EuroTimes Vol. 19 - Issue 7/8

special focus practice management & development Cornea

Carbon nanomaterials may provide biomechanical support to weak corneas July/Aug 2014 | Vol 19 Issue 7/8

Paediatric ophthalmology

Refractive surgery could help a minority of high hyperopia patients

Delivering World-class Medical Consultations LEADERSHIP

COMMUNICATION

QUALITY

TEAMWORK

ORGANISATION

Breathtaking Ecknauer+Schioch ASW

Strong Any nucleus from soft to hardest, any incision from 1.6 to 3.2 mm, fast, safe and the AC always stable.

That’s easyPhaco®. CortexModeTM for precisely controlled cortical clean-up. HF capsulotomy for difficult cases. 1200 cuts anterior vitrectomy.

Beautiful So easy to operate! DirectAccess® to any function without confusion. Programmable for 20 surgeons.

Bright, easy to read display. A marvel of design, brings a friendly note in your OR. Unique Truly portable, 5 kg, fits in a pilot’s case. HFDS ab interno glaucoma function, the future of combined glaucoma surgery. Fantastic toe tip of flow control.

Built-in compressor. Just plug to 90-230 V. For You Lets you enjoy most advanced surgery from low to highest volume in any set-up at controlled costs. www.oertli-catarhex3.com

p.40

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

3 Newsmaker

Interview

Gunther Grabner talks to EuroTimes about his career to date

SPECIAL FOCUS Practice Management & Development 4 Cover Story: Experts

discuss how to deliver world-class medical consultations

8 Valuable tips on how to turn more phone calls into potential customers

FEATURES Cataract & Refractive 9 Studies look at range of accommodation with selection of IOLs

10 Preventing postoperative presbyopia in cataract surgery patients

11 Going for the best lens available is best option, says surgeon

12 Combining LASIK and CXL beneficial, but there are risks

13 Fluidic settings must 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.

change depending on the surgical situation

™

Cornea

p.38

14 Weakened corneas

could be aided with carbon nanomaterials

15 Microkeratome is reliable

technology for dissection of ultrathin grafts

22 Study looks at role of

increased oestrogen on cornea during pregnancy

Glaucoma 24 High-pressure yoga

could have implications for glaucoma patients

25 Could glaucoma

education increase adherence to medication?

Retina 27 PDGF inhibitors could reduce anti-VEGF resistance

p.50

Ocular 33 Highlights from

the ARVO congress

34 Ocular health

and microgravity

Paediatric Ophthalmology 35 A look at the options

for highly hyperopic children

REGULARS 37 Industry News 38 Eye on Technology 40 Travel 41 Book Reviews 42 EBO Diploma update 44 Ophthalmologica update 45 ESCRS and Charities 48 Resident’s Diary 49 JCRS Highlights 50 Eye on History 51 ESASO update 52 Calendar

Eurotimes | july/august 2014

2

editorial A Word from Arthur Cummings MB.ChB, FCS(SA), FRCSEd

BUILD YOUR PRACTICE The ESCRS Practice Management and Development Programme is helping ophthalmologists to become better service providers

T

hank you to EuroTimes for the invitation to write has managed to attract over the past five years has been this guest editorial for this Practice Management and exceptional. I cannot recall a single practice development Development issue. workshop that was not well attended and where participation If you consider how much time the average was not enthusiastic. ophthalmologist has put into the medical This year, Rod Solar is leading the masterclass and for (educational) aspects of our chosen profession, it’s those who have not heard Rod speak before, this will be an actually quite scary. ideal opportunity to hear him talk about “Delivering WorldTypically, six years of medical school, then internships and class Medical Consultations”. I can guarantee that you will residencies that can cover another six to 10 years and then finally not take one nugget or gem from this masterclass but rather we’re fit to practise. several that will undoubtedly improve the way in which you That may be true if you work in a university or state or your practice serve your patients. setting, but if you’re in private practice or even doing The three-day programme part-time private practice, you suddenly realise that also includes presentations We get to spend a lot of time none of your formal training prepared you for the on leadership, innovation, “practice” side of practising medicine. finance and human resources working IN our businesses When we attend conferences, we tend to spend all and for the first time there and don’t spend enough time our time listening to academic lectures, attending will be two separate modules working ON our businesses. courses and generally learning more about the field of for ophthalmologists and Part of the learning experience ophthalmology. We hardly spend any time learning for practice staff. While about how to better our ophthalmic practices and ophthalmologists continue to was that our ophthalmology become better service providers and businesses. make up the majority of the practices are indeed businesses.

Since the first masterclass with Prof Keith Willey attendees at the programme, of London Business School in Barcelona in 2009 there has been a noticeable which discussed entrepreneurship, I have been a supporter increase in attendance from practice staff and this year's of the ESCRS Practice Management and Development programme reflects the need for practice staff to improve Programme. When I was invited in 2012 to join the ESCRS their business skills.

Practice Management and Development committee, You would be hard-pressed to spend your time better I jumped at the chance. during ESCRS if your mission is to build your practice. I We get to spend a lot of time working IN our businesses and would encourage all EuroTimes readers who are attending the don’t spend enough time working ON our businesses. Part of XXXII Congress of the ESCRS to take part in the programme. the learning experience was that our ophthalmology practices are indeed businesses. As doctors we don’t always appreciate this. My thought process was that being involved with this committee would ensure that I was continually exposed to like-minded ophthalmologists and other professionals and * Arthur Cummings is a member of the that it could only be beneficial for my practice.

ESCRS Practice Management and This is exactly how things have panned out. The calibre Development Committee of speakers that the committee, chaired by Paul Rosen,

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 | july/august 2014

Newsmaker

steady progress Prof Grabner has 40 years of experience in the field of cataract surgery and shows little sign of letting up Gunther Grabner MD, professor of ophthalmology and chairman, University Eye Clinic, Paracelsus Medical University, Salzburg, Austria, spoke with EuroTimes contributing editor Roibeard O’hEineachain in a Newsmaker interview about his experiences stretching back to the early days of modern cataract surgery. This will also be the theme of the Ridley Medal Lecture which he will be giving at the XXXII Congress of the ESCRS in London this September.

I

've been doing cataract surgery for very close to 40 years. I was trained in Vienna and started doing cataract surgery in May 1975. At that time, the standard procedure was intracapsular cataract extraction (ICCE) with cryo-extraction without implantation of IOLs. I was probably among the last to receive training in that technique. The procedure involved making 160o to 180o incisions with about eight to 10 sutures. There was typically a lot of corneal swelling and astigmatism. Patients would get their aphakic spectacles and stay in hospital for about five days and have to stay in bed for a week.

In those days, there were very few people that implanted lenses like Binkhorst, Choyce and Barraquer.

They had a hard time of it because the then very conservative professors were strongly against implanting lenses.

They had seen all the reports on these old anterior chamber lenses that had to be explanted because of uveitis glaucoma hyphaema (UGH) syndrome.

And honestly the lenses at this time certainly were not of the highest quality.

In 1981-82, I went to the US for a year of research and fellowship at the University of California in

In those days, there were very few people that implanted lenses like Binkhorst, Choyce and Barraquer Gunther Grabner MD

INDIA

San Francisco at the Proctor foundation. It was a wonderful year. I received very good training in cornea and uveitis. At that time in the US there was a big boom in radial keratotomy and astigmatic keratotomy and I received training in those techniques. It was also during this time that I first saw people doing extracapsular cataract extraction (ECCE) and posterior chamber lens implantation. Then in 1984 I spent a second fellowship with Dennis Shepard in Santa Maria and he trained me in ECCE and IOL implantation techniques – great teacher and wonderful times.

When I came back to Austria after that second short fellowship I convinced my teachers at the clinic to go ahead and adopt ECCE and posterior chamber IOLs. I'm very grateful to these teachers that they took advice from me. In 1993, at the age of 42, I became the chairman of the Department of Ophthalmology at the Paracelsus Medical University Hospital in Salzburg. This is when we bought four phaco machines and we really got started with phaco in all the patients.

In Europe, phaco was still very new at that time and people were still debating its advantages. It wasn’t until the late 1990s that it became the dominant technique. It was finally accepted that it was safer to have a 3.5mm incision compared to a 9mm or 10mm incision with ECCE. It was definitely different, it was faster healing and patients liked it. The big switch finally came with the advent of foldable lenses in the early 1990s, which gave phaco an added impetus as there were now lenses that could take full advantage of the small incision.

I started doing femtosecond cataract surgery in October 2012. I was convinced from early on that this technology was the future of cataract surgery. Not yet to replace phaco but to add safety for the patient and possibly more precision. I think the time is not far off when every cataract centre will have one. Most of my staff of 33 surgeons, fellows and residents is receiving training in the use of the femtosecond laser. I hope that by the end of year they will all be doing this form of surgery and in this way provide the best service to our patients.

Gunther Grabner: G.Grabner@salk.at

VISIT OUR WEBSITE FOR INDIAN DOCTORS

www.eurotimesindia.org Eurotimes | july/august 2014

3

4

special focus: Practice Management & development

WORLD-CLASS PRACTICES

Ophthalmologists and their practice staff must have excellent consultation skills. Colin Kerr reports

H

ow can ophthalmologists and practice staff deliver world-class medical consultations?

That will be the topic for discussion when Rod Solar of LiveseySolar Practice Builders presents a masterclass during the ESCRS Practice Management and Development Programme at the XXXII Congress of the ESCRS in London, UK, on Saturday September 13.

The day-long masterclass has been designed to help ophthalmologists understand the importance of the consultation process and, more importantly, that they deliver this message to their patients.

Eurotimes | july/august 2014

You may be a great listener but you may not be good at answering questions succinctly...

Rod Solar “Consultations involve the active and cooperative participation of every team member,” said Mr Solar. “Often, people hired into clinical positions in ophthalmological practices are not commercially aware and resist the idea of selling, even in a private setting."

Mr Solar suggests that doctors can increase their conversion rates by an average of 50 per cent after adopting his techniques.

“There are a number of questions that ophthalmologists need to ask throughout the consultation process,” he said. “They need to understand their patients’ emotional wants and rational needs. Patients will have questions about the costs and the risks of individual procedures and it is very important that the ophthalmologists and their practice staff are able to answer these questions convincingly,” he said.

special focus: Practice Management & development “Today's patients are very knowledgeable and have high expectations of the service they should receive. During the masterclass, we will discuss how to greet your patients, how to make them feel at ease and how to understand their needs and wants, especially their emotional wants. Then, we’ll discuss how to build a scaffolding of logic to support emotional decisionmaking that sticks.”

For the ophthalmologists who are leading the practice, said Mr Solar, it is very important to have good staff with good social skills working in the clinic or hospital.

“You may be a great listener but you may not be good at answering questions succinctly or speaking about money or organising and following up on appointments,” he said. “That is why it is important to recruit staff that can help you deliver world-class medical consultations.”

While some ophthalmologists may argue that they do not need special training in delivering consultations, Mr Solar said there are key reasons that they should develop these skills.

“If doctors believe in what they are doing, they will want more people to benefit from it, with or without money as part of the equation. Some doctors may be in salaried positions where they do not get paid any more money for doing more procedures but if they see more patients, more people will benefit from the procedures the doctors are offering,” he said. “Their skills will also improve when they are doing more of what they are trained to do.”

One misconception that some ophthalmologists may have, said Mr Solar, is that training in delivering consultations is best suited to large practices. “I would argue that if you are on your own you must be a good communicator. Large practices have the luxury of spending a lot more money on marketing and they have a lot more patients coming through their practices. The smaller your resources, the greater the imperative to make the most of them, which means converting as many consultations into treatments as possible.”

Good consultations also save time, said Mr Solar. “Nobody wants to waste time, whether you are big or whether you are small. A lot of patients are expecting free consultations before they agree to a procedure so it is important that you try and convert as many of these consultations into procedures.”

Building trust Arthur Cummings MB.CHB, FCS(SA), FRCSED, consultant ophthalmologist at the Wellington Eye Clinic in Dublin, Ireland, says good consultations are essential for a successful practice.

“The way you greet the patient, by looking at them and smiling immediately establishes a better rapport,” he said. “You

Rod Solar interacting with practice staff

have to connect emotionally with the patient. Instead of asking ‘Do you want to get rid of glasses?’ or ‘Do you want to see better?’ you must find out what is motivating your patients.

“They may tell you, ‘I want to be able to swim with my kids.’ If you probe further you may find that they can’t see their children in the swimming pool, so that becomes a security or safety issue for them.”

With every procedure, said Dr Cummings, there is an element of fear involved and it is essential to have a good relationship between the doctor and patient to build up trust. “That first consultation is crucial and if you don’t have a good consultation, you are not going to build up trust.”

Dr Cummings said it is also essential that every member of staff in the practice or hospital is part of the consultation process. “Everybody needs to be sharing the same message. They need to be positive and reassuring. When we recruit staff to our practice, one of the first things we look for is a positive attitude.”

Leader or follower?

Some of the best consultations are delivered by doctors who are good leaders and this is a theme that will also be discussed at a presentation on Sunday September 14, the day after the masterclass.

“Are you a leader or a follower?” is the question that Prof Keith Willey of London Business School will ask delegates.

Leadership is not just about your own

personal skills, said Prof Willey, but also about teamwork. “You must take responsibility if you decide to assume the main leadership role. Your staff will look to you for certain things and if you don’t deliver them, they will be disappointed and unhappy with their own role in the practice,” he said. “You must be able to get your staff motivated without coercing them. That is hard work and to do this you must build a good team.”

While the doctor who owns or runs the practice will inevitably assume the central leadership role, those who may consider themselves to be “followers” also need to assume some responsibility.

“If you are happy to follow the leader in your practice,” said Prof Willey, “you should also search for the leader who matches your expectations. There is a distinction between the individual leader and the actual act of leading,” he said.

“Even if you consider yourself to be a follower, you can still develop leadership skills in areas you are comfortable in.”

Dr Cummings will also take part in the leadership discussion with Prof Willey. “I think an ophthalmologist must be both a leader and a follower,” he said. “In areas that you are familiar with, you can lead.

In those areas that you are not familiar or competent, you become a follower.

Also, if you find that you are leading all the time, you will be surrounded by people who agree with you all the time and never challenge you. Obviously if the ophthalmologist owns the business, they will drive the medical protocols and the route the practice is taking but you should

That first consultation is crucial and if you don’t have a good consultation, you are not going to build up trust Arthur Cummings MB.CHB, FCS(SA), FRCSED Eurotimes | july/august 2014

5

6

special focus: Practice Management & development be able to lead by consensus by involving your staff in the decision-making process.”

Introducing new technologies Prof Willey will also discuss how ophthalmologists and their staff can introduce new technologies into their practices. “Again there are a number of fundamental questions that need to be asked before you introduce these technologies,” said Prof Willey. “Why are you introducing them, what are their characteristics and will your staff be able to use them? You will also need to consider what is the advantage of a new technology over an existing technology; can you trial it and are the results visible?”

Prof Willey recommends that delegates attending this module should read Diffusion Of Innovations, by Everett Rogers.

Prof Rogers says that adopters of a new innovation or idea can be categorised as innovators, early, early majority, late majority and laggards based on a mathematically based Bell curve. Each adopter's willingness and ability to adopt an innovation depends on their awareness, interest, evaluation, trial and adoption.

“Everett Rogers’ theories can be applied to all disciplines, including ophthalmology,” said Prof Willey. “I would also recommend Geoffrey Moore’s Crossing The Chasm, which begins with Everett Rogers’ “Diffusion of Innovations Theory” and then goes on to discuss the ‘chasm’ between the early adopters of a product or technology and the early majority.”

Mr Moore points out that visionaries and pragmatists have different expectations and he explores these differences and suggests techniques to successfully cross the “chasm”.

The “chasm” can be crossed by those who choose their target markets and who understand how a product works and is positioned. It is also important, he says, to develop a marketing strategy, a distribution channel and a pricing policy.

More interaction Other topics to be addressed during the three-day sessions include “Financial Basics”, “Don’t get sued” and “Cost effective ways to attract new patients”. For the first time, there will be two separate modules for doctors and practice staff with the ophthalmologists’ module taking place on Sunday, September 14 and the Practice Managers’ module taking place on Monday September 15.

“This is the first time that we have decided to hold separate modules,” said

Arthur Cummings examines a patient

Since we established this programme in 2008, we have had an increasing number of practice staff taking part...

Paul Rosen

Dr Paul Rosen, chairman of the ESCRS Practice Management and Development Committee. “Since we established this programme in 2008, we have had an increasing number of practice staff taking part in the sessions and this year we decided we should directly meet their needs with a module which we hope will help them to meet their expectations in developing their skills.”

