vinciguerra said. The reason that the scar occurs is uncertain. Suggested causes include chronic lid trauma, corneal dystrophy resulting from increased epithelial turnover and altered tear film production. It is unlikely to result from severed nerves, since it is less common after LASIK than after PRK. Treatment and prevention of the scars both involve insuring that the cornea's e value is not excessively high. Treating the scars involves decreasing the e value by flattening the central cornea with a myopic ablation. Preventing the scars involves using an ablation profile that results in the cornea’s

curvature changing by a gradual rate of less than 3.0 D per millimetre. High rates of change in corneal curvature change are also responsible for the high amounts of regression that can occur after hyperopic ablations. That is because the conventional corneal ablations for hyperopia produce sharp changes in the cornea’s curvature gradient in the region of the annular ablation. The natural healing response of the cornea is to correct the irregularity, which in turn reverses the refractive correction. To achieve a cornea that has a rate of curvature that will prevent both apical scars and regression in photoablative hyperopic corrections, Dr Vinciguerra recommended using large optic zones and wide transition zones that blend imperceptibly with the cornea’s natural flattening at the periphery. However, even in eyes with an ideal asphericity there will still be a poor visual outcome if the ablation is centred on the centre of the pupil rather than the visual axis. In patients with hyperopia there is frequently a very large difference between the pupil centre and the position of the visual axis. Therefore, if the laser tracks the centre of the pupil, the treatment will be completely de-centred, Dr Vinciguerra said. “When you track the centre of the pupil and not the visual axis, even if the patient achieves a visual acuity of 20/20, you have some residual astigmatism that is not really astigmatism but is actually coma, and that generates double vision,” he added. Paolo Vinciguerra: paolo.vinciguerra@humanitas.it

The scar destroys the quality in the centre because it is very close to the maximum curvature Paolo Vinciguerra MD

Türkiye TURKISH LANGUAGE EDITION ONLINE Visit: www.eurotimesturkey.org Eurotimes | June 2014

retina

STEM CELL RESEARCH High hopes for stem cells for retinal repair.

Dermot McGrath reports

fter successful “proof of principle” trials in animal models, researchers are hopeful that stem cell technology can be successfully used in the near future to reverse photoreceptor loss in humans with advanced retinal disease, according to a presentation at the 13th EURETINA Congress in Hamburg. “There is a lot of exciting research in this field at the moment and the results from the early experiments in animal models are very encouraging. However, we do need to urge caution for our patients and bear in mind that more studies will be needed to establish the safety and efficacy of using stem cells for retinal repair in humans,” Mandeep Singh FRCSEd told delegates at the first ever symposium of the Young European Retinal Specialist Group held during the EURETINA meeting.

Courtesy of Mandeep Singh FRCSEd

Most Beneficial Dr Singh, a vitreoretinal Fellow at Oxford Eye Hospital, UK, and a researcher at the Nuffield Laboratory of Ophthalmology at the University of Oxford, said that stem cells could be potentially most beneficial when used in late-stage retinal disease such as advanced age-related macular degeneration and severe retinitis pigmentosa. “Stem cells really fit into the replacement paradigm for treatment. In early-stage disease, the photoreceptor cells are still present, so gene therapy can be used to target the photoreceptors and make them functional again. In latestage disease, however, when there are no photoreceptor cells present, the approach has to focus on replacement of the photoreceptors and perhaps the retinal pigment epithelium as well,” he said. The concept that adult tissues – including the retina – could be generated through stem cell technology was demonstrated by the cloning of Dolly the sheep using somatic cell nuclear transfer in 1996, said Dr Singh. Another key breakthrough came in 2006 when Robert MacLaren et al succeeded in transplanting photoreceptors directly into the eyes of mice and restored their visual function. The study found that transplanted photoreceptor precursor cells survived and became integrated into the mouse retina. Crucial to the success of the Eurotimes | June 2014

In this mouse model, transplanted photoreceptors show up as green-labelled cells, restoring the layer organisation of the retina. The restoration of the photoreceptor layer forms the basis of the return of visual function

technique was the fact that the cells were isolated when they had reached a certain level of maturity. Progress has accelerated since then, said Dr Singh, citing his 2013 study performed in Prof MacLaren's laboratory showing that the entire light-sensitive layer could be reconstructed in mice with a complete lack of light-sensing photoreceptor cells in their retinas.

Restoring Vision Rather than placing discrete photoreceptors among pre-existing host outer retinal cells, Dr Singh’s study paves the way to total photoreceptor layer reconstruction as a potentially viable means of restoring vision.

