EuroTimes Vol. 19 - Issue 9 by EUROTIMES

SPECIAL FOCUS CATARACT & REFRACTIVE OCULAR

CALL FOR MORE PROACTIVE APPROACH TO BLINDNESS PREVENTION September 2014 | Vol 19 Issue 9

RESEARCH

YOUNG OPHTHALMOLOGISTS WILL BENEFIT GREATLY BY GETTING INVOLVED

THE

APP WILL

SEE YOU

NOW

The Essence of Perfection

Ecknauer+Schoch ASW

When the best engineers and designers give their best, they are bound to develop the best machine. “We have redefined the concept of the operating platform for cataract, glaucoma and retina surgery. The OS4 includes everything we are good at: cuttingedge technology, perfect design, irresistible simplicity, the highest degree of safety and Swiss quality. In short: 100 percent Oertli®.“ From 12 to 16 September 2014, the OS4 will see its world premiere at the ESCRS in London. At our booth B09, we will have the pleasure of showing you all the details of the device, which will provide you with clear added value.

P.38

Publisher Carol Fitzpatrick Executive Editor Colin Kerr Editors Sean Henahan Paul McGinn Managing Editor Caroline Brick Production Editor Angela Sweetman 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

COVER STORY 4 Popularity of mobile

health applications soars

SPECIAL FOCUS CATARACT & REFRACTIVE 7 EuroTimes app showcases best of magazine

8 Results of ESCRS Member

Colour and Print W&G Baird Printers Advertising Sales Amy Bartlett ESCRS Tel: 353 1 209 1100 email: amy.bartlett@escrs.org Published by the European Society of Cataract and Refractive Surgeons, Temple House, Temple Road, Blackrock, Co Dublin, Ireland. No part of this publication may be reproduced without the permission of the managing editor. Letters to the editor and other unsolicited contributions are assumed intended for this publication and are subject to editorial review and acceptance. ESCRS EuroTimes is not responsible for statements made by any contributor. These contributions are presented for review and comment and not as a statement on the standard of care. Although all advertising material is expected to conform to ethical medical standards, acceptance does not imply endorsement by ESCRS EuroTimes. ISSN 1393-8983

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.

9 11 12 13 14 15

17 19

Practice Survey to be presented at meeting Question of utility of bilateral cataract surgery brought to the fore Alternative design approach to gel accommodating IOL Good economic implications with antibiotic prophylaxis Many advantages found with femtosecond laser technology Abberometer can help to differentiate cataract from clear lens surgery Survey shows variation in measures taken by surgeons to avoid endophthalmitis Patient management key to postoperative success with multifocal IOLs New IOL shows good results in initial trials Increase in adoption of IOL calculation formulas could improve predictability

FEATURES CORNEA 20 Compliance with

treatment critical in keratitis cases 21 Vaccination in over 50s can help prevent HZO 22 Improvement in dry eye treatment down to better understanding 23 Ocular infections as a result of STIs increasing 25 Imaging techniques could ensure better management for KPro patients 27 Recurrent sterile vitritis in KPro patients can cause lasting damage 28 Excellent vision can be restored in cancer patients

GLAUCOMA 30 Getting the most 31 32 33

34 35

out of selective laser trabeculoplasty Research important in understanding earlyonset glaucoma Laser iridoplasty can help manage angle-closure glaucoma in some cases Glaucoma researchers could learn from other neurodegenerative disorder experts New class of drugs to provide different approach to treatment Glaucoma eye drop preservatives: yea or nay?

Included with this issue... Preliminary programme for the 19th ESCRS Winter Meeting, Bayer HealthCare & Kowa supplements

RETINA 36 Survey finds connection

between vasodilators and AMD development 38 Implantable device showing positive results in end-stage AMD patients 39 More studies needed to understand risk factors for post-vitrectomy endophthalmitis 41 Irish study compares real-life data with Geneva study results

OCULAR 44 Research shows vitamin

supplement beneficial in reducing cataract risk 45 Patients underestimating severity of illnesses - study 46 Road safety in Morocco could be improved by visual acuity testing 48 Prevention of blindness should be prioritised more, experts say 51 Joint ICOI/ESCRS meeting programme offers diversity 52 Impact of pregnancy on ocular health

PAEDIATRIC OPHTHALMOLOGY 53 More research needed to prove benefits of multifocal IOLs

REGULARS 54 JCRS Highlights 56 Industry News 58 Review 60 ESASO update 62 Research 64 Book Reviews 66 Ophthalmologica update 68 Calendar EUROTIMES | SEPTEMBER 2014

EDITORIAL A WORD FROM DAVID O’BRART MD, FRCS, FRCOphth

A UNIQUE FORUM

The ESCRS is helping to facilitate the sharing of expertise by ophthalmologists from all over the world

he XXXII ESCRS Congress convenes in London, one of continue with the full-day Young Ophthalmologists Programme the most exciting cities in the world and the birthplace, at on Saturday and on Sunday morning, the refractive surgery St Thomas’ Hospital half a century ago, of the intraocular didactic course and the EBO-accredited instructional courses. lens (IOL). As Europe's leading organisation for cataract We are also delighted to welcome delegates attending the and refractive surgeons, the ESCRS within its annual UKISCRS annual meeting, the EuCornea annual meeting, the meeting endeavours to present and scientifically evaluate EURETINA congress, the ESCRS Glaucoma Day and the World innovative developments in anterior segment surgery. Society of Paediatric Ophthalmology & Strabismus (WSPOS) subThe ESCRS congress is a unique forum for discussion and specialty day. education, helping to facilitate the sharing of expertise by UKISCRS will hold its 38th Annual meeting on Friday ophthalmologists not only from Europe but all over the world. September 12 with the Rayner Medal lecture delivered by Prof For our young colleagues – residents and fellows – the ESCRS Harminder Dua, a lifetime achievement award for Prof John continues to offer reduced meeting registration rates and we are Marshall and symposia on femtosecond lasers and getting involved proud to support the future leaders and drivers of our profession with ophthalmology in the developing world. and their input into the meeting. EuCornea will hold its 5th congress on Friday and Saturday, The programme consists of main scientific symposia, 12 and 13 September, with a free papers, posters, videos, instructional and didactic comprehensive programme Education is the main courses, workshops and a practice management & encompassing the latest development weekend. developments in corneal research mission of the ESCRS and Hot topics covered in the main symposia include safety, and innovations in corneal surgery. over the past few years efficacy and the unexpected in corneal cross-linking (in a Similarly EURETINA will hold particular focus has been combined ESCRS/EuCornea symposium), vitreo-retinal its 14th congress from September complications of anterior segment surgery (in a combined 11-14 with an extremely inclusive on the development of an ESCRS/EURETINA symposium), femtosecond-assisted programme covering the latest educational programme for cataract surgery, corneal refractive surgery, combined developments in the management surgeries for cataract and glaucoma and the intricacies of retinal pathologies. young ophthalmologists of targeting emmetropia after cataract surgery. Clinical The ESCRS Glaucoma Day will scientific symposia will address topics such as optimising take place immediately preceding refractive procedures, new laser technologies, multifocal the main meeting on September IOLs and cornea intra-stromal surgery. 12 and the WSPOS subspecialty day takes place on Friday An interactive video symposium on surgical complications will September 12. take place on Sunday, organised by ESCRS in conjunction with I wish you a very enjoyable congress and I am sure you will have the United Kingdom and Ireland Society of Cataract and refractive a wonderful time full of education, science and discussion with Surgeons (UKISCRS). A highlight of the meeting will be the your peers from all over the world. Opening Ceremony where Prof Günther Grabner will present the Ridley Medal Lecture entitled, “Four Decades of Cataract Surgery – Personal Visions for the Future.” Education is the main mission of the ESCRS and over the past * David O’Brart is president of the United Kingdom few years particular focus has been on the development of an and Ireland Society of Cataract and Refractive educational programme for young ophthalmologists. This year we Surgeons and a member of the ESCRS Board

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 | SEPTEMBER 2014

Across the page. Across the room. Across the years.

THE PRESBYOPIA SOLUTION THEY’VE BEEN WAITING FOR. UNCORRECTED NEAR VISUAL ACUITY (INLAY EYE ONLY)* SNELLEN ACUITY

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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-1232 Rev A

COVER STORY: OPHTHALMOLOGY APPS

THE APP WILL SEE YOU NOW The revolution in mobile applications is shaking up the healthcare sector and ophthalmology is no exception. Dermot McGrath reports

the space of a decade, the mobile phone, with an estimated 6.8 billion mobile subscriptions worldwide, equivalent to 96 per cent of the world population, has become arguably the fastest-spreading technology in human history. Medicine in general, and ophthalmology in particular, have lagged behind retail and business services in embracing mobile phone applications, with regulatory and data security concerns partly to blame for the slow uptake. EUROTIMES | SEPTEMBER 2014

But that picture is changing rapidly. For Apple’s popular iPhone and iPad, there are currently more than 60 ophthalmologyrelated applications available for download in the iTunes store, and more are coming on stream all the time. Many of these apps are now also available for download on other smartphone platforms such as Android, Symbian and Windows Phone. The applications cover a broad range of clinical and educational use, many free, some with a nominal fee and the most expensive for an eye-popping $550. Some apps such as the Eye Handbook seek to offer a one-stop diagnostic and reference tool for ophthalmologists, while a large number of individual testing or screening apps

are available for visual acuity, visual field, contrast sensitivity, toric IOL calculations, glaucoma screening and much more. Reference and educational apps are also in plentiful supply, giving ophthalmologists instant access to texts such as the Atlas of Ophthalmology or Clinical and Experimental Ophthalmology. More than 3,000 surgical videos can also be consulted on a smartphone via the popular EyeTube application.

CRITICAL MASS “I think we are now reaching a certain critical mass in mobile health applications,” believes Ken Lord MD, a vitreoretinal

COVER STORY: OPHTHALMOLOGY APPS

Courtesy of Harvey A Fishman MD, PhD

AppVisit

Dr Sinclair said that the development of the iVFQ app was partly borne out of his own frustration at seeing patients only after retinal disease had already taken hold. “We usually do not see patients in our offices until they have significant vision loss, most often in the second eye, and by then it is late down the course of the disease process. Unfortunately patients do not come to us prophylactically as they do with their dentist. As physicians we are frustrated because we are seeing things far too late to have significant vision impact even in spite of all the drugs that we give,” he said.

The iVFQ app in use

Courtesy of Stephen H Sinclair MD

specialist at Retina Associates of Southern Utah, US, and co-developer of the Eye Handbook, which has logged over one million downloads and more than 25,000 registered users. “More people are spending time on mobile devices now than at any other period because the functionality has got so much better,” he added. While younger ophthalmologists have unsurprisingly been the early adopters of mobile technology, their more seasoned colleagues are now following suit in everincreasing numbers, said Dr Lord. “There was initially the generation gap but we are definitely seeing more experienced ophthalmologists now catching the bandwagon. Some of these user interfaces for these newer devices are just so intuitive, you don’t need to be particularly tech-savvy to navigate on them and be able to pull out the information you need,” he said. Much of the momentum behind the uptake in mobile apps is also coming from patients, points out Stephen H Sinclair MD, a retinal specialist in private practice in Media, Pennsylvania, US, who developed the iVFQ app, a quality-of-life, visual function questionnaire based on the National Eye Institute VFQ 25 and intended for use with patients having moderate vision loss associated with ocular disease. “There is a desire on the part of patients to have more control over their health, with more and more patients proactively asking what they can do to improve their health. We are also seeing huge marketing behind this trend with companies like Microsoft and Google realising that the next big wave of Internet devices are probably going to be 24/7 health monitoring devices. It is really just beginning,” he said.

VISUAL FUNCTION The disparity between patients’ scores on traditional visual acuity charts and their real-life experience prompted Dr Sinclair to find a better way of measuring their visual function. “Very commonly I would see that the measurement on the eye chart did not parallel with what the patients were telling me. The eye chart is the oldest thing in continuous use in medicine today, and it fails every single time. My app enables clinicians to evaluate the effect of clinical treatments and rehabilitative programmes on their patient’s vision in real-world conditions,” he said. The desire to repurpose tried-and-trusted clinical tests for mobile devices and, if possible, make them better, was also what inspired Christophe Huber MD, a retired ophthalmologist in Zurich, Switzerland, to develop his own Contrast Vision app for the iPad. While testing patients it became clear to Dr Huber and his co-workers that not only could a type of modulation transfer function be measured and stored, but that they had in the process created a practical low-vision test (App Store “Contrast Vision” $9.90). “Measuring visual acuity during the course and treatment of macular pathology is frustrating because of the few large test figures available. With the contrast vision test used in 30cm the range of visible test figures was increased. Testing not only size but also contrast made the function of eyes with a maculopathy accessible to quantitative testing,” he said. Dr Huber said that the app may be particularly useful to monitor the efficacy of anti-VEGF treatment for AMD patients. Even without downloading a specific application, most smartphones already have the capability to make life easier for

the busy ophthalmologist thanks to the device’s built-in camera, says Allon Barsam MB, BS, MA, FRCOphth, a consultant ophthalmic surgeon in the UK. “A standard photo application on any smartphone allows you to take very good quality slit lamp photographs of the anterior segment,” he said. “I use the iPhone camera regularly as a way of monitoring disease progress in the clinic or to help explain particular pathologies to my patients. A dedicated slit lamp camera can be expensive and technically difficult to master, whereas the iPhone gives ophthalmologists a quick and efficient way of documenting and recording what is happening with a patient’s eye,” he added.

COLOUR VISION TEST Dr Barsam also uses other apps such as the Eye Handbook and Snellen, a free app that includes an Ishihara colour vision test. “I use it for testing distance, intermediate and near vision. It is especially useful in between operating on patients if the patient is having their eyes done close together where there is not sufficient gap to warrant or justify a clinic appointment,” he said. Photography is not just confined to the anterior segment. For retinal imaging, researchers at the Massachusetts Eye and Ear Hospital recently developed a simple technique of fundus photography using an iPhone, an imaging app called Filmic

A standard photo application on any smartphone allows you to take very good quality slit lamp photographs of the anterior segment Allon Barsam MB, BS, MA, FRCOphth EUROTIMES | SEPTEMBER 2014

Courtesy of Christophe Huber MD

Eye Handbook logo

Plots of sensitivity versus size of E in a normal subject and in a patient with a severe age-related macular degeneration

Dr Neves said that his app, which sells for $0.99, has now reached over 50,000 downloads from all parts of the world. “This was achieved despite the fact that I could not find a sponsor for my app because large companies were not aware of the reach and importance of this application. It is also difficult and expensive to continually upgrade the app for new software versions,” he said. Test figure seen in changing orientations and contrasts. The orientation as seen by the subject is stored with the black arrows

Pro and a 20 D lens with or without a Koeppe lens. Apps may also play an important role in helping ophthalmologists deal with everincreasing patient numbers as populations grow older and existing services are stretched to breaking point. “We are already using texting and emails to confirm and follow up surgeries because so many of our patients are now online with their phones and can respond instantly,” said Renato Neves MD, director of the Eye Care Eye Hospital, Sao Paulo, Brazil, and creator of the Eye2Phone app, a collection of commonly used eye tests in one application.

CUSTOMISED APPS Despite these obstacles, Dr Neves believes that more ophthalmologists will switch to using customised apps for more efficient patient management and follow-up. “We are sure to see growth in everything that connects patients to clinics and enables them to administer tests off-site such as macular and glaucoma screening using secure applications,” he said. One such application already gaining traction in the market is AppVisit, which uses the power of mobile devices to connect doctors and their patients for virtual “visits” using a secure communications platform. Its co-developer, Harvey A Fishman MD, PhD, an ophthalmologist in private practice in Palo Alto, California, thinks

We are already using texting and emails to confirm and follow up surgeries because so many of our patients are now online with their phones and can respond instantly Renato Neves MD EUROTIMES | SEPTEMBER 2014

that the demand for such applications is sure to increase as ophthalmologists seek to make more efficient use of their time and resources. “I think there is no question that the number of patients is going to far exceed the capacity of ophthalmologists to take care of them in the near future. Furthermore, the amount of money that it is going to cost to take care of patients in an office setting is going to be prohibitive. As the United States healthcare system moves towards an increasing number of Accountable Care Organizations (ACOs) spending will shift from physical capital (eg, buildings) to more efficient technology. This trend will only intensify in the coming years,” he said. Dr Fishman emphasised that AppVisit is not a replacement for one-on-one consultations, but rather a way for practitioners to manage their existing patients more efficiently. “What the app does is provide the opportunity to triage much more effectively and to treat many of the routine, low-level cases that simply don’t need to be seen in person every time. Patients can take a visual acuity test, use an Amsler grid (for macular degeneration and other detection), snap a picture of their eye and send all that information along with exam questions via AppVisit. If the patient has blepharitis or conjunctivitis and has been seen regularly from month to month, the app enables the doctor to monitor their progress, prescribe or alter treatment and, if necessary, call them in for an office consultation,” he said. To those who raise concerns about such virtual consultations, Dr Fishman points out that worldwide, there are an estimated one billion phone calls per year (200 million in the US alone) already involve clinicians or nurse practitioners conducting medicine on the phone. Ken Lord: dr.kenlord@gmail.com Stephen Sinclair: ssinclair@stephensinclairmd.com Christophe Huber: huber.christophe@gmail.com Allon Barsam: abarsam@hotmail.com Renato Neves: renatoneves1@gmail.com Harvey A Fishman: drfishman@fishmanvision.com

Courtesy of Ken Lord MD

COVER STORY: OPHTHALMOLOGY APPS

SPECIAL FOCUS: CATARACT & REFRACTIVE

EUROTIMES APP The new EuroTimes app will give the magazine’s readers an immersive and feature-rich experience. Dermot McGrath reports

o coincide with the XXXII Congress of the ESCRS in London, EuroTimes, the official news magazine of the ESCRS, is now available as an app for download. The latest development is key to consolidating EuroTimes’ role as one of the flagship publications of the ESCRS, the leading forum in Europe for discussion, learning and the development of cataract and refractive surgery. Now in its nineteenth year of publication, the print version of the magazine has grown into Europe’s leading resource for ophthalmology news and now circulates to more than 40,000 ophthalmologists in Europe and around the world. The new app will showcase the very best of EuroTimes’ compelling monthly mix of breaking news and features from leading ophthalmic surgeons and vision researchers. In addition, the app opens up exciting new possibilities for enhanced interactivity and more dynamic content for its readers.