Dr Rosen said the ESCRS Practice Management and Development Committee also wanted to ensure that delegates were given time to discuss the topics presented in the question and answer sessions.

Everett Rogers’ theories can be applied to all disciplines, including ophthalmology Prof Keith Willey Eurotimes | july/august 2014

“We have allowed more time this year for the question and answer sessions,” he said, “because our audience includes doctors and practice staff from a wide variety of countries where there are different protocols in place. For that reason, we want our delegates to be able to discuss how the ideas presented at our sessions can be applied to their individual practices and the best way to do this is to allow them time to interact directly with our presenters,” said Dr Rosen.

Calling all marketing gurus The ESCRS Practice Management and Development Committee is also excited to announce the first marketing prize to be awarded at this year’s meeting.

With a prize of a €1,000 travel bursary to attend the XXXIII Congress of the ESCRS in Barcelona, Spain in 2015, this competition seeks to highlight the innovative ways that ophthalmologists and their staff are marketing their practices around the world today.

“The winning submission will demonstrate a successful campaign that resulted in an increase in patient volume or practice revenue,” said Kris Morrill of medeuronet, who will be one of the judges for the competition.

Entries should consist of a three-tofour slide presentation that illustrates the campaign, costs, as well as the results of the marketing campaign. The submission deadline is Friday August 15. To enter delegates should contact Colin Kerr, ESCRS practice management and development project manager at: colin@eurotimes.org.

Rod Solar: rod@liveseysolar.com Arthur Cummings: abc@wellingtoneyeclinic.com Keith Willey: kwilley@london.edu Paul Rosen: phrosen@rocketmail.com Kris Morrill: kmorrill@medeuronet.com

advertorial

7

8

special focus: practice management & development

getting results Rod Solar of LiveseySolar Practice Builders gives some tips on how to turn more phone calls into consultations

E

very day 5. How have they ophthalmology attempted to solve businesses are this problem in the losing potential past? The answer customers on the helps you understand telephone, and it’s where they’ve been completely unnecessary. before, to probe into After evaluating possible disqualifying thousands of recorded information saving inquiry calls made by real you time and helping patients to ophthalmology to see how serious businesses large and small, they are. You also there is no mystery as to want to know if what works and what does they’ve visited with not work. your competition, and Our 10 years of research why they might have reveals 34 best practice rejected those options. distinctions correlated 6. The priority words with world-class telephone that they use to call handling performance describe their ideal and better conversion provider.

These rates. Results of putting are “need-to-have” these distinctions into things. They are nonpractice are independent of negotiable priorities the experience of the call that the caller must handlers, the size of the have present in a business, the price point solution provider. of the product, the 7. The criteria words geographic location or that they will respond number of locations. to. These things are In this article I’ll share 10 similar to priorities, of the 34 most important but are nice-to-have, inquiry call handling and are somewhat practices that I routinely more negotiable if the train telephone handlers priorities can be met. to do, resulting in not only 8. The name and “I’ve never encountered a more leverageable, better conversion rates relationship of any but also better customer other decision makers cost-effective method of increasing business service reviews. involved. You need to results in such a short time...”

To make the most from prepare yourself for your inquiry calls, you need the caller’s objection to ask your callers questions that they need to seek that reveal the following: approval from another party. Invite this person to the consultation.

1. Their objective and subjective view of the problem. Go 9. The deadline for when the benefits of this solution need to beyond facts. Explore the caller’s feelings and how the be in place. problem affects their life.

10. The timing for the next step (eg, the appointment) 2. The trigger for their desire, or “the straw that broke the in the buying process. camel’s back”. The specific event that motivates the caller to Handling telephone inquiries from patients is a critical success cross the “do-something” line. If you get a superficial answer, factor for ophthalmology businesses. The calculation is simple: probe further for a descriptive past motivating incident. any business converting more inquiry calls than its competitor Probe for how the problem affects them at work or leisure. receiving just as many calls will perform better. More face-to3. What success means to them. Have them paint a picture face consultations results in more business for the same fixed of what future success looks and feels like. Make sure that costs, which could mean the difference between profit and loss, you hear and use their own specific words when paraphrasing and success and failure. this back to them – do not assume you understand I’ve never encountered a more leverageable, cost-effective them – verify it. method of increasing business results in such a short time as 4. The date for when the solution must be in place. Specific I’ve seen with inquiry call handling training. Ophthalmology events and dates work best. You may discover their decision businesses typically see conversion rate per cent increases of 88 is time sensitive and you can refer to this later in the per cent, and a return on training investment of 47 to one, all conversation. Probe for how the problem affects them at within three months of training. work or leisure.

Eurotimes | july/august 2014

cataract & refractive

IOL TECHNOLOGY Decent results but no real accommodation with forward-shift IOLs. Dermot McGrath reports

O

bjective measurements of accommodating intraocular lenses (IOLs) designed on the forward shift principle show only minimal mobility of these IOLs in the capsular bag and do not constitute real accommodation, according to Gerd U Auffarth MD, PhD, FEBO. “Multiple studies have now shown that the optical forward shift principle is not enough for a sufficient range of accommodation.

Nevertheless the combination of pseudo-accommodative features such as micro-monovision and other factors may still lead to decent functional results especially for distance and intermediate vision with these lenses,” Dr Auffarth, chairman, Department of Ophthalmology at the University of Heidelberg, Germany, told the XXXI ESCRS Congress in Amsterdam.

Dr Auffarth said that the technology dates back at least 30 years, with very few of the patents for accommodative IOLs lodged with the US patent office ever making it to market. He said that many clinical studies have been conducted on forward-shift lenses such as the CrystaLens (Bausch + Lomb), the Synchrony lens (Abbott Medical Optics Inc) and the 1CU (HumanOptics AG).

A meta-analysis by Findl et al in 2007, which looked at randomised controlled studies of the 1CU, the CrystaLens and the BioComFold (Morcher), reported that the visual acuity results showed moderate to no improvement in near visual acuity compared with control IOLs, and a statistically significant but small and inter-patient variable anterior shift of the IOL optic after pilocarpine stimulation.

The difficulty of reliably measuring pseudophakic Gerd U Auffarth accommodation using a variety of subjective and objective measurement methods was underscored by a recent study by Uthoff et al, said Dr Auffarth. In that study, 21 patients implanted with the 1CU lens were examined over an average period of 34 months. The results showed a large variation of the measured accommodative effects with both methods.

“They concluded that a differentiation of pseudophakic accommodation and pseudophakic pseudo-accommodation was not possible with the methods applied in the study. There was also no correlation found between visual outcome and actual movement of the optic. Some patients showed no movement and had good near visual acuity while others had more significant movement of the optic but did not obtain good near vision,” said Dr Auffarth.

Comparing the performance of accommodating IOLs to monovision solutions, Dr Auffarth cited a recent study by Beiko et al in which 31 patients were randomised to bilateral implantation of one of three IOLs: the CrystaLens, the Tetraflex IOL (Lenstec), or the Tecnis (AMO Inc) one-piece monofocal control IOL. Dr Beiko’s study concluded that there were no statistically significant differences between the three IOLs in terms of visual acuity or contrast sensitivity and that single-optic accommodating IOLs did not offer a significant advantage in near visual acuity over mini-monovision with a monofocal IOL.

COST EFFICIENT COMPATIBILITY PRECISION ENGINEERED BI-MANUAL AND MONOMANUAL I/A HANDPIECES FOR MULTIPLE USE co-axial and bi-manual models validated for 10 autoclave sterilisation cycles • sterile packed, ready to go • 20, 21 and 23G versions available for incisions a small as 1.8 mm • silicone sleeve technology for improved chamber stability • no wound leakage • engineered to high precision standard • •

Medicel AG 9427 Wolfhalden SWITZERLAND

Tel. +41 + 41 71 727 10 50 info@medicel.com www.medicel.com

Gerd U Auffarth: ga@uni-hd.de Eurotimes | july/august 2014

9

Cataract & refractive

PRESBYOPIA

Corneal and lenticular approaches available for spectacle independence after cataract surgery. Roibeard O’hEineachain reports

T

he two main rivals for preventing postoperative presbyopia in patients who undergo cataract surgery are monovision and multifocal lenses, said Roberto Bellucci MD, University of Verona, Verona, Italy, at the 18th ESCRS Winter Meeting in Ljubljana.

Both approaches involve some compromise. With multifocal IOLs there tends to be a reduction in contrast sensitivity, compared with monofocal IOLs. With monovision treatment, there is a reduction in the distance vision acuity in the eye that has been made myopic.

Research suggests that patients with multifocal IOLs achieve higher rates of spectacle independence and higher levels of satisfaction than those with monovision.

He cited a recent published randomised study from Moorfields Eye Hospital in London, UK (Wilkins et al, Ophthalmology.

2013 ;120(12):2449-2455).

It compared the visual outcomes and satisfaction levels in 94 patients implanted with multifocal IOLs Tecnis® ZM900 (AMO) to the results achieved in 93 patients implanted with monofocal IOLs (Akreos® AO, Bausch + Lomb) targeted for emmetropia in one eye and -1.25 D of myopia in the other eye.

At four months' follow-up, 71.3 per cent in the multifocal group reported never wearing glasses compared to only 25.8 per cent in the monovision group (P<0.001). In addition, although distance visual acuity in the two groups was similar, the multifocal group had significantly better near visual acuity.

“This does not come as a surprise. The reason to consider monovision is not because multifocal IOLs don’t work, they do. But with monovision we get slightly better results for contrast sensitivity than we do with multifocals,” Dr Bellucci said.

He added that 35 per cent of those in the multifocal group said they had glare that was very annoying, compared to only 15 per cent of those in the monofocal group.

However, in terms of general satisfaction the multifocal group again prevailed, 58 per cent of patients said that they were very satisfied, compared with only 44 per cent in the monofocal group.

For patients who have already undergone implantation of monofocal IOLs, add-on multifocal IOLs can be an effective option, he said. Studies conducted to date with the lenses indicate that they provide basically the same multifocal visual acuity and optical quality as conventional multifocal IOLs. Eurotimes | july/august 2014

Courtesy of Roberto Bellucci MD

10

Ablation pattern of the hyperopic and myopic Supracor algorithm

Laser enhancement There are also many corneal refractive procedures available to pseudophakes who seek spectacle independence. They include various presbyopic LASIK procedures and a range of corneal inlays.

The most popular of the multifocal presbyopic LASIK approaches is the PresbyMax® (Schwind), which has central zone for near. It is available for both hyperopic and myopic eyes.

Another, newer LASIK ablation profile is the Supracor® (Bausch + Lomb), which also has a central zone for near. It is currently available for hyperopic and myopic eyes.

Dr Bellucci reported that he has used the Supracor presbyopic treatment in 12 eyes of nine patients who were hyperopic after they underwent cataract surgery. Six months after they underwent the LASIK procedure, uncorrected distance visual acuity was 0.10 logMAR and uncorrected near visual acuity at 40cm was 0.14 logMAR. “I had pretty good results and obtained good uncorrected distance and near vision in all these eyes and obtained the extended depth of focus for which PresbyLASIK treatment was intended,” Dr Bellucci said.

Corneal Inlays Finally, there are the corneal inlays which combine multifocality and monovision.

They exist in three types, all designed for unilateral implantation. They are the refractive annular microlens Flexivue

Microlens™, the small aperture Kamra Vision™ (AcuFocus) inlay and the space-occupying Raindrop® (ReVision Optics) inlay.

In a study in which five pseudophakic patients underwent implantation of the Raindrop inlay, the mean near, intermediate and distance visual acuities in the treated eyes were 20/20, 20/25 and 20/20, respectively, he noted (Tran et al, 2013 ESCRS Congress). A larger study with the inlay is due for publication soon, he added.

In another study, involving pseudophakic patients implanted with the Kamra inlay, mean uncorrected near visual acuity improved five lines from J10 to J4. Mean uncorrected distance visual acuity, corrected distance visual acuity and corrected near visual acuity remained stable and were 20/20, 20/16 and J1, respectively (Huseynova et al J Refract Surg, 2014 ; 30: 110-115).

Dr Bellucci concluded his presentation by cautioning surgeons to be attentive to the different age profile of pseudophakic patients, particularly when carrying out corneal procedures.

“Regardless of the treatment you apply to the cornea, you have to keep in mind that pseudophakic patients are generally older than phakic presbyopic patients.

They will therefore be more prone to eye surface problems such as blepharitis, dry eye syndrome and epithelial dystrophy,” he said.

Roberto Bellucci: robbell@tin.it

Cataract & refractive

RISING STANDARD

Epithelial Removal Has Never Been Easier

Restoring functional vision isn’t ‘premium’ surgery, it’s necessary. Howard Larkin reports

I

t’s time to let the concept of “premium” IOLs and cataract surgery die a natural death, Keiki R Mehta MD told the 2013 Congress of the ESCRS in Amsterdam.

There is no clinical definition of “premium” cataract surgery. What it means is that medical insurance does not cover the extra cost of advanced lens or small incision surgical equipment beyond the “standard” monofocal solution.

By that logic, no insurance at all would make every IOL a “premium” IOL, argued Dr Mehta, surgical chief and director of the Mehta International Eye Institute, Mumbai, India.

The term is misleading for patients, he said. “The patient must believe that doing better surgery, utilising more advanced lenses and techniques, is rational surgery and not premium surgery.”

Corneal Xlinking, PRK & Advanced Surface Ablation Improved Clinical Outcomes of CXL and PRK with Amoils Epithelial Scrubber

Go for the best But it’s a challenge helping patients accept the fact that if they want good, stable vision, with no aberrations, they should go for the best lens available.

“What we have to do is let the patient see the premium IOL as a necessity. Explain the three functional ranges of vision. A standard IOL will allow patients to see one out of the three ranges, but a premium IOL may allow them to have all three,” Dr Mehta suggested.

For the patient to believe, you must believe yourself. To help your patients you must believe in the superiority of the technology and in your ability to deliver it, Dr Mehta said.

That goes for staff, too. From the first visit to the optometrist to the OR team, everyone should understand everything about IOLs and be able to communicate their advantages to patients.

Regardless of how great premium IOLs are, problems arise, Dr Mehta said. “The higher the price of the lens, the greater the expectations.”

Be wary of patients with unrealistic expectations, stress that vision will improve over time, and set realistic expectations, Dr Mehta said. “Explain that post-op visual aberrations may occur and glasses may be needed for some activities. But stress the positives of functional vision all day as opposed to the problems driving an hour at night. Time is the best investment.

Under promise and over deliver,” he advised.

But realise that the unhappy patient is inevitable. Social networks are a big outlet for discontent. So turn it around by encouraging happy patients to tweet and Facebook their satisfaction, Dr Mehta suggested.

Most of all, help patients believe they are premium and their eyes deserve the most premium vision you can give, Dr Mehta said.

“It’s not premium vision, its necessary vision.”

Keiki R Mehta: drkeiki@mehtaeyeinstitute.com

The higher the price of the lens, the greater the expectations

• Uniform epithelium removal in only 5 - 7 seconds • Avoid alcohol damage to surrounding tissue • Minimize total procedure time • No need for subsequent scraping

T. +1 416.398.3306 F. +1 416.631.8272 | www.innovativexcimer.com

Keiki R Mehta MD Eurotimes | july/august 2014

11

Cataract & refractive

CROSS-LINKING Risks of routinely combining LASIK and CXL may outweigh potential benefit. Howard Larkin reports

G

iven how successful combined corneal collagen crosslinking (CXL) and excimer laser ablation has been in rehabilitating vision in ectasia patients, it’s tempting to suppose that routinely following LASIK with CXL might prevent iatrogenic ectasia. The prospect of undoing some of the corneal structural damage of LASIK, or reducing the need for careful topographic screening are also enticing – as is charging patients extra for CXL, George Kymionis MD, PhD, told the 2013 ESCRS Congress in Amsterdam.

However, the prophylactic effect of routine CXL has yet to be demonstrated, said Dr Kymionis, who has researched crosslinking and combined excimer-CXL procedures extensively at the University of Crete. Indeed, given that newer screening techniques have reduced post-LASIK ectasia rates to about one in 5,000 cases, an enormous study would be required to statistically validate the hypothesis.

patient to a lot of unknown postoperative risks,” Dr Kymionis said.

He believes there are better, proven ways to reduce the risk of post-refractive corneal ectasia. One reason post-LASIK ectasia rates are falling is that flap thickness is more controllable using femtosecond lasers, so it makes sense to use one, he noted.

Improved topography and tomography algorithms make it easier to detect abnormal corneal profiles, Dr Kymionis said. New biomechanical devices, such as the Ocular Response Analyzer (Reichert Technologies, Buffalo, NY, US) also help detect patients at higher risk. He recommends using these as well.