Dr Singh said that many current research efforts are focused on using induced pluripotent stem cells (iPSC) as a potential limitless source of cells for transplantation. iPS cells can be generated directly from adult cells without the need for embryos and can be propagated indefinitely. A pilot study to assess the safety and feasibility of the transplantation of iPSCderived retinal pigment epithelium (RPE) cell sheets in patients with exudative agerelated macular degeneration has started at Dr Masayo Takahashi’s laboratory in Japan. Mandeep Singh: enquiries@eye.ox.ac.uk

There is a lot of exciting research in this field at the moment and the results... are very encouraging Mandeep Singh FRCSEd

14th EURETINA Congress

LONDON 11-14 September 2014

9 Main Sessions 17 International Society Symposia 21 Free Paper Sessions 38 Instructional Courses 5 Surgical Skills Courses EURETINA LECTURE

KREISSIG LECTURE

Robert MacLaren UK

Johanna Seddon USA

Gene Therapy for Retinal Disease – What Lies Ahead

Understanding the Mechanisms and Etiology of Macular DegenerationGenetics and Modiﬁable Factors

www.euretina.org/london2014

Satellite Education Programme

THURSDAY 11 SEPTEMBER

FRIDAY 12 SEPTEMBER

Morning Symposium

Morning Symposia

Lunchtime Symposia

10.00 – 11.00

Boxed Lunch Included

13.00 – 14.00 Novartis Satellite Meeting

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14th EURETINA Congress 11 – 14 September

FRIDAY 12 SEPTEMBER

SATURDAY 13 SEPTEMBER

Lunchtime Symposia

Morning Symposia

Lunchtime Symposia

Boxed Lunch Included

10.00 – 11.00

Boxed Lunch Included

13.00 – 14.00 Changing Perspectives in DME: Recognising & Understanding Chronic DME

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Moderator: U. Chakravarthy UK Y. Yang UK Overview of efficacy of ILUVIEN in chronic DME; outcomes in pseudophakic patients and patients who underwent cataract surgery M. Diestelhorst GERMANY Understanding & managing steroid induced IOP A. Augustin GERMANY The role of inflammation in DME over the course of the disease P. Dugel USA Understanding the transition of DME to a chronic stage, no longer primarily driven by anti-VEGF P. Massin FRANCE Breaking news: interim analysis of a phase 4 study with ILUVIEN in patients with or without previous treatment with anti-VEGF Sponsored by

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paediatric

AMAZING ARTIST Low vision no barrier for talented teen.

orn with congenital glaucoma and anterior segment dysgenesis, 14-year-old Ayesha Moore has undergone about 20 ophthalmic procedures during her young lifetime, not counting numerous examinations under anaesthesia. Corneal opacities limited her vision since birth, and recently, a gradually progressive keratopathy is threatening the remaining functional vision in her right eye so that limbal stem cell therapy and deep lamellar keratoplasty are now being considered. However, Ayesha’s story is of interest for reasons beyond her complex ophthalmic history, because it should be told that Ayesha excels in school and is a talented artist who at the request of her ophthalmologist, Ken Nischal MD, created the beguiling cartoon logo for the World Society of Paediatric Ophthalmology and Strabismus (WSPOS). These details about Ayesha serve as an inspiring reminder to all that disability is not synonymous with inability. “Ayesha has always demonstrated a remarkable spirit and resolve despite being affected by low vision. She developed interest in drawing at a very early age, and it was a natural evolution to invite her to design two novel characters for the WSPOS logo. Of course, she was delighted by the opportunity, but not half as happy as we were that she accepted the charge and produced two fantastic cartoon

Eurotimes | June 2014

Cheryl Guttman Krader reports figures,” said Dr Nischal, executive director of WSPOS. “Ophthalmologists can’t always make their patients see 20/20, but we need to approach children as a whole and inspire them to achieve their maximum potential. By supporting a child’s aspirations, physicians can have an immeasurable positive effect,” he told EuroTimes. Ayesha came under the care of Dr Nischal at Great Ormond Street Hospital in London soon after her birth in Frimley, England. A few years ago, Dr Nischal joined the faculty of the University of Pittsburgh, where he is professor of ophthalmology and director, paediatric ophthalmology, strabismus and adult motility. He continues to see Ayesha in the London private practice he maintains. Ayesha’s father, Jim Moore, told EuroTimes that she has retained functional eyesight far longer than anticipated thanks to the excellent care she’s received. However, she’s faced an ongoing battle in which advancing corneal neovascularisation and opacification is now threatening her sight. Use of optical coherence tomography as a noncontact method to visualise the palisades of Vogt where the limbal stem cells are believed to reside was developed at the University of Pittsburgh. Ayesha will undergo evaluation there to determine if limbal stem cell deficiency underlies her condition. Ayesha’s father recalls that she has loved to draw since the time she could take pencil to paper. Although she has an incredible visual memory, because of her low vision, she has no visual recollection for realistic details. Therefore, the artwork she produces is in a cartoon style influenced by the animated programmes she’s seen on television and the Internet. A gallery of Ayesha’s drawings is available online (www.ayeshamoore.com), and while she is gratified to be sharing her creations with the world through that website, Ayesha’s dream is to build a career on her artistic talent. “Ayesha does well in her academic studies, but art is her true passion, and while she finds enjoyment in drawing, Ayesha, like other creative people, gets particular fulfillment from having an audience for her work. It is partly for that reason that she was especially pleased to draw the cartoon logo for WSPOS,” Mr Moore said. “Knowing her sight is deteriorating and with the future uncertain, Ayesha is very keen to do as much as she can as an artist

while she is able, and she would be thrilled to have offers for more projects. Most importantly, Ayesha wants people to not make assumptions about her based on her visual impairment. Ayesha would say, ‘Just give me a chance, and I will show you what I can do.’” Illustrations by Ayesha Moore, including illustration for WSPOS logo (below) www.wspos.org

ocular

COLOUR VISION Ageing process can affect colour vision. Dermot McGrath reports

bnormal colour vision increases significantly with ageing, affecting half or more of people in the oldest age groups, according to a recent study. While few people younger than 70 have problems with colour vision, the rate increases rapidly through later decades of life, according to research published in Optometry and Vision Science by Marilyn E Schneck PhD, and colleagues of The Smith-Kettlewell Eye Research Institute, San Francisco, US. “We find the colour discrimination declines with age and that the majority of colour defects among the older population are of the blue-yellow type,” said Dr Schneck. In the study, researchers administered colour vision tests to a random sample of 865 older adults ranging from 58 to 102 years. The study excluded those with any type of congenital colour-vision defect, with the types and rates of colour vision abnormalities assessed in different age groups.