FEATURE RICH The development team behind the EuroTimes app said that the goal was to offer more than simply a static online version of the print magazine, giving the magazine’s loyal readers a more immersive and feature-rich experience.

Harnessing the power of the latest mobile technologies, the team set out to create a digital version at the cutting edge of design with a fully interactive tablet and phone product compatible with both iOS and Android devices. Emanuel Rosen, chairman of the ESCRS Publications Committee, said that the EuroTimes app was consistent with the ESCRS philosophy of continually innovating to better serve the needs of its members. “The new app is a further ambitious step for EuroTimes and I believe it will offer exciting new opportunities for the publication. We have already stepped up our online presence in recent years through Facebook, Twitter and a revamped website, so the next logical step was to offer an enhanced digital version of our awardwinning magazine for our readers,” he said. Dr Rosen said that the app will present a platform for further growth for the magazine, enabling it to explore new modes of presenting dynamic and interactive content for its discerning readership. “The app will combine our print heritage with the exciting possibilities of an online format, all the while respecting our core principles of offering a trusted source of information and debate for our readers,” he said. Emanuel Rosen: erosen9850@aol.com

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September 2014 | Vol 19 Issue 9

Full interactivity featuring: SPECIAL FOCUS

APP APP

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SEE YOU September 2014 | Vol 19 Issue 9

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APP SEE YOU

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...and more! Search for ‘ESCRS EuroTimes’

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SPECIAL FOCUS: CATARACT & REFRACTIVE

ESCRS PRACTICE SURVEY Toric IOLs, smaller incisions gain, slow movement to femto-cataract in 2013. Howard Larkin reports

orrecting astigmatism and preventing endophthalmitis remained popular endeavours among European cataract and refractive surgeons in 2013. More than half reported using toric intraocular lenses (IOLs) while two-thirds now inject intracameral antibiotics, according to the 2013 ESCRS Member Practice Survey, conducted by David Leaming MD, Palm Springs, California, US. Dr Leaming will present his findings at the XXXII ESCRS Congress in London, UK. Of those that correct astigmatism at cataract surgery, half favoured toric IOLs for correcting astigmatism of 1.12 to 1.87 D, with three-quarters opting for them in cases with 2.0 D or more. At 21 per cent, blade-cut limbal relaxing incisions remained the top choice for correcting 0.5 to 1.0 D cylinder, though 64 per cent responded they don’t treat such low astigmatism. Alcon’s AcrySof Toric remained the preferred toric IOL with 46 per cent naming it, down slightly from 50 per cent in 2012. Abbott Medical Optic’s Tecnis Toric came in second at 11 per cent, up from six per cent last year. Those responding they don’t use toric lenses fell to 27 per cent, down from 30 per cent in 2012 and 42 per cent in 2010. Interest in toric and multifocal toric lenses was also high among ESCRS members, scoring +108 and +61 respectively on a scale ranging from -200 to +200. By comparison, preloaded lens injectors scored +132 and multifocal lenses +67, both up significantly from 2012. Of less interest were accommodating lenses at -28, light-adjustable IOLs -31, corneal inlays for presbyopia -64, excimer laser for presbyopia -74 and intracorneal femtosecond laser for presbyopia -81.

PRESBYOPIA CORRECTION Just over half of ESCRS members responding reported using multifocal IOLs in 2013, essentially unchanged since 2011. By comparison, only six per cent reported using accommodating IOLs, six per cent multifocal LASIK and four per cent presbyopic corneal inlays. The presbyopic IOL most often used in 2013 was the AcrySof IQ ReSTOR which 52 per cent reported using most often, followed by Oculentis M Plus at nine per cent, AT LISA Tri at eight per cent, Tecnis Multifocal and Trifocal FineVision at seven per cent and AT LISA or AT LISA Toric at six per cent. About 10.4 per cent of surgeons responded that they implant presbyopia correcting lenses in more than 10 per cent of patients. When asked what kind of lens they would choose if having cataract surgery without astigmatism next week, 72 per cent selected monofocal aspheric lenses, 21 per cent multifocal, five per cent accommodating and two per cent other.

MEDICATIONS Dexamethasone remained the most preferred steroidal drop for both cataract and refractive surgery, chosen by 62 per cent and 42 per cent respectively. However, those numbers are down in both groups from recent years, with prednisolone and betamethasone gaining ground.

FEMTO-CATARACT SURGERY Access to femtosecond lasers for cataract surgery by ESCRS members increased to 17 per cent in 2013, up from 10 per cent EUROTIMES | SEPTEMBER 2014

EUROPEAN PRACTICE TRENDS 2013 Cataract incisions continue to shrink

2.8mm

2013 2012 2011 2010

2.6mm

2013 2012 2011 2010

2.4mm

2013 2012 2011 2010

2.2mm

2013 2012 2011 2010

28% 30%

36% 38%

16% 14% 16% 17%

12% 10%

18% 17%

25% 26% 22% 17%

in 2012 and five per cent in 2011. However, only nine per cent reported using femtosecond lasers for cataract in 2013, up from seven per cent in 2012 and two per cent in 2011. The most common platform was the Alcon LensSx at 54 per cent followed by the Bausch + Lomb Technolas at 22 per cent and Optimedica at six per cent. Nearly 45 per cent said they had no plans to add femto-cataract surgery. Reasons for not doing so were ‘lack of cost-effectiveness’ at 70 per cent, ‘no good data to prove benefit’ at 34 per cent and ‘procedure takes too long’ at nine per cent. However, many surgeons expressed interest in femto-cataract, with overall interest at +8 on a -200/+200 scale. Lens softening attracted the most interest at +15 followed by capsulorhexis at +8. These interest figures roughly track surgeons’ self-reported problems with capsule ruptures, with 45 per cent saying the most often run into problems during nuclear dismantling followed by 33 per cent during cortical clean-up and 10 per cent during capsulorhexis. The survey was conducted by Dr Leaming in November 2013. A total of 2,924 surveys were emailed to ESCRS members of which 486 were completed for a 17 per cent response rate. Corporate sponsors were Bausch + Lomb Europe and Abbott Medical Optics. David Leaming: eyeoper8@aol.com

SPECIAL FOCUS: CATARACT & REFRACTIVE

SECOND EYE INTERVENTIONS Are second eye cataract interventions justified in elderly patients? Dermot McGrath reports

he debate over the utility of second-eye cataract surgery in elderly patients would benefit greatly from more rigorous scientific data in order to help clinicians better defend the interests of their patients, according to Jean-Jacques Saragoussi MD. “Many of the randomised studies in the literature have not been designed to look at the issue of second-eye surgery and few publications have the level of proof needed for the application of evidence-based medicine. We need more specific methodologies to look at this question and contribute to the debate with strong scientific arguments that defend the interests of the patient,” Dr Saragoussi told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris, France. The difficult economic climate has brought the question of the utility of bilateral cataract surgery to the fore, noted Dr Saragoussi. “We are seeing increased pressure on health services with restrained budgets and a need for insurance companies to prioritise healthcare with new restrictions and exclusions.” Going forward, these healthcare priorities will be designated based on the proven efficacy of treatments in line with the strictures of evidence-based medicine, drawing on publications classified as “weak”, “moderate” or “strong” according to the level of proof provided, said Dr Saragoussi. To assess the utility of second-eye surgery in older patients, four questions need to be answered, he said: Will it improve the patient’s vision? Will it improve the patient’s quality of life? What will the surgery cost to the health service as a whole? And finally, why and Jean-Jacques Saragoussi when is it useful to carry out second-eye cataract interventions in elderly patients? In terms of vision, there is good evidence that second-eye surgery improves stereopsis, contrast sensitivity, stereoacuity and visual field over and above the benefits of first-eye surgery, said Dr Saragoussi. For quality of life, those studies that used subjective patient questionnaires found that the improvement was not constant and was less clear-cut for second-eye surgery than it was after the first intervention. “This depended, however, on the level of visual acuity achieved in the first eye as well as the preoperative visual acuity of the second eye,” said Dr Saragoussi. Using cost-utility analysis, however, a study by Brown et al in 2013 showed that bilateral surgery equated to a gain of 2.8 quality adjusted life years (QALYs) versus 1.6 QALYs for unilateral surgery. In terms of cost to the health system, Brown et al also showed that the unit cost of cataract surgery has diminished by about 34.2 per cent between 2000 and 2012, while the number of operations has multiplied six-fold in the last 20 years, said Dr Saragoussi. The same study also found that cataract surgery – unilateral and bilateral – is very cost-effective in the long term. Summing up Dr Saragoussi said that there was a clear need for additional trials examining this important procedure.

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SPECIAL FOCUS: CATARACT & REFRACTIVE

ACCOMMODATING IOL New design approach to gel IOL.

Howard Larkin reports

eveloping an extruded gel accommodating intraocular lens (IOL) that provides excellent optical quality over a wide refractive range using natural physiological accommodative effort is a complex engineering challenge. A prototype lens with a corresponding mathematical model suggest it can be done, Sean J McCafferty MD of the University of Arizona, Tucson, AZ, US, told the 2014 American Society of Cataract and Refractive Surgeons (ASCRS) in Boston. The design is based on the NuLens concept, a sulcuspositioned lens in which gel extruded through a central aperture interface creates lenticular deformation under contraction of the ciliary muscles leading to accommodation, Dr McCafferty said. However, the NuLens design works counter to the natural direction of accommodative effort, increasing rather than decreasing power with relaxation. The new prototype uses a bicameral chamber filled with a high-index fluid in front of the deforming surface, Dr McCafferty said. This creates a counter force vector from the sulcus that decreases lens power under relaxation, which is physiologically similar to the action of the natural crystalline lens.

McCafferty said. A wide range of design and material variables can be plugged into this validated model for testing without manufacturing hundreds of varying prototypes, speeding the development process. So far, the model suggests that maximising the refractive index change at the interface reduces actuation force. Minimising the gel’s Poisson’s ratio, which is a measure of how much a material deforms in one direction in response to force exerted in another direction, also reduces force and improves image quality – though Poisson values for gels run in a narrow range and are all fairly high. Reducing the elasticity, or Young’s modulus, and total disc area compressed also lower force requirements – though this runs counter to improving image quality by maximising the ratio of axial gel thickness to aperture diameter. Multiple input parameters can be combined using a Monte Carlo simulation to derive a root sum square merit function that provides precise answers for the diameter, Young’s modulus and other design and materials trade-offs that will optimise force and visual quality outcomes, Dr McCafferty said. “This is the process that any deformable interface IOL should go through before final development and FDA approval.”

DEVELOPING A MATHEMATICAL MODEL

Sean McCafferty: sjmccafferty66@hotmail.com

The primary development goal of the new design is to minimise the force required to accommodate, Dr McCafferty said. “There is a very limited amount of force available inside the eye to produce accommodation. But accommodation accompanied by major optical aberrations isn’t worth much, so the secondary goal is optimising image quality on the retina, expressed as a visual Strehl ratio.” Small changes in lens design and materials, such as the size of the deformable aperture, and the axial thickness and elasticity of the gel material, have major effects on the force required and the optical quality achieved, Dr McCafferty explained. For example, decreasing axial gel thickness from 2.0mm to 0.5mm with a 3.0mm aperture changes the lens interface profile from a smooth lenticular curve with very low aberrations to a wavy surface with extreme aberrations. The mathematical model developed for the lens correlates closely with the observed characteristics of the prototype, Dr

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Courtesy of Sean J McCafferty MD

Optical modelling of image quality using the deformed surface

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Intracameral cefuroxime beneficial in reducing endophthalmitis, study shows. Dermot McGrath reports

he introduction of intracameral cefuroxime for routine cataract surgery in a French private hospital significantly reduced the incidence of endophthalmitis and had a high clinical and economic impact on its prevention, according to a study presented at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris. “The evaluation of professional practices (EPP) carried out at our private hospital (Océane Private Hospital) showed that using intracameral cefuroxime in cataract surgery provides a clear benefit to the patient, with the prevalence of endophthalmitis reduced by a factor of 4.8 after its introduction. Our study also demonstrated the cost-effectiveness of intracameral cefuroxime use and makes a strong case for its introduction to the wider health system for every cataract intervention,” said Jean-Luc Bertholom MD. The study conducted by Drs Bertholom, Raffray MD and Le Bail MD and colleagues, included 11,198 cataract surgeries carried out after the introduction of the intracameral cefuroxime protocol at a private hospital in Vannes, France, between 2011 and 2013. These results were then compared with a retrospective analysis of 9,999 cataract operations without cefuroxime carried out from 2007 to 2009. Dr Bertholom noted that cataract surgery is the most practised form of surgery in France, with more than 700,000 operations a year, and an average endophthalmitis rate of 0.28 per cent. The cefuroxime protocol was instituted at the private hospital in Vannes according to recommended ESCRS guidelines, with an intracameral injection of 1mg cefuroxime in 0.1ml into the anterior chamber at the end of phacoemulsification surgery before closing the wound. The results showed that the prevalence of endophthalmitis at the private hospital prior to the introduction of cefuroxime was 0.26 per cent, or 26 cases of endophthalmitis in 9,999 cataract operations. After the introduction of intracameral cefuroxime, however, the incidence was reduced to 0.05, or six cases in 11,198 cataract operations. Overall there was almost a five-fold (4.8) reduction in the incidence of endophthalmitis after the introduction of cefuroxime, said Dr Bertholom. He noted that the results were comparable with those in the landmark ESCRS study published by Barry et al in JCRS in 2007, which recorded 23 (0.28 per cent) presumed cases of endophthalmitis in 8,244 patients that did not receive intracameral cefuroxime compared to five presumed cases (0.06 per cent) among the 7,997 patients that did receive intracameral cefuroxime. Looking at the economic implications of antibiotic prophylaxis, Dr Bertholom estimated the cost of treating endophthalmitis at €7,500 per case or a total of €195,000 for the 26 cases recorded at Vannes prior to the use of cefuroxime. The cost of Aprokam, the first premixed intracameral cefuroxime formulation, is €9.10 per dose or €91,000 per 10,000 cataract surgeries. “By avoiding an estimated 20.6 cases of endophthalmitis, which would cost around €154,000, we estimated the savings to be around €63,500 per 10,000 cataracts and €4,445,000 per 700,000 cataracts which is a very significant saving for the national health system if such a protocol was put in place nationally,” he concluded. None of the authors has any commercial or financial interest in the products submitted. Jean-Luc Bertholom: jeanluc.bertholom@gmail.com

EUROTIMES | SEPTEMBER 2014

SPECIAL FOCUS: CATARACT & REFRACTIVE

FEMTO-CAT UPDATE Femtosecond laser-assisted cataract surgery shows benefits. Roibeard O’hEineachain reports

he femtosecond laser’s accuracy and predictability in the performance of capsulotomy and corneal incisions, and the reduction it provides in the need for ultrasound energy can translate into a more accurate and stable positioning of the IOL, improved visual outcomes and less trauma to intraocular structures than is the case with conventional phacoemulsification techniques, according to Zoltan Nagy MD, Semmelweis University, Budapest, Hungary. “The advantages of femtosecond laser technology include higher safety, higher predictability, less phaco energy, shortened treatment time, better results with premium lenses and significant help in complicated cases like traumatic cataracts, loose zonules, and white and tumescent cataracts,” Dr Nagy said at the 18th ESCRS Winter Meeting in Ljubljana. In the first clinical study to evaluate the performance of a femtosecond laser (LensX®, Alcon) in cataract procedures, which Dr Nagy and his associates published in 2009 (Nagy et al, J Refract Surg 2009; 25:1053-1060), the results demonstrated that a femtosecond laser can effectively perform corneal incisions, a central and guaranteed diameter capsulotomy and fragmentation and liquefaction of the crystalline lens. Dr Nagy noted that since that time he and his team have published around 20 studies concerning femtosecond laser-assisted cataract surgery, all using the LensX system. They show that the femtosecond lasers have demonstrated a statistically significant superiority over conventional ultrasound phacoemulsification in several clinical parameters. For example, one study showed that the mean amount by which the capsule overlapped the anterior surface of the IOL at one year was significantly higher in eyes with femtosecond laser-created capsules than in those that had undergone manual capsulorhexis. The study also showed the amount of overlap had an inverse correlation with amount of decentration (Kranitz K et al, J Refract Surg 2011; 27:558-63). In another study, imaging with a Pentacam Scheimpflug camera supported those findings and also indicated that the mean amount of IOL-tilt was significantly greater in eyes that had undergone conventional phacoemulsification than it was in those that had undergone femtosecond laser-assisted surgery. It also showed that the amount of tilt and decentration had a statistically significant inverse correlation with corrected distance visual acuity (Kránitz, J Refract Surg 2012; 28:259-63). Results of another study indicate that the superior IOL positioning afforded by femtosecond laser capsulotomy is also reflected in the quality of vision. Aberrometry performed with the NIDEK OPD-Scan II showed that eyes that had undergone femtosecond cataract surgery had significantly lower mean values of tilt and coma, and significantly higher mean Strehl ratios and modulation transfer function (MTF) values than eyes that had undergone conventional phacoemulsification with manual capsulorhexis (Miháltz, J Refract Surg. 2011; 27:711-716). Recent studies have also shown that the femtosecond laser may be gentler to the eye than conventional phacoemulsification. That is probably the result of the much reduced requirement for phaco power during nuclear fragmentation and emulsification, he noted. In one study, measurements taken with the Pentacam showed that mean central corneal thickness was significantly greater at day one postoperatively in eyes undergoing standard phacoemulsification (607µm) than in those undergoing femtosecond-laser assisted cataract surgery(580µm). Both groups had similar mean central

corneal thickness preoperatively, and at one week and one month postoperatively (Takács, J Refract Surg. 2012; 28:387-391). In the same study confocal microscopy showed that endothelial cell count was higher in the femtosecond laser group than in the phacoemulsification group, though not statistically significant. “We found that the postoperative corneal oedema and endothelial damage was less in the femtosecond group than in the manual procedure group. That is especially due to the shorter treatment time and less heating of the aqueous,” Dr Nagy said. In another study, OCT measurements (Stratus OCT3, Carl Zeiss Meditec, AG) showed significantly less thickening of the inner macular ring in eyes that had undergone cataract surgery with the femtosecond laser than in those that had undergone conventional phacoemulsification (Nagy et al, J Cataract Refract Surg. 2012 Jun; 38(6):941-6). Dr Nagy noted that femtosecond laser-assisted cataract surgery is a very new technology system, having been in clinical use for only five years. The chief barriers to its wider adoption is its high expense, which includes not only the capital investment in the machines, but also a click fee and a service fee. However, he said it is the technology that will ultimately provide patients with the best results in terms of safety and visual outcomes. Zoltan Nagy: zoltan.nagy100@gmail.com

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EUROTIMES | SEPTEMBER 2014

29.07.2014 18:09:03

SPECIAL FOCUS: CATARACT & REFRACTIVE

ROLE OF ABERROMETRY OQAS system is an ideal tool for the evaluation of patient complaints. Sean Henahan reports

s performing aberrometry in cataract surgery really necessary? Damien Gatinel MD addressed this question in a session of the 2014 World Ophthalmology Congress in Tokyo. “The short answer is yes. Aberrometry has a critical role to play both before and after cataract surgery,” said Dr Gatinel, director of anterior and refractive surgery, Rothschild Foundation, Paris, France. “A major issue with cataract is light scatter. The best tool for preoperative assessment is double pass aberrometry. The Optical Quality Analysis System (OQAS) aberrometer (recently renamed HD Analyzer, Visiometrics) allows you to measure double pass the point spread function, which contains information about scatter. It then converts it into an objective measure, the objective scatter index (OSI). I use it on a daily basis for preoperative objective assessment. It helps to differentiate objectively cataract from clear lens surgery.” The OSI measures the ratio of scattered light and light in the path of the point spread function. This is particularly helpful when a patient presents with 20/20, but complains about visual symptoms that may be related to cataract. An increase in the OSI signals that it may be time to consider cataract surgery, explained Dr Gatinel.