When a high-risk patient is identified, consider PRK or a phakic IOL instead of LASIK, or abort the procedure entirely, Dr Kymionis said. “Do not routinely perform CXL on a LASIK case until we can determine the risk and benefits.”

On the other hand, CXL exposes patients to several complication risks, Dr Kymionis said. These include corneal scarring, anterior and posterior corneal haze, corneal infiltrates, diffuse lamellar keratitis and endothelial cell damage. Longer exposure at surgery may increase infection risk.

Also, some known crosslinking effects raise as-yet unanswered questions about its routine use, Dr Kymionis said. Potentially significant issues include synergistic refractive effects that are not always predictable; long-term refractive changes due to progressive corneal flattening after CXL; and changes in post-CXL tissue ablation rates complicating re-treatment.

The long-term effect of routine UVA exposure on stromal keratocyte loss, including the possibility of corneal melting when keratocytes repopulate, is also unknown, as are long-term effects on the conjunctiva, corneal stem cells and the crystalline lens. “For a very low incidence of complications we are exposing the

George Kymionis: kymionis@med.uoc.gr

Across the page.

Across the room.

Across the years.

The KAMRA™ inlay provides a full range of vision and long-term performance, while leaving the natural lens in place.

UNCORRECTED NEAR VISUAL ACUITY (INLAY EYE ONLY)* 20/12.5 SNELLEN ACUITY

12

INLAY EYE

20/20

J2

20/32 20/50 20/80 20/125 20/200

LOSS OVER TIME IN EYE WITHOUT INLAY 0

10

20

30 MONTH

40

50

60

THE PRESBYOPIA SOLUTION THEY’VE BEEN WAITING FOR. ESCRS Booth #C01 KAMRA; the KAMRA logo; Across the page. Across the room. Across the years; and The Presbyopia Solution are trademarks of AcuFocus, Inc. ©2014 AcuFocus, Inc. CE Mark since 2005. The KAMRA inlay is an investigational device in the United States. It is limited by United States federal law to investigational use. All rights reserved. MK-1221 Rev B

Eurotimes | july/august 2014

Mean near acuity improved 3.2 lines to 20/25 at 1 month and was maintained over the 5 year follow-up. * Data presented by Prof. Dr. Günther Grabner at the 2013 DOC in Nuremberg, Germany.

Cataract & refractive

PHACO FLUIDICS Different fluidic settings are necessary for different surgical situations.

Roibeard O’hEineachain reports

D

ifferent strategies are necessary to achieve the ideal fluidic settings in phacoemulsification procedures, depending on such factors as the incision size, the instruments and techniques used, the stage of the cataract surgery, the density of the cataract and the experience of the surgeon, said Richard Packard MD, FRCS, FRCOphth, London, UK. “With all the different systems and techniques the basic issues are the same: matching instrumentation to incision size to avoid unnecessary leakage, providing adequate irrigation and adequate aspiration and vacuum for each surgical manoeuvre while at the same time maintaining a stable anterior chamber,” Dr Packard told the 18th ESCRS Winter Meeting in Ljubljana.

The goal in phaco fluidics is to maintain a balance between the inflow of saline solution and the outflow of fluid and lens matter, he said. That in turn will prevent a dangerous shallowing of the anterior chamber called “surge” that can occur following a break in the occlusion of the phaco tip.

Dr Packard noted that one common source of post-occlusion surge, namely aspiration tubing compliance, has largely been addressed by most of the major manufacturers. He noted that in earlier times the tubing attached to the handpiece was very flexible. Therefore, when there was full occlusion the tubing would decrease in volume, and when occlusion occurred the tubing would quickly expand and pull more fluid out of the eye than was going into the eye leading to anterior chamber instability.

In modern phaco systems the tubing is much stiffer. For example, the latest tubing in Centurion system (Alcon, Fort Worth, USA) is almost impossible to compress.

However, a range of factors must also be kept in mind when setting up the fluidics of a phacoemulsification machine. For example, the size of the phaco needle is very important because very small changes

in the diameter can increase the resistance to flow significantly.

He noted that current machines have different ways of maintaining infusion.

The most common infusion systems use gravity-feed. Here the pressure in the eye is determined by the height of the irrigation bottle. Some of the newer systems control the infusion in response to changes in outflow through compression of the irrigation bag, as in the case of the Centurion® system (Alcon).

The Stellaris (Bausch + Lomb) uses gasforced infusion to help maintain the anterior chamber depth, this occurs at a much higher pressure than gravity feed alone.

Two Types of Pumps With regard to aspiration of fluid there are two different types of pumps in use in phaco machines, the Venturi and the peristaltic pumps. The Venturi pumps work by passing compressed gas across a tube opening. That in turn creates a pressure differential resulting in vacuum at the tube’s distal end. Peristaltic pumps work by compressing the aspiration tube between rotating rollers.

With both types of pump, vacuum is preset depending on stage of operation, type of cataract and type of phacoemulsification procedure. For example, when using a divide-and-conquer approach, low settings of vacuum are optimal during the sculpting stage of the procedure, whereas higher vacuum needs to be enabled when removing pieces of nucleus.

In eyes with very dense cataracts these higher vacuum and flow settings are generally accompanied by an increased use of ultrasound.

“As you gain experience and get better at your surgery your surgery will move more quickly and you will find that you want to have higher settings,” Dr Packard said.

Dr Packard described the settings he used in a procedure he had recently performed with the Centurion system using a 1.8mm incision. The system has active fluidics with a number of parameters that may be adjusted as the surgery requires.

The first parameter is the Patient’s Eye Level, which will vary between surgeons depending on their height. Then there is the target intraocular pressure (IOP).

This can be set at high levels which is the equivalent of bottle heights used on most gravity feed machines for surgeons who like a firm eye. Alternatively a lower IOP may be used that approaches a more physiological level without a major reduction in fluidics parameters. This is controlled by the Irrigation Factor, which is how the machine will know to push more or less fluid into the eye, depending on the incision size and the needle size. It is possible to control the speed at which the chosen IOP is achieved.

In this particular case, for the chop and segment stage of the procedure Dr Packard set the IOP at 60 mmHg and he set the irrigation factor at 2.0 because it was a micro-incision procedure. However, he left the IOP ramp and vacuum rise at neutral settings because those parameters generally do not require adjustment in normal cataract procedures with this machine, he said. In addition, he put the ultrasound delivery at burst mode, with on-time of 35ms and an off-time 40ms, which he said provides good control with minimal use of ultrasound.

Richard B Packard: eyequack@vossnet.co.uk

As you gain experience and get better at your surgery your surgery will move more quickly...

Richard Packard MD, FRCS, FRCOphth

Türkiye TURKISH LANGUAGE EDITION ONLINE Visit: www.eurotimesturkey.org Eurotimes | july/august 2014

13

cornea

EYE CHAT Exclusive interviews Up to date information Problem solving

NANOTECH CORNEAS Carbon nanomaterials could enhance corneal stiffness.

Roibeard O’hEineachain reports

C

arbon nanomaterials can be safely implanted into corneal tissue and might be able to provide some biomechanical support to weakened corneas, reports Alfredo Vega MD, MSc, Vissum Corporación Oftalmológica and Universidad de Alicante, Alicante, Spain.

In an in vivo experiment involving 24 eyes of 12 white rabbits, corneas implanted with carbon nanotubes and graphene showed no signs of inflammation or scarring, with a trend towards increased corneal rigidity when examined at three months’ followup, Dr Vega told the XXXI Congress of the ESCRS.

Courtesy of Alfredo Vega

14

Masson Trichrome staining shows no inflammation and no foreign body giant cell reaction

Limbal Deficiency Challenging the Dogma Dr Oliver Findl speaks with Dr Harminder Dua about new approaches to treating limbal deficiency.

podcast

www.eurotimes.org

Also available on iTunes

Scan this QR code to gain access to EuroTimes podcasts

Graphene is a nanomaterial composed of a one-atom thick layer of carbon atoms arranged in hexagonal patterns. Carbon nanotubes are allotropes with a cylindrical nanostructure. Carbon nanomaterials have been used in several fields including aviation, telecommunication and robotics as well as for reinforcement of construction materials.

“The properties these materials share include high resistance, 200 times greater than that of steel and almost the same strength as that of diamonds. Moreover, they are inert and almost completely transparent,” Dr Vega said.

In their in-vivo study, the Vissum team implanted half of the rabbit eyes with a balanced salt solution mixed with carbon nanotubes and graphene in a corneal pocket at two different concentrations, 0.1 mg/ml and 1.0 mg/ml. The remaining eyes served as controls. At three months the animals were euthanised, Dr Vega explained.

He noted that in the treated eyes, staining of the corneal stroma samples with blue Alcian showed no signs of fibrous scarring and no alterations in the stromal mucopolysaccharides. It also showed no signs of active inflammation. Masson trichrome staining also showed no inflammation as well as no foreign body giant cell reaction. It also showed a strong adhesion of the tissue in the area surrounding the carbon nanomaterials (see figure).

In addition, biomechanical evaluation of stress-strain of measurements performed on the corneal tissues showed a trend to higher levels of rigidity in those samples treated with carbon nanomaterials compared to the controls.

“These carbon nanostructures are compatible with biological tissues including the cornea and there is enough scientific evidence in the literature that these nanostructures are able to interact with and improve the mechanical properties of the collagen fibres. We are working on improving the distribution within the corneal stroma, which we hypothesise should lead to a strengthening of the tissue,” he said.

Alfredo Vega: alfredovega@vissum.com

Eurotimes | july/august 2014

Courtesy of Mor Dickman MD

cornea

Anterior-Segment OCT (Cassia SS-1000, Tomey, Japan) images of a 509-μm thick organ medium preserved cornea prior to (above) and after (middle) dissection of a 23-μm PDAEK (Pre-Descemetic Automated Endothelial Keratoplasty) graft without profile correction

PRECUT TISSUE

Innovative microkeratome predictably harvests ultrathin grafts. Cheryl Guttman Krader reports

T

he use of pre-cut tissue for Descemet stripping automated endothelial keratoplasty (DSAEK) provides a safe alternative to surgeon-cut grafts. Surgeons performing DSAEK have been asking for thinner grafts (<100 microns) based on reports of better visual outcomes after transplantation of such ultrathin grafts.

According to results of a study reported at the 4th EuCornea Congress, the Gebauer SLc microkeratome is a reliable technology for safe dissection of ultrathin DSAEK grafts.

“Variability in thickness of lamellae cut with available mechanical microkeratomes creates a challenge to reliably harvesting ultrathin grafts without risking donor perforation.

Compounding this problem, the deeper microkeratome cutting heads that are required for dissecting the oedematous organ culture preserved tissues used by European eye banks are associated with higher standard deviation, resulting in greater discrepancies between requested and achieved thickness,” said Mor Dickman MD, University Eye Clinic Maastricht, The Netherlands.

The Gebauer SLc microkeratome is a motor-driven system that cuts ultrathin grafts with a single pass. It has an oscillating blade with a cutting speed of 10,000 rpm and a constant forward speed of 1.5 mm/ sec along with a built-in applanation plate that allows adjustment of lamellar diameter.

Its performance for harvesting ultrathin

DSAEK grafts and the effect of the dissection on endothelial cell viability was investigated in a study using 24 paired donor corneas considered unsuitable for transplantation for reasons other than endothelial pathology. The corneas were stored in organ culture medium (Minimal, Essential, Medium), underwent deswelling and then one eye of each pair was dissected and the fellow eyes were used as controls.

As measured by Fourier domain OCT, mean graft thickness was 65 microns right after dissection with a standard deviation of 13 microns. Mean graft thickness increased to 125 microns over the next 30 minutes and was unchanged during 2.5 days of storage in organ culture medium supplemented with six per cent dextran. Graft thickness was independent of both central corneal thickness measured prior to dissection and microkeratome slit width, said Dr Dickman.

Endothelial cell viability evaluated using trypan blue exclusion showed no significant differences in endothelial cell density (ECD) or morphology comparing the dissected and control corneas immediately post-dissection, 2.5 days later, or at any earlier time points.

Additional analyses of factors affecting endothelial cell viability showed lengthening of the interval between donor death and enucleation time was associated with faster ECD decline.

Mor Dickman: mor.dickman@mumc.nl

Variability in thickness of lamellae cut with available mechanical microkeratomes creates a challenge...

Mor Dickman MD

Learn what makes LENSAR® the intelligent choice for cataract surgery by visiting www.topcon.eu

© 2014 LENSAR, Inc. All rights reserved. LENSAR and the LENSAR logo are registered trademarks and Augmented Reality is a trademark of LENSAR, Inc. 05/14

Eurotimes | july/august 2014

15

13-17 September

2014

London XXXII Congress of the ESCRS

NEW

Poster Village • E-poster library • Presented e-posters • Interactive e-poster sessions

NEW

The Best of the Best Session An exciting selection of the best science from the Congress summarised in 1 session

www.escrs.org

Ridley Medal Lecture Professor G端nther Grabner Paracelsus Medical University, Salzburg, Austria

Four Decades of Cataract Surgery: Personal Visions for the Future

Main Symposia Corneal Cross-linking: Safety, Efficacy and the Unexpected Vitreoretinal Complications of Anterior Segment Surgery Why Bother with Femto-assisted Cataract Surgery?

What Really Works in Corneal Refractive Surgery?

Combined Surgery for Cataract and Glaucoma Targeting Emmetropia

sc aN me

Scan and watch the video to see why so many people are coming to London

Satellite Education Programme SATURDAY 13 SEPTEMBER

SATURDAY 13 SEPTEMBER

SATURDAY 13 SEPTEMBER

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

The VICTUS® Femtophaco Show Moderator: S. Daya UK P. Stodulka CZECH REPUBLIC The New 3rd generation VICTUS® femtosecond laser platform E. Mertens BELGIUM Moving to zero phaco S.P. Chee SINGAPORE 1001 routine and challenging cases

It’s Time to Make a Move.

The New FEMTO LDV Z8 Cataract System Moderator: T. Seiler SWITZERLAND L. Izquierdo PERU B. Pajic SWITZERLAND T. Seiler SWITZERLAND Sponsored by

Sponsored by

New IOL and Laser Technologies in Premium Cataract Surgery Sponsored by

Maximising Treatment Outcomes with Premium IOL Technologies Moderator: G. Auffarth GERMANY

Cataract Pre-op Screening, IOL Selection and IOL Power Calculation with the OCULUS Pentacam® Moderator: T. Neuhann GERMANY T. Neuhann GERMANY Pentacam® for general screening and detection of early ectasia T. Kohnen GERMANY Pentacam® as a comprehensive diagnostic tool for refractive corneal and lens surgery T. Olsen DENMARK IOL power calculation with ray tracing and Pentacam® Sponsored by

O. Findl AUSTRIA M. Amon AUSTRIA

MicroPulseTM for Glaucoma and Retina

Sponsored by Sponsored by

Croma Satellite Meeting Sponsored by

Topcon’s Cataract Solutions of the Future, Today Combining ALADDIN Biometry, the LENSAR Laser System and LENTIS Laser Lens

Refractive Surgery & Preserving the Cornea for the Future Sponsored by

Sponsored by

Evening Symposium 18.00

Heidelberg Engineering Satellite Meeting

Alcon Satellite Meeting Sponsored by Sponsored by

XXXII Congress of the ESCRS 13 – 17 September

SUNDAY 14 SEPTEMBER

SUNDAY 14 SEPTEMBER

SUNDAY 14 SEPTEMBER

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

Complex Cataract Cases – The Simple Truths Moderator: R. Osher USA R. Osher USA A new insertion and removal technology that simplifies the Malyugin Ring B. Malyugin RUSSIA Malyugin Ring technical pearls in IFIS: how to get out of trouble B. Little UK Traumatic resorbed cataract with fibrotic capsule Sponsored by

Optimising Surgeon Confidence and Patient Outcomes Leveraging Minimally Invasive Cataract Surgery

Precision Dry Eye Care in Refractive Surgery Sponsored by

Moderator: D. Allen UK - How Active Fluidics™ and target IOP influence anterior chamber stability during cataract surgery - New opportunities to optimize US efficiency Balanced Energy™ with Active Fluidics™ - The NSAID of choice for diabetics cataract surgery - AutoSert® Polymer I/A for the optimization of the lens implantation Sponsored by

To register your interest go to: www.escrs.org/london2014/ satellite-meetings.asp

Sharing Best Practice – How ZEISS Refractive Laser Solutions Result in Clinical Success Stories Moderator: D. Reinstein UK D. Reinstein UK Dispelling myths of SMILE with science: 1 day vision, optical quality and enhancements J. Alió SPAIN My experience with starting to SMILE and where I believe this will take us in the future O. Ibrahim EGYPT Expanding the applications of SMILE beyond the virgin eyes G. Carp UK The new excimer platform from Carl Zeiss: MEL90 M. Sachdeva INDIA Convincing results, happy patients and an effective business model- success all along with SMILE

Sponsored by

Cutting Edge Innovations for Maximizing Patient Outcomes Moderator: J. Stevens UK Sponsored by

Satellite Education Programme SUNDAY 14 SEPTEMBER

SUNDAY 14 SEPTEMBER

SUNDAY 14 SEPTEMBER

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

Use of Intracameral Cefuroxime

New Technical Developments to Improve Surgical Performance

Sponsored by

Moderator: A. Mohr GERMANY

Future Built-in – The Next Generation of Laser and Diagnostic Technologies Moderator: R. Bellucci ITALY R.E. Ang PHILIPPINES The TECHNOLAS® TENEO™ 317 in practice L. Buratto ITALY The new 3rd generation VICTUS® Femtosecond laser platform K. Liesto FINLAND SUPRACOR™ myopia – expanding the presbyopic treatment range D. Gatinel FRANCE Latest advances in diagnostic technologies Sponsored by

Leading Technology in Refractive Surgery Sponsored by

Rule your Toric Plan for Improved Refractive Outcomes with the LENSTAR LS 900 Sponsored by

G. Scharioth GERMANY Glaucolight canaloplasty for open angle glaucoma I. Dapena THE NETHERLANDS DMEK, 2014 update R. Lehmann GERMANY EVA in combination with 1.8 mm MICS and nano laser phaco surgery.