Overall, 40 per cent of the participants had abnormal results on one of the two colour vision tests used in the study. Twenty per cent failed both tests. The failure rate was markedly higher in older age groups. Although colour-vision abnormalities were uncommon in people younger than 70, they were present in about 45 per cent of people in their mid70s, up to 50 per cent of those 85 and older, and nearly two-thirds of those in their mid-90s. Nearly 80 per cent of the abnormalities involved confusion of the lighter (pastel) shades of blue versus purple and yellow versus green and yellow-green. The results confirm previous studies showing that colour vision deteriorates measurably with ageing. While most subtle ageing-related colour vision abnormalities are likely to go unnoticed, the researchers note that nearly 20 per cent of older adults failed the easier of the two tests, “designed to only detect defects sufficiently severe to affect performance in daily life.”

... the majority of colour defects among the older population are of the blue-yellow type Marilyn E Schneck PhD

“These individuals would have problems carrying out some tasks that rely on colour vision,” said Dr Schneck.

Educate patients In terms of measures that could be taken to potentially counteract the loss of colour discrimination in elderly patients, Dr Schneck told EuroTimes that it was important to educate patients on the need for enhanced lighting in the home. “Colour vision declines with lower light levels, so the main thing that can be done is to optimise lighting with bright, non-glaring light. Increasing awareness of the issue is also important,” she said. She added that improved lighting conditions will also help to reduce the risk of falls which are one of the most common sources of accident in the home for this population group. “We know that the most common age-related eye diseases such as cataract, glaucoma, age-related macular degeneration and diabetic retinopathy are all associated with blue-yellow colour defects early on. These diseases also affect contrast-sensitivity, a very important aspect of vision that makes it difficult to see the edges of stairs, curbs and so on, which would increase the risk of falls,” she concluded. Marilyn E Schneck: mes@ski.org Eurotimes | June 2014

Meeting report

AN EXCELLENT LEADER Emanuel Rosen’s contributions to ESCRS and as editor of JCRS acknowledged as he takes on new role. Howard Larkin reports

Stephen A Obstbaum (right) presents an award to Emanuel Rosen for his leadership as European editor of the JCRS for the past 18 years

he American Society of Cataract and Refractive Surgery (ASCRS) bestowed a special honour on Emanuel Rosen MD, FRCSEd at its 2014 annual meeting in Boston, prompting a standing ovation by thousands of colleagues in anterior segment surgery attending from the world over. “It is with great pleasure that we recognise Emanuel Rosen for his contributions to our profession, and specifically for his excellence of leadership as editor of the Journal of Cataract and Refractive Surgery for the past 18 years,” said Stephen A Obstbaum MD.

Ongoing success Dr Obstbaum headed JCRS when it merged in 1996 with the European Journal of Implant and Refractive Surgery, where Dr Rosen was editor. Dr Obstbaum hailed the longstanding joint effort as “one of the most successful partnerships in organised medicine and one that has benefited all of us who practise surgery of the anterior segment of the eye.” Dr Obstbaum also lauded Dr Rosen’s leadership of the European Intraocular Implant Council during and after its transition to the ESCRS.“Through the years there were few ESCRS initiatives that have not been enlightened by his insight or touched by his skilfull management. Emanuel Rosen continues to be a steady and constant influence in Eurotimes | June 2014

the ongoing success of that organisation.” Dr Rosen is succeeded as editor by Thomas Kohnen MD, PhD, who now shares the role with Nick Mamalis MD. Dr Rosen will continue as case reports section editor, responsible for case reports published in print and online. “It would be both foolish and selfish on our part to permit this great talent to escape us,” said Dr Obstbaum, lauding the decision. Contributions of European ophthalmologists were also recognised in this year’s inductees to the ASCRS Ophthalmology Hall of Fame. The late Vladimir P Filatov MD, Ukraine, was so honoured for his pioneering work in corneal transplantation and tissue therapy. Theo Seiler MD, PhD, Switzerland, was recognised for his ground-breaking work developing wavefront-guided refractive ablation, and inventing corneal collagen cross-linking.

Glaucoma to the fore As a condition affecting about one in five cataract patients, and one increasingly

treated in tandem with cataract surgery, glaucoma played a prominent role in this year’s ASCRS meeting. Not only was the prestigious Binkhorst Lecture delivered by glaucoma specialist Iqbal K “Ike” Ahmed MD, incoming ASCRS President Richard A Lewis MD is himself a glaucoma specialist. “This is a unique time of ophthalmology. Technology has broadened our diagnostic and surgical options in ways not envisioned only a few years ago,” said Dr Lewis, who was unable to attend due to injuries from a recent accident, but delivered his comments via video. Yet pressure from government mandates including adoption of the ICD10 coding system and artificial budget caps challenge the profession even as other government programmes seek to expand access, Dr Lewis added. “I want to see ASCRS continue to guide its members through these and other, yet unforeseen challenges.”