CROSS-SECTIONAL STUDY Dr Gatinel and colleagues conducted a prospective, single-centre, cross-sectional study to evaluate the clinical utility of the OQAS system in 135 patients referred for cataract evaluation (AJO, Vol. 155, Issue 4, 629–63). They found that the objective scatter index, modulation transfer function and visual acuity were correlated with different types of cataract. In patients with good visual acuity and moderate functional symptoms, the OSI values also correlated with the severity of posterior subcapsular cataract. He cited one case of a patient with subcapsular posterior cataract. The OSI was elevated before surgery, then dropped

Courtesy of Damien Gatinel MD

The Toreasy app enables you to capture photos of the anterior segment of the eye. It uses augmented reality to project an oriented reticule, which is robust to the smartphone inclination and constantly keeps the proper orientation. This reticule can be used to locate precisely the angular position of a mark or prominent limbal vessel

following implantation of a diffractive IOL. The OSI then increased with the development of posterior capsule opacification (PCO). The OSI returned to normal following YAG capsulotomy. In another case, an unhappy patient presented asking for explantation of a multifocal IOL. Instead, Dr Gatinel evaluated the eye with corneal topography and the OQAS system, which both suggested a significant amount of corneal astigmatism, given the shape of iterative point spread functions that looked similar to a Sturm conoid on the OQAS. He decided to correct the corneal astigmatism instead, with good visual results for the patient.

OBJECTIVE INFORMATION

SMARTPHONE APP

“The OQAS/HD Analyzer system is an ideal tool for the evaluation of patient complaints in the postoperative period. It can provide some objective information regarding visual symptoms such as haloes, ghosting, glare and monocular diplopia.” He described another case of an unhappy refractive multifocal IOL

Dr Gatinel also described a new smartphone app he helped to develop. The Toreasy app allows you to take and store oriented pictures of the anterior segment of the eye. The surgeon can use it to find the orientation of natural (limbal vessels) or artificial (ink) marks of the eye for precise positioning of a toric IOL. The app takes advantage of the gravity and horizon tracking functions of the phone. Using the reticule, the surgeon can align the head of the patient, zoom in on the eye and take a snapshot. Using a reference such as a blood vessel or ink mark, the surgeon can then orient the eye properly under the microscope at the time of surgery.

A major issue with cataract is light scatter. The best tool for preoperative assessment is double pass aberrometry Damien Gatinel MD EUROTIMES | SEPTEMBER 2014

recipient. The OPDscan III (Nidek, Japan) examination revealed that the problem was not really a problem with the multifocal IOL per se, rather the patient was not well corrected for defocus, as was shown on the OPD map, which helps to explore the variation of the local vergence throughout the entrance pupil, when autorefractometer becomes unreliable in such circumstances. The patient underwent LASIK to correct a slight hyperopic error and had a good result. Another case involved a dramatic toric IOL mislocation resulting in 7 D of error. An exam showed that the IOL was poorly oriented. Subsequent 30° rotation of the IOL led to a good outcome.

Damien Gatinel: gatinel@gmail.com

SPECIAL FOCUS: CATARACT & REFRACTIVE

VARIED RESULTS No consensus in Europe on prevention of endophthalmitis after cataract surgery.

Roibeard O’hEineachain reports Regarding the use of intracameral antibiotics, 66 per cent of respondents said they used them in all of their cataract procedures, 29 per cent said they never used them and the remaining 15 per cent said they only used them in specific cases. Preparation of antibiotics was performed by nurses in 77 per cent of centres, hospital pharmacies in 20 per cent, compounding pharmacies in nine per cent, and by the surgeon in seven per cent of cases. The use of intracameral antibiotics varied from country to country, from 100 per cent in Sweden and 95 per cent in Spain to 36 per cent in Germany. Cefuroxime was the most widely used. Other agents included vancomycin and moxifloxacin. Regarding the use of antibiotics after surgery, 47 per cent prescribed topical antibiotics and steroids, 40 per cent prescribed NSAIDs with-or-without antibiotics, 34 per cent prescribed steroids alone, and five per cent prescribed NSAIDs plus antibiotics. Among those prescribing postoperative antibiotics, length of treatment ranged from one week to more than two weeks. Dr Pleyer noted that the study’s authors include one key opinion leader from each country surveyed, together comprising the ETHICS (European Team for the prophylaxis of infection in Cataract Surgery) board. Their plan is to conduct the survey in addition to other information-gathering approaches annually to obtain the up-todate on current practice in cataract surgery. Uwe Pleyer: uwe.pleyer@charite.de

Courtesy of Uwe Pleyer MD

survey of European cataract surgeons reveals that there is considerable variation in the measures taken to avoid postoperative endophthalmitis, said Uwe Pleyer MD, Eye Clinic of the University Hospital, Charité, Berlin, Germany, at the 18th ESCRS Winter Meeting in Ljubljana. The participants included 479 cataract surgeons from nine European countries, with between 19 and 100 surgeons per country, one surgeon per clinic. All completed a questionnaire regarding the endophthalmitis prophylaxis measures they took before, during and after cataract surgery. The survey revealed that there is at present little in the way of an international consensus regarding infection prophylaxis measures taken before the patient arrives in the operating room. For example, in the UK the percentage of surgeons who prescribe preoperative topical antibiotics is very low, 1.3 per cent, while in Italy 80 per cent prescribe them. Overall, 42 per cent of ophthalmologists surveyed prescribed preoperative topical antibiotics Once the patient is in the surgical theatre, the use of antisepsis is nearly universal with povidone iodine being the most popular agent, followed by chlorhexidine. However, the concentrations used varied considerably, in the case of povidone iodine, from one per cent to 10 per cent. The median time that the iodine was applied before surgery was suboptimal at 120 seconds. Research has shown that most complete antisepsis is achieved with a three-minute application.

Survey of European Cataract Surgeons regarding endophthalmitis prophylaxis measures

EUROTIMES | SEPTEMBER 2014

SPECIAL FOCUS: CATARACT & REFRACTIVE

MULTIFOCAL IOL IMPLANTS

Patient selection and rigorous preoperative evaluation key to success. Dermot McGrath reports

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horough preoperative clinical evaluation and careful patient management are crucial to postoperative success with the latest generation of multifocal IOLs, according to a study presented at the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris. “Today’s range of multifocal IOLs can deliver consistently precise refractive outcomes and high levels of spectacle independence for our patients once certain conditions have been respected,” said Laurence Lesueur MD. “In our experience, a personalised preoperative evaluation is essential to enable us to obtain the best possible outcomes for patients and to ensure that they obtain the IOL which best meets their own individual needs.” Dr Lesueur, an ophthalmologist at Centre d’Ophtalmologie Jeanne d’Arc, Toulouse and CHU Toulouse Purpan, France, presented a four-year retrospective study of a range of IOLs – multifocal and multifocal toric lenses – implanted in 97 eyes of 49 adult patients (mean age: 64 years) between 2010 and 2014 with a minimum follow-up of three months. Looking at the published scientific literature of over 700 publications on multifocal IOLs since 1987, Dr Lesueur said that the principal causes of failure in multifocal lenses include visual and refractive factors; ocular issues such as dry eye and posterior capsule opacification (PCO); retinal problems and glaucoma; optical factors and strabismus. The patient profile is also critically important, she said.

EXCELLENT OUTCOMES Looking at the results, Dr Lesueur said that the implants delivered excellent visual outcomes for her patients, with a mean postoperative uncorrected visual acuity of 0.78 compared to 0.60 corrected visual acuity preoperatively and with a mean postoperative refraction of + 0.02 D compared to + 0.60 D preoperatively. Patient satisfaction was also very good, with a mean score of 8.1 on a scale of zero to 10. Total spectacle independence was achieved in over 73 per cent of patients, said Dr Lesueur. YAG laser treatment was necessary in 9.7 per cent with a mean delay of 28 months for intervention. Ten patients experienced some visual symptoms (22.4 per cent); four (eight per cent) had issues with residual ametropia, two patients (four per cent) had ocular surface problems, while psychological issues occurred in two patients. Dr Lesueur said that the overall results showed a strong correlation between patient satisfaction and spectacle independence and also uncorrected distance visual acuity. There was only a weak correlation between patient satisfaction scores and issues such as photic problems, YAG incidence, postoperative refraction and near vision. Summing up, Dr Lesueur said that the low failure rate of just four per cent for multifocal IOLs, with no explantations required, underscored the fact that excellent outcomes can be achieved with these lenses once certain rules were adhered to. Laurence Lesueur: lesueur.lc@gmail.com

EUROTIMES | SEPTEMBER 2014

SPECIAL FOCUS: CATARACT & REFRACTIVE

ECLIPSE IOL Photochromic IOL performs well in initial trials.

new photochromic IOL has performed very well in initial trials and seems to offer the safety advantages of existing blue-light blocking implants but without compromising mesopic or scotopic vision. Addressing delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris, Francis Ferrari MD, in private practice in Strasbourg, France, said that the eclipse IOL (Focus Acrylic eclipse by eyePx LLC and distributed by Ophta France) combines retinal protection from harmful blue light with excellent quality of vision in all light conditions. “There are several studies now showing the harmful effects of blue light to the retina and choroid. It is known to increase oxidative stress and the EUREYE study showed a clinical correlation between cumulative environmental blue light exposure and neovascular AMD in patients with low antioxidants in the blood. Furthermore, the photochromic effects of this IOL means that it will not interfere with patients' sleep patterns or circadian rhythms in the same way that a yellow-filter IOL may do,” Dr Ferrari commented. Describing the implant in more detail, Dr Ferrari said that the eclipse lens is a one-piece hydrophobic acrylic IOL incorporating a pigment with photochromic properties. This pigment is made up of two substructures connected together by a spiro-carbon bond. Upon exposure to ultraviolet light, the spiro-carbon bond breaks followed by the appearance of a large co-planar molecule that absorbs a part of the blue-coloured rays. As a result, the lens is “activated” and turns yellow, with an absorption curve comparable to that of a 53-year-old human crystalline lens. The aspheric lens can be inserted through a 2.4mm incision, said Dr Ferrari (http://www.ophta-france. com/index.php?alias=eyepx_eclipse&funct ion=display&tplentry=vid&moid=31&tem plate=video.html&oid=T002:g9fgwajde8g &video=1). In Dr Ferrari’s comparative study carried out at two centres in France between November 2012 and July 2013, 43 patients were implanted with the Eclipse IOL and 48 patients with the Alcon SN60WF incorporating a yellow chromophore. The study was primarily focused on the colour vision of the two groups of patients.

BLUE LIGHT There were no statistically significant differences between the performance of the two lenses in terms of postoperative best-corrected visual acuity, postoperative uncorrected visual acuity and preoperative and postoperative pachymetry and IOP. However, comparisons of blue colour vision using rack 3 of the FarnsworthMunsell 100 Hue Test showed superior performance for the eclipse lens under both photopic (1,500 lux) and mesopic (40 lux) conditions, said Dr Ferrari. While filtering out harmful blue light, the eclipse lens still allows sufficient blue light to penetrate the eye in order to prevent changes to patients’ circadian rhythms. “Just as the basic function of the ear is hearing and maintaining balance, so the eye also has functions that are more than purely visual. This stems from the discovery in 1998 of a new retinal pigment called melanopsin, which is found in the photosensitive ganglion cells. These photoreceptor cells do not provide visual information as such, but are involved in the regulation of circadian rhythms. Since melanopsin photoreceptors reach peak light absorption at blue light wavelengths, they may therefore be less affected by a photochromatic lens than a traditional blue-blocking IOL,” he said. Francis Ferrari: francisferrari@icloud.com

Courtesy of Francis Ferrari MD

Dermot McGrath reports

Eclipse IOL, total change

EUROTIMES | SEPTEMBER 2014

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1. 166 Data on File_Extended Range of Vision IOL 3-Month Study Results (NZ). 2. TECNIS® Symfony DFU TECNIS® Symfony Extended Range of Vision Lenses are indicated for primary implantation for the visual correction of aphakia and preexisting corneal astigmatism in adult patients with and without presbyopia in whom a cataractous lens has been removed by extracapsular cataract extraction, and aphakia following refractive lensectomy in presbyopic adults, who desire useful vision over a continuous range of distances including far, intermediate and near, a reduction of residual refractive cylinder, and increased spectacle independence. These devices are intended to be placed in the capsular bag. For a complete listing of precautions, warnings, and adverse events, refer to the package insert. TECNIS and TECNIS SYMFONY are trademarks owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates. ©2014 Abbott Medical Optics Inc., Santa Ana, CA 92705 www.AbbottMedicalOptics.com PP20140012

SPECIAL FOCUS: CATARACT & REFRACTIVE

GENDER AND BIOMETRY Some IOL calculation formulas fall short for short eyes. Roibeard O’hEineachain reports

ider adoption of the Haigis and similar IOL calculation formulas will improve the predictability of refractive outcomes in cataract surgery and eliminate the gender differences in biometry prediction error, said Anders Behndig MD, Umea, Sweden, at the 18th ESCRS Winter meeting in Ljubljana. Dr Behndig presented an analysis of data from cataract procedures included in the Swedish National Cataract Register during the period from 2008 to 2013. It showed that the mean biometry prediction error decreased from around 0.5 D in 2004 to around 0.4 D in 2013, although there was considerable variation among the different clinics. The analysis also showed that, whereas in 2005 the mean biometry prediction error was greater by about one-third of a dioptre in women than it was in men, by 2013 the mean biometry prediction error in men and women was roughly equal, though still slightly higher in women. However, an analysis of biometry prediction errors with correct signs showed that there remained a much larger myopic shift in women than in men.