A. Mohr GERMANY DMEK my way!

G. Melles THE NETHERLANDS 15 Years of VisionBlue Staining Sponsored by

Bioanalogic WIOL-CF: Functional Principles and Practical Guidance to Optimize Clinical Outcomes Moderator: J. Güell SPAIN J. Güell SPAIN WIOL-CF functional principles M. Hlozanek CZECH REPUBLIC Extensive experience from prospective observational registry and retrospective, long-term (2-9 years) clinical evaluation of WIOL-CF R.E. Ang PHILIPPINES How use of femtosecond laser optimizes WIOL-CF clinical outcomes P. Stodulka CZECH REPUBLIC Optimizing WIOL-CF selection to maximize polyfocal optics benefit Sponsored by

Laser Vitreolysis and Retinal Rejuvenation Therapy (2RT) for Early AMD & DME: Two Revolutions in Nanopulse Lasers

IOLAMD – A New Surgical Approach to Managing Dry AMD

C. Van der Windt THE NETHERLANDS Details coming soon

B. Qureshi UK The need for IOLAMD in clinical practice

W. Heriot AUSTRALIA Details coming soon

P. Artal SPAIN IOLAMD system optics and design

M.J. Tassignon BELGIUM Details coming soon Sponsored by

Sponsored by

XXXII Congress of the ESCRS 13 – 17 September

SUNDAY 14 SEPTEMBER

MONDAY 15 SEPTEMBER

MONDAY 15 SEPTEMBER

Lunchtime Symposia

Lunchtime Symposia

Lunchtime Symposia

Boxed Lunch Included

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

13.00 – 14.00

OCT Findings in Cataract and Glaucoma Eye

Optimizing Cataract Surgery Outcomes with Innovative Technology

One Year Later: Clinical Highlights of the neXt Generation of LENTIS IOLs!

Sponsored by

Sponsored by

Achieving Reliable, Repeatable Outcomes with a Small Aperture Corneal Inlay

Orbis Satellite Meeting

Sponsored by

Evening Symposia 18.00 Optimise your Cataract and Refractive Workflow with Alcon Technology Moderator: B. Aslan TURKEY - Introducing Centurion® vision system: gravity infusion vs Active Fluidics™ - Balanced tip: minimizing wound stress and optimizing lens fragmentation efficiency - Toric IOL integration with Verion planning: my personal approach - Excimer and femto laser integration for treating refractive patients Sponsored by

Sponsored by

Moderator: G. Grabner AUSTRIA Sponsored by

360° Overview on Astigmatism Surgical Management: 3D Alcon Visionarium Moderator: R. Nuijts THE NETHERLANDS - Why toric IOL for astigmatic cataract patients: is this the best option?

- Optimizing surgical planning and IOL positioning through VERION vision system - Customization of astigmatism treatment with Wavelight refractive suite Sponsored by

This is a preliminary programme and is subject to change

Trifocal IOL: A Must in Premium Refractive Surgery Moderator: S. Daya UK S. Daya UK Introduction & refresh on the FineVision optical concept P. Stodulka CZECH REPUBLIC Laser assisted MICS + FineVision (Micro F) – special handling of lens with 2,5 years follow-up E. Mertens BELGIUM New FineVision design (Pod F) combined with femto laser cataract: 6 months follow-up. Tips & tricks R.E. Ang PHILIPPINES Visual outcomes and rotational stability with FineVision Toric combined with femto laser cataract All Speakers Discussion: what about the trifocal conversion rates?

S. Daya UK Questions & Answers Sponsored by

Cornea

ECTASIA

practice management

escrs

Increased oestrogen levels may trigger late-onset post-LASIK ectasia in borderline corneas.

& development

13 – 15 september

Howard Larkin reports

london, uk

marketing prize 2014

call for eNtries ophthalmologists and practice staff are invited to submit presentations that show how their marketing campaigns are being used to promote their practices.

priZe €1,000 Bursary for XXXiii congress of escrs, Barcelona 2015

to enter email colin@eurotimes.org

B

A

study examining the physiology of the human cornea during pregnancy and after delivery is nearing completion, Farhad Hafezi MD, PhD of Geneva University Hospitals, Switzerland, told the 2013 ESCRS Congress in Amsterdam. It focuses on the role of increased oestrogen on corneal biomechanics during pregnancy which has been observed during pregnancy as much as nine years after LASIK. The study began in 2011 and concludes this year, Dr Hafezi said. It is examining corneal physiology using Scheimpflug imaging to detect changes in topography as well as the Ocular Response Analyzer (Reichert Technologies, Buffalo, NY, US) and Corvis (Oculus, Wetzlar, Germany) to measure changes in corneal biomechanics. Oestrogen levels are also being recorded and correlated with corneal biomechanical changes.

The study builds on previous findings of oestrogen receptors in the cornea and of the fact that oestrogen may upregulate collagenases via prostaglandin release, Dr Hafezi said. Oestrogen exposure reduces biomechanical strength in vitro, and pregnancy-related exacerbation of keratoconus and iatrogenic keratectasia have been reported.

“Pregnancy may affect biomechanically borderline corneas,” he said.

Dr Hafezi recounted an early case he observed. A 33-year-old woman had LASIK in late 2000, and her vision remained stable for over two years. In early 2003 she became pregnant and reported a decrease in vision.

Examination revealed a shift from 20/20 uncorrected to 20/63 with -3.5 sphere and -4.0 cylinder at 90 degrees in her right eye, and 20/50 with -5.0 sphere and -4.5 cylinder at 140 degrees in her left. Kmax values in her right eye had climbed from 41.3 after surgery to 44.0 by the end of her pregnancy.

“We didn’t dare touch a pregnant woman with corneal cross-linking (CXL), so we followed her,” Dr Hafezi said. Her ectasia continued to progress, with Kmax reaching 49.3 in January 2005, when she was treated with crosslinking. Her ectasia then regressed. When she became pregnant again in February 2007, her right eye visual acuity again deteriorated sharply, and her Kmax rebounded from 46.4 to 49.0 (Hafez et al. JCRS 2008).

A second case series by Dr Hafezi and colleagues examined five cases of late-onset post-refractive ectasia in pregnancy, ranging from four to nine years after LASIK. All five were treated successfully using standard protocol CXL (Hafezi et al. J Refract Surg.

2012 Apr;28(4):242-3).

“CXL after pregnancy gives amazing results,” Dr Hafezi said. However, additional research is needed to identify risk factors for pregnancy-related ectasia.

Farhad Hafezi: farhad@hafezi.ch

closing date friday 22 august

U I L

Courtesy of Farhad Hafezi MD

22

D Bilateral iatrogenic keratectasia that occurred in a 32-year-old patient during pregnancy, five years after LASIK

Eurotimes | july/august 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

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

J. Güell SPAIN

Satellite Education Programme Lunchtime Symposia (Boxed Lunch Included) 13.00 – 14.00 FRIDAY Allergan Satellite Meeting

SATURDAY Treating Non-healing Corneal Epithelial Defects

Sponsored by

Moderator: H. Dua

Assessment of Dynamic Corneal Response with the Corvis® ST Applications for Refractive Surgery, Crosslinking and Glaucoma Moderator: R. Ambrosio Jr.

BRAZIL

R. Ambrosio Jr. BRAZIL Tomography and biomechanics for enhanced ectasia diagnosis: update 2014 C. Roberts USA The influence of IOP on corneal deformation characteristics

UK

H. Dua UK Persistent epithelial defects – diagnosis and clinical manifestations U. Pleyer GERMANY Update on medical and surgical management B. Cochener FRANCE Regenerating agents: a new alternative in matrix therapy for tissue regeneration Sponsored by

Sponsored by

To register your interest go to: www.eucornea.org/london2014/satellite-meetings.asp

www.eucornea.org

glaucoma

HIGH-PRESSURE YOGA Head­-downward yoga postures may place glaucoma patients at higher risk of progression. Roibeard O’hEineachain reports

C

ertain yoga postures can increase intraocular pressure (IOP) dramatically while others can slightly reduce it and that could have implications for glaucoma patients who practise yoga, said Isabel Signes-Soler PhD, MSc, FAAO, University of Valencia, Spain at the XXXI Congress of the ESCRS in Amsterdam.

She presented a study which showed that IOP nearly doubled when yoga practitioners took the Adho Mukha Svanasana (or downward-facing dog) yogic posture, but decreased by 16 per cent when they adopted Mukha Svanasana (upward-facing dog) yogic posture.

The study involved 20 eyes of 10 patients between 27 and 50 years of age.

The researchers measured IOP before and during the yoga positions, or asanas, with a rebound tonometer.

Patients stayed in each yogic posture for 20 seconds just prior to IOP measurements and took a 15 minute break between each yogic position, Dr Signes-Soler said.

Dr Signes-Soler and her associates found that the patients’ mean IOP was 16.6 mmHg while in a resting position before taking the yoga postures, but it rose to 33.0 mmHg during the downwardfacing dog position, amounting to a 1.98fold increase. In contrast, when patients were in the upward-facing dog position, their IOP was 16 per cent lower than it was when they were in a resting position at 14.4 mmHg. She noted that concern over the possible adverse effects of some yoga postures on IOP and optic nerve health has been a subject of study for several decades. In particular many previous studies have implicated the use of the Sirsasana (headstand) yogic posture as a risk factor for the progression of glaucomatous disease.

Examples, include two case-studies involving glaucoma patients whose rapidly progressing optic neuropathy appeared to be associated with the

Dog facing down posture

Dog facing up posture

routine practise of the headstand yoga posture (De Barros et al Ophthalmic Surgery, Lasers & Imaging 2008, 39(4):339-340) and (Gallardo et al, Adv Ther. 2006; 23(6):921-5).

In both case-studies, and similar to this study, the authors were able to

It can be concluded that IOP is affected by the different yoga postures Isabel Signes-Soler PhD, MSc, FAAO

demonstrate that there was a dramatic increase in IOP in the patients when they were in the headstand posture compared to a resting posture, “It can be concluded that IOP is affected by the different yoga postures. The transient elevation of intraocular pressure during some yoga exercises should be considered, especially in patients diagnosed with glaucoma. Moreover, the practise of yoga should be done under the supervision of qualified staff as it may involve risks associated with certain positions,” Dr Signes-Soler added.

Isabel Signes-Soler: isabel@onvivim.com

Eurotimes | july/august 2014

Courtesy of Isabel Signes-Soler PhD, MSc, FAAO

24

glaucoma

IMPROVE COMPLIANCE Study reinforces messages on motivating patients in their own care. Cheryl Guttman Krader reports

T

he problem of sub-optimal adherence to glaucoma medication is well-documented and provides an impetus for developing strategies to improve patient behaviour.

To that end, investigators at the Glaucoma Research Unit of the Norfolk & Norwich University Hospital Trust, Norwich, UK, undertook a randomised, controlled trial to evaluate whether a novel glaucoma education and motivational support programme could increase adherence among patients being initiated on IOPlowering treatment with a topical prostaglandin analogue.

A total of 208 patients were randomised to receive the intervention or standard clinical care, and more than 90 per cent of patients in both groups completed the eightmonth study. The study showed no statistically significant differences between the intervention and control groups in mean adherence rate (74.8 per cent vs. 77.2 per cent) or proportion of patients with at least 80 per cent adherence (66.7 per cent vs. 62.5 per cent).

Despite its null results, the study still contains messages about the importance of providing counselling and support to encourage adherence, according to Heidi Cate BSc, MSc, Glaucoma Research Unit Manager, and lead author of the published paper [BMC Ophthalmology. 2014;14(1):32].

“It is difficult to say precisely why we found Heidi Cate no benefit from our intervention. However, considering the relatively and perhaps surprisingly, high rate of adherence in the control group, it may be that the counselling received as part of the research process emphasised to all patients that good medication adherence is beneficial and necessary.

“The main message may be that patients in our study were well motivated to use their drops and strived toward good adherence.

Healthcare systems need to help patients achieve this goal by providing support and information, beginning when treatment is first prescribed and continuing throughout the course of care.”

Ms Cate said that the study was unique as it focused education and exploration of potential ambivalence to medication use at the point of initial diagnosis and prescribing. This timing was chosen because information from patient interviews and focus groups identifies it as when patients formulate attitudes and intentions about their newly prescribed medicines.

Questionnaires completed during the study showed the intervention patients had higher satisfaction with information received about their medication than the controls. Ms Cate told EuroTimes that further qualitative research with the study participants suggested that the intervention patients were more engaged with the “care process” and felt empowered to ask more questions about their diagnosis and treatment. “Patients who ‘engage’ and take ownership of their care and treatment may stay adherent for the lifespan of their disease. Greater satisfaction with care also works to improve the patient-doctor relationship and may improve the belief that medication is beneficial and lead to better adherence over a lifetime of use,” she said.

Heidi Cate: heidi.cate@nnuh.nhs.uk Eurotimes | july/august 2014

25

Glaucoma Day2014 ESCRS

Friday 12 September Registration Fee â&#x201A;Ź150

www.escrs.org

Scientific Programme organised by

A New and Unique Fixed Combination Lunchtime Sponsored by

retina

27

therapy Limitations PDGF inhibitors could reduce anti-VEGF resistance.

A

gents that block the activity of platelet derived growth factor (PDGF) offer a new front in the battle against age-related macular degeneration (AMD).

Ongoing clinical trials suggest this approach could help overcome some of the limitations of current anti-VEGF therapy, Donald J D’Amico MD told a session of the World Ophthalmology Congress in Tokyo.

While there is no doubt that treatment of exudative AMD with anti-VEGF agents including ranibizumab (Lucentis) and bevacizumab (Avastin) has provided considerable benefits, recent follow-up studies indicate that the effects of these agents can diminish over time, noted Dr D’Amico, professor and chairman of ophthalmology at Weill Cornell Medical College and ophthalmologist-in-chief at the New York Presbyterian Hospital.

He cited two studies in particular to support his point.

The Seven Up study (Ophthalmology, 2013 Nov;120(11):22929.) looked at long-term outcomes seven to eight years after initiation of intensive ranibizumab therapy from three wellknown clinical trials, ANCHOR, MARINA and HORIZON. Patients tended to show marked improvement in the initial three- or four-month treatment period, followed by a plateau effect. The study found that after long-term anti-VEGF therapy, a significant percentage of patients had regressed with poor visual outcomes.

Flexible treatment schedule The SECURE study (Ophthalmology. 2013;120(1):130-139) also looked at long-term results of treatment with ranibizumab.

That study followed more than 200 patients for two years who received ranibizumab on a flexible treatment schedule. In that study, patients also showed improvements in the beginning stages, then tended to lose best-corrected visual acuity over the longer term.

These and related findings have given rise to the concept of anti-VEGF resistance. Cancer researchers first reported this phenomenon more than 10 years ago. Research implicates pericytes, cells that produce vascular endothelial growth factor to proliferating endothelial cells, as an important factor in anti-VEGF resistance. PDGF in turn drives the recruitment of pericytes.

It now appears that drugs that inhibit PDGF could help reduce neovascularisation, particularly when administered with anti-VEGF agents, said Dr D’Amico.

An international Phase II randomised, double blind study compared the efficacy of ranibizumab alone versus ranibizumab plus a platelet derived growth factor inhibitor, Fovista (Ophthotech).