Advancing care Outgoing president Eric Donnenfeld MD also emphasised the vital role ASCRS plays in advancing care technology and improving access. Among ASCRS’ major undertakings this year is to organise and support ophthalmologists in providing cataract surgery for patients who cannot afford treatment. “In this 40th anniversary year [of the ASCRS annual meeting] we look ahead not just to follow but to surpass our past accomplishments. In the next 40 years we will improve eye care for our patients and work toward the noble goal of making treatable blindness a thing of the past,” Dr Donnenfeld said. “I remember hearing in my training that I had just missed the golden age of ophthalmology. Today I know better. The golden age of ophthalmology is right now. With courage and leadership we can make tomorrow even better,” Dr Donnenfeld said.

In this 40th anniversary year we look ahead not just to follow but to surpass our past accomplishments Eric Donnenfeld MD

ophthalmologica

ophthalmologica Vol: 231 Issue: 4 month: May 2014

New potential biomarker Microaneurysm turnover analysed using the RetmarkerDR software (Critical Health SA, Coimbra, Portugal), could have a potential role as biomarker for responsiveness to ranibizumab in the treatment of diabetic macular oedema, a new study suggests. Analysis of images obtained with nonmydriatic ultra-widefield scanning laser ophthalmoscopy (Optomap) prior to ranibizumab treatment and one month later showed that eyes treated with ranibizumab had a reduction in the number of microaneurysms, with the amount of disappearing aneurysms out-pacing the appearance of new ones. In contrast, an analysis of untreated control eyes with diabetic retinopathy but without macular oedema showed that over the same period there was an increase in the number of microaneurysms. SF Leicht et al “Microaneurysm Turnover in Diabetic Retinopathy Assessed by Automated RetmarkerDR Image Analysis Potential Role as Biomarker of Response to Ranibizumab Treatment. • Ophthalmologica 2014 ; DOI:10.1159/000357505.

PDT achieves its best results in subfoveal CNV In eyes with CNV secondary to pathological myopia, photodynamic therapy (PDT) appears to provide a more persistent benefit in those with juxtafoveal CNV than it does in those with subfoveal CNV, according to a 10-year retrospective analysis of 19 eyes of patients who underwent the treatment. That is, in seven eyes with subfoveal CNV, mean visual acuity progressively worsened from 0.68 to 0.80 logMAR, during the 10-year followup. In contrast, in the 12 eyes with juxtafoveal CNV the mean visual acuity improved from 0.59 to 0.33 logMAR. In addition, the prevalence and extension of chorioretinal atrophy (CRA) were greater in eyes with subfoveal compared with juxtafoveal CNV. M Varano et al, “Photodynamic Therapy in Subfoveal and Juxtafoveal Myopic Choroidal Neovascularisation: A 10-year Retrospective Analysis”, Ophthalmologica 2014; DOI:10.1159/000357504.

Predictive disease characteristics The long-term functional outcome of eyes with myopic CNV may depend more on their baseline pathological characteristics and consequent progression of macular atrophy than on the treatment they receive, whether it is PDT, intravitreal ranibizumab or the combination of the two, according to a retrospective study. It showed that in 54 eyes that received PDT and IVR, the two combined, or no treatment, macular atrophy progressed significantly in the three active treatment groups (p < 0.05) and the amount of atrophy was predictive of visual acuity. Factors predictive of progression included age, the degree of myopia and the presence of staphyloma. The choice of treatment had no predictive value. CL Farinha et al, “Progression of Myopic Maculopathy after Treatment of Choroidal Neovascularisation” Ophthalmologica 2014; DOI: 10.1159/000357290.

José Cunha-vaz Editor of Ophthalmologica

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Eurotimes | June 2014

travel

MUST SEE...

LONDON

Continent: Europe Major river: The Thames UNESCO world heritage sites: Tower of London, Maritime Greenwich, Westminster Palace, Kew’s Royal Botanic Gardens

A long-running West End spectacle is Afternoon Tea at the Ritz. It’s a favourite ritual of celebrities, and those who are prepared to be treated like a celebrity for two hours. Expect a variety of tiny sandwiches, scones, cakes, pastries and a choice of loose teas, all impeccably presented in a show-stopping gilded room. “Afternoon Tea” is available seven days a week in the Palm Court at 11.30, 13.30, 15.30, 17.30 and 19.30. Book on the website at least 12 weeks in advance. www.theritzlondon.com/tea.html For a dramatically different night out in the East End, make a reservation for dinner at ‘Back in five minutes’... You enter a Brick Lane clothing shop, proceed to the rear, pull aside curtains that might lead to a changing room but don’t; they lead to a stairway down to the restaurant. The room is dimly lit, the tables are communal but the ambience, like the complimentary cocktail, is fabulous. There’s a short menu except on Wednesday when it’s down to what the chef chooses to serve. The address is 224 Brick Lane, Shoreditch. More info and to book at (07507 754318). www.disappearingdiningclub.co.uk The average cost of a West End theatre ticket is £50 but £75 would be nearer to the mark for a sought-after play. Trim your costs for a night at the theatre by getting a cut-price ticket. The dependable Society of London Theatre booths, one at Leicester Square and the other at the Canary Wharf DLR station, offer same day tickets at a discount. Book online for the longest running show of any kind in the world, Agatha Christie’s mystery, the Mousetrap. The play opened on the West End in 1952 and is still going strong. A monument has been erected to the playwright, Dame Agatha; the 2.5-metre-high bronze sculpture is at the end of Cranbourn Street in the West End. www.the-mouse-trap.co.uk