REDUCTION IN GENDER DISPARITY He noted that data from 2013, when the National Cataract Register (NCR) first included the IOL calculation formula and axial length, indicate that a shift in recent years to the Haigis and similar formulas may account for the reduction in the gender disparity. The data showed that the gender difference in biometry prediction error remained in cases where the SRK-T formula was used for IOL calculation, but not where the Haigis formula was used. “When we look at women and men in large population studies, it turns out that women have steeper corneas and shorter eyes, whereas men have flatter corneas and longer eyes. These two variables are linked. A person with steep corneas will generally have shorter eyes and a person with flat corneas will generally have longer eyes. “The SRK-T formula renders a myopic error in patients with steep corneas and short axial lengths. These features are predominant in women, which explains the gender difference in biometry prediction between men and women. An increased preference for the Haigis formula over the SRK-T formula have likely diminished the historical gender differences,” Dr Behndig explained. He also noted that, when he and his associates divided the patients in the registry study into quintiles according to the steepness of their corneas and the shortness of their eyes, it showed that men with short eyes and sharp corneas had the same mean prediction error with the SRK-T formula as did women with similar ocular dimensions. “Using the Haigis formula or other similar formulas to a greater extent can improve biometry prediction in cataract surgery and also eliminate the prediction error difference between men and women,” Dr Behndig concluded. Anders Behndig: anders.behndig@ophthal.umu.se EUROTIMES | SEPTEMBER 2014

CORNEA

INFECTIOUS KERATITIS New drugs, better diagnostics improve treatment, but compliance is key. Howard Larkin reports

ewer drugs and fortified versions of existing agents are often effective in treating difficult infectious keratitis cases, including many involving resistant organisms, according to presenters at the American Academy of Ophthalmology (AAO) annual meeting in New Orleans. However, compliance with treatment regimens remains critical for success. Lack of compliance may lead to treatment failure more often than antibiotic resistance. Organisms found resistant to antibiotics in other parts of the body often can be treated with those compounds on the cornea, said Eduardo C Alfonso MD, medical director of the ocular microbiology lab and chairman at Bascom Palmer Eye Institute, University of Miami, Florida, US. This is because organisms are deemed resistant to specific anti-infective compounds if the minimum inhibitory concentration, or MIC, required to control the organism exceeds the maximum safe serum concentration for systemic use. But with topical application, much higher concentrations can safely be reached in the eye than systemically. “If we can increase concentration and increase dosing, we can overcome intermediate resistance. We see this over and over in our clinical practice using fortified antibiotics,” Dr Alfonso said. This may also explain why some patients started empirically on a drug get better even though lab tests later find the organisms resistant to that drug. However, increasing concentration is not effective against highly resistant organisms, said Francis S Mah MD, Scripps Clinic, La Jolla, California, US. He tested the effects of higher concentrations of antibiotics on various levels of resistance by infecting rabbit eyes with Staphylococcus aureus K950 from a keratitis patient. In the lab, the organism proved sensitive to vancomycin with an MIC of 2.0 micrograms/mL, considered a safe serum concentration for the compound. But it

was considered resistant to gatifloxacin, with MIC of 12 micrograms/mL; levofloxacin, with MIC of 32 micrograms/ mL; and highly resistant to ciprofloxacin, with MIC of 256 micrograms/mL. In the rabbit eyes, both gatifloxacin and levofloxacin were effective as rated by clinical outcomes scores and colony count data, Dr Mah said. But ciprofloxacintreated eyes fared no better than untreated controls on colony counts, and were actually graded worse clinically. Therefore, there is a certain amount of resistance which can be overcome with the higher concentration and more frequent dosing of topical therapy, however, there is a limit to this clinical phenomena. FDA trials of fortified topical antibiotics have found them effective despite being labelled resistant by the microbiology laboratories, Dr Mah noted. Indeed, for peripheral keratitis lesions up to 2.0mm, the AAO preferred practice patterns call for Gram staining and empirical therapy with topical fluoroquinalones and/or fortified antibiotics, such as cefazolin with tobramycin, every one to two hours. Larger, central or treatmentresistant lesions and those with clinical features suggesting fungal, amoebic or mycobacterial involvement should be cultured. Loading doses every five to 15 minutes for the first hour followed by applications every 15 minutes to one hour around the clock may be indicated. In case of treatment failure, look first at compliance, Dr Mah said. “Organism resistance is almost never a reason for failure in a keratitis trial. Compliance is almost always the biggest reason medications don’t work in clinical trials.” The tolerance of the ocular surface to highly concentrated antibiotics also allows greater use of fluoroquinolones, the most toxic antibiotics ever developed, Dr Alfonso said. “Fluoroquinolones are the mainstay, but corneal specialists make more use of fortified antibiotics.” Fluoroquinolones are good for many Gram positive organisms. Cephalosporins

If we can increase concentration and increase dosing, we can overcome intermediate resistance Eduardo C Alfonso MD EUROTIMES | SEPTEMBER 2014

are about 65 per cent effective, but sometimes vancomycin is needed, Dr Alfonso said. Gram-negative organisms are mostly well covered by fluoroquinolones, but sometimes aminoglycosides are required. MRSA is not well covered by fluoroquinolones and may require vancomycin. Agents including oxazolidinones, and synercid are useful when certain bacteria appear, he said. Mycobacteria can be more difficult to treat as they develop resistance under treatment, Dr Alfonso said. He recommended combinations, with amikasin and clarithromycin the drugs of choice, but azithromycin, quinolones and linezolid may also be used.

FUTURE TREATMENTS Dr Alfonso expects future antibiotics will include oxazolidinones, synercid, glycopeptide and more fluoroquinolones. He also sees greater use of genomics and lipidomics to target medications as drug resistance increases. Options for fungal keratitis are fewer, with natamycin 5.0 per cent the only commercially available topical preparation. However, systemic antifungals are also useful, including amphotericin B, ketoconazole, fluconazole and voriconazole, which is highly effective against candida, Dr Alfonso said. Newer antifungals such as caspofungin and posaconazole should also be considered. Genotyping helps target antifungal therapy, Dr Alfonso said. For example, Fusarium other than F solani respond well to voriconazole, but F solani may respond better to natamycin, with infections often proceeding to keratoplasty. For acanthamoeba, a combination of cationic antiseptics and aromatic diamides is effective for early disease, Dr Alfonso said. Eliminating bacteria which the acanthamoeba organism feeds on with neomycin can be helpful. Clotrimazole and miconazole are available in topical preparations and ketoconazole and itraconazole can be added orally. Microsporidia on the conjunctival and epithelial surfaces generally goes away spontaneously, requiring no treatment, Dr Alfonso said. However, stromal keratitis is difficult to treat and often progresses to keratoplasty. Eduardo Alfonso: ealfonso@med.miami.edu Francis Mah: Mah.Francis@Scrippshealth.org

CORNEA

PREVENTING ZOSTER Recommending zoster vaccine may help slow rapid incidence rise. Howard Larkin reports

phthalmologists can help prevent herpes zoster ophthalmicus (HZO) by strongly recommending the herpes zoster vaccine (Zostavax, Merck) to patients aged 50 and over, Elisabeth J Cohen MD told Cornea 2013 at the American Academy of Ophthalmology meeting in New Orleans. Now professor of ophthalmology at New York University School of Medicine, New York City, Dr Cohen cared for many HZO patients during 30 years at Wills Eye Hospital in Philadelphia, where she headed the cornea service. Then she contracted HZO herself. “I got herpes zoster ophthalmicus in my 50s and despite the very best care, I lost vision and had to give up practising ophthalmology. Personally, I strongly recommend this vaccine for people in their 50s,” she said. Herpes zoster is caused by reactivation of the varicella-zoster virus, which also causes chicken pox and is latent in almost all adults. While zoster cannot technically be an epidemic because it is not communicable, its scope may qualify, Dr Cohen said. With mean age of onset in the US at 52 years, 30 per cent of persons will have zoster in their lifetime, rising to half at age 85, Dr Cohen noted. Incidence is higher among women.

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RECENT STUDIES Based on 21 recent national studies, overall European incidence is about 3.4 per 1,000 person-years. That means about 1.7 million new zoster cases in Europe annually (Pinchinat et al. BMC Infect Dis 2013; 13:170). Beyond the painful rash and potentially permanent ocular damage in its chronic phase, zoster presents other longterm risks, Dr Cohen said. One-third of patients over 80 suffer post-herpetic neuralgia. HZO raises stroke risk within one year 4.5 times (Lin. Neurology 2010; 74:792). Studies in Taiwan found a nine times risk increase for cancer (Ho Ophthalmology 2011; 118:1076-81), and 1.68 times risk for lymphoid malignancies (Liu BMC Cancer 2012; 12:503). Available in the US since 2006, the zoster vaccine launched in Europe last year. The vaccine reduces incidence 51 per cent in people aged 60+ (Oxman NEJM 2005; 352:2271) and 68 per cent in people aged 50 to 59 (Schmader Clin Infect Dis 2012; 54(7):922-28). The vaccine also reduces severity, duration and postherpetic neuralgia. Nonetheless, in 2012, 20 per cent of eligible persons aged 60 and older in the US had received the vaccine (MMWR 2014 Feb 1; 62:66-72). In a study Dr Cohen conducted, many patients followed the recommendation of the ophthalmologist to have the vaccine, but the recommendation of the primary care doctor is very important. (Jung JJ, Elkin ZP, Li X, Goldberg JD, Edell AR, Cohen MN, Chen KC, Perskin MH, Park L, Cohen EJ. Increasing use of the vaccine against zoster through recommendation and administration by ophthalmologists at a city hospital. Am J Ophthalmol. 2013; 155:787-95.) Antiviral drugs including valacyclovir are also effective in treating acute HZO.

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Elisabeth Cohen: Elisabeth.cohen@nyumc.org EUROTIMES | SEPTEMBER 2014

CORNEA

DRY EYE Research yielding improved dry eye diagnosis and treatment.

Roibeard O’hEineachain reports

n improved understanding of dry eye is leading to the development of several new technologies for diagnosing and treating the condition, said Beatrice Cochener MD, PhD, University of Brest, France. “Today we have a better understanding of the underlying mechanisms of ocular surface disease. We also have greater consideration of the ocular surface as a key factor in visual performance and quality of life. Moreover, we have new diagnostic tools for quantification of the ocular surface properties and we have innovative options for the treatment of dry eye,” she told the 18th ESCRS Winter Meeting in Ljubljana. Modern definitions of dry eye stress the multifactorial nature of the condition. Contributing factors include increased osmolarity of the tear film and inflammation of the ocular surface, she said.

POST-LASIK DRY EYE Dry eye and ocular surface disease have gained renewed attention over recent years because of their high incidence among patients who undergo corneal refractive surgery, Prof Cochener noted. “The ocular surface is a key factor in vision and comfort. With modern refractive surgery we are close to achieving real emmetropia in most patients and therefore the most common source of dissatisfaction nowadays is related to the ocular surface,” she said. Mild dry eye that is responsive to treatment with lubricants occurs in up to 50 per cent of LASIK patients. More severe dry eye occurs in only 10 per cent of these patients. The condition results primarily from a combination of neurogenic and inflammatory factors. Flap creation and photoablation sever a large amount of corneal nerve fibres. The reduced sensitivity of the ocular surface reduces blinking and the amount of tears produced. The decrease in the tear production in turn increases the osmolarity of the tear film. That in turn causes an increased secretion of proinflammatory cytokines and matrixdegrading enzymes into the tear film. “All these factors lead to a level of inflammation that can directly damage the ocular surface epithelial cells and prolong injury to the corneal nerves and thereby alter the lachrymal gland function leading to damage of the ocular surface,” Prof Cochener said. Meanwhile, the alteration of corneal shape alters tear film distribution and changes the relationship between the ocular surface and the upper lid, increasing evaporative tear loss, Beatrice Cochener MD, PhD she added.

Osmolarity testing can detect at-risk patients among the refractive surgery population. Early detection can enable preop and post-op management of dry eye

EUROTIMES | SEPTEMBER 2014

PREVENTION THROUGH DIAGNOSIS Research has shown that preclinical signs of dry eye are often present in eyes that later develop post-LASIK dry eye. It therefore behoves refractive surgeons to carry out an assessment of the health of the ocular surface prior to carrying out the refractive procedure. Treatment and resolution of pre-existing ocular surface dryness may reduce the risk of postoperative dry eye, Prof Cochener said. There are a number of tests available to measure the various physiological aspects of dry eye. They include the Schirmer’s test, the tear break-up time and lissamine green staining. However, those tests lack specificity with regard to specific subsets of dry eye disease. They are also difficult to perform and are prone to error. She noted that a new test for tear film osmolarity (Tear Lab) may provide a more objective approach. It is designed to detect the aqueous defect or evaporation from the ocular surface. The test can be performed by a technician and requires less than 50nl of a tear sample for a valid measurement Research has established a link between tear instability and hyperosmolarity. The test provides physicians with the ability to quantify and grade the severity of dry eye and base their treatment accordingly. “Osmolarity testing can detect at-risk patients among the refractive surgery population. Early detection can enable pre-op and post-op management of dry eye. Tear osmolarity can also be used to monitor patients’ response to treatment,” Prof Cochener said. However, she added that even though the Tear Lab test is an interesting tool, it is more dedicated to university and clinical research trials [at the time of this presentation] because of the cost of the tips. Another instrument which shows potential in the assessment of tear osmolarity is The Optical Quality Analysis System (OQAS, Visiometrics). The device uses a double-pass technique to measure scattering of the point spread function, which in turn can serve as a surrogate for tear film osmolarity in eyes where the cornea is clear. Another new instrument is the LipiView® interferometer (TearScience). It operates on the principle of broad-spectrum white light interferometry, and quantifies the lipid content of the tear film in terms of interferometric colour units (ICU). It is designed to work in conjunction with the new LipiFlow® technology designed to restore normal function to the meibomian gland in eyes where it is impaired. The LipiFlow® device is designed to remove obstructions in the meibomian gland through the application of heat and gentle pulsatile pressure, and thereby increase the lipid content of the tear film, she explained. Prof Cochener presented results of a prospective randomised trial she and her associates conducted involving 30 dry eye patients. It showed that those receiving a single 12-minute treatment with the LipiFlow device had better response to treatment in terms of tear film quality and dry eye symptoms at one month than patients who underwent daily treatment with an eye-lid warming eye patch, the Meibopatch. By three months there was no significant difference between the groups. Beatrice Cochener: beatrice.cochener@ophtalmologie-chu29.fr

CORNEA

OCULAR INFECTIONS Concern over lack of awareness about ocular issues being caused by STIs. Priscilla Lynch reports

n increasing number of ocular infections caused by gonorrhoea or syphilis are being diagnosed in Ireland, the 2014 Irish College of Ophthalmologists annual conference in Limerick heard. Dr Susan Knowles, consultant microbiologist, Royal Victoria Eye and Ear Hospital (RVEEH), Dublin, gave a presentation on the re-emergence of ‘old’ diseases such as syphilis and gonorrhoea, during the conference. She said a small but significant number of patients complaining of eye problems at RVEEH in recent years have tested positive for the two sexually transmitted diseases (STIs). There have been 13 such cases caused by syphilis and 14 by gonorrhoea in the past few years at the hospital.

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LONG-TERM PROBLEMS Syphilis can cause blurred vision, pain in the eye, painful sensitivity to light and floaters in the patient’s vision. If left untreated it can result in more serious, long-term problems. “If someone might have syphilis it is important to get the blood test done, which is very straightforward, as the treatment for syphilis would be very different than for the normal treatment of various eye conditions,” she told the conference. Gonorrhoea, in a small minority of patients, can cause severe purulent conjunctivitis and eyelid swelling, which can be mistaken for standard conjunctivitis and/or keratitis. In the past, ocular gonorrhoea was seen very rarely in Ireland, usually in newborn babies whose mothers had undiagnosed gonorrhoea. Now it is being seen in young adults, most frequently males, but also females, commonly aged under 25 years, Dr Knowles explained. To treat these ocular issues, the gonorrhoea itself needs to be treated, typically with an antibiotic injection, compared to topical antibiotics for regular conjunctivitis or keratitis. There has been a well-publicised, seven-fold rise in gonorrhoea cases in the east of Ireland in the past number of years (6.9 per 100,000 in 2003 rising to 49.2 per 100,000 in 2012), Dr Knowles noted. Her presentation was well received and a number of ophthalmologists in the audience reported that they too had seen such cases, with at least one case causing a corneal melt. The doctors noted that due to a lack of awareness about the possibility of ocular issues being caused by an STI in general practice and general hospital medicine, diagnosis took some time and thus led to an unfortunate treatment delay. Speaking to EuroTimes, Dr Knowles said she hoped increased awareness of the issue would make it easier for doctors to diagnose these cases and arrange the appropriate treatment as quickly as possible. These cases typically present to emergency departments or GPs and, once diagnosed, should be referred to genito-urinary medicine/infectious disease clinics for other investigations and treatment, she said.

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Susan Knowles: susan.knowles@rveeh.ie EUROTIMES | SEPTEMBER 2014

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CORNEA

IMAGING KPRO

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Better imaging needed for the retina in KPro patients.

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Priscilla Lynch reports

he ophthalmology community needs to develop better imaging techniques for keratoprosthesis (KPro) patients, to ensure any postoperative and long-term ocular complications are detected and managed in time, a major Irish ophthalmology conference has been told. Presenting at the 2014 Irish College of Ophthalmologists Annual Conference, Dr Emma Duignan, ophthalmologist, Royal Victoria Eye and Ear Hospital (RVEEH), Dublin, said KPro is increasingly being used for patients with serious corneal issues and as the procedure becomes more refined and lasts longer, the ophthalmology profession needs to develop better ways of managing the chronic pathology that can occur in these patients. Addressing why imaging in KPro is so important, Dr Duignan noted that these patients are a high risk of fundal pathology, including glaucoma (up to 75 per cent of patients) and retinal detachment. Imaging of the posterior segment is important, especially as digital palpation is the method relied upon to evaluate the intraocular pressure, she explained.

IRISH DATA Dr Duignan presented data from a small Irish study that evaluated the use of non-mydriatic, ultra-wide field scanning laser ophthalmoscopy (Optomap) along with optical coherence tomography (OCT) to image the fundi of nine KPro patients over a six-month period. All nine patients underwent Optomap fundal imaging, of which eight had a fluorescein angiogram. OCT was obtained in five patients and was of good quality unless there was a retroprosthetic membrane present (one of the five), she reported. “Patient cooperation is vital in this setting as the camera must point straight through the centre of the KPro optic, which is longer in the type 2 Boston KPro, which makes it more difficult to ensure that the light is perpendicular to the Emma Duignan optic entering the eye and more difficult to achieve wide-angle imaging,” Dr Duignan noted. Retro-prosthetic membrane was the most common reason for inability to image the fundus, and four patients were excluded from the imaging study due to the presence of a severe membrane. Summarising, Dr Duignan said Optomap fundal imaging can provide wide-angle images of the retina in KPro patients, though the biggest obstacle to imaging is retro-prosthetic membrane. OCT can also be performed through the KPro optic. “As new imaging techniques become available we must identify those that give the most accurate and consistent results. With advanced imaging many disorders can be managed in a semi-traditional fashion, Dr Duignan concluded.

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CORNEA

KPRO COMPLICATION Recurrent sterile vitritis is a sight-threatening condition.