Patients receiving the combination Donald J D’Amico MD

It now appears that drugs that inhibit PDGF could help reduce neovascularisation, particularly when administered with anti-VEGF agents

Courtesy of Donald J D’Amico MD

Sean Henahan reports

Chronic and recurrent wet AMD

showed statistically significant clinical responses compared to those receiving ranibizumab alone. In particular, patients in the combination groups showed a mean gain of 10.6 letters from baseline, compared with 6.5 letters for those on monotherapy. Fovista was well tolerated, with no safety concerns.

The hope is that such combined therapy approaches could help to overcome limitations of current therapy, extending the duration of effect and even creating the conditions for regression of choroidal neovascularisation, he noted.

Clinical trials A Phase III study of ranibizumab/Fovista combination therapy is now under way. Initial results from that study could appear as early as 2016. The company also announced clinical trials with Fovista in combination with bevacizumab, and Fovista in combination with aflibercept (Eylea, Regeneron). Regeneron, for its part, is reported to be collaborating with Bayer to develop its own PDGF-inhibitor for possible combination therapy with aflibercept.

Ophthotech has another drug in development, Zimura, that is designed to interrupt the macular disease process at another step in the disease process, complement-mediated inflammatory component. The new compound is a chemically synthesised aptamer that inhibits complement factor C5, a central component of the complement cascade believed to be involved in the development of AMD.

Improvements in visual acuity In a Phase II clinical trial that combined Zimura and anti-VEGF treatment, treatment naïve patients showed improvements in visual acuity throughout the 24-week study. Additional clinical trials are planned to evaluate the complement inhibitor in the treatment of geographic atrophy, and in patients with antiVEGF resistant exudative AMD. Ophthotech announced recently that the company would collaborate with Novartis to develop Fovista commercially.

Novartis will provide as much as $1bn dollars to support clinical development and clinical trials of the drug. If and when the drug gains regulatory approval, Novartis would have the right to market the drug outside of the US, while Ophthotech would retain American marketing rights.

Donald J D’Amico: djd2003@med.cornell.edu Eurotimes | july/august 2014

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 MAIN SESSIONS

EURETINA LECTURE

The Eye & The Brain

Robert MacLaren UK

Diabetic Retinopathy

Gene Therapy for Retinal Disease – What Lies Ahead

Translational Research Tumours Neovascular AMD Dry AMD Imaging Vein Occlusion

KREISSIG LECTURE Johanna Seddon USA

Understanding the Mechanisms and Etiology of Macular DegenerationGenetics and Modifiable Factors

Retinal Detachment / Innovative Vitreoretinal Surgery

www.euretina.org/london2014

membership UNLOCK A WORLD OF BENEFITS INCLUDING: Reduced Registration Fees

EURETINA is delighted to announce the 3rd Retina Race

Annual EURETINA Membership Directory Access to EURETINA on Demand Access to Ophthalmologica

The Official Journal of EURETINA

Date: Saturday 13 September, 06.30

Access to Online Members Area

Location: ExCeL, London Registration Fee: £25 in aid of Orbis

For more information

www.euretina.org

www.euretina.org

Satellite Education Programme THURSDAY 11 SEPTEMBER

FRIDAY 12 SEPTEMBER

FRIDAY 12 SEPTEMBER

Morning Symposium

Morning Symposia

Morning Symposia

10.00 – 11.00

10.00 – 11.00

10.00 – 11.00

Ranibizumab: Compelling Evidence and Clear Guidance in Myopic CNV Management

Aflibercept and the Evolution of CRVO Management

Sucessful New Clinical Approaches with Diagnotic and Intra-operative OCT

Moderator: A. Tufail UK

Moderator: A. Lotery UK

Moderator: S. Binder AUSTRIA

Sponsored by

A. Lotery UK Welcome and introduction

S. Sadda USA Next generation OCT imaging

B. Eldem TURKEY Aflibercept: leveraging efficacy and the window of opportunity

A. Gaudric FRANCE Macular pseudoholes and lamellar macular holes: role of en face OCT in the diagnosis and post-operative assessment

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Allergan Satellite Meeting Sponsored by

A. Loewenstein ISRAEL Beyond clinical trials: the proactive treat-and-extend approach S. Michels SWITZERLAND Treat-and-extend in the clinic: case study review Sponsored by

Ranibizumab: Optimizing Benefits and Risks in DME Management Moderator: C. Pruente SWITZERLAND Sponsored by

Faster and Smaller in Retina Surgery: A Video Presentation of New Technologies and Techniques Moderator: P. Dugel USA Sponsored by

S. Binder AUSTRIA Intrasurgical continuous OCT guided surgery

Sponsored by

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 DME: When Every Letter Counts Moderator: J-F. Korobelnik FRANCE M. Evans UK What ophthalmologists need to know about diabetes J. Arnold AUSTRALIA Evidence for a proactive anti-VEGF treatment regimen J. Arnold AUSTRALIA, J-F. Korobelnik FRANCE, S. Wolf SWITZERLAND Clinical conversations: impact of treatment regimen on patients and clinics Sponsored by

14th EURETINA Congress 11 – 14 September

FRIDAY 12 SEPTEMBER

FRIDAY 12 SEPTEMBER

SATURDAY 13 SEPTEMBER

Lunchtime Symposia

Lunchtime Symposia

Morning Symposia

Boxed Lunch Included

Boxed Lunch Included

10.00 – 11.00

13.00 – 14.00

13.00 – 14.00

Ranibizumab: Expanding Horizons in RVO Management

Stellaris® PC Next Generation – Latest Advances in Combined Surgery

Ocriplasmin: Beyond Clinical Trials into Real-World Experience

Moderator: P. Lanzetta ITALY

Moderator: P. Dugel USA

Y. Le Mer FRANCE First experiences with the next generation system

I. Pearce UK The treatment experience with Ocriplasmin: the safety profile from pivotal trials and post-marketing

Moderator: J. Monés SPAIN Sponsored by

Swept Source: 3rd Generation OCT Moderator: P. Patel UK J.M. Ruiz Moreno SPAIN Study by “En Face” sweep-source OCT of pigment epithelium detachments (PED) U. Thelen GERMANY Early detection of glaucoma and/or neurologic defects under observance of GCL G. Anastassiou GERMANY Tumor detection with Swept Source

F. Faisal JORDAN Update on the management of complex cases F. Hengerer GERMANY Instrumentation for combined cases Sponsored by

Changing Perspectives in DMO: Recognising & Understanding Chronic DMO

See the Impact of Oraya Therapy on Wet AMD Patients

Moderator: U. Chakravarthy UK

Moderator: T.L. Jackson UK

A. Augustin GERMANY The role of inflammation in chronic DMO

New Advances in Retinal Imaging: Rapidly Improving Diagnosis & Treatment Outcomes

Y.Yang UK Overview of ILUVIEN in chronic DMO

P. Stanga UK Improving treatment outcomes by targeting vascular peripheral disease in diabetic retinopathy S. Sadda USA Peripheral retinal nonperfusion and treatment response in retinal vein occlusion Sponsored by

I. Pearce UK, P. Dugel USA, P. Stalmans BELGIUM Panel discussion on patient cases Sponsored by

Sponsored by

Moderators: S. Sadda USA P. Stanga UK

P. Dugel USA Ocriplasmin efficacy in clinical practice: defining patient profiles and intial real world outcomes

U. Chakravarthy UK Review of 3 Year INTREPID Safety Results I. Rennie UK Safety aspects of using radiotherapy for treating the retina

M. Diestelhorst GERMANY Understanding and managing steroid induced elevation of IOP in the context of the FAME studies

T. Aslam UK One year patient results and observations in the UK

P. Massin FRANCE Real-world experiences with ILUVIEN

I. Keskinaslan, K. Hatz SWITZERLAND One year patient results and observations in Switzerland

Sponsored by

To register your interest go to: www.euretina.org/london2014/ satellite-meetings.asp

S. Grisanti GERMANY Patient selection for best wet AMD outcomes C. Brand UK Oraya therapy in the NHS and treatment of the naive patient Sponsored by

Satellite Education Programme SATURDAY 13 SEPTEMBER

SATURDAY 13 SEPTEMBER

SATURDAY 13 SEPTEMBER

Morning Symposia

Lunchtime Symposia

Lunchtime Symposia

10.00 – 11.00

Boxed Lunch Included

Boxed Lunch Included

13.00 – 14.00

13.00 – 14.00

Allergan Satellite Meeting Sponsored by

New Technical Developments to Improve Surgical Performance Moderator: P. Stalmans BELGIUM

Lunchtime Symposia Boxed Lunch Included

13.00 – 14.00 Is Now the Time to Challenge our Treatment Approach in Wet AMD? Lessons Learned from Patient and Clinical Experience Moderator: P. Lanzetta ITALY P. Lanzetta ITALY Evolving priorities in wet AMD management – the increasing importance of regimen and practicality P. Mitchell AUSTRALIA, J. Talks UK Putting trial results into clinical practice: real-life evidence and experience P. Lanzetta ITALY Matching treatment regimen to clinical, practical and patient priorities: the role for proactive treat-and-extend Sponsored by

Forging the Future in nAMD: The Role of anti-VEGF and Novel Therapeutic Targets Moderator: R. Hamilton UK Sponsored by

P. Stalmans BELGIUM My surgical experience with EVA in combination with 16.000 cuts Twin Duty Cycle (TDC) vitrectome F. Pavlidis GERMANY 27G surgery with the new EVA system and the Twin Duty Cycle (TDC) vitrectome P. Szurman GERMANY Surgery with new MVR style cannula systems, ultraspeed vitrectomy transformer and LEDStar endoIllumination

Retina, Choroid and Vitreous: The Impact of Latest and Advanced Imaging on Clinical Practice Sponsored by

Say No to Blindness with Second Sight’s Argus II Bionic Eye F. Arevalo SAUDI ARABIA Middle East: huge demand for treatment for RP S. Rizzo ITALY Beyond functional benefit

H. Heimann UK Tumor biopsies with the fantastic “Bornfeld” biopsy forceps

M. Mura THE NETHERLANDS Surgical pearls implanting Argus II bionic eye

T. Jackson UK Posterior staining surgery in combination with the EVA surgical system

P. Stanga UK Argus II, beyond retinitis pigmentosa P. Szurman GERMANY Comparing epiretinal and subretinal approaches

Sponsored by Sponsored by

This is a preliminary programme and is subject to change

ocular

ARVO HIGHLIGHTS Over 11,000 delegates gathered in Florida for the 2014 Meeting of the Association for Research in Vision and Ophthalmology. Sean Henahan reports

P

rogress in gene therapy for retinal disease

Researchers from Oxford University reported promising clinical results in a gene therapy trial of choroideraemia. Six patients received gene therapy via an adenoassociated viral vector. Six months after surgery, visual acuity improved by two lines and four lines in two patients in whose visual acuity was less than 20/30 at baseline, which was sustained at one year.

Visual acuity returned to within one line of baseline in the other four patients. Despite undergoing foveal detachment, there was improvement in retinal sensitivity in the treated eyes compared to the control eyes one year after gene therapy. Improvements in retinal sensitivity correlated to the total dose of vector administered. Treated eyes did show some mild progression of cataract, but showed no significant retinal thinning.

The researchers believe these results show the potential of gene replacement therapy when applied before the onset of foveal thinning, and validate the concept of subretinal gene delivery.

In a separate study, US researchers reported promising animal data of gene therapy to stop the progression of RPGR gene-associated retinitis pigmentosa. An AAV-mediated gene transfer of RPGR 1-ORF15 cDNA delivered at early, mid and late stages produced stable and long-term photoreceptor rescue for up to 90 weeks.

Urine test for RP gene A urine test for genes associated with retinitis pigmentosa (RP) would be a boon for clinicians and their patients.

Investigators at Bascom Palmer Eye Institute, University of Miami, determined that urinary dolichol profiles identified in patients with autosomal recessive RP might serve as quantitative biomarkers for dehydrodolichol diphosphate synthase, a key enzyme in dolichol biosynthesis. A study of patients including those with autosomal recessive RP, carriers of the DHDDS gene, and controls indicated that urine and serum testing could reliably determine if the gene was the disease causing form.

They conclude that the test could be readily adapted for clinical use.

New nystagmus treatment A new class of drugs could make a big difference in the treatment of nystagmus.

The discovery was entirely serendipitous.

A patient with nystagmus reported seeing better after accidentally spraying a nerve agent in his right eye. US researchers report that applying various concentrations of the agent in a canine model of the disease produced significant decreases in the nystagmus symptoms, along with reduced intraocular pressure.

AMD treat and extend One of the great debates among retina specialists is which anti-VEGF regime benefits patients the most. US and European researchers used a “treat and extend” approach, in which the frequency of office visits and injections were tailored to each patient’s individual response to therapy.

They followed 185 patients over a three-anda-half-year period. Using this approach, the average number of visits and injections was reduced from 12 to 8.3 times per year.

They observed that, contrary to previous clinical trial findings, monthly injections to counteract age-related macular degeneration (AMD) may not be necessary in all patients.

Follow-up analyses showed better longterm outcomes in patients with Type I neovascularisation, who appeared less likely to develop geographic atrophy.

New reversible glue An innovative thermoresponsive reversible adhesive offers a promising new technique for treating ocular trauma in the emergency setting. When pNIPAM )Poly(Nisopropylacrylamide), is applied to the eye, it warms up, sealing the wound while the patient is transported. Once at the hospital, surgeons would need only apply a cold saline solution to the eye, after which the glue can be removed easily with minimal discomfort.

fluid pressure from the brain maintained their ability to respond to light better than rats with lower pressure. They note that these findings give a potential clue as to why some patients with normal intraocular pressure go on to develop glaucoma, while others with elevated intraocular pressure do not.

Making stem cells from eyes, eyes from stem cells Two groups report the development of methods to convert non-embryonic stem cells into eye cells that could further research in ophthalmological regenerative medicine. One group of researchers described a technique for using induced pluripotent stem cells derived from human Tenon’s capsule fibroblasts to express retinal progenitor cell-related genes with the capacity to directly differentiate into retinal neurons in vitro. A second group describe a method of introducing stem cells to adding human insulin-like growth factor to human embryonic stem cells and induced pluripotent stem cells, and then forming three-dimensional retinal tissue.

New direction in glaucoma An observation that pressure from the fluid surrounding the brain plays a role in maintaining proper eye function could open a new direction for treating glaucoma. Australian researchers presented research based on a rat model indicating that elevating intracranial pressure can counterbalance elevated pressure in the eye, preventing the optic nerve from bending backward. Rats with higher Eurotimes | july/august 2014

33

ocular

space travel risk NASA probes vision issues in long-term space missions.

Dermot McGrath reports

L

ast October an OCT examination with a difference took place – approximately 370km above the earth.

The “patient” in this particular case was an astronaut and the “clinic” was the microgravity environment of the International Space Station (ISS). The OCT examination was carried out as part of NASA’s ongoing Ocular Health Study, which seeks to understand ocular changes in astronauts during long-term space missions.

Since its arrival at the ISS in June 2013, the OCT device (Spectralis, Heidelberg Engineering) has been used for eye examinations of ISS crew members every four weeks. The astronauts have all had OCT baseline examinations prior to their space missions, with the follow-up examinations in orbit allowing observation of possible ocular changes developing during the mission.

Astronauts also perform an additional series of in-flight tests to include IOP measurements, Fundus photography, ocular ultrasound and visual acuity testing.

As well as OCT examinations, each astronaut undergoes pre-flight, and postflight IOP measurements, dilated fundus examination with fundus photography, optical biometry, MRI, ocular ultrasound imaging and cycloplegic refraction.

Effect largely unknown Although physiologic and pathologic changes associated with the microgravity environment have been studied extensively in the past, the effect of this environment on the eye and brain remains largely unknown.

A landmark study published in Ophthalmology in 2011 found that space flights lasting six months or more can cause a spectrum of changes in astronauts’ visual systems. Varying degrees of disc edema, globe flattening, choroidal folds and hyperopic shifts after long-duration space flight have all been documented by NASA in recent years.

Of seven astronauts in the Ophthalmology study who spent at least six continuous months in space, six reported that their vision became blurry, to varying degrees, while on the space station. Vision changes usually began around six weeks into the mission and persisted in some astronauts for years after their return to Earth.

Such visual impairment, even if only transitory, has wide-reaching implications Eurotimes | july/august 2014

Japanese astronaut Koichi Wakata, performs SPECTRALIS OCT examination on board the ISS

for the future of space travel, and is being treated with appropriate seriousness

by NASA, Thomas H Mader MD, lead author on the 2011 Ophthalmology study told EuroTimes.

“Prolonged or persistent optic disc edema is potentially sight-threatening and could theoretically limit interplanetary space travel for some astronauts. The good news is that once NASA researchers first identified these ocular changes they immediately began a series of tests to quantify the extent and possible progression of these anomalies. Thanks to the onboard equipment such as OCT and fundus camera we now at least have some limited objective data to base an opinion on,” he said.