Eurotimes | June 2014

Oldest music hall in London

WEST END... AND EAST

A vibrant theatre scene awaits delegates for London congresses. Maryalicia Post reports Once the West End meant simply the area to the west of London’s financial district, upwind of the smoke of the busy city. Now the West End usually means ‘theatre’. At any one time some 40 world-class plays vie for attention here.The theatre district and the West End, extend to Covent Garden, home of the legendary Royal Opera House. (During the ESCRS London meeting, Verdi’s Rigoletto features; booking at www. roh.org.uk from July 15.) The portico of the Royal Opera House borders on a lively piazza, normally a stage for acrobats, jugglers and assorted buskers. Last year, the roster included a surprise free gig as Sir Paul McCartney kicked off his new album here. Fittingly, the ‘actor’s church’, St Paul’s, is tucked away in a tiny park off the piazza. Its plain interior (the architect was instructed to make it ‘not much better than a barn’) is a backdrop for plaques commemorating dozens of theatrical greats. Although the West End is now synonymous with theatre, it didn’t start out that way. London’s commercial theatre scene was established in the East End - the first playhouse, called simply ‘The Theatre” was built in Shoreditch in 1576 . That was long before the Puritans closed the theatres in 1642. After the Restoration, the King was a frequent visitor to the Theatre Royal Bridges Street, built in 1663 where the Theatre Royal Drury Lane stands now. The Coliseum opened on St Martin’s Lane in the West End as the ‘London Coliseum Theatre of Varieties’. That was in 1904, and it’s still there, now as home of the English National Opera. The Coliseum is a newcomer compared to Wilton’s Music Hall in the East End. That started life as an ale house in 1743 before morphing into a magnificent, chandelier-lit theatre and then, a century later, a Methodist Mission soup

kitchen. After WW2, left to decay in the bomb-ravaged East End, the ruined building was saved. Despite ongoing restoration, Wilton’s is already bringing the East End’s performance tradition back to life. Details and performance schedules: www.wiltons.org.uk For East End theatre of a different kind, a ‘still life’ drama of a family of Huguenot weavers, call in at the Dennis Severs House. Severs bought this small Georgian building in 1966, transforming it into an evocation of the life and times of the imaginary Jervis family in the periods between 1724 and 1914. The rooms seem to have been recently abandoned with unmade beds in the museum-quality interiors. The painter David Hockney described his visit, conducted in silence and by candle light, as among the world's 'five greatest operatic experiences’. For details: www.dennissevershouse.co.uk

Old Coliseum Theatre in the West End

BOOK Reviews

EXPENSIVE surgery Femtosecond-assisted cataract surgery will likely remain a hot topic for years to come. However, it still remains a technique beyond the reach of most ophthalmologists due to the great expense involved in acquiring and maintaining a femtosecond laser. It is thus by means of PUBLICATION scholarly books, journal articles Femtosecond Cataract Surgery and ophthalmology conferences EDITORS that the ophthalmic community Federica and Luca Gualdi must stay up to date regarding the continuing developments of PUBLISHED BY Jaypee the field. Femtosecond Cataract Surgery, authored by more than two dozen surgeons, and edited by Federica and Luca Gualdi, fulfils this task. This book, according to the foreword, “is addressed to all surgeons, phacoemulsification experts and young ophthalmologists as a guide to the new experience with femto-cataract” surgery. According to the authors, the purpose of the book is “to describe femtosecond laser surgery for cataract; to explain the treatment and underline the benefits of this type of digital computerised surgery, and to compare it with the traditional phacoemulsification, which represents the current gold standard.” The book starts with a history of cataract surgery but quickly moves on to the physics of the femtosecond laser, with many interesting factoids to maintain the reader’s interest: who knew that “femto,” which stands for 10-15, or a millionth of a billionth, comes from the Danish word femten, or fifteen? A quick overview on femtosecond technique is next, followed by two to three chapters for each of the five femtosecond lasers currently on the market: the LenSx (Alcon); Victus (Bausch + Lomb); LansAR (Topcon), Catalys (Abbott) and LDV Z8 (Ziemer).

BOOK

REVIEWs

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TRAINING POSTS On a different note, before one can consider advanced surgical techniques, one must obtain an ophthalmology training position. In many countries, this is no easy task. How to Get That Training Post in Ophthalmology: The Essential Guide to Getting into an Ophthalmic Postgraduate Training Program (Ang), written by Brian Ang, Shi Zhun Tan and Ken Lee Lai, helps medical students navigate the selection process in the UK, where “ophthalmology is one of the most sought after specialties. The competition is keen.” The authors lead the reader from a description of “Ophthalmology as a Specialty,” through “Improving your CV” and “The Application Process,” including timelines, essential criteria and tips to make the candidate more competitive. Advice on “The Interview Process” follows, as well as advice for “The Unsuccessful Applicant,” including pursuing training abroad. Particularly useful are the appendices, which include an example CV and example questions for applications, and interviews.