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Roibeard O’hEineachain reports

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terile vitritis in eyes with Boston KPro type 1 karatoprostheses generally respond well to treatment. However, its recurrent form may result in more lasting damage, said Christina Marsica Grassi AB, MD, candidate at Harvard Medical School Massachusetts Eye and Ear Infirmary, Boston Massachusetts, US, at a Cornea Day session at the 18th ESCRS Winter Meeting in Ljubljana. Ms Grassi presented a case report regarding a patient implanted with a Boston KPro type 1 keratoprosthesis who had three episodes of vitritis over the following eight years. The patient was a 70-year-old male who was monocular from trachoma. He had undergone a KPro type 1 keratoprosthesis implantation after two prior failed corneal transplants. Some 13 months after undergoing implantation of the device he developed pain in his eye and his uncorrected vision decreased from 20/400 to light perception only. Slit-lamp examination revealed trace cells in the anterior chamber and 1+ to -2 + cells in the vitreous. He had a wellplaced keratoprosthesis. His B-scan confirmed vitreous debris but also showed the absence of retinal detachment. He underwent a vitreous tap and received an injection of antibiotics and corticosteroids. He also received a sub-Tenons triamcinolone injection, and his topical steroids were increased. His cultures were negative and two-and-a-half weeks after the vitritis event, his visual acuity had returned to 20/400, although the vitreous took 11 weeks to clear. Seven years later the same patient developed a second episode, this time with severe photophobia, tearing and a gradual drop in vision. His visual acuity dropped from 20/60 at last visit to 20/200. His IOP was 15 mmHg to 20 mmHg and he complained of having a tender eye. Slit-lamp examination showed the presence of 2+ cells in the vitreous. The keratoprosthesis had no infiltrates. B-scan confirmed the presence of vitreous debris and showed no retinal detachment. Macular OCT confirmed that the fovea was normal. The patient received an increase in his prednisolone, acyclovir and vancomycin and his moxifloxacin was stopped. He did not receive a triamcinolone injection. The vitreous took six days to clear. However, it took the patient nine weeks to achieve his best visual acuity of 20/100. The patient’s third vitritis episode occurred one-and-a-half years later. This time, he presented with an acute overnight loss of vision, but without pain or any discharge. His vision was limited to light perception. Slit lamp confirmed 3+ cells in the vitreous and a quiet anterior chamber. This time his B-scan showed significant macular thickening. The patient’s condition did not respond to a sub-Tenons injection of triamcinolone or intravitreal antibiotics. Three days later the patient underwent pars plana vitrectomy. At two weeks follow-up macular OCT revealed loss of inner segment/outer segment contours and vitreomacular traction on the fovea. The reasons for the recurrences and for the failure of therapy are not clear, but a microscopic break in the seal at the juncture of the artificial cornea and its carrier graft tissue optic may have played a role, Ms Grassi said.

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Christina Marsica Grassi: mary_leach@meei.harvard.edu Anzeigenserie-ESCRS EuroTimes_08_2013_halfPage.indd 5

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29.07.2014 18:10:54

CORNEA

Courtesy of Rosella Spena MD

Elevated tumorous mass extending across the corneoscleral limbus into the cornea over the visual axis and exhibiting anomalous vascularisation

Persistent corneal opacity after excision of the tumour and surrounding conjunctiva

CORNEAL CANCER Excision followed by graft yields excellent results.

Roibeard O’hEineachain reports

quamous cell carcinoma can sometimes masquerade as pterygium, but timely removal of the tumour followed by lamellar keratoplasty can prevent further damage to the eye and restore excellent vision to the patient, said Rossella Spena MD, Forlí, Italy, who presented a case report at a Cornea Day session at the 18th ESCRS Winter Meeting in Ljubljana. The patient was a 60-year-old male with a two-year history of a slowly developing corneal lesion that had originally been diagnosed as pterygium. At the time the patient was referred to Dr Spena and her associates, the patient had a solid mass that extended into the optical zone and infiltrated the cornea and underlying sclera with abnormal vascularisation. Dr Spena and her associates decided on a surgical treatment using a two-step approach. The first step was the removal of the cancerous mass, including the infiltrated underlying sclera and cornea, associated with cryotherapy of the residual corneo-scleral bed. A biopsy confirmed that the lesion was a squamous cell carcinoma, which is of conjunctival origin and only in very rare cases infiltrates the cornea beyond Bowman’s layer. Microscopic examination of the excised tissue showed the infiltrated corneal and scleral tissue as well as the clear margins.

The eye was fully healed without complications at one month’s follow-up and Dr Spena and her team then proceeded with the lamellar keratoplasty. The second step was to restore the patient’s vision in that eye with a large lamellar keratoplasty. At the beginning of the graft procedure a superficial portion of the cornea, 9.0mm diameter and about 250 microns in depth, was dissected and removed. As the initial dissection was not deep enough to remove the entire corneal opacity, the surgeon continued with a pneumatic dissection of the residual stroma from the underlying Descemet in the central optical zone and the removal of the central 6.0mm of the deepest stroma. Finally, a donor lamella with a thickness of about 350 microns, was prepared by means of the microkeratome, punched to a diameter of 9.0mm and sutured into place with a double running 10-0 nylon suture. At six months’ follow-up the best corrected visual acuity was 0.8 and there was no recurrence of the neoplastic lesion, Dr Spena said, adding: “Removal of the squamous cell carcinoma was helpful in curing the lesion and at the same time lamellar keratoplasty was instrumental in restoring vision.”

Histology of the superficial corneal tissue removed at the time of the tumour excision: the dashed line separates the neoplastic infiltration (above) from the normal stroma (below)

Corneal appearance six months after lamellar keratoplasty. The 6mm optical zone, where the recipient stroma has been removed up to Descemet’s membrane, is perfectly clear; the surrounding crown of tissue, about 1.5mm in width, results from the apposition of the 9.0mm donor lamella onto the deep recipient stroma left in place

EUROTIMES | SEPTEMBER 2014

Rossella Spena: mbusin@yahoo.com

GLAUCOMA

SUCCESSFUL SLT Care in patient selection, laser energy control and visualising the angle help get the most out of selective laser trabeculoplasty. Howard Larkin reports

elective laser trabeculoplasty (SLT) is an attractive option for lowering intraocular pressure (IOP) because it is at least as effective as argon laser trabeculoplasty but causes less coagulative damage to the trabecular meshwork (TM). However, SLT can have its challenges, Hady Saheb MD, MPH, FRCSC told Glaucoma Day 2014 at the American Society of Cataract and Refractive Surgery annual meeting in Boston. Along with his own SLT settings, Dr Saheb of McGill University offered five pearls for avoiding some of the more common problems he encounters with SLT.

DR SAHEB’S SETTINGS Currently, Dr Saheb uses pilocarpine 1-2 per cent and Iopidine preoperatively to prevent IOP spikes. He uses a Latina SLT gonio lens to visualise the angle during the procedure. He applies three nanosecond 400 micron bursts centred on the TM, but notes this spot size overlaps the TM both anteriorly and posteriorly. He starts at 0.7 mJ and titrates power up, adjusting two to three times during the procedure as outlined below. He usually delivers 70 to 90 shots over 360 degrees, rotating the lens in the opposite direction as the laser. Postoperatively, Dr Saheb checks IOP at one hour, and two months after surgery. He recommends a closer follow-up at one week for patients with an IOP spike at the one-hour check, and those with a history of uveitis, advanced glaucoma, pigment dispersion glaucoma or highly pigmented TM, who also usually have pseudoexfoliation glaucoma. He does not routinely use steroids, but has a low threshold for prescribing them as mentioned below.

1. CHOOSE THE RIGHT PATIENT Dr Saheb noted that the goal of SLT shares some similarities with that of microinvasive glaucoma surgery – moderately reducing IOP by improving the physiologic outflow pathway. So he applies similar criteria, considering SLT for patients with ocular

w.euretina.org ww

Access of the gonio lens is so much easier when the head is at an angle in these patients Hady Saheb MD, MPH, FRCSC

hypertension, primary open-angle glaucoma, pseudoexfoliation and pigment dispersion glaucoma. Dr Saheb avoids patients with very uncontrolled IOP. “What you are doing with SLT is optimising trabecular outflow. So if someone has very diseased trabecular outflow, such as with severely uncontrolled glaucoma, SLT is not a good option.” Likewise, he avoids post-filtration surgery patients and those with normal tension glaucoma because their very low IOP targets cannot be met by adjusting trabecular outflow.

2. DON’T GET DRUNK “Champagne bubbles” are a sign that adequate treatment power has been reached, but seeing them with every burn means you’re using too much power, Dr Saheb said. He recommends titrating to see bubbles every second or third burn, and adjusting power two or three times as TM pigmentation varies over 360 degrees.

3. GET A GOOD LOOK An unobstructed view aids accuracy. Dr Saheb recommends moving the gonio lens toward the target to better visualise narrow angles, turning down the light to reduce light scatter from hazy corneas, and cleaning or moving the gonio lens as needed to reduce excess reflections. For patients with brows that extend well anterior of the eye surface, he suggests asking the patient to tilt their head back slightly. “Access of the gonio lens is so much easier when the head is at an angle in these patients.”

4. EASY WITH THE PDG Pigment dispersion glaucoma (PDG) patients are particularly prone to IOP spikes, so Dr Saheb goes easy with them. He starts with a test dose as low as 0.3 mJ, and checks IOP after 10 spots. If the test is successful, he treats one-quarter of the TM at a time and checks IOP after each. He also follows these patients closely after laser.

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5. DON’T SWEAT THE STEROIDS It’s theorised that SLT’s mechanism of action involves an inflammatory response that helps clear the TM. Therefore, steroids should not be used as they might counteract this effect. However, this theory has not been substantiated, and unpublished randomised trials reported to Dr Saheb by research colleagues found no difference in efficacy with or without postoperative steroids. Even so, Dr Saheb does not routinely prescribe steroids. But if there is pain in the first eye or if a patient in for retreatment had pain the first time, he does not hesitate. Following these tips can help improve SLT outcomes, Dr Saheb said. Hady Saheb: hady.saheb@mcgill.ca

EUROTIMES | SEPTEMBER 2014

GLAUCOMA

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Research explains why TM cells might face challenges with mutant myocilin. Dermot McGrath reports

novel high-throughput screening process has enabled scientists for the first time to identify molecules with the potential to block the accumulation of a toxic eye protein that can lead to early-onset glaucoma. Researchers at the Georgia Institute of Technology in Atlanta, Georgia, identified the aggregated structure of a mutant protein called myocilin which may underlie the root cause of the protein’s contribution to increased intraocular pressure (IOP). Previous studies have shown that mutant myocilin is toxic to pressure-regulating cells in the eye and can damage the trabecular meshwork and impede fluid egress, thereby leading to elevated IOP. To find molecules that bind to mutant myocilin and block its aggregation, researchers designed a simple, high-throughput assay and then screened a library of compounds. They identified two molecules with potential for future drug development to treat early-onset glaucoma. “These are really the first potential targeted drug leads for glaucoma,” said Raquel Lieberman, an associate professor in the School of Chemistry and Biochemistry at the Georgia Institute of Technology in Atlanta, whose lab led the research. It has been known for over a decade that mutant forms of myocilin lead to early-onset glaucoma, at least in part due to aggregation of the mutant protein, Dr Lieberman said. “In general, cells are able to handle mutant proteins by quickly promoting their degradation; however, this degradation process does not seem to be efficient in the trabecular meshwork [TM] of the eye challenged with mutant myocilin. Instead, TM cells die, leading to meshwork dysfunction and a hastening of ocular hypertension that leads to glaucoma.”

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MUTANT MYOCILIN Dr Lieberman said that her team’s research provides an explanation for why TM cells might encounter a particular challenge with mutant myocilin. “Our extensive biophysical characterisation demonstrates that the aggregated form of mutant myocilin consists of a particularly stable, non-native structure called amyloid, that is resistant to degradation. Amyloids are common to other ageing and neurodegenerative diseases, most notably Alzheimer's where they form neurotoxic plaques in the brain,” she said. Dr Lieberman noted that direct evidence of amyloid has now been demonstrated in vitro and in cells. “We have used these systems to identify two compounds that bind to myocilin and reduce aggregation. We are extending our assays to test larger compound libraries. As we move forward, we will test our compounds in available animal models of earlyonset glaucoma,” she said. While the focus of this particular study was early-onset glaucoma, Dr Lieberman believes that it may well have important implications for other forms of glaucoma or ocular pathologies. Dr Lieberman’s study was published in the journal ACS Chemical Biology. Raquel Lieberman: raquel.lieberman@chemistry.gatech.edu

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IRIDOPLASTY Laser iridoplasty can relieve angle closure in cases where iridectomy is not possible. Howard Larkin reports

hile no longer widely practised, laser iridoplasty can be helpful in managing angle-closure glaucoma in select cases, particularly those due to mechanisms other than pupillary block, Robert J Noecker MD told Glaucoma Day 2014 at the American Society of Cataract and Refractive Surgery annual meeting in Boston. “It’s not something I practise every week or every month, but there are cases where it is appropriate.” First described in 1973, iridoplasty uses an argon or equivalent solid state green thermal laser to coagulate the iris base, thinning it and shrinking it away from the angle. The most common indication is plateau iris, in which a bulging peripheral iris may keep the angle narrow or closed even after iridectomy, Dr Noeker said. Less common indications include nanophthalmos, lens-related glaucoma and angle closure following vitreoretinal procedures. Plateau iris often results from anteriorly positioned ciliary processes, which push the peripheral iris into the angle, Dr Noecker said. This often can be clearly seen using ultrasound imaging before surgery. Dr Noecker usually starts treatment with a laser iridectomy. This also helps identify the cause. If angle narrowing results from lens issues, iridectomy usually opens the angle as it relieves the aqueous pressure pushing the iris into the angle. But if it is primarily anteriorly placed, ciliary processes pushing the iris into the angle, iridectomy often has little or no effect as aqueous pressure is at best a secondary cause. In cases with residual angle closure, Dr Noecker may move on to iridoplasty once iridectomy-associated inflammation has subsided.

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Iridoplasty generally involves targeting the peripheral iris with 24 to 32 spots of 200 to 500 micron size at 200 to 400 mW for 0.2 to 0.5 seconds each. These relatively long, high-energy pulses enable coagulation of not only the iris surface but also the ciliary processes behind it, allowing the iris to move posteriorly away from the angle, Dr Noecker said. For nanophthalmos, iridoplasty may be combined with iridectomy and gonioplasty as needed to keep the angle open as the lens grows, Dr Noecker said. Similarly, iridoplasty can be helpful in cases of phacomorphic angle closure to keep the angle open until lens extraction is possible. Robert J Noecker Vitreoretinal procedures including scleral buckle and panretinal photocoagulation may also cause ciliary body oedema, narrowing the angle. Iridectomy is the first choice, but iridoplasty may also be helpful. In those cases you want to shrink the ciliary processes as well, Dr Noecker said. Iridoplasty is also useful for treating peripheral anterior synechiae of less than six months’ duration, and in eyes in which iridectomy is not possible, Dr Noecker said. When used appropriately it is effective and generates few complications. Robert Noecker: noeckerrj@gmail.com

GLAUCOMA

MORE TRIALS NEEDED Feasibility in glaucoma awaits further proof, but keep the faith. Roibeard O’hEineachain reports

or the concept of neuroprotective treatment of glaucoma, independent of intraocular pressure (IOP) reduction, to progress from theory into practice, glaucoma researchers will have to apply the same energy and unity of purpose as researchers do into other neurodegenerative disorders, said Francesca Cordeiro MBBS, PhD, University College London, London, UK. “I think we have to learn from researchers in other areas of neurodegeneration who have gotten together to compare notes and establish consortiums to gain acceptance from the regulatory authorities,” she said, at the 11th European Glaucoma Society Congress in Nice. There are many potential targets for neuroprotection in glaucoma, although as yet only two agents, memantine and brimonidine, have made it to the clinical trial stage. Allergan has not yet published the results of the memantine trial, but its press release states that patients receiving the treatment did not reach their endpoints. In contrast, in the Low Tension Glaucoma Treatment Study (LOGTS), progressor analysis of visual field end points indicated a beneficial effect in patients receiving brimonidine compared to patients receiving timolol. That was despite a close similarity between the groups in terms of IOP reduction. Francesca Cordeiro However, the trial has received criticism on multiple grounds. For example, some have suggested that the 20 per cent of patients who dropped out of the brimonidine group, mainly because of side effects, may have had a preponderance of rapid progressors. Alternatively, the poorer results with timolol may actually have been the result of deleterious effect of the agent on the optic nerve. “Nonetheless, this is the first published study to include the effect on visual fields and I think it gave us a little bit of confidence, especially after the memantine trial,” she said. Dr Cordeiro noted that the obstacles to bringing neuroprotective approaches in glaucoma from the laboratory to the clinic are the same as those encountered in other neurodegenerative diseases. They include the need for large numbers of patients with long periods of follow-up. However, unlike glaucoma, and despite previous failures there are numerous phase II and even phase III clinical trials under way in neurodegenerative conditions like stroke and Alzheimer’s disease, but only one trial now under way into neuroprotection in glaucoma. Many of the obstacles to further clinical research could be overcome by the use of more sensitive biomarkers and endpoints and using a more adaptable style in the design of trials, Dr Cordeiro said. For example, agents could be first tried on patients with a historically high risk of progression to provide proof of concept for the treatment more quickly and with fewer patients. In addition, endpoints and selection criteria could be adjusted on the basis of interim results. Francesca Cordeiro: M.Cordeiro@ucl.ac.uk EUROTIMES | SEPTEMBER 2014

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NEW GLAUCOMA DRUGS ROCK inhibitors may provide benefits beyond IOP lowering. Sean Henahan reports

new class of drugs that targets trabecular outflow appears to provide IOP-lowering effects in clinical trials, reported Hidenobu Tanihara MD, PhD at the World Ophthalmology Congress in Tokyo. The new class of drugs, known as Rho kinase (ROCK) inhibitors, represents a different pharmacological approach to the treatment of glaucoma. Several drugs in this class are now in clinical trials. Dr Tanihara, professor and chairman, Dept of Ophthalmology, Facult of Life Sciences, Kumamoto University, Kyushu, Japan, reviewed the latest findings. He presented his own recent work with one agent, K-115 (Ripasudil), which has completed Phase III studies. He reported that the drug produced significant, dose-dependent reductions in IOP in eyes with glaucoma and ocular hypertension. The effects were additive when combined with current prostaglandin agent or β–blocker. A randomised, placebo controlled Phase I study confirmed the safety of a selective ROCK inhibitor, K-115, in healthy male adult volunteers. The investigators noted IOP reductions after each instillation in dose concentrations ranging from 0.05 per cent, 0.1 per cent, 0.2 per cent, 0.4 per cent and 0.8 per cent. In a subsequent Phase II study, 210 patients with primary open-angle glaucoma or ocular hypertension were divided into four groups and given one of three doses (0.1 per cent, 0.2 per cent or 0.4 per cent) of K-115 or placebo twice daily for eight weeks. The study showed statistically significant, lasting dosedependent reductions in mean IOP. IOP dropped 4.5 mmHg two hours after instillation, with the effect lasting at least 12 hours. Based on that study, Phase III clinical studies were conducted using a K-115 dose of 0.4 per cent and revealed the additive IOP-lowering effects of 0.4 per cent K-115 to 0.005 per cent latanoprost or 0.5 per cent timolol in patients with primary open-angle glaucoma or ocular hypertension. The new drug produced tolerable side effects mostly limited to transient hyperaemia. However, this event has been seen in up to 70 per cent of patients. The drug is under review by the administrative authority (PMDA) in Japan, noted Dr Tanihara. “This is one of the new classes of drugs to target the trabecular meshwork directly. ROCK inhibitors appear to enhance aqueous drainage by acting on the actin cytoskeleton and cellular motility in the trabecular meshwork, Schlemm’s canal and in ciliary muscle. These drugs may lower IOP by decreasing resistance to aqueous outflow by cellular relaxation in the trabecular meshwork,” he explained. The mechanism of action of ROCK inhibitors suggests there may be benefits beyond IOP lowering. Studies indicate that drugs in this class increase retinal blood flow by relaxing vascular smooth muscle cells. This could provide a neuroprotective effect. A better understanding of how these drugs work will also provide new insights into the pathology of glaucoma. In addition to K-115 (Kowa), several other drugs in this class are at or near the clinical trial stage. These include AM0076 (Amakem) now in Phase II and Roclatan (Aerie Pharmaceuticals) also in Phase II, which combines a ROCK inhibitor with latanoprost. Hidenobu Tanihara: tanihara@pearl.ocn.ne.jp

EUROTIMES | SEPTEMBER 2014

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Debate examines cases for and against preservatives in medications. Howard Larkin reports

t Glaucoma 2014 at the American Society of Cataract and Refractive Surgery annual meeting in Boston, US, presenters were asked to defend or attack the use of preservatives in topical glaucoma medications. Though his presentation did not reflect his true opinions or practice patterns, Malik Y Kahook MD of the University of Colorado, Denver, US, presented the case for preservatives, while Paul Harasymowycz MD, University of Montreal, Canada, argued against. Dr Kahook noted that BAK is a quaternary ammonium compound with detergent properties that non-selectively disrupts cell walls. For decades it has been used quite successfully to protect multi-dose containers from microbial contamination. But studies and clinical experience also suggest that BAK exposure may complicate existing ocular surface disease or precipitate it over time, a finding supported by much clinical observation. BAK also complicates filtration surgery, Dr Harasymowycz said. Preoperative exposure to BAK is an independent risk factor for early trabeculectomy failure (Boimer C, Birt CM. J Glaucoma. 2013 Mar 20. Epub ahead of print), though this may be reversible with pre-surgical steroid treatment (Broadway D et al. Arch Ophthalmol. 1996, 114:262-267. Breusegem C et al. Ophthalmology. 2010 Ju;117(7):1324-30).