Research studies Dr Mader added that although the visual acuity problems appear, thus far, to be completely correctable with a new spectacle lens prescription, the research team is still very concerned about potential visual loss from chronic disc edema.

“At this point the focus of NASA ocular research is to carefully follow and critically evaluate data as it is acquired and to conduct prospective research studies to understand the mechanisms involved. Hopefully this information will help us to sort out who may be most at risk for visual impairment during long duration space flight,” he said.

While it is still too early to pinpoint the exact cause of the visual disturbances experienced by certain astronauts on longer space missions, a number of

plausible theories exist, points out C Robert Gibson OD, an optometrist at NASA’s Flight Medicine Optometry Clinic.

“At this point we are simply not certain of the specific aetiology of our findings although a rise in intracranial pressure (ICP), an optic nerve (ON) compartment syndrome, and changes in intraocular pressure (IOP) have all been proposed as possible mechanisms,” he said.

While researchers hope that one day they might be able to identify risk factors for visual impairment during long-term missions, the current data is not sufficiently robust to allow anything more than tentative observations, said Dr Gibson.

“We simply have not examined enough astronauts pre, during and post mission to develop a list of proven risk factors. At this point the information we have suggests that men are more likely to have these ocular changes than women and the right eye is more likely to be involved than the left, but we do not have enough data to draw firm conclusions,” he said.

Intriguingly, Dr Gibson noted that a recent study on MRI imaging in 27 astronauts suggests that the ocular effects of space travel may have a dose-response.

“In other words anatomical changes that occur during an early mission may set the stage for recurrent or additional changes when the astronaut is again exposed to the physiologic stress of repeat space flight,” he said.

Thomas H Mader: tmader@acsalaska.net Charles Robert Gibson: Charles.Gibson-1@NASA.Gov

Courtesy of NASA

34

paediatric ophthalmology

HIGH HYPEROPIA Refractive surgery a promising option for a minority of cases.

Roibeard O'hEineachain reports

T

here are some children with high hyperopia who are intolerant of spectacles or contact lenses but who appear to benefit significantly from surgical refractive correction, according to Ken Nischal FRCOphth, Children’s Hospital, University of Pittsburgh, US. “We know that hyperopia will not only cause amblyopia but will also have a behavioural effect if it’s left uncorrected. Nonsurgical management of high hyperopia is very successful in the majority of children.

However, there is a minority of children who don’t cope with conventional therapies and they are the ones we hope to help with refractive surgery,” Dr Nischal said at the XXXI Congress of the ESCRS in Amsterdam.

Studies have shown that, without correction, there is a high risk of amblyopia in cases where there is more than 4.0 D of bilateral hyperopia, anisometropic hyperopia of greater than 1 D or hyperopic astigmatism of greater than 1.5 D. Moreover, hyperopia can have permanently damaging consequences for a child’s fine motor skills and education.

There is a great volume of published research showing that children with hyperopia of greater than 4 D tend to have a lower level of educational achievement at primary school level.

Surgical approaches The types of refractive surgery available today for highly hyperopic children include corneal ablative procedures and phakic IOLs, Dr Nischal said.

In a study involving 47 children who underwent LASEK to treat up to 12.5 D of hyperopia, all eyes were within 2.0 D of emmetropia and, overall 41.7 per cent had improvements in their corrected distance visual acuity. Among children with hyperopia with anisometropia, 83 per cent of eyes were within 1.0 D of the fellow eye and 65 per cent had improvements in uncorrected visual acuity (Astle et al, J Cataract Refract Surg 2010 ; 36, : 260-267).

Dr Nischal noted that in cases where there was more than 5 D of hyperopia, the researchers applied a 0.02 per cent solution of mitomycin-C to the corneal surface for 60 seconds.

“I think it is a bit of a worry because we’re already talking about the possibility of ectasia from corneal refractive procedures in adults. The addition of mitomycin-C on a more elastic tissue, one that is going to continue to grow, I think that for me would be Ken Nischal FRCOphth a concern.”

We know that hyperopia will not only cause amblyopia but will also have a behavioural effect if it’s left uncorrected

Another finding of the study was that hyperopia appeared to diminish over time after LASEK rather than progress and patients came closer to the optimal refraction as the duration of followup increased. The study’s lead author has suggested that the progression that would normally occur is offset by the regression that usually follows correction of high refractive errors.

“We know refraction improves and that's good. But at this moment in time, do we know that it is safe? That is really the question we need to think about,” Dr Nischal said.

Another study involved 63 eyes of 46 patients who underwent LASIK to treat up to 6 D of hyperopia.

At 12 months' followup, 70 per cent had an improvement in their bestc o r r e c t e d visual acuity, and amblyopia decreased in 24 eyes, and disappeared completely in 20 eyes with no other treatment (Dvali et al, Journal of Refractive Surgery 2005, 21(5 Suppl):S614-6).

“My one word of warning is that children with behavioural problems rub their eyes a lot. If we’re going to do LASIK we have to be prepared for flap problems,” Dr Nischal said.

The literature concerning correction of high hyperopia in children with phakic IOLs is much more sparse, consisting of only two cases implanted with Artisan/Verisyse IOL. Dr Nischal noted that the greatest concern about the implants is that they might induce a progressive corneal endothelial cell loss.

“We know we have concerns about phakic IOLs because there are only two reputed reported cases, and because there’s endothelial cell loss in the high ametropes maybe the posterior chamber ICL would be a better bet,” he suggested.

Accommodative esotropia Regarding the use of refractive surgery for accommodative esotropia, there are 15 series of patients treated for PRK, LASIK and phakic IOL implantations. The studies showed that among eyes who got within 10 PD of orthotropia, over 90 per cent were successfully aligned without spectacle correction.

He noted that the complications occurring in the eyes undergoing LASIK included corneal striae in two series, diffuse lamellar keratitis in two series, and permanent corneal opacity in one series, and the need for enhancement procedures in one series. Most, but not all of the complications occurred in the paediatric cases.

“Surgery for high hyperopia should be considered in children who have multiple issues, including, but not limited to, neurodevelopmental and behavioural disorders. Parents and guardians of such patients should be made aware of the phakic IOLs and LASIK and LASEK,” he concluded.

Eurotimes | july/august 2014

35

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

15.00 – 17.00

SESSION IV: Ocular motor disorders

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

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

37

The power of one

Two types of incisions – one module

industry

NEWS

Chinese distribution IOPtima Ltd, a subsidiary of BioLight Life Sciences Investments Ltd has announced that it has signed an exclusive distribution agreement for the sale and marketing of the IOPtiMateTM system in China. As part of the agreement, IOPtima received a commitment that at least 100 systems will be purchased during the initial term of the agreement.

“The IOPtiMate system is a state-of-the-art system that is based on CO2 laser technology that enables the performance of a unique filtration surgery to treat glaucoma without penetrating the inner part of the eye. This allows for substantial reduction in postoperative complications and use of eye drops, compared with alternative treatments,” said a company spokeswoman. www.bio-light.co.il

Exclusively available for the FEMTO LDV Z6

CLEAR CORNEAL & ARCUATE INCISIONS

Long axial length normative database NIDEK has launched the long axial length normative database, which is software for use with its RS-3000 optical coherence tomography series. “This normative database is designed to assist clinicians in diagnosing macular diseases and glaucoma and was developed based with data from normal eyes (free

• • • • of ocular pathology) with long axial length,” said a company spokesman.

“Data was collected from Asian cases by measuring the macular area in 3-D to obtain retinal thickness values, such as full retinal and [NFL+GCL+IPL] thickness, which is important for the diagnosis of macular diseases and glaucoma,” he said. www.nidek.com

Custom-designed incisions Topographically matched Added precision and reproducibility Intrastromal incisions possible

www.femtoldv.com The Ziemer FEMTO LDV Z Models are FDA cleared and CE marked and available for immediate delivery. The FEMTO LDV Z6 is FDA cleared and CE marked for creation of corneal incisions in patients undergoing cataract surgery. For some countries, availability may be restricted due to local regulatory requirements; please contact Ziemer for details.

Eurotimes | july/august 2014 EuroTimes_jul2014_FEMTO_LDV_Corneal_Inscisions_Ad_93x266mm.indd 1

04.06.14 11:11

38

eye on technology

Figure A: Subluxated cataract; B: Capsular tension ring implanted; C: Glued capsular hook configuration; D: Glued capsular hook engaged; E: Post IOL implantation - haptic tucked into Scharioth tunnel, flap and conjunctiva glued; F: One month post-op showing well centred, stable IOL

NEW TECHNIQUE

Glued capsular hook for sutureless trans-scleral fixation of the capsular bag and its contents has many advantages.

S

ubluxated cataracts and IOLs are managed effectively by many of the current devices/ techniques available.

Smaller subluxations, less than one quadrant are managed by implantation of a capsular tension ring (CTR) whereas subluxations larger than one quadrant need scleral fixation of the capsular bag. This has been achieved effectively in the past by various sutured segments/rings available. However, all of these require suturing of the device to the scleral wall.

The inherent disadvantages of techniques involving suturing are the longer time taken, the greater level of skill required for suture fixation and the need to pass long and thin needles across the anterior chamber, all of which make surgery challenging. It also leads to risk of suture-related complications such as suture degradation, knot exposure, knot Eurotimes | july/august 2014

Soosan Jacob reports unravelling, delayed onset subluxation and so on. 9-0 prolene and Goretex have been used in an attempt to address these suture-related problems, however, they still leave issues related to the challenging nature of surgery unaddressed.

Capsule hooks/retractors have also been used during phacoemulsification for intra-operative support to the bag. They are introduced via paracenteses to engage the rhexis rim and hold the bag fixed to the limbus during cataract extraction and are then replaced by a sutured device for continued IOL centration and stabilisation in the postoperative period.

However, this makes surgery a two-step procedure, having to again perform a set of complicated manoeuvres for suturing in the device immediately after having removed the subluxated cataract.

Glued capsule hook/retractor This is a new technique that I started for eliminating complicated manoeuvring and increasing ease and rapidity of surgery in subluxated cataracts. This technique

avoids the need for suturing a device by continuing to utilise in the postoperative period, the same hook that is used during cataract surgery to centre the bag. The technique is as follows: The capsular hook is modified by straightening out the bend on its shaft and a new 90 degree bend given to the shaft. A lamellar scleral flap is created centred on the dialysis as done for sutured devices. Next, a 20-gauge needle is used to create a sclerotomy under the scleral flap. The needle is passed vertically until it crosses the plane of the posterior capsule of the lens and then directed horizontally.

This prevents the needle from touching the posterior capsule. A rhexis is then created centred on the anterior capsule.

The capsular hook is inserted through the sclerotomy between the iris and the anterior capsule and used to engage the rhexis.

Pushing the silicone stopper down centres and holds the bag in place.

Additional capsular hooks may be passed trans-limbally if greater support is needed for intra-operative manoeuvres. In case

eye on technology of larger subluxations additional transscleral hooks may be used evenly spaced around the limbus to obtain even support and good centration. Once the bag is thus stabilised, cortical cleaving hydrodissection is done followed by insertion of a standard CTR. This is because though the capsular hooks attach the capsular bag to the sclera, they do not expand the fornices, hence a CTR is mandatory. Nucleus extraction and cortical aspiration are carried out following standard precautions taken for a subluxated cataract. The IOL is then injected into the bag.

Once this is done, all trans-limbal hooks are removed and the trans-scleral hook/ hooks fixed into their final position. For this, a 26-gauge needle is used to make an intra-scleral Scharioth tunnel at the edge of the scleral flap. The hook is then held firmly with a needle holder at the sclerotomy and the silicone stopper removed. The haptic of the hook is cut to the desired length and is tucked into the intra-scleral tunnel. The degree of centration of the IOL is adjusted by adjusting the degree of tuck of the haptic.

Vitrectomy is done under the flap and both the scleral flap and conjunctiva are glued down using fibrin glue (see figures A-F).

Many advantages This technique, therefore, allows sutureless trans-scleral fixation of the

hook and thereby the bag to the sclera.

The advantages of this surgery are many.

It removes the element of suturing from the surgery which by itself removes technical challenges associated with passing long and thin needles across the anterior chamber, achieving centration etc. Surgery becomes easy and rapid. The hook is easy to pass into the anterior chamber trans-sclerally. It is easy to find the plane between the iris and the anterior capsule by inserting the hook at the correct angle and also if required by instilling viscoelastic under the iris in the affected quadrant and thereby creating space between the iris and the anterior capsule. If required, the hook may also be exteriorised through the sclerotomy in an ab-interno technique by introducing the haptic of the hook through the corneal incision into the jaws of a microforceps that is passed in through the sclerotomy.

The hook may be created from various materials of which PVDF and polyimide may be most suitable. This gives longevity to the scleral fixation and also does away with long-term issues related to suture degradation that are associated with 10-0 prolene and other sutures. The stability of the IOL is better than with sutured devices as it is not a suture but rather the intra-scleral tuck

of a significant portion of the haptic that fixes the bag trans-sclerally. For the same reason, pseudophakodonesis is also likely to be less with the glued capsule hook technique rather than with sutured devices. Centration is easy to achieve by adjusting the degree of tuck of haptic into the tunnel and one is not locked down into position as with sutured devices on tying down the suture.

To conclude, glued capsule hook is a new technique for sutureless transscleral fixation of the capsular bag and its contents and has significant advantages over other presently used techniques. * 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.

She has a patent pending for modified versions of the glued capsular hook.

Scan this QR code to go to video link for surgery

Don`t limit yourself to

Femto assisted cataract surgery!

S

LOND

S o m e benef i ts are:

O

h boot 2 0 D . o n

N

ESCR

Perform full cataract surgery with the new Nano Laser - at a fraction of the cost.

• F eather wei g ht s i ng l e us e hand pi ece • I/A wi th y o ur s tandard P haco m achi ne • N o m o v i ng needl e - no tem perature at the i nci s i o n

info@arclaser.com 2014_06_Anzeige EuroTimes_half Page.indd 2

10.06.2014 10:22:22

Eurotimes | july/august 2014

39

40

travel

Table with a view: City Social Restaurant

City Centre

3

DAYS IN...

LONDON EUROSTAR: Arrive by Eurostar at St Pancras Station.

WEATHER: Expect a little rain; monthly cumulative average is 49mm.

TAXIS: Call Radio Taxis on: 7272 0272.

See London from the 24th floor of Tower 42, London’s second tallest building; the City Social Restaurant offers a view of the Gherkin, the Cheese Grater and other quirky neighbours from every table. Diners who can look away from the glittering city below watch the action in the centrally located kitchen. If you want a closer look, book a seat at the Chef’s Table. The decor of City Social is elegant Art Deco and the menu showcases the best British ingredients. There’s a separate 85-seat bar serving cocktails inspired

by Scotch and American whiskies, gins and cognacs. Tower 42, 25 Old Broad Street, London, EC2N 1HQ. Reservations: 020 7877 7703 or email: reservations@citysociallondon.com.

View Canary Wharf from the fourth floor of the glass and metal Canada Place. Contemporary Eero Saarinen furniture sets the tone for the artistically presented cuisine of the Plateau Restaurant. Order either a la carte or treat yourself to a six course ‘dinner gourmand’. A similar menu gourmand is presented for vegetarians.

Either menu can be paired with wine. Plateau serves lunch Monday-Friday from12:00 to 15:00, dinner every day but Sunday 18:00 to 22:30. 4th Floor, Canada Place, London, E14 5ER. Telephone 020 7715 7100 or book online at: plateaureservations@danddlondon.com.

(Plateau is situated above Waitrose and Reebok.

Use the lifts on the right side of the building as you enter.)

Book a table at the Design Museum and enjoy magnificent views from Canary Wharf to the East through to Tower Bridge and the City to the West.

The museum’s Blueprint Café is only one floor up, but its window wall offers an unobstructed panorama of the river. Binoculars are offered so you don’t miss a thing. With luck, Tower Bridge may be raised while you are enjoying your meal. The three-course “market value” dinner is priced at £23. Other special offers are shown on the cafe’s website. Blueprint Café, The Design Museum, London, SE1 2YD Telephone 020 7378 7031. To be sure of a seat, book online at: blueprintcafe@danddlondon.com.

Eurotimes | july/august 2014

SPORT, WAR AND THEATRE

New attractions and revamped favourites await delegates to London congresses. Maryalicia Post reports It took 10 years to transform 568 acres of east London into the biggest new park Europe has seen in 150 years, but at last, Queen Elizabeth Olympic Park has opened to the public. Relive the thrills of the 2012 Olympics on a tour that takes in all the sights of the park and the highlights of the games. Tours start at the DLR Pudding Mill Lane station at 11am Thursday and Saturday. Book online at www.queenelizabetholympicpark.co.uk.