Only the GALILEI G4 unites Placido and Dual Scheimpflug technologies in one measurement. With the GALILEI G4, you get highly precise measurements for posterior and anterior curvature, pachymetry, Total Corneal Power, Total Corneal Wavefront and the anterior segment of your patient’s eye. The new GALILEI G4, for first-class clinical results. The GALILEI G4 is a modular platform, which can be upgraded according to your needs. Learn more on galilei.ziemergroup.com.

Leigh Spielberg Books Editor

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

Eurotimes | June 2014

WSPOS World Society of Paediatric Ophthalmology & Strabismus

PAEDIATRIC SUB SPECIALTY DAY FRIDAY 12 SEPTEMBER 2014

Preceding the XXXII Congress of the ESCRS 13 – 17 September 2014

A DAY WITH A CHILD’S EYE Sub Specialty Day Organisers:

W. Aclimandos UK, D. Bremond-Gignac FRANCE, R. Hertle USA

Preliminary Programme 08.30 – 11.30

SESSION I: Systemic implications of paediatric eye disease

11.30 – 12.30

SESSION II: What’s new in the adult world that might help the child?

Moderator: W. Aclimandos UK

V. Sarnicola (EuCornea) ITALY B. Pellet Sylvie (EuCornea) FRANCE T. Krohne (EURETINA) GERMANY

13.30 – 14.30

SESSION III: International collaborations in paediatric cataract outcomes Including the following presentations:

- International Met analysis outcomes, A. Mataftsi GREECE - The Delphi Project outcomes, M. Seraﬁno ITALY - The role of aRc’s, K.K. Nischal UK/USA

15.00 – 17.00

SESSION IV: Ocular motor disorders Moderator: R. Hertle USA

17.00 – 17.30

SESSION V: Video venture

Moderator: D. Bremond-Gignac FRANCE

Registration, Hotel Bookings & Preliminary Programme Online

www.wspos.org

Clarity Satellite Meeting Lunchtime Sponsored by

Industry news

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industry

NEWS

CE approval Ziemer Ophthalmic Systems AG has received CE approval for the FEMTO LDV Z8. “Approval is given for clear corneal and arcuate incisions, capsulotomy, lens fragmentation and all previously covered cornea and presbyopia applications,” said a company spokesman. “The monitored rollout of the device will now begin in combination with an in-depth education programme for femtosecond laser-assisted cataract surgery,” he said. www.femtoldv.com

collaboration Leica Microsystems and TrueVision 3D Surgical have announced that Leica will incorporate key components of TrueVision’s 3D intelligent digital visualisation and guidance platform into selected Leica Microsystems surgical products under the Leica brand. “In addition to co-marketing the Leica and 3D by TrueVision products, the two companies will collaborate on projects that will further integrate their optical and digital technologies to improve microsurgery outcomes in ophthalmology and neurosurgery, “said a TrueVision spokesman. www.truevisionsys.com

New financing Kala Pharmaceuticals, Inc. has completed a $22.5m Series B financing. “New venture investor Ysios Capital led the round, which also included a new strategic investor, as well as current investors Crown Venture Fund, Lux Capital, Polaris Partners and Third Rock Ventures,” said a company spokeswoman. “In conjunction with the financing, Karen Wagner PhD, general partner at Ysios Capital, will join Kala’s Board of Directors,” she said. www.kalarx.com

two programmes Haag-Streit Diagnostics has introduced the OCTOPUS 600 which the company says is the first perimeter combining the Pulsar method for early diagnosis and standard white-on-white perimetry in one device. “HaagStreit is updating the OCTOPUS® 600 with the two most commonly used macula programmes: the physiology-based M-program unique to the OCTOPUS® product family and the 10-2,” said a company spokesman. www.haag-streit.com

EYE CHAT Exclusive interviews Up to date information Problem solving

Small Pupils and Floppy Iris Syndrome Dr Oliver Findl speaks with Dr Boris Malyugin about how to handle these cases before, during and after surgery.

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Eurotimes | June 2014

JCRS

JCRS highlights

Vol: 40 Issue: 5 month: MAY

SAN DIEGO APRIL 17–21

ADDITIONAL PROGRAMMING WORLD CORNEA CONGRESS VII ASCRS GLAUCOMA DAY ASOA WORKSHOPS TECHNICIANS & NURSES PROGRAM

HOUSING IS NOW OPEN RESERVE EARLY TO STAY AT YOUR PREFERRED HOTEL.

www.ascrs.org www.asoa.org All ASCRS and ASOA programming will be held in the San Diego Convention Center. A joint meeting with

Toric IOL vs. AK A randomised prospective trial enrolled 34 patients to compare toric intraocular lens (IOL) implantation and astigmatic keratotomy (AK). Consecutive patients with visually significant cataract and moderate astigmatism (1.25 to 3.00 D) were randomised to either undergo temporal clear corneal 2.75mm phacoemulsification with toric IOL implantation or 30-degree coupled AK at the 7.0mm optic zone. Evaluations postoperatively showed no difference in uncorrected distance visual acuity or corrected distance visual acuity between the two groups at any follow-up visit. The mean preoperative and postoperative refractive cylinder was 2.00 D ± 0.49 (SD) ± 0.41 D, respectively, in the keratotomy group. The mean residual astigmatism at three months was 0.44 ± 1.89 @ 160 in the toric IOL group and 0.77 ± 1.92 @ 174 in the keratotomy group. All eyes in the toric IOL group and 14 eyes (84 per cent) in the keratotomy group achieved a residual refractive cylinder of 1.00 D or less. JS Tityal et al., JCRS, “Toric intraocular lens implantation versus astigmatic keratotomy to correct astigmatism during phacoemulsification”, Vol. 40, No. 5, 741 -747.