A NUANCED CASE FOR PRESERVATIVES But while such findings make a compelling case for avoiding BAK-preserved glaucoma eye drops in filtration patients, eliminating them altogether may not be practical or even desirable. According to Dr Kahook, the case against preservatives rests largely on in vitro studies showing that BAK kills cultured human corneal and conjunctival epithelial cells in concentrations found in eye drops. Further, a dose-response relationship between BAK concentration and cell death rate makes the in vitro case even more compelling. These studies also

show that adding an active ingredient, such as latanoprost, to the BAK solution does not increase cell death, suggesting that the preservative is the main culprit. However, these studies have several weaknesses. For one, in vitro exposure generally runs 25 to 30 minutes, much longer than drops remain in the eye. So unless BAK accumulates in human tissue – which has not been definitively proven – soaking cells in BAK “may not perfectly replicate clinical exposure. The leap in conclusions from the petri dish to the patient requires more investigation with better clinical metrics than those available to us today,” Dr Kahook said. Several large randomised studies also have failed to show that BAK damages the corneal surface, at least initially, Dr Kahook noted. For example, two studies comparing latanoprost BAK with bimatoprost BAK or travoprost with sofZia, found no significant differences in conjunctival hyperaemia, corneal staining or tear break up time at three months (Whitson et al. J Ocul Pharmacol Ther. 2010 June; 26(3): 287-92) or 12 weeks (Chricton et al. Adv Ther. 2013 Mar; 30(3): 26-70). BAK provides benefits, Dr Kahook said. It is a very effective preservative that meets global standards for multi-dose bottles. It enhances formulation options with some medications, and enhances penetration of less-lipophilic medications, increasing their efficacy. In his practice, Dr Kahook finds the majority of patients do well on generic medications that contain significant BAK. So alternative preservatives or preservative-free formulations can be reserved for patients with significant ocular surface disease. “Like everything we debate there is always a grey zone. BAK is safe for many patients, but many others do suffer from ocular surface disease related to chronic exposure,” Dr Kahook said. He looks forward to greater use of less toxic but equally effective preservatives, such as polyquad, and lowercost preservative-free formulations. Malik Kahook: malik.kahook@gmail.com Paul Harasymowycz: pharasymowycz@sympatico.ca

BAK is safe for many patients, but many others do suffer from ocular surface disease related to chronic exposure Malik Y Kahook MD

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RETINA

CARDIO MEDS AND AMD Major population study finds vasodilators may raise likelihood of age-related macular degeneration. Sean Henahan reports

atients receiving common vasodilator and anti-hypertensive agents could be at increased risk for macular disease, suggests the latest report from the Beaver Dam Eye Study, a long-term survey of age-related eye disease including cataract, macular degeneration and diabetic retinopathy. The latest findings, reported in the journal Ophthalmology (in press) indicate that use of vasodilator anti-hypertensive medications, including hydralazine (Apresoline) and minoxidil (Loniten) was associated with a 72 per cent increase in the risk for developing early stage age-related macular degeneration (AMD). Oral nitroglycerine was also associated with the development of early AMD. Some 19 per cent of study participants who were receiving vasodilators during the study developed signs of early AMD compared with only eight per cent of those not receiving vasodilators. The difference was statistically significant after adjusting for age, sex and other potential confounding factors. Moreover, the study found that patients receiving the much more commonly prescribed oral beta-blocker antihypertensive agents also appeared to be at increased risk. One half of one per cent of patients not receiving oral beta-blockers showed signs of neovascular AMD, compared with 1.2 per cent of those taking beta-blockers. However, no significant association between vasodilators or antihypertensive medications was observed with late AMD, pure geographic atrophy or the progression of AMD.

FURTHER RESEARCH NEEDED The researchers cautioned that the current study was not able to discern effects of the medications themselves and the conditions for which participants were taking those medications. In addition the association may be due to uncontrolled confounding, that is not adjusting for factors related to the endpoint AMD and the use of these medications. The relationship may be due to chance. “As significant as these results may be, it’s important that they be replicated first, and if possible tested in a clinical trials setting before changing anyone’s medication regimens. Further research is needed to determine the cause of these increased risks,” said Ronald Klein MD, MPH, professor of ophthalmology, University of Wisconsin, and lead researcher of the study. In particular, the researchers note that they do not know the reasons for this association of vasodilators with AMD. Interestingly, they note that in the past, systemic vasodilators were used in the treatment of AMD. At one time it was hypothesised that vasoconstriction of the retinal and choroidal vessels were involved in the pathogenesis of AMD. At the same time, vasodilators were not recommended by some in the treatment of exudative AMD because they were thought to increase the risk of haemorrhage.

The researchers caution that the association between coronary vasodilators with early AMD seen in the study could be the result of bias by indication. This means that it might not be the result of the use of the vasodilator drugs themselves, but rather of the condition for which the drugs were used. However, they note that the association remains even after excluding patients who had had a myocardial infarction, arguing against this.

WIDELY PRESCRIBED TREATMENTS In addition to the treatment of hypertension, vasodilators are often prescribed for the treatment of angina pectoris. More recently they have become a widely prescribed treatment for erectile dysfunction. These conditions are all common in those patients who are considered at risk for macular disease. Hydralazine is currently not used as a first-line treatment for hypertension. Rather it is reserved for severe, refractory disease, typically in combination with beta-blockers and diuretics. Hydralazine elicits the baroreceptor reflex, which can increase heart rate and cardiac output. This can produce angina pectoris and even myocardial infarction. Minoxidil is another vasodilator that is reserved for hypertension patients who do not respond to standard treatment with diuretics and other antihypertensive agents. It is probably best known for its effects on hair growth. It is available in topical form for the treatment of baldness. The new findings are just the latest contribution to the understanding of eye disease and the elderly provided by the Beaver Dam Eye Study. Conducted under the auspices of the US National Eye Institute, the study has produced more than 300 journal publications on the prevalence and incidence of vision loss, cataract and macular disease. The Beaver Dam Eye Study produced a better understanding of risk factors associated with cataract and macular disease, particularly cigarette smoking. The study also showed the association of retinal drusen and retinal pigment and progression to late stages of AMD. This in turn has helped researchers to design clinical trials in this area. Another recent publication from the Beaver Dam Study Group, also in the journal Ophthalmology, reviewed the effects of lifestyle on vision and visual impairment over the 20-year study period. Cigarette smoking was confirmed as a significant risk factor for vision impairment. People who did consume alcoholic beverages appeared to be at increased risk for visual impairment compared with moderate drinkers. People who were sedentary appeared to be at higher risk for vision impairment compared to those with more active lifestyles. Ronald Klein: kleinr@epi.ophth.wisc.edu

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Positive results for implantable device for AMD patients.

n implantable miniature telescope can provide useful visual function in carefully selected patients with endstage age-related macular degeneration (AMD), Irish researchers report. Speaking at the 2014 Irish College of Ophthalmology Annual Conference in Limerick, Kirk Stephenson MB, BCh, BAO, Mater Private Hospital, Dublin, presented the results of a six-month follow-up study on the use of the implantable miniature telescope (IMT, Visioncare Ophthalmic Technologies, Inc.) for the treatment of end-stage AMD in the Irish population. For the study, the AMD patients of one consultant in the Mater Private Hospital were screened for eligibility. Those with geographic atrophy or stable disciform scars, and were phakic were selected. Motivated suitable patients without any limiting co-morbidities were shortlisted for the procedure, Dr Stephenson told the conference. Five patients, with a mean age of 81 years, underwent IMT implantation between March 2013 and March 2014. The baseline best corrected distance visual acuity ranged from 1/60 to 6/24. The three IMT patients that had reached six months' postoperative follow-up point at the time of the conference had a mean improvement of 3.3 lines (range one to seven lines, no lines lost) on the ETDRS chart. Of the two patients who were three months post-op, none had lost any lines, Dr Stephenson said. These findings are in keeping with the IMT002 study (Hudson et al. 2006), where EUROTIMES | SEPTEMBER 2014

Priscilla Lynch reports at one year there was a mean three line improvement in patients who received the device, he reported. One patient – the one who had only gained a visual improvement of one line – had a reactivation of her wet AMD. This patient was subsequently started on a course of intravitreal anti-VEGF treatment but has since stopped attending follow-up appointments. “This really highlights the importance of rigorous patient selection. You have to be very careful in assessing these patients. Motivation and compliance with rehabilitation and treatment is a critical factor,” Dr Stephenson told the conference. Patients who have received an IMT implant require ongoing monitoring and potentially treatment for macular disease, Dr Stephenson added.

VISUAL BENEFITS In addition, the costs for the device are high, though the visual benefits of the procedure really have to be considered, he stated. Speaking to EuroTimes, Dr Stephenson acknowledged the data presented was just for six months for three patients and a longer period of at least a year would be needed for better analysis. However, so far the results for the implant are promising and offer real visual benefits, he stressed. “It is one of a few intraocular devices available for implantation in AMD and can give these patients some degree of visual repair. It won’t bring them back to previous visual levels but it is a way

to improve visual function, and so allow them to do basic daily tasks like cooking and cleaning, as well as continue some hobbies,” he concluded. The IMT is the most advanced medical device so far to be implanted inside the eye for AMD patients missing their central vision. It is implanted only in one eye, replacing the natural crystalline lens. Once implanted, the device magnifies images, which are projected onto the healthy area of the retina not affected by AMD. The IMT patient selection process includes testing vision using external telescope simulators, Dr Stephenson explained. There are also quite stringent exclusion criteria, he noted, including active retinal disease, any history of retinal detachment or retinal vascular disease, high myopia or hyperopia, any evidence of low corneal endothelial cell count (<1600cells/mm2), as well as serious medical morbidities such as stroke or dementia. The telescope implant allows patients to use natural eye movements to see better and be able to regain independence and carry out everyday tasks like cooking, recognising people, reading activities and leisure activities. “This is a significant advantage over external magnifying devices, which can frustrate patients and lead to poor compliance. In this way, with the appropriate visual rehabilitation, patients can get real visual benefits in their daily lives,” Dr Stephenson concluded. Kirk Stephenson: kirkstephenson@hotmail.com

RETINA

VITRECTOMY

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Poor visual prognosis in post-vitrectomy endophthalmitis. Dermot McGrath reports

ostoperative endophthalmitis remains a rare but potentially serious complication of vitrectomy surgery with a very poor visual prognosis for affected patients, according to a study presented at the French Society of Ophthalmology (SFO) annual meeting. “Vitrectomy is a fairly frequent surgical procedure for a range of ocular problems but serious complications are rare with an incidence of endophthalmitis after pars plana vitrectomy of less than one per cent,” said Clemence Virevialle MD. She added, however, that the visual prognosis is usually very poor and that more prospective studies are needed to help understand possible risk factors for post-vitrectomy endophthalmitis Presenting a retrospective analysis of post-vitrectomy endophthalmitis treated at the Quinze-Vingts Hospital in Paris between 2008 and 2013, Dr Virevialle said that 31 cases requiring hospitalisation had been identified in that period. The mean patient age was 65.9 years, ranging from 33 to 84 years. Eight of the treated patients had diabetes. The mean delay for diagnosis of endophthalmitis was five days after the vitrectomy surgery, with 90 per cent of the cases detected in the first postoperative week. Most of the vitrectomies were performed as part of epiretinal membrane procedures (19 patients), with the remaining cases concerning silicone oil removal +/- cataract surgery, retinal detachment, retained lens fragments, diabetic retinopathy and macular hole.

BACTERIAL ANALYSIS Bacterial analysis identified the causative organisms of the postvitrectomy endophthalmitis in 17 patients: staphylococcus in 10 patients, seven of which were staphylococcus epidermidis; streptococcus in two patients; the rest were divided between Gram-positive cocci, various bacillus strains and one case of Candida endophthalmitis. Dr Virevialle said that the visual acuity outcomes associated with endophthalmitis following pars plana vitrectomy (PPV) are generally poor. In the study, there was an improvement of visual acuity in 16 patients after hospitalisation, while three patients lost visual acuity and eight patients remained stable. The final visual acuity depended on the underlying pathology and the initial visual acuity before surgery. She said that bacteria in the conjunctival flora were responsible for most cases of post-vitrectomy endophthalmitis. With this in mind, she advised preoperative application of povidone-iodine to the eyelid margins, eyelashes and conjunctival ocular surface to reduce the risk of infection. The major risk factors of endophthalmitis after smallgauge vitrectomy remain uncertain, but particular attention should be paid to diabetic patients, who comprised 26 per cent of affected patients in Dr Virevialle’s group. The type of intervention may also be significant, she said, with twothirds of patients being operated for epiretinal membranes. Other potential predisposing factors to watch for include vitreous wick in the sclerotomies, less vitreous removal during small-gauge vitrectomy and lower infusion rates in 25-gauge vitrectomy. Clemence Virevialle: c.virevialle@gmail.com

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RETINA

OEDEMA Irish study compares real-life data with the results of Geneva study. Priscilla Lynch reports

n audit of the safety and efficacy of a biodegradable dexamethasone intravitreal implant (OZURDEX®) in Irish patients with macular oedema has found it is less successful than the results reported in a published controlled clinical study. However, this complex Irish patient cohort primarily had chronic macular oedema that was resistant to treatment with anti-vascular endothelial growth factor (anti-VEGF) agents and Kenalog. Ozurdex is used to treat adults with macular oedema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) and to treat adults with non-infectious posterior uveitis. The Irish study aimed to compare reallife data with the results of the Geneva study (Haller, J A, et al, Randomized, Sham-Controlled Trial of Dexamethasone Intravitreal Implant in Patients with Macular Edema Due to Retinal Vein Occlusion. Ophthalmology, 2010. 117 (6)). The published study concluded that these implants reduce the risk of vision loss and improve vision in eyes with macular oedema secondary to BRVO and CRVO. The Irish data was presented at the 2014 Irish College of Ophthalmology Annual Conference by Kevin Kennelly MB, BCh, BAO, MRCOphth, MRCSI(Oph), FEBO, BMedSc, MSc, PhD, specialist registrar in ophthalmic surgery at the Mater Misericordiae University Hospital, Dublin. A retrospective chart review was undertaken of all patients who received the dexamethasone intravitreal implant by a single surgeon, David Keegan MB, BCh, BAO, MMeddSc, FRCSI(Oph), FRCOphth, PhD, consultant vitreoretinal surgeon. A range of data was analysed at one, three, six, 12 and 24 months post-implantation. Some 20 patients (11 female, nine male) were included in the study, with a mean treatment age of 69.5 years. The mean duration of symptoms was 30 months. Some 50 per cent of eyes had preceding pathology in the treated eye. Patients had

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previously received a mean of 7.2 antiVEGF injections, 2.2 intravitreal Kenalog injections and 0.2 sub-tenons Kenalog injections. During the study, six patients received multiple Ozurdex implants. The mean baseline visual acuity was 50±18 EDTRS letters. The proportion of eyes that gained at least 15 letters was 22 per cent at day 30, 19 per cent at day 90 and seven per cent at day 180.

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KEY FINDINGS

· Glare test

Some 60 per cent of patients suffered at least one ocular adverse event; 50 per cent of phakic patients required cataract surgery within two years, at a mean of 12 months post-implantation. Some 30 per cent of patients developed raised intraocular pressure (IOP), which was controlled in all cases with topical IOP-lowering agents, while 20 per cent developed subconjunctival haemorrhage during the implantation. This real-life audit found inferior beneficial effects and higher rates of ocular adverse events with Ozurdex compared to the results of the Geneva study. However, this is likely due to broader inclusion criteria, particularly the inclusion of patients with previous ocular pathology, longer duration of symptoms before treatment, off-label use and longer follow-up, Dr Kennelly said. “In this real-life setting and complex patient cohort we found that Ozurdex was equally effective up to three months, but did not have a sustained effect to six months as was seen in the Geneva study. The higher rate of complications was most probably a consequence of longer followup in terms of cataract progression and related to multiple implants in terms of raised intraocular pressure. Nevertheless, our data demonstrates that intravitreal dexamethasone implants provide a definite treatment option for those patients with resistant macular oedema where first-line agents such as anti-VEGF injections have proven ineffective,” Dr Kennelly told EuroTimes.