Alternatively, follow one of four selfguided trails. Crown your visit with the view from the ArcelorMittal Orbit. A lift zips you up 80 metres to the top viewing platform from which a panorama of London extends for some 20 miles. Book online at: www.arcelormittalorbit.com.

The Imperial War Museum reopens in time to honour the centenary of World War I. The museum unveils its groundbreaking First World War Galleries and the biggest exhibition of war art in 100 years, “Truth and Memory.” In addition, a new central atrium features some of the museum’s iconic artefacts, including a Spitfire from the Battle of Britain during World War II. The popular exhibits of “Secret War” and “War Story” have also reopened. New shops and a park-side cafe complete the transformation. Daily 10:00 to 18:00. Lambeth Road, Southwark, London SE1 6HZ. www.iwm.org.uk If you grow tired of the city and yearn for a “day in the country,” you can travel to Hampstead Heath on the edge of London. Kenwood House recently reopened after a 10-month restoration. This mansion, which owes its architectural beauty to an 18th century renovation by the Scottish architect Robert Adam, counts among its interiors a magnificent library. Kenwood’s last

private owner was Edward Guinness, first Earl of Iveagh. In 1927, Guinness donated the house to the nation along with its collection of paintings that features a Rembrandt self-portrait. There is a restaurant, cafe, acres of parkland (picnics welcome) and wonderful views over London. Open every day from 10:00 to 17:00. Admission is free. www.english-heritage.org.uk Experience theatre by candle light. A new ‘old’ theatre, the Sam Wanamaker Playhouse, opened earlier this year, to present performances as in Jacobean times when a similar theatre augmented the open-air Globe. Based on drawings of a Jacobean theatre auditorium by a protégé of Inigo Jones, the candle-lit Playhouse sits next to its open-air sister theatre, the Globe. To check what is on and to book, go to: www.shakespearesglobe.com.

Olympic Park viewing platform

BOOK Reviews

LET THERE BE FLUX The field of cataract surgery is in perpetual flux. Although the basics remain the same, new equipment and techniques are regularly made available to help the surgeon achieve the best possible outcomes.

Keeping up with this renewal can be time-consuming, but books can help us focus on PUBLICATION what’s important and what can CATARACT SURGERY AND be ignored. Cataract Surgery INTRAOCULAR LENSES and Intraocular Lenses (Slack), EDITORS

by Lucio Buratto, Stephen F LUCIO BURATTO, STEPHEN F BRINT Brint, and Domenico Boccuzzi, AND DOMENICO BOCCUZZI concentrates a great deal of practical information into a PUBLISHED BY SLACK INCORPORATED single 200-page book, third in the cataract series of five books published by Dr Buratto.

This book focuses on the different types of IOLs. “In today’s surgical universe, biometric errors are no longer acceptable; the surgeon is duty-bound to be fully aware of the wide range of IOLs available for implantation,” states the foreword.

After a short history of IOLs, Section 1 delves into the details of monofocal lenses, torics, multifocals, accommodative IOLs and so-called “Mix & Match” techniques in which a different lens type is implanted in each eye to fill the refractive gap left by a certain type of lens.

After the review of IOLs, the book considers such surgical topics as refractive cataract surgery, IOL exchange and correction of astigmatism. The text ends with a chapter titled, “Avoiding and Managing Patient Dissatisfaction After IOL Implantation.”

OCULUS Corvis® ST

BOOK

Highspeed Scheimpflug camera visualizes the future of diagnosis

WHEN THINGS GO WRONG What happens when things go wrong, and what you can do to correct them, is covered in Amar Agarwal’s new book, Management of Phaco Complications: Newer Techniques (Jaypee). This concise, 120-page book, co-written by Priya Narang, does not simply repeat the advice of its many predecessors. Instead, more advanced procedures are explained, such as sleeveless phacotip-assisted levitation of a dropped nucleus and various methods of fixating glued IOLs. Particularly interesting is the IOL scaffold technique, as it is a relatively simple solution to a devastating problem. Other techniques are more complicated, such as glued intrascleral haptic fixation of an IOL. The authors recognise this and include two interactive DVD-ROMs, which illustrate what to do with, for example, Descemet’s detachment or a dropped nucleus.

But what if the surgery goes well and the patient still has complaints? Chapter 13 covers dysphotopsias, both negative and positive, which can interfere significantly with the perceived success of surgery and lead to unrelenting patient dissatisfaction after an otherwise uncomplicated procedure.

Both texts are richly illustrated with intraoperative photographs and animated illustrations, and are appropriate for all residents and ophthalmologists who perform cataract surgery.

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

Please note: The availability of the products and features may differ in your country.

Specifications and design are subject to change. Please contact your local distributor for details.

REVIEWs

Highspeed Scheimpflug camera in combination with non-contact tonometer: •

Precise measurement of the IOP

•

•

Precise measurement of corneal thickness

Potential to measure biomechanical properties

•

Screening for ectasia

www.oculus.de

Eurotimes | july/august 2014

41

42

European Board of Ophthalmology

EBO promotes excellence in European education

Vesela Ivancheva (left), winner of the Alan Ridgway award is pictured with Prof Catherine Creuzot-Garcher, president of the EBO

HARMONISING STANDARDS

EBO exams harmonise standards and training for the benefit of ophthalmologists and patients.

A

Dermot McGrath reports

record-breaking 453 candidates from 28 European countries came to Paris this year to take part in the 2014 European Board of Ophthalmology Diploma (EBOD) examinations.

“I am delighted to announce that the 2014 examinations have once again attracted the highest ever number of candidates from more European countries than ever before. I want to say thanks and to pay tribute to you – the candidates and the examiners – because without you, the EBO would not exist.

Thank you for your commitment to the EBO and to the European spirit which is really what this organisation is all about,” said Catherine Creuzot-Garcher, president of the EBO. Held every year in Paris, the EBOD examination is designed to assess the knowledge and clinical skills requisite to the delivery of a high standard of ophthalmic care both in hospitals and in independent clinical practices.

Addressing the assembled audience, Jean-Francois Korobelnik, president of the Eurotimes | july/august 2014

French Society of Ophthalmology (SFO), said that SFO was honoured to host the EBO exams every year and he looked forward to continued collaboration in the future.

“As the president of the SFO I would like to welcome you all to Paris. This year we have made changes to make some more room available for the candidates and the examiners and I am very happy that everything went smoothly and that over 90 per cent of the candidates have succeeded in passing the examination,” he said.

Congratulating the candidates on their achievement, Prof Christina Grupcheva, Chair of the Education Committee of the EBO, said that the EBO was proud to have played its part in promoting a pan-European qualification that was increasingly recognised in the majority of countries in the region.

“It is not always easy to share across borders with so many different languages and cultures, but the EBO has shown that it is possible to harmonise standards and training for the benefit of our profession and also our patients in our respective countries,” she said.

The annual EBO examinations bring into focus a unique European spirit of cooperation and harmony, said Prof Christina Grupcheva, Chair of the Education Committee of the European Board of Ophthalmology.

“It is very difficult to harmonise so many different cultures and traditions and so many different languages, yet I believe that the EBO has shown that it is possible to work together for the benefit of European education and training in ophthalmology,” she said.

Prof Grupcheva said that EBO was continually striving to ensure that its examinations were as fair and balanced as possible for the hundreds of candidates who came from all over Europe Christina Grupcheva in search of the prized “FEBO” accreditation.

“We have done a lot of work in recent years in standardising the multiple choice questions (MCQs) and making them as objective as possible. We are also working on standardising the viva voce part of the exam to give everyone an equal chance of success,” she said.

Prof Grupcheva also paid tribute to the examiners who give so generously of their time and expertise to ensure the exam’s success.

In terms of future development, Prof Grupcheva said that EBO was currently in discussion with a number of European ophthalmic societies with a view to introducing sub-specialty examinations. “That will make the educational system and proficiency recognition in Europe more efficient and beneficial for our young colleagues,” she said.

Education has a leading role to play in harmonising standards across Europe, according to Prof Grupcheva.

“Harmonisation starts with the very first step in education. That is why the EBO is not only a judging institution but has many more roles in this process of delicate balancing between traditions and standards,” she said.

Jack J Kanski

The Polish-born ophthalmologist Jack J Kanski MD, MS, FRCS, FRCOphth was honoured at the EBO Diploma Award Ceremony as the recipient of the Peter Eustace Medal for his contribution to ophthalmic education in Europe.

European Board of Ophthalmology

An interesting and challenging exam Vesela Ivancheva (pictured on opposite page), Bulgaria, was the winner of the Alan Ridgway award for best MCQs result.

"The idea of taking the EBO examination was inspired a few years ago by EBO affiliated Bulgarian professors who have been introducing the exam among all residents to prove our knowledge and clinical skills in a high level competition.

My local Head of Department also encouraged me to sit the International Council of

Ophthalmology (ICO) MSQ examination. As I was sitting my Bulgarian state examination in May 2014 I decided to study for all examination challenges simultaneously.

The examinations were difficult and stressful, but at the same time fair, very interesting and challenging.

I like the format of EBO as it involves personal contact with real examiners.

I would recommend all Bulgarian residents to take the

examination in the future, for experience and also to prove that even though we are a small country we still have excellent training and knowledge.

My plans for the future are to continue my career in ophthalmology in Bulgaria, however, I am looking for subspecialty training (fellowship).

Over the next few months I will be finalising my PhD thesis on, ‘Corneal disease diagnosed by computerised technology.’”

A

B

C

I like the format of EBO as it involves personal contact with realAexaminers B C Vesela Ivancheva

A

B

C

'An objective view of knowledge' Daniel Zapp, Germany, was a joint

Daniel Zapp

overall winner, EBO Diploma exams 2014.

"My main motivation for taking the EBO exams was the possibility to have an objective view on where I stand in terms of knowledge compared to, not just my colleagues or local residents, but on a more European-wide scale.

It was a largely positive experience especially since I thought of it as a bonus examination, providing very good feedback on my standing

before taking my localised German Board examination.

I think everyone who has the opportunity to try and take the EBO exam should do so, if only for the experience of such a large and growing community of ophthalmologists coming together from all parts of Europe. I met people in Paris that I hadn't seen for years.

I think that the movement towards an EBO examination is an unstoppable and reasonable development that we will see continuing in the years to come.

I think everyone who has the opportunity to A try and take Bthe EBOC exam should do so, if only for the experience of such a large and growing community of ophthalmologists Daniel ZappA

B

C

A

B

C

A

B

C

A positive experience

Áron Szabó

Áron Szabó, Hungary, was the joint overall winner, EBO Diploma exams 2014.

"My main source of motivation for taking the exams was the head of our department, Andrea Facskó.

After having completed the Hungarian national specialist exam she encouraged me to submit my application for EBO. The test is a good way to screen a large number of candidates, although trueor-false questions, whether in medicine in general or

ophthalmology in particular are not always black and white.

The viva voce part of the exam was a lot of fun and I really enjoyed the rapid fire sessions of eight different topics. The one hour provided was over even before I had time to realise it began.

As for the future, I would like to specialise in glaucoma and start my PhD. Gaining experience abroad is sometimes necessary and I hope the EBO Diploma will be of benefit when needed."

Eurotimes | july/august 2014

43

44

ophthalmologica

ophthalmologica Clot-prone patients at higher risk for rvo

SAN DIEGO APRIL 17–21

A study comparing 139 patients with central (CRVO) and branch retinal vein occlusion (BRVO) with 40 healthy controls showed that those with the retinal conditions were also more likely to have known risk factors for blood clots. That is, the CRVO/ BRVO patients were significantly more likely than the controls to be homozygous for the methylene tetrahydrofolate reductase (MTHFR) C677T mutation and to have elevated factor VIII activity.

They also were more likely to have anticardiolipin antibodies (ACA), as well as elevated fibrinogen levels. F Risse et al, “Thrombophilia in Patients with Retinal Vein Occlusion: A Retrospective Analysis”, Ophthalmologica 2014; DOI: 10.1159/000360013.

Immune response to anti-VEGF therapy

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

SUBMISSIONS OPEN AUGUST 13–SEPTEMBER 23 BOOK HOUSING 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 new study suggests that a proportion of patients who receive intravitreal ranibizumab will develop an immune response to the anti-VEGF agent, and the likelihood of an immune response may increase with the number of injections. The study showed that anti-ranibizumab immunoglobulin was present in the blood of 14 (17 per cent) of 82 patients who had received the injections, but was absent from the blood of nine patients who had not received the injections. Furthermore, the immunoglobulin was present in only four (11.1 per cent) of 36 patients who had received 10 or fewer injections, compared to 10 (21.7 per cent) of 46 patients who had received more than 10 injections.

N Leveziel et al, “Detection of Antiranibizumab Antibodies among Patients with Exudative Age-Related Macular Degeneration”, Ophthalmologica 2014; DOI:10.1159/000360186.

Anti-VEGF improvements sustained for five years Anti-VEGF therapy results in a sustained improvement in bestcorrected visual acuity over the medium to long term in eyes with neovascularisation secondary to pathologic myopia, according to the findings of a retrospective study. The authors of the study analysed the two-year results of the treatment in 67 eyes, the three-year results in 52 eyes, the four-year results in 28 eyes and the five-year results in 13 eyes at two years. The mean change from baseline BCVA was a gain of (+8.6 letters (p < 0.001) and this gain remained stable for a period of five years. In addition, the mean central retinal thickness was significantly decreased throughout follow-up and reached its nadir at two years (-104.0 μm; p < 0.001).

The mean number of injections performed during the first year was 5.2, with fewer injections in subsequent years (p < 0.001).

P Freitas-da-Costa et al “Anti-VEGF Therapy in Myopic Choroidal Neovascularization: Long-Term Results”, Ophthalmologica 2014; DOI:10.1159/000360307.

A joint meeting with José Cunha-vaz Editor of Ophthalmologica The peer-reviewed journal of EURETINA

Eurotimes | july/august 2014

charities

Continued support Orbis and Oxfam charities will be represented at the ESCRS congress in London

D

elegates attending the XXXII Congress of the ESCRS in London can support the society’s charities by making a donation online when they register. A total of €35,435 was donated to Orbis and Oxfam in 2013.

“Our support of Orbis and Oxfam continues to be very rewarding,” said Dr Roberto Bellucci, president of the ESCRS, “and it is a very important part of the society’s activities.”

ESCRS is supporting Orbis in its work with the Gondar University Hospital to establish a Child Eye Health Tertiary Facility (CEHTF) for North West Ethiopia from 2011 to 2015 and the development of a paediatric eye-care team.

The society is also supporting Oxfam’s Water and Sanitation and Hygiene Promotion (also known as WASH) programme in the Democratic Republic of Congo (DRC).

Orbis and Oxfam booth at the ESCRS congress in Milan 2012

Self-sustaining programmes The ESCRS has been supporting both charities since 2010 following an initiative agreed by the ESCRS Board under the presidency of Dr Jose Guell. The decision to support the two charities was taken as the Board felt it was not enough to address the problems of global blindness simply as surgeons and that they also needed to address the challenge of supporting communities by helping them to develop selfsustaining programmes.

“When we operate on patients with cataracts in the developing world, we reach out to those who have survived long enough to develop a cataract,” said Dr Guell in an interview with EuroTimes in 2010. “But other help is urgently required such as food and shelter and projects to help local communities to sustain themselves.”

Doctors from the Gondar University Hospital who attended the XXX Congress of the ESCRS in Milan in 2012 at the invitation of the ESCRS, will also attend in London.

Delegates who want to find out more about the supported projects can visit the Orbis and Oxfam Booth during the congress.

Further details are also available at: http://www.escrs.org/ charitable-donations/default.asp.

Eurotimes | july/august 2014

45

escrs

practice management

& development

13 – 15 september london, uK

B

BUSINESS

U

UTILISE BUSINESS

I

INNOVATE UTILISE BUSINESS

L

LEADERSHIP INNOVATE UTILISE BUSINESS

D

DEVELOPMENT LEADERSHIP INNOVATE UTILISE BUSINESS

programme saturday 13 september 09.00 – 17.00 delivering world-class medical consultations – a masterclass Rod Solar

LIVESEYSOLAR PRACTICE BUILDERS

(Free to delegates but must pre-register)

sunday 14 september

monday 15 september

Doctors’ Module

Practice Staff Module

10.00

10.00

cost-effective ways to attract new patients

financial Basics Ed Toland WELLINGTON EYE CLINIC

Rod Solar LIVESEYSOLAR PRACTICE BUILDERS Mike Malley (pictured) CENTRE FOR REFRACTIVE MARKETING

10.45 maximising your internet marketing strategy

11.00 how a single-handed private practice can work

David Evans CEATUS MEDIA GROUP

Ina Conrad-Hengerer CENTER FOR VISION SCIENCE, RUHR UNIVERSITY EYE HOSPITAL

12.00

11.30 don’t get sued Paul McGinn BL

don’t get sued Paul McGinn BL

12.00 what makes practice staff happy and productive?