Triamcinolone acetonide-assisted anterior vitrectomy Researchers looked at long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss in 15 patients. Ocular examination and spectral-domain optical coherence tomography showed significant improvement in mean corrected distance visual acuity. The study concluded that triamcinolone acetonideassisted anterior vitrectomy during complicated cataract surgery with vitreous loss was safe and effective. M Shai et al., JCRS, “Long-term outcomes of triamcinolone acetonide-assisted anterior vitrectomy during complicated cataract surgery with vitreous loss”, Vol. 40, No. 5, 722-727.

Crosslinking comparison A study of 16 patients (21 eyes) used anterior segment optical coherence tomography to compare corneal stroma demarcation line depth after corneal collagen crosslinking with two treatment protocols. Patients were either treated for 30 minutes with 3 mW/cm2 according to the standard Dresden protocol or for 10 minutes with 9 mW/cm2 of UVA irradiation intensity. All crosslinking procedures were performed using the same ultraviolet-A irradiation device (CCL-365). The mean corneal stroma demarcation line depth was 350.78 μm ± 49.34 in the 30-minute group compared with 288.46 ± 42.37 μm in the shorter time treatment group. The difference was statistically significant. GD Kymionis et al., JCRS, “Corneal stroma demarcation line after standard and highintensity collagen cross-linking determined with anterior segment optical coherence tomography”, Vol. 40, No. 5, - 736 -740.

Thomas Kohnen European editor of jcrs

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

Eurotimes | June 2014

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Eurotimes | June 2014

review

CONTROL AND TAME

Everything you want to know about making the capsulorhexis behave. Soosan Jacob reports IRST STEPS

A capsulorhexis should always be well controlled and needs to be tamed if misbehaving. This may be easy or difficult according to the situation. General principles to be followed for a rhexis were mentioned in a previous article. To make a rhexis behave, the anterior chamber (AC) should always be full of viscoelastic and the anterior capsule flat. Good visualisation is vital, if required by staining with Trypan blue (0.06 per cent) and this is especially important in cases with poor red reflex (white or brown cataracts, vitreous haemorrhage etc); Eurotimes | June 2014

paediatric and other complex cataracts. Cortex should not be churned up which can hinder visualisation. All manoeuvres should be gentle and careful.

YOUNG CATARACT Elastic nature of the capsule, positive vitreous pressure and low ocular rigidity create a tendency for a run-away rhexis â&#x20AC;&#x201C; the younger the child, the stronger the tendency. Trypan blue staining gives better visualisation and makes the capsule stiffer. Aiming for a smaller size allows a final rhexis of the desired size as the elastic capsule stretches. The first nick should therefore be made smaller than in an adult cataract. The flap is lifted and the tear always directed

towards the centre of the lens to avoid a run-away rhexis. High viscosity ophthalmic viscosurgical device (OVD), (Healon5 and Healon GV) may be used to maintain space and flatten the anterior capsule. Various other techniques such as vitrectorhexis, two incision pushpull technique, Fugo blade rhexis etc, have also been described. Depending on age, a posterior continuous curvilinear capsulorhexis (PCCC) may be required.

CALCIFIED OR FIBROSED CAPSULE Seen in some hypermature cataracts, membranous congenital cataracts or as post-traumatic sequelae â&#x20AC;&#x201C; the rhexis can be started in a normal area and circumnavigated around the affected

review area to include it. If not possible, microscissors or vitrector may be used in the affected zone in which case, subsequent manoeuvres should be as described for torn rhexis. White cataract: Mature, white capsules are thin and together with increased intra-lenticular pressure increases likelihood of tears and run-outs. Capsular staining is vital. Oblique external illumination can help visualisation. Too small a rhexis carries risk of capsule blow-out, zonulodialysis, posterior capsular rent etc. Too large a rhexis has a tendency to run away.

Subluxated cataract

Folds seen because of lax capsule

Rhexis should have adequate capsular rim and is spiralled around to enlarge

Completed rhexis

spiralling around. This may be done before ending the rhexis or after IOL implantation. In the latter case, a Vannas or a microscissors makes an oblique cut at the rhexis margin which is then spiralled around.

Slow-motion phaco is then carried out extremely carefully. However, in case of doubt or lack of experience, it may be better to convert into an extracapsular cataract extraction.

RUNAWAY RHEXIS

POSTERIOR CONTINUOUS CURVILINEAR CAPSULORHEXIS

INTUMESCENT CATARACT These leak and make the aqueous cloudy. An initial aspiration with a needle from the centre of the capsule before initiating the rhexis can decrease the intra-lenticular pressure as well as leakage of obscuring lens material. In case of leak, AC should be washed and high viscosity OVD refilled. Once lens material is released, intra-lenticular support for needle capsulorhexis may be inadequate and a forceps may be required to continue.