· Accurate objective measurement (REF, KRT, R/K) · Subjective measurement for far & near

· Contrast test · Grid test · Pre- and post-cataract screening

Kevin Kennelly: kpkennelly@gmail.com

...our data demonstrates that intravitreal dexamethasone implants provide a definite treatment option...

www.topcon-medical.eu

Kevin Kennelly PhD EUROTIMES | SEPTEMBER 2014

Alcon S AV E T H E D AT E F O R T H E S E K E Y E V E N T S D U R I N G 1 4 t h Faster and Smaller in Vitreoretinal Surgery: A Video Presentation of New Technologies and Techniques Friday, September 12th, 2014 from 10:00 to 11:00am EXCEL CONGRESS CENTER / BOULEVARD C Moderated by Pravin Dugel, USA After an introduction on the evolutionary steps in vitreoretinal surgery by the moderator, speakers will review and discuss a number of videos on vitreoretinal surgeries demonstrating a variety of surgical procedures.

Opening new treatment possibilities: Simbrinza Friday, September 12th, 2014 from 12:45 to 1:45pm EXCEL CONGRESS CENTER / CAPITAL 11 Moderated by Robert Fechtner, USA and Stefano Gandolfi, Italy A comprehensive review of the clinical data and benefits of the new fixed combination which will provide new treatment possibilities.

Ocriplasmin: Beyond Clinical Trials into Real-World Experience Saturday, September 13th, 2014 from 10:00 to 11:00am EXCEL CONGRESS CENTER / BOULEVARD C Moderated by Pravin Dugel, USA Speakers will review the efficacy and safety profiles of ocriplasmin from clinical studies to real life post-marketing experience, including discussions on patient profile and personal clinical experience with the product.

Live Surgery: Advancements in Techniques and Technologies Telecast live in high definition from Clinica Rementeria, Madrid

Saturday, September 13th, 2014 Registration: 5:45 – 6:15pm Program: 6:15 – 8:00pm AUDIENCE SITE: ExCel Center, Auditorium, London SURGEON SITE: Clinica Rementeria, Madrid Surgical Faculty Laureano Rementeria, Spain – Host Surgeon Kjell Gundersen, Norway Daniele Tognetto, Italy Marc Weiser, France Panel Faculty Donald N. Serafano, United States – Moderator Philippe Crozafon, France Ed Holland, United States Robert H. Osher, United States Richard Packard, United Kingdom Mahipal Sachdev, India

Enhancing surgeon confidence and patient outcomes leveraging minimally invasive cataract surgery Sunday, September 14th, 2014 from 1:00 to 2:00pm EXCEL CONGRESS CENTER / BOULEVARD B Moderated by Khiun Tjia, Netherlands Our Key Opinion leaders will debate on how optimizing Centurion utilization to perform a minimally invasive cataract surgery and improve patients outcomes.

7/14

in London

11-17 September, 2014

EURETINA/ XXXII ESCRS CONGRESSES IN LONDON Precision Dry Eye Care in Refractive Surgery

Moderated by Richard Packard, UK

Sunday, September 14th, 2014 from 1:00 to 2:00pm

Speakers will review the supportive clinical data on Nevanac’s indication to reduce the risk of postoperative macular oedema in diabetic patients. After which, speakers will expand on the experience with the Centurion phacoemulsification vision system for cataract removal.

EXCEL CONGRESS CENTER / CAPITAL A Moderated by James McCulley, USA Speakers will cover topics related to the etiopathogenesis and pathophysiology of dry eye disease, available treatments for dry eye and the associated implications of dry eye in patients scheduled to cataract and refractive surgery.

Optimize your cataract and refractive workflow with Alcon Technology Sunday, September 14th, 2014 from 6:15 to 7:15pm EXCEL CONGRESS CENTER / BOULEVARD F Moderated by Bekir Sitki Aslan, Turkey Our Key Opinion Leaders will share their techniques in optimizing the usage of the Cataract Refractive Suite by Alcon existing of LenSx laser, VERION Image guided system and Centurion Vision System. As well the key advancements of using the WaveLight Refractive Suite and it’s WaveNet.

360° Overview on Astigmatism Surgical Management Monday, September 15th, 2014 from 1:00 to 2:00pm EXCEL CONGRESS CENTER / CAPITAL B Moderated by Philippe Crozafon, France Astigmatism is a refractive error which has a dramatic prevalence in cataract and refractive patients: today’s advanced technologies support the surgeon to further achieve the final desired refractive target. Our Key Opinion Leaders will explore all the treatment options for astigmatism correction and the related patient segmentation leveraging VERION™ Image Guided System in combination with AcrySof® IQ Toric, LenSx® Laser System benefits in cataract surgery and the WaveLight® Refractive Suite for a complete customization of extra ocular treatment.

Cataract Surgery outcomes optimization with innovative drugs and technologies Monday, September 15th, 2014 from 1:00 to 2:00pm EXCEL CONGRESS CENTER / BOULEVARD F

Innovation Theater Booth Talks Friday, September 12th to Monday September 15th, 2014 FROM 10:00AM TO 4:00PM 20 MIN PER PRESENTATION EXCEL CONGRESS CENTER / Alcon Booth B10 / Innovation Theater

Alcon Wet Lab Saturday, September 13th to Tuesday September 16th, 2014 HELD FROM 9:00AM TO 6:00PM (EXCEPT TUESDAY ONLY FROM 9AM TO 1.30PM) By registration only. Registration link: http://starcite.smarteventscloud.com/alconwetlab EXCEL CONGRESS CENTER/ South Gallery 31-32 Surgeons will have the opportunity to try on a pig eye our latest active fluidics phaco technology and vitreoretinal machine coupled with LuxOR™ microscope technology.

Alcon Surgical Lab Saturday, September 13th to Tuesday September 16th, 2014 HELD FROM 9:00AM TO 6:00PM (EXCEPT TUESDAY ONLY FROM 9AM TO 1.30PM) By registration only. Registration link: http://starcite.smarteventscloud.com/AlconCRSPreview EXCEL CONGRESS CENTER/ South Gallery 31-32 Enjoy the journey that will guide surgeons discovering and understanding better the quality of our products: from surgery planning to intraoperative product optimization. A unique experience tailored specifically on needs.

OCULAR

SUPPLEMENTS Data show benefit for reducing cataract risk. Cheryl Guttman Krader reports

itamin supplements may indeed reduce the risk for developing cataracts, suggests recent findings from the Physicians’ Health Study, a large long-term research project. The study randomised 14,641 US male physicians aged 50 years or older to daily use of a multivitamin/mineral supplement (“MVI”; Centrum Silver) or placebo. After a mean follow-up of 11.2 years, the risk of cataract was significantly reduced in the supplement group compared with the controls (p=.04). There were 872 cataracts in the multivitamin group and 945 cataracts in the placebo group (hazard ratio [HR], 0.91; 95 per cent confidence interval [CI], 0.830.99; P = 0.04). More cases of visually significant AMD occurred in the vitamin group, but the between-group difference was not statistically significant. Emily Chew MD, deputy clinical director, National Eye Institute, and lead investigator of the Age-Related Eye Disease Study (AREDS) and AREDS2, spoke to EuroTimes about the data. She emphasised the need to consider the randomisedcontrolled clinical trial design of the Physicians’ Health Study. “The nine per cent reduction in cataract risk may seem small, but it would be important for reducing the burden from this common

th EURETINA

Winter Meeting

condition. However, the impact of this particular multivitamin on cataract and visually significant AMD needs further verification prior to implementation because such analyses are often thought of as hypotheses generating,” said Dr Chew. In addition, she noted the benefit on cataract risk is consistent with other published data. The placebo-controlled Italian-American Clinical Trial of Nutritional Supplements and Age-Related Cataract, which investigated the effect of multivitamin treatment on cataract development or progression as a primary objective, found their use significantly decreased lens events. Because the results were mixed, nuclear cataract events were significantly decreased but posterior subcapsular cataract risk was significantly increased, the investigators made no treatment recommendations. AREDS observational data also support multivitamin prevention of cataract. In a logistic regression analysis adjusting for propensity score and other variables, Centrum significantly reduced lens opacity. Again, the benefit was mostly for nuclear cataract. Dr Chew said the absence of benefit of vitamin supplement treatment on risk of visually significant AMD in the Physicians’ Health Study is not surprising considering the supplement’s ingredients. Compared with the AREDS formulation, which significantly reduced the risk for progression to advanced AMD in those at high risk, the current study’s supplements contain much lower levels of antioxidant and neither copper or zinc, she explained. “In the interest of optimising ocular and general health and until more information is available, it is important to recommend that patients have a healthy diet that is replete with fish and green vegetables,” said Dr Chew. “For patients at risk for developing AMD, based on the results of AREDS and AREDS2, we would suggest using the AREDS formulation and considering using lutein/zeaxanthin in place of beta-carotene.” The study results appeared recently in the journal Ophthalmology. (2014;121(2):525-34]. Emily Chew: echew@nei.nih.gov

Saturday 24 January 2015 University of Oxford, UK www.euretina.org

...it is important to recommend that patients have a healthy diet... Emily Chew MD

EUROTIMES | SEPTEMBER 2014

OCULAR

URGENT CASES Patients downplay severity of ocular emergencies in French hospital study. Dermot McGrath reports

many patients experienced in self-evaluating the severity of their condition, with 18 per cent finding it impossible to allocate a score to their condition. In terms of objective severity, the condition of patients was deemed to be normal or sub-normal in 25 per cent, of moderate severity in 40 per cent and serious or maximal in 35 per cent. For subjective severity, one-third of patients considered their condition as minor, 39 per cent deemed it moderate to severe and 18 per cent said they were incapable of evaluating its severity. Dr Pison said that on the one hand, there was a clear overestimation of the severity in 271 cases (nine per cent) and a tendency towards overestimation in 502 cases (17 per cent). But on the other hand, there was a clear underestimation in 301 cases (10 per cent) and a trend towards underestimation in 1,366 cases (46 per cent) (see figure below). The score for pain allocated by the triage staff was correlated with the subjective severity score evaluated by the ophthalmologist, (Kendall Tau correlation coefficient T=0,216, p<10-3), said Dr Pison. The majority of patients estimated their pain at about two out of 10 (27 per cent, n= 805 patients). A total of 43 per cent of patients estimated the severity of their complaint as absent or minor (score zero or one), and 50 per cent of patients had normal behaviour. However, 10 per cent of patients clearly underestimated the severity of their condition and 50 per cent had a tendency towards underestimating their severity, she concluded. Aurelie Pison: aurelie.pison@gmail.com

Courtesy of Aurelie Pison FEBO

atients presenting for ocular emergencies at a French public hospital tended to underestimate the severity of their condition, a fact which medical staff should bear in mind in the triage of such cases, according to Aurelie Pison FEBO. “Ophthalmic emergency triage is essential for prompt recognition of urgent cases. However, the concept of severity is broad and tends to be interpreted differently by physicians and patients. Our study, comparing the subjective severity perceived by patients and the objective evaluation of physicians showed that patients had a clear tendency towards underestimating the severity of their condition,” she told the delegates attending the annual meeting of the French Society of Ophthalmology (SFO). Dr Pison’s study was carried out over a two-month period: July and October 2013 at the Hôtel-Dieu Cochin Hospital in Paris. Of a total of 4,400 ocular emergencies that presented at the hospital during that period, 1,429 were excluded from the study for various reasons. The average age of the patients was 43.23 years (+/-19). In addition to evaluation by triage staff and patient self-assessment, patients were allocated a pain classification score, with pain graded on a scale from one to 10. Patients’ behaviour was also rated from zero (normal) to five (violent or highly incoherent). After examination, an objective severity score was allocated by the ophthalmologist. The results showed that more than half of the patients (56 per cent) displayed normal behaviour (score zero), and no patient scored five. Dr Pison noted the difficulty that

EUROTIMES | SEPTEMBER 2014

OCULAR

ROAD SAFETY AND VISION Morocco overhauls vision tests to improve road safety. Dermot McGrath reports

reform of visual acuity tests for driving licence applicants has been successfully included as an integral part of Morocco’s efforts to improve its patchy road safety record. “Morocco has been making major efforts to reform the system for the attribution of driving licences and thereby helping to reduce its very high road accident rate, which is one of the highest in the region,” Adil Mchachi MD told delegates attending the annual meeting of the French Society of Ophthalmology (SFO). Dr Mchachi said that the goal of his study was to evaluate the presence of visual problems in candidates presenting for their driving test in Casablanca, Morocco, and to highlight the importance of an ophthalmic examination for the benefit of road safety and general health.

REFORM NECESSARY The road accident statistics for Morocco underscored the primary reason why the government felt that reform of the driving licence attribution system was absolutely necessary, said Dr Mchachi. “Around 3,838 people are killed on the roads in Morocco annually for a population of 32 million inhabitants and 2.7 million vehicles. That equates to 28.7 people killed per 100,000 inhabitants.

Experienced Premium Lens Refractive Surgeon/ Cataract Surgeon wanted for expanding central European Refractive Surgery Group EuroEyes is a progressive clinic group specialising in Presbyopic Lens Exchange and ReLEx smile technology, and is expanding in Europe and Asia. We require the services of an experienced refractive surgeon in our German and Chinese clinics. EuroEyes has a Premium Eye Surgery Centre in the prestigious district of Pudong in Shanghai, and is opening clinics in Beijing and other regions in China. The EuroEyes clinics are equipped with the latest diagnostic and laser/lens technology - LenSx, Femtosecond Laser technology, Zeiss VisuMax (ReLEX smile). The surgeon should be fluent in English, be surgically skilled (>1000 lens surgeries) and interested in working in a dynamic and prestigious high-end environment. Femto-Lasik experience is a plus, but not necessarily a must. We are looking forward to receiving your complete application including cover letter, curriculum vitae and references.

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Around 3,838 people are killed on the roads in Morocco annually for a population of 32 million... Adil Mchachi MD In France, the figure is 7.5 deaths per 100,000 inhabitants, which is a lot less than Morocco,” he said. These stark figures gave rise to a series of legislative reforms governing road safety and driving licence attribution in 2010 and 2011. Under the old system, basic eye examinations were conducted by the ophthalmic service of designated hospitals, with an overall measure of visual acuity for both eyes being used to establish a candidate’s aptitude to drive.

NEW LAWS Under the new laws, a multidisciplinary approach has been introduced using physicians from both public and private sectors to carry out a wide range of medical tests: cardiology, neurology, respiration, muscular-skeletal etc. In addition to visual acuity, the requirements for visual aptitude have been widened to include tests for visual field, colour vision, diplopia, hemeralopia, nystagmus and hemianopia. Dr Mchachi’s study collected socio-demographic and visual acuity data of driving licence candidates at the ophthalmic service of the “20 August 1953” Hospital in Casablanca over a one-year period from January 2012 to January 2013. Data from complete ophthalmic examinations on those candidates who failed to meet the initial visual requirements or where ocular anomalies were detected were also collected. A total of 3,600 files were examined with an average of 15 candidates a day over the one-year period. The mean age of the candidates was 34 years (range 18 to 72), of whom 72 per cent were male. The results overall showed that binocular visual acuity was 10/10 or better in 52 per cent of candidates, between 7/10 and 9/10 in 32 per cent, 3/10 to 7/10 in 12 per cent and less than 3/10 in four per cent of candidates.

MORE SCREENING NEEDED For those patients who underwent a complete ophthalmological examination, problems diagnosed included non-corrected refractive errors in 16 per cent, ocular surface problems in nine per cent, cataract in six per cent, diabetic retinopathy in four per cent and glaucoma in two per cent. The main treatable causes of disqualification for the licence included refractive problems, certain ocular surface pathologies and cataract. Summing up, Dr Mchachi said that refractive problems were frequently under-diagnosed as they often only came to light at the time of the eye test for the driving licence. He suggested that more screening in educational establishments or work places might help to detect some of these problems earlier. Adil Mchachi: adilmchachi@gmail.com

EUROTIMES | SEPTEMBER 2014

ESCRS EUROTIMES SATELLITE EDUCATION PROGRAMME Saturday 13th September • 13:00 • Capital Suite 12 Maximising treatment outcomes with premium IOL technologies

Prof. G. AUFFARTH

Prof. O. FINDL

C-flex and Superflex: the benefits of aberrationneutral technology

Long-term performance of Toric IOLs versus LRIs in the management of astigmatism

Education program sponsored by:

Prof. M. AMON

Dr. V. ANTUNES

Indications and long term results of primary (Duet) or secondary Sulcoflex implantation

Visual outcomes after implantation of a multifocal supplementary lens

escrs.org/London2014/satellite-meetings.asp

➚

rayner.com EC201448 07/14

OCULAR

PREVENTING BLINDNESS

Experts say prevention and treatment of vision loss should be a public health priority. Roibeard O’hEineachain reports

more proactive approach to the prevention of blindness in Europe could yield real benefits not only for patients but also for society as a whole, said Omer Saka MD, MSc, partner – health economics and outcomes research, Deloitte Consulting, who presented some of its initial findings from a pan-European study on the economic costs of blindness at a meeting in Dublin. The Deloitte group’s study will eventually include data from 16 European countries. Its findings so far indicate that around 50 per cent of cases of blindness in Europe are either treatable or could have been prevented. In sheer numbers that means that of the roughly 700,000 people who are blind in Europe, there are 350,000 people who would not be had they received the appropriate medical intervention. Money spent on preventing or at least delaying blindness would be easily recouped through patients having a longer working life, a reduced need for assistance and a reduced need for family members to take time off work or to leave employment to provide that assistance, Dr Saka told EuroTimes in an interview. “If you were to think of vision loss only in terms of healthcare costs you would be missing a major chunk of the picture, because healthcare providers don’t pick up the bill for the majority of the burden that blindness represents,” he added.