Kris Morrill MEDEURONET

14.00 am i a leader or a follower?

Keith Willey LONDON BUSINESS SCHOOL, John Marshall FROST PROFESSOR OF OPHTHALMOLOGY AT THE INSTITUTE OF OPHTHALMOLOGY LONDON,

Arthur Cummings OPHTHALMOLOGIST, WELLINGTON EYE CLINIC

14.00 eurotimes marketing competition 15.00 closing remarks Paul Rosen CHAIRMAN OF ESCRS PRACTICE

15.00 how to introduce new technologies to your practice

MANAGEMENT & DEVELOPMENT COMMITTEE

Free to all registered doctors and staff

Keith Willey LONDON BUSINESS SCHOOL, Arthur Cummings OPHTHALMOLOGIST, WELLINGTON EYE CLINIC

16.15 close

www.escrs.org

48

Resident’s diary

PROVING MYSELF? Leigh Spielberg explains why he travelled from Rotterdam

to Paris to take the EBO exam

I’m going to Paris,” for the yearly exams that I answered through residents are required to take my operating mask in the Netherlands – I figured I when asked why I wasn’t would know enough to pass. scheduled to be in the operating But there was no time left for room that afternoon. these sorts of considerations.

“Taking a little vacation?”

Two hours later I was on the asked Dr Nieuwendijk, the high-speed TGV. The train from attending surgeon in the cataract Holland to Paris is a dream. centre that day. “Good idea,” he Starting in Amsterdam, it zooms continued. “We can all use some south through the countryside time off once in a while.” at 300 kilometres per hour, After all the stress I had given stopping only momentarily him in the OR over the past few in Rotterdam, Antwerp and months – with him stretching Brussels before arriving in Paris the limits of my surgical abilities three hours later. while making sure I didn’t The following day, the overstep my boundaries – Dr exam centre was full of young Nieuwendijk certainly deserved doctors from 28 European a holiday. countries. Although it was all “A vacation?” I said. “Not well organised and efficient, it exactly. I’m taking the EBO took me a while to figure out exam tomorrow,” referring where I had to sign in because to the European Board of my mind was concentrating on Ophthalmology Diploma how to differentiate disc oedema Examination. from papilledema rather than on “Excellent, good luck with which escalators to take to the that,” he replied. “I took the correct floor. exam a few years ago.”

Before I knew it, however, I I continued looking at him as was in the main examination he pulled on his operating gown room with a 260-question and gloves. multiple-choice exam in front Before I knew it, however, I was in “Yes, I passed,” he added, of me with two-and-a-half the main examination room with a before handing me the knife. hours to complete it. The topics That was what I wanted to spanned the whole spectrum of 260-question multiple-choice exam hear. I wasn’t really looking ophthalmology. The questions in front of me with two-and-a-half forward to it all, and was mostly tested useful knowledge, hours to complete it questioning why I made the like relevant prognostic and decision to sign up. Was I therapeutic factors in glaucoma, looking to prove something to but occasionally asked silly myself or to someone else? Did I just want the extra “FEBO” title details like drug concentrations and genetic percentages. Each after my name? Honestly, I was more interested in doing cataract question had three options: true, false and I don’t know. “I don’t operations all day than travelling to another country to take an know” is an interesting choice, I thought. If I didn’t’ know it, how exam, but I convinced myself to consider the whole ordeal as a could one be faulted for telling the truth? little adventure, if not a vacation.

The afternoon session was more interesting. It was an hourI hadn’t told too many people about my plans, just in case long, viva voce session with photo-based questions and four they didn’t work out as planned. The exam is not required for different two-examiner duos who each presented a clinical residents in the Netherlands, so only a few take it every year. case and interrogated us until we reached the outermost limits First-hand information is scarce, particularly in relation to our of our knowledge. I have to admit, this part was actually fun. collective training experience. Would it be easy or difficult?

It was like working in the emergency room, examining very My main sources of information were Belgian ophthalmology demanding patients with reasonably challenging pathology and residents with whom I went to medical school. For them, passing a lot of well thought-out questions. I was shown a photo of the exam is a prerequisite for receiving their licence. They have to an iris with radial, spoke-like transillumination defects in the pass, so they make sure they’re very well prepared. midperiphery. “Pigment dispersion... young myopic males... haloes after exercise....” It all went by in a blur, and before I knew it, I was outside, on my way to the station to catch the TGV back Organised and efficient north to Rotterdam.

My assumption was that I should be able to pass the exam based A few days later I received notice that I had passed. With that, on what I had learned during the first four years of residency.

I immediately booked a long weekend trip to Paris to celebrate After so much time in the clinic, in the operating room, and on with my wife. call in the emergency department – not to mention preparation Eurotimes | july/august 2014

JCRS

MMC okay in PRK Researchers in Iran conducted a doublemasked randomised clinical trial to assess the effect of mitomycin-C (MMC) on the tear film, corneal biomechanics, and surface irregularity in PRK. At one and six months after surgery highlights MMC-treated and untreated eyes in the Vol: 40 Issue: 6 month: june 60 participants showed no difference in tear film index. No significant differences were observed in total higher-order aberrations, spherical aberration, coma or Q values in the same follow-up period. The researchers conclude that MMC in PRK does not contribute to surface irregularity, transient tear-film dysfunction or biomechanical weakening of the cornea. S Mohammadi et al., JCRS, “Effects of mitomycin-C on tear film, corneal biomechanics, and surface irregularity in mild to moderate myopic surface ablation: Preliminary results”, Volume 40, Issue 6, 937-942.

JCRS

FS lenticule extraction Corneal resection refractive procedures remove a thin planar slice of corneal stroma for the correction of myopia. However, the results of this surgery have varied, possibly because the mechanical microkeratome is not precise enough to treat refractive errors. A Japanese study compares the biomechanical changes after femtosecond (FS) lenticule extraction and smallincision lenticule extraction for myopia. The study of 48 eyes found that FS lenticule extraction was essentially equivalent to small-incision lenticule extraction in terms of the corneal hysteresis and corneal resistance factor. This indicates that the presence or absence of flap lifting does not significantly affect these biomechanical parameters. K Kamiya et al., JCRS, “Intraindividual comparison of changes in corneal biomechanics parameters after femtosecond lenticule extraction and smallincision lenticule extraction”, Volume 40, Issue 6, 963-970.

Biomechanics of ectasia In the past decade corneal biomechanics has moved from the academic arena to the clinic. The transition coincides with the development of devices that allow biomechanical measurements, as well as biomechanical approaches to treating cornea ectasia.

However, there is still no consensus on how best to detect those corneas most at risk for ectasia following refractive surgery.

Roberts and colleagues propose a new approach based on the focal nature of biomechanical changes following surgery. They suggest that a detection system to measure nonuniformity in biomechanical properties across the cornea and localise focal weakening would be ideal in the effort to screen for at-risk patients to reduce the incidence of post-refractivesurgery ectasia. While no such instrument exists now, the authors are encouraged by the recent acceleration of research and development efforts in this area. C Roberts et al., JCRS, “Biomechanics of corneal ectasia and biomechanics treatments”, Volume 40, Issue 6, 991-998.

JCRS SYMPOSIUM Controversies in Cataract and Refractive Surgery Sunday, September 14, 2014 14:00–16:00 Chairs: Thomas Kohnen, MD, PhD, FEBO Nick Mamalis, MD Simultaneous Bilateral Cataract Surgery: Pro and Con Steve A. Arshinoff, MD, FRCSC, José L. Güell, MD Crosslinking for Forme Fruste Kerataconus: Is It Indicated?

A. John Kanellopoulos, MD, Peter S. Hersh, MD Correction of Low Astigmatism in Cataract Surgery Setting: IOL Versus Laser Oliver Findl, MD, Douglas D. Koch, MD

During the XXXII Congress of the ESCRS, London, United Kingdom Thomas Kohnen European editor of jcrs

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

Eurotimes | july/august 2014

49

50

eye on history

A modest SCHOLAR Prof Andrzej Grzybowski discusses the life and work of English

ophthalmologist William Bowman

W

illiam Bowman was born in 1816 in Nantwich Bowman also supported Florence Nightingale, the founder of in Cheshire and was the son of a banker and modern nursing. In 1846 he became assistant surgeon to Moorfields distinguished geologist and botanist. In 1837 Eye Hospital and he was the first of many distinguished surgeons Bowman became the member of the Medical who decided to specialise in ophthalmology in this hospital.

Department of King’s College, London.

Many of his contributions were remarkable, including his The following year, he became the cornea description with its anterior elastic membrane prosector to the Physiology (Bowman’s membrane), the radial fibres of the Lectures under Robert Bentley Todd (1809ciliary muscle (Bowman’s muscle), and glands 1860), professor of physiology, who greatly in the olfactory mucosa (Bowman’s glands). influenced Bowman’s work.

He corresponded frequently with Charles In 1838, Bowman accompanied by Darwin and with Frans Cornelius Francis Galton (1822-1911), visited Donders, who became his great friend hospitals in Paris, Vienna, Germany from the time they first met together and Holland. During this trip Bowman with Albrecht von Graefe at the Great showed himself to be a skilled Exhibition in 1851 in London. surgeon operating Galton’s inflamed ingrowing toenail using a bent pin Modest and humble and scissors.

Hermann von Helmholtz described In 1840, Bowman passed his Bowman as one of those people examination for membership of the who “have contributed most to Royal College of Surgeons, and in ophthalmic medicine by extended 1844 was elected Fellow. During these application of well-understood years his most important histological methods of investigation and accurate papers were written. He was involved insight into the causal connection with Todd in the work on Cyclopaedia of phenomena”.

William Bowman of Anatomy and Physiology (1852) and In 1880 he was a co-founder of the [US federal government The Physiological Anatomy and Physiology of Ophthalmological Society of the UK and public domain image.

Man (1843–1856), the first physiological books Source: NLM] became its first president. Due to his many in which accurate histological descriptions were achievements he received honorary degrees from related to anatomical structures. the universities of Cambridge, Dublin and Edinburgh, Many illustrations used in this book were made by and was made a baronet.

Bowman. In 1842, he gained the Royal Medal of the Royal Society To the end of his days, he was a modest and humble man, who for the paper, in which he described the glomerular capsule (now never called any structure by his own name. He used the term known as Bowman’s capsule) and its function.

‘Malpighi capsule’ for glomeruli capsule (Bowman’s capsule), Bowman became assistant surgeon to King’s College Hospital long after his work on this subject was highly appreciated. in 1840, and was elected surgeon in 1856. It was partly due to his He declined the invitation to be a founding member of the influence that Joseph Lister, father of antiseptic surgery, was invited Physiological Society in 1876 as he believed he had been too far to the Chair of Clinical Surgery at King’s College. from this field for too many years. He died of pneumonia in 1892.

In times when some call their findings by their name much before they are confirmed and appreciated by their peers, William Bowman should be remembered as a true and modest scholar. He still deserves, 122 years after his death, to be remembered as a giant of ophthalmology.

To the end of his days, he was a modest and humble man, who never called any structure by his own name Andrzej Grzybowski MD, PhD

* Andrzej Grzybowski MD, PhD Professor of ophthalmology, Poznan City Hospital, Poznan, Poland; Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.

РОССИЙСКИЙ ВЫПУСК Visit: www.eurotimesrussian.org

Eurotimes | july/august 2014

RUSSIAN LANGUAGE EDITION NOW ONLINE

esaso

esaso RETINA ACADEMY A new style of meeting focused on the diseases of retina

T

he Scientific Programme is now available for the ESASO Retina Academy 2014.

The ESASO Retina Academy is a CMEaccredited advanced educational meeting focused on diseases of the retina and will be held in Istanbul, Turkey, from 14-15 November 2014.

This year, the dynamic programme will include six different and innovative session formats to optimise learning and faculty interaction. These include ESASO MasterClasses for small groups, rapid fire breakfast sessions, ESASO-style debates and two new Retinamour case study sessions. Delegates will be provided with many styles of education and opportunities to collaborate with and learn from the expert faculty.

The programme offers advanced-level sessions on diabetic macular edema, vascular pathologies, macular edema in retinal vein occlusions and the management of retinal non-perfusion, AMD and macular disorders. The international faculty come from leading institutions around the globe and will lead sessions that are highly interactive and varied in format across the two days.

Highlights Highlights of this yearâ&#x20AC;&#x2122;s meeting include two prestigious Lectio Magistralis (keynote lectures). The first on Idiopathic chorioretinal inflammatory diseases will be led by Laurence Yannuzzi (USA), professor of clinical ophthalmology at Columbia University College of Physicians and Surgeons, vice-chairman and director of The Retinal Research Center of the Manhattan Eye, Ear & Throat Hospital, and founder and president of The Macula Foundation.

The second will be on Neovascular Glaucoma and delivered by Rupert Bourne (UK), consultant ophthalmic surgeon at Huntingdon Glaucoma Diagnostic & Research Centre and Moorfields Eye Hospital, Francesco Bandello professor of ophthalmology at Anglia Ruskin University and honorary consultant ophthalmic surgeon at Addenbrooke's Hospital.

A further highlight is the introduction of the Retinamour case study sessions where delegates may submit case studies for presentation and discussion.

The chairman of the Scientific Committee, Prof Francesco Bandello, chairman, Department of Ophthalmology, Scientific Institute San Raffaele, Milan, Italy, said: "The Scientific Committee is delighted to welcome the most prestigious faculty to the ESASO Retina Academy 2014. This meeting is unique in its varied formats and commitment to delegate learning. We are very focused on clinical outcomes and bring many real-world cases for discussion. We aim to provide every delegate with an opportunity to interact with our faculty and involve themselves in the sessions to challenge their current clinical practice with latest techniques and experiences from around the world." www.esaso.org/14th-esaso-retina-academy-2014/ congress@esaso.org Eurotimes | july/august 2014

51

calendar

august

NEW ENTRY ever 2014 congress

september

aao annual meeting

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

iser xxi biennial meeting 20–24 july san Francisco, California www.iserbiennialmeeting.org

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

november

escrs glaucoma day

Femto congress 2014

wspos paediatric sub speciality day

soi national congress

12 september london, uK www.escrs.org

12 september london, uK www.wspos.org

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

xxxii congress of the escrs 13–17 september london, uK www.escrs.org

2nd european conference on aniridia 19-20 september venice, italy www.aniridiaconference.org

international annual course and workshop on diagnostic ultrasound in ophthalmology 22–26 september vienna, austria www.echography.com

the 112th dog congress of ophthalmology 25–28 september leipzig, germany www.dog-kongress.org

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

april

ascrs.asoa symposium and congress

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

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

27th apacrs annual meeting 13–16 November jaipur, india www.apacrs2014.org

may

joint irish/ukiscrs refractive surgery meeting 21 November Dublin, ireland Email: hmurphy@materprivate.ie

NEW ENTRY arvo annual meeting 3-7 may Denver, Colorado, usa www.arvo.org

june

december

6th amsterdam retina debate 12 December amsterdam, the Netherlands www.amc.nl/retinadebate

NEW ENTRY soe 2015 congress 6-9 june vienna, austria www.soe2015.org

january 2015

NEW ENTRY 9th international congress ‘macula of paris’ 9 january Paris, France www.maculaofparis.org

February

73rd annual conference of aios 5–8 February New Delhi, india www.aios.org

19th escrs winter meeting 20–22 February istanbul, turkey www.escrs.org

↙

2nd asia-pacific glaucoma congress 10th international symposium of ophthalmology

nice

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

FOUR EVENTS ONE VENUE e

Corn

WSPOS

a

Eu

a

july 2014

11–14 september london, uK www.euretina.org

1-4 october Nice, France www.ever.be

C o r n

XXXII Congress of the ESCRS 13-17 September

14th EURETINA Congress 11-14 September

e

↙

14th euretina congress

last call

october

nordic congress of ophthalmology (nok 2014)

Eu

52

European Society of Cornea and Ocular Surface Disease Specialists

5th EuCornea Congress 12-13 September

WSPOS Paediatric Sub Specialty Day 12 September

E E R HIP S F R YE A R S E E 3 BE AIN EM TR M OR F

Become an ESCRS Member and avail of reduced registration fees for London Congress, September 2014 Also free to members: Access to iLearn Online interactive courses ESCRS on Demand Online library of presentations from ESCRS Congresses Subscription to Journal of Cataract & Refractive Surgery

Visit www.escrs.org today

ESCRS