SUBLUXATED CATARACT The loose capsule offers inadequate resistance and initiation of rhexis may be done by a sharp needle or by side port knife. Larger subluxations may require rhexis by forceps. Rhexis should be centred on capsular bag and not on the visible portion of the lens. This may be done, if required, by centring the lens by engaging it with a Sinskey hook. Rhexis may be started small and if required spiralled around to enlarge. Adequate rim should be left on dialysed side to allow engagement by capsular hooks, segments or rings. Capsular hook should never be applied on incomplete rhexis to avoid run-out.

DIFFICULT VISUALISATION This may be because of corneal opacities, white or brown cataracts, or because of poor red glow secondary to inadequate co-axial lighting/vitreous opacities such as haemorrhage or asteroid hyalosis. Visualisation can be enhanced by capsular staining, high magnification and co-axial lighting. An endoilluminator may be used for oblique illumination in corneal opacities.

SMALL PUPIL Various pupil dilating techniques such as pupil stretching, iris hooks, Malyugin ring etc, may be used. With experience, the rhexis can generally be taken beyond the pupillary edge safely. Small rhexis: Small rhexes are prone to zonular disinsertion and tears intraoperatively and capsular phimosis postoperatively. It may be enlarged by

Little's Rhexis trick is used to effect a change in direction as soon as early tendency for peripheral extension is seen. The earlier it is performed, the easier it is to retrieve. AC is deepened with cohesive OVD and the flap laid flat. A forceps grasps the flap at the very root of the tear and pulls centrally to redirect the tear inwards. Blind pulling is avoided to avoid posterior capsular extension. In this case, can-opener capsulotomy from the opposite side connects to visible rhexis margin. Surgery should be as in torn rhexis. Argentinian flag sign: This is the classical split rhexis in a Trypan blue stained, white, mature cataract and resembles the Argentinian flag. If it occurs, it may be saved by making a nick and tearing around circularly to join the other/both ends. However, if difficult, the tear may be converted to can opener capsulotomy. Surgery should be as in torn rhexis.

Done in paediatric cataracts and with posterior capsular fibrosed plaques. A flap of posterior capsule is raised with 26 gauge cystitome and viscoelastic instilled through the nick. The flap is then torn in a continuous curvilinear manner. It may or may not be combined with anterior vitrectomy. * Dr Soosan Jacob is a senior consultant ophthalmologist at Dr Agarwal's Eye Hospital, Chennai, India and can be reached at: dr_soosanj@hotmail.com

Scan this QR code to go to video link for surgery

TORN RHEXIS Only a continuous curvilinear rhexis can stretch. Tensile strength of the capsule is lost in case of any discontinuity, however small. All intra-capsular manoeuvres are avoided and the nucleus prolapsed out. Eurotimes | June 2014

calendar

JulY

IseR XXI Biennial Meeting 20–24 July san Francisco, California www.iserbiennialmeeting.org

lasT call

June 2014

sePTeMBeR

14th euReTIna congress 11–14 september london, uk www.euretina.org

escRs glaucoma day

7–11 June nice, France www.eugs.org/eng/default.asp

12 september london, uk www.escrs.org

wsPos Paediatric sub speciality day 12 september london, uk www.wspos.org

5th eucornea congress 12–13 september london, uk www.eucornea.org

2nd asia-Pacific glaucoma congress 10th International symposium of ophthalmology

Vienna

26–28 september hong kong www.apgc-isohk-2014.org/

noVeMBeR

27th aPacRs annual Meeting

ocToBeR

13–16 november Jaipur, india www.apacrs2014.org

18–21 october Chicago, illinois, usa www.aao.org

Joint Irish/uKIscRs Refractive surgery Meeting

aao annual Meeting

21 november Dublin, ireland Email: hmurphy@materprivate.ie

femto congress 2014

7–9 november budapest, hungary www.femtocongress2014.hu

deceMBeR

6th amsterdam Retina debate

soI national congress

12 December amsterdam, the netherlands www.amc.nl/retinadebate

12–15 november rome, italy www.congressisoi.com

feBRuaRY 2015

73rd annual conference of aIos

XXXII congress of the escRs

5–8 February new Delhi, india www.aios.org

NEW ENTRY 2nd european conference on aniridia

19th escRs winter Meeting

19-20 september Venice, italy www.aniridiaconference.org

↙

13–17 september london, uk www.escrs.org

20–22 February istanbul, turkey www.escrs.org

aPRIl

International annual course and workshop on diagnostic ultrasound in ophthalmology

NEW ENTRY ascRs.asoa symposium and congress

22–26 september Vienna, austria www.echography.com

17-21 april san Diego, Ca, usa www.ascrs.org/meetings-and-events

FOUR EVENTS ONE VENUE e

Corn

WSPOS

11th egs congress

20–23 august stockholm, sweden www.nok2014.com

25–28 september leipzig, Germany www.dog-kongress.org

C o r n

XXXII Congress of the ESCRS 13-17 September

14th EURETINA Congress 11-14 September

↙

augusT

nordic congress of ophthalmology (noK 2014)

sePTeMBeR

The 112th dog congress of ophthalmology

European Society of Cornea and Ocular Surface Disease Specialists

5th EuCornea Congress 12-13 September

WSPOS Paediatric Sub Specialty Day 12 September

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