10th International Congress of Corneal CrossLinking

December 5-6, 2014 Zurich, Switzerland

The CXL Congress is an international forum for the most recent advance in corneal cross-linking Abstract submission ends on September 30, 2014

One day instructional course on CXL - all levels Scientific presentation, laboratory science, clinical results and latest developments

www.cxl-congress.com

Cover of Your Eyes manual which Dr Banks would like to see in all workplaces where vision is critical for safety of workers and others

Among the countries studied so far (France, Germany, Italy, Slovakia, Spain, Ireland and the UK), blindness incurs a total cost of €7.1bn, or roughly €10,000 annually per patient. Only 19 per cent of that is due to health costs, while 56 per cent is due to informal care. Another 25 per cent of the cost is due to lost productivity and in fact, 123 million workdays are lost per year in Europe due to blindness.

COST-EFFECTIVE “This study demonstrates that prevention and timely diagnosis are the most cost-effective healthcare intervention, and that such interventions could help offset total economic costs of €20bn across the region, “said Prof Ian Banks, chairman of the European Forum Against Blindness and senior lecturer at Queen’s University, Belfast, in an interview. He noted that the recommended interventions include screening for diabetic retinopathy, to allow for earlier access to treatment when necessary; treatment with anti-VEGF for wet AMD screening for cataracts; and access to surgery where needed. The study’s findings indicate that currently in Europe there are around 27 million patients with cataract, around four million with glaucoma, three million with wet AMD and around two million with diabetic retinopathy. “Cost-effective interventions will lead to a healthier population, which could result in a more sustainable healthcare budget for governments. The prevention and treatment of vision loss should be a public health priority,” Prof Banks added. Ian Banks: ian.banks@emhf.org R Ömer Saka: rsaka@deloitte.com

If you were to think of vision loss only in terms of healthcare costs you would be missing a major chunk of the picture... Omer Saka MD

EUROTIMES | SEPTEMBER 2014

NEW ICARE HOME SELF-TONOMETER FOR EASY 24H IOP MONITORING BY OPHTHALMOLOGIST RECOMMENDATION

XXXIII Congress of the ESCRS 5 â&#x20AC;&#x201C; 9 September 2015 Barcelona, Spain

Instructional Course Submission Deadline 31 October 2014

www.escrs.org

OCULAR

OCULAR INFECTIONS

discover

The ICOI/ESCRS joint meeting will offer something for all ophthalmologists. Colin Kerr reports

he International Conference on Ocular Infections (ICOI) will be held for the first time together with the XXXIII Congress of the ESCRS in Barcelona, Spain from September 3-4, 2015. Terrence P O’Brien MD says The ICOI represents “the Olympics” of ocular infectious diseases. Prof O’Brien, professor of ophthalmology and Charlotte Breyer Rodgers Distinguished Chair at the Bascom Palmer Eye Institute Miami, Florida, US is serving as the ICOI meeting chairman. The meeting will also coincide with the 6th EuCornea Congress and the 3rd World Congress of Paediatric Ophthalmology and Strabismus (WSPOS). “After successful prior conferences in Europe, Asia and the United States, the ICOI is excited to hold its next meeting in conjunction with ESCRS, WSPOS and EuCornea,” said William Freeman MD, meeting president. The ICOI, which formally convenes every four years, expects next year's meeting with ESCRS to attract its largest attendance to date. “The conference agenda provides broad material of practical interest to general and subspecialty ophthalmologists,” said Prof O'Brien. “With a unique comprehensive programme format, the conference hopes to expand participation from delegates in related disciplines such as bioinformatics, biostatistics, epidemiology, microbiology, molecular biology, pharmacology, drug delivery, systemic infection, and others to diversify and enrich the discussions on ocular infections. “We are fortunate to have the support of an outstanding international expert scientific advisory board as well as strong national and regional organising groups from Europe, Asia, Latin and South America and the United States,” he said

EURETINA LUNCH SEMINAR NEXT GENERATION VITRECTOMY EVA AND OTHER SURGICAL INNOVATIONS

Saturday, September 13 13:00-14:00 | Room: Boulevard H

ESCRS LUNCH SEMINAR ANTERIOR INNOVATIONS, LATEST THINKING DMEK, CANALOPLASTY AND NANO-PHACO

Sunday, September 14 13:00-14:00 | Room: Capital Suite 1

COLLABORATION Prof O'Brien said they hoped to deliver a diverse scientific programme with significant contributions from faculty experts outside of ophthalmology in related areas of infectious diseases and microbiology. This will help to educate attendees on the latest advances that may have relevancy to ocular infectious diseases rather than simply speaking to each other on concepts already familiar. "In this way I believe participants can truly learn new concepts and think of innovative ways to apply them for the ultimate benefit of those suffering from ocular infections,” he said. ICOI co-president Prof Joseph Frucht-Pery said, "The location, timing and unique scientific programme are very attractive to interested individuals both from outside and within the European Union”. Details of the full programme and previews of the key topics, will be included in future issues of EuroTimes.

www.evabydorc.com

Terrence P O’Brien: tpob3333@hotmail.com EUROTIMES | SEPTEMBER 2014

109-1319_ADV_Discover_Eva_tbv_Eurotimes_93x266_toevoegen_seminars.indd 1

7/15/14 2:02 PM

OCULAR

OCULAR HEALTH The ocular effects of pregnancy may be physiological or pathological. Dermot McGrath reports

mpact of pregnancy on the ocular health of women tends to be underestimated by both patients and the medical profession, according to a study presented by Daëna Hobeika MD at the 120th annual meeting of the French Society of Ophthalmology. Pregnancy can induce a large number of effects on vision which may be physiological or pathological, and ocular diseases occurring during pregnancy may be transitional or may persist for a long time. Ocular health problems in pregnant women are often not given due attention by professional health services and most patients are not aware that pregnancy can be associated with progression of previous ocular disease or the appearance of new ocular symptoms. Dr Hobeika’s study was conducted in the Catholic University of Lille (Lille, France), resulting from collaboration between the Ophthalmology Department Daëna Hobeika directed by Dr Tran and professionals from a network of 10 maternity hospitals in the north of France. A questionnaire was drawn up and distributed to pregnant women over a two-month period. It included social data, term of pregnancy, previous ocular diseases, ocular symptoms occurring during pregnancy and knowledge of ocular problems. A total of 281 out of 291 questionnaires were included in the final analysis. The mean patient age was 29 years and the mean term of pregnancy was six months. Only 28 pregnant women (10.2 per cent) had previous systemic disease (hypertension, diabetes, lupus, sickle-cell disease). The main previous ocular problem was refractive errors (45 per cent) which were evolving in 11 per cent of patients during their pregnancy. Serous ocular disease occurred in three patients: one retinal break, one ocular toxoplasmosis, and one case of central serous chorioretinopathy. The main ocular problem reported was ocular surface disease (22.5 per cent) followed by photophobia (12.1 per cent). Only 16.5 per cent of women were aware that their vision may change or that they might experience ocular problems during pregnancy. Only 10 per cent of the women informed their ophthalmologist of their pregnancy. Since information on ocular conditions was hard to obtain from busy medical professionals (15.6 per cent from staff of maternal hospitals and 15.6 per cent from ophthalmologists), 78.3 per cent of patients said that they used discussion groups and the Internet to understand ocular symptoms occurring in pregnancy. Summing up, Dr Hobeika said that the study emphasised the need for enhanced communication and information between patients, ophthalmologists and health professionals to ensure better management of pregnancy and ocular health. Daëna Hobeika: hobeika.daena@ghicl.net EUROTIMES | SEPTEMBER 2014

PAEDIATRIC OPHTHALMOLOGY

MIOLS IN KIDS

Courtesy of Clement Paya MD

More data needed for multifocal implantations in paediatric patients. Dermot McGrath reports

ore long-term studies are needed to conclusively demonstrate the potential benefits and drawbacks of implanting multifocal IOLs in paediatric eyes, according to a recent French study. “There are still a lot of unanswered questions surrounding this issue and we definitely need more longitudinal studies that can guide our choice of implant for paediatric cataract patients,” Clement Paya MD told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR). With evolving IOL technology and designs, more surgeons are willing to contemplate multifocal IOLs as a potential alternative to monofocal pseudophakia in selected paediatric cataract patients, said Dr Paya, Ophthalmology Department, Bordeaux University Hospital, Bordeaux, France. Assuming that indications are rigorously respected, multifocal IOLs in children can offer independence from glasses, limit amblyopia, assist binocular vision and improve quality of life without any significant complications.

CAUTION URGED Despite these potential benefits, many paediatric ophthalmologists urge caution in the use of multifocal lenses, fearing that the loss of intermediate vision and loss of contrast sensitivity associated with their use may exacerbate amblyopia in young patients. Dr Paya presented data from a comparative retrospective study carried out at the University Hospital of Bordeaux from January 2000 to October

... we still do not know enough about issues such as refractive shift and ocular growth Clement Paya MD

2012. Inclusion criteria were paediatric cataract patients aged between three and 15 years, with primary IOL implantation in the bag and a follow-up of at least two years. Patients younger than three and older than 15 were excluded from the study, as were secondary implantations, glaucoma patients and also those with other causes of visual loss besides cataract. Patients were divided into two groups: group one was comprised of 19 eyes of 13 children who received a multifocal IOL, and group two included 50 eyes of 41 children who received a monofocal IOL. Bilateral cataracts were present in six children for the multifocal group and nine children in the monofocal group. The mean postoperative spherical equivalent was -0.17 D in group one and -0.26 D in group two. The visual acuity outcomes were broadly equivalent for both groups of patients, said Dr Paya. Almost 84 per cent of children younger than eight years of age attained 8/10 visual acuity or better in the multifocal group compared to 69 per cent in the monofocal group, although this was not statistically significant. There was also no significant difference in the scores obtained for patients older than eight years in both groups.

MORE RESEARCH NEEDED Looking at the published literature, Dr Paya said that while good results have been obtained using multifocal IOLs in children, much more research was needed to better understand issues such as axial growth, which has been shown to continue throughout the second decade of life, refractive shift and patient variability. “While our study indicates that multifocal implants are safe, we still do not know enough about issues such as refractive shift and ocular growth. While we may try to target emmetropia at adult age, there is important variability from one child to another, with spectacle independence at adult age very difficult to predict,” he said. Clement Paya: clementpaya@hotmail.com

EUROTIMES | SEPTEMBER 2014

JCRS

JCRS HIGHLIGHTS

VOL: 40 ISSUE: 7 MONTH: JULY

PRISM IOL FOR AMD

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, Doyle Stulting, MD, PhD 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

An innovative Fresnel prism intraocular lens (IOL) could benefit patients with stable end-stage age-related macular degeneration (AMD). Researchers implanted the first of its kind in-the-bag Fresnel prism IOL (P-Flex, Rayner) in three patients with AMD. All underwent cataract surgery and unilateral implantation of the prismatic IOL. All patients reported displacement of the scotoma, and no patient reported diplopia. One patient developed posterior capsule opacification. The Fresnel prism was selected in favour of a conventional prism to reduce bulk and to make implantation easier. The researchers believe that the image degradation that occurs with a Fresnel prism might be less important in these eyes because the best expected decimal CDVA would be on the order of 0.1, which is the resolving power of the extrafoveal retina. While the current pilot was performed using a prototype IOL with single power and single angle of deviation, there is much potential for individual patient optimisation, they note. FJ Potgieter et al., JCRS, “Safety and efficacy of an intraocular Fresnel prism intraocular lens in patients with advanced macular disease: Initial clinical experience”, Volume 40, No. 7,1085-1091.

HOW’S THE WEATHER? What affect might meteorological conditions have on refractive surgery outcomes? To answer this question, German researchers compared the outcomes of two groups of consecutive patients who underwent refractive laser surgery over a two-year period, some in the winter months, some in the summer. The study included 1,052 eyes of 1,052 patients. At one month's follow-up, the efficacy index was 0.023 higher in eyes with refractive surgery during summer than in eyes treated during winter (P=.032), indicating less efficacy during winter. The differences in the safety index and postoperative SE between summer and winter were not statistically significant. No eye had a change of more than one line on the logMAR scale (corrected distance visual acuity). However, the overall difference in the outcomes of LASIK was not clinically relevant, the researchers note. I Neuhaus et al., JCRS, “Variation in the effectiveness of refractive surgery during the year: Results from the Hamburg Weather Study”, Volume 40, No. 7,1139-1146.

ADJUSTABLE OUTCOMES Adjustable IOLs now available and in the pipeline offer the capability of changing the IOL power to correct and improve the initial visual outcomes after implantation. US researchers present an overview of the adjustable IOL surgical procedures. These include the light-adjustable IOL, the multicomponent IOL, the mechanically adjustable IOL and the repeatedly adjustable IOL. They also discuss IOLs that can be adjusted non-invasively in the postoperative setting, such as the magnetically adjustable IOL, the liquid crystal IOLs with wireless control. Also in the pipeline are IOLs that can be adjusted using the femtosecond laser or 2-photon chemistry. J Ford et al. JCRS, “Adjustable intraocular lens power technology”, Volume 40, No. 7,1205-1223.

THOMAS KOHNEN European editor of JCRS

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EUROTIMES | SEPTEMBER 2014

3rd World Congress of Paediatric Ophthalmology and Strabismus

Barcelona, Spain September 4â&#x20AC;&#x201C;6, 2015

www.wspos.org

INDUSTRY NEWS

Jessica Vos (left, NASA) floats to the ceiling and Roman Kowalchuk (right, Duke University) poses after taking measurements of corneal deformation characteristics in microgravity (Photo: NASA)

NEWS IN BRIEF EXPANDING PRESENCE Oraya Therapeutics, Inc. is expanding its presence in Europe, with Oraya Therapy being offered for the first time at a National Health Service hospital in the UK and at four university hospitals in Germany. “Royal Hallamshire Hospital, part of the Sheffield Teaching Hospitals NHS Foundation Trust and the first National Health Service hospital in the UK to offer Oraya Therapy, began treating patients in April. In Germany, the four centres offering Oraya Therapy are University Hospital Essen, University Hospital Schleswig-Holstein Campus Luebeck, University Hospital Freiburg and the Medical Care Centre of the University Hospital of Cologne,” said a company spokeswoman. www.orayainc.com

INDUSTRY

NEWS

HIGH-SPEED CAMERA NASA made successful use of the Corvis® ST high-speed Scheimpflug camera during two parabolic flights on June 5 and 6 in Houston, Texas, US. The OCULUS device examined the effect of microgravity on intraocular pressure (IOP) and the biomechanics of the eyeball. “This NASAfunded project constitutes a first step towards exploring reasons for loss of visual acuity in outer space,” said a company spokeswoman. www.oculus.de

WIRELESS REVIEW STATION Topcon Medical Systems (TMS) has announced the availability of a wireless review station that can be used with the TRC-NW300 and TRC-NW8 non-mydriatic capture systems running IMAGEnet® 5. “This innovative device allows reviewing images from an IMAGEnet® 5 capture station via Wi-Fi up to a distance of 30ft. The transfer period is only five seconds when saving captured images in JPEG format,” said a company spokesman. www.topconmedical.com

EUROTIMES | SEPTEMBER 2014

CE MARKING

NEW BIOMETER

Abbott has received CE Marking in Europe for the TECNIS® Symfony Extended Range of Vision intraocular lens (IOL) for the treatment of cataract patients who may also have a diminished ability to focus on near objects (presbyopia). “Standard IOLs can be used in cataract treatment to improve distance vision, but the TECNIS Symfony IOL is a first-of-its-kind lens that is intended to provide patients with a continuous range of vision including far, intermediate and near distances with reduced incidence of halo and glare comparable to a monofocal lens,” said a company spokeswoman. www.abbott.com

NIDEK has announced that the United States Food & Drug Administration (FDA) has issued 510K clearance for the new AL-Scan Optical Biometer. Motoki Ozawa, president of NIDEK stated, “We are pleased to have this clearance and confident the results reflect the quality of our diagnostic tools in measurements that assist doctors in pre/postoperative evaluations.” www.nidek.com

FDA DETERMINATION AcuFocus has announced that deliberations of the US Food and Drug Administration (FDA) Ophthalmic Devices Advisory Panel have resulted in a determination that the benefits of the KAMRA inlay outweigh the risks for patients suffering vision loss as a result of presbyopia. The vote was cast after the panel reviewed clinical data on 508 patients implanted monocularly with the inlay in the US IDE clinical trial. “The FDA will consider the advisory panel outcome as part of its own determination of the benefit-risk of AcuFocus' Pre-Market Approval (PMA) submission for the KAMRA inlay,” said an AcuFocus spokeswoman. www.acufocus.com

NEW DYE Alamedics GmbH & Co KG has developed a new ILM dye that the company says connects excellent contrast with simpler and more convenient application. “The active dye in ala®purple, ‘Acid Violet 17’ from the group of triphenylmethane dyes, selectively stained the ILM, thus facilitating safe removal. The increased density of the dye solution guarantees a particularly rapid drop on the retina when injected into the eye and thus provides more control. The slight discrepancy of the colour into the red zone allows ala®purple high contrast values even in case of surgery to patients with artificial intraocular lenses with so-called 'blue filtering’,” said a company spokesman. www.alamedics.eu

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

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ESCRS

REVIEW

SAFE PHACOEMULSIFICATION Everything you want to know about hydroprocedures. Soosan Jacob reports

SAFE PHACOEMULSIFICATION Hydrodissection and hydrodelineation are vital for safe phacoemulsification and it is important to understand the forces involved. These are performed preferably using a 27-gauge cannula mounted on a 2cc syringe filled with balanced salt solution (BSS). Hydrodissection refers to the fluid wave in the cortical plane that separates the cortex and capsule from the nucleus. This allows rotation of the nucleus and its mobilisation which helps later in nucleus disassembly. Hydrodissection is performed by introducing the cannula into the outer layers of the cortex and injecting fluid gently. This allows the epinucleus and endonucleus to be separated from the cortex.

PARTIAL ENTRY The cannula is introduced through the main port. It is important to create the main port incision up to the full extent of the keratome before performing hydrodissection. A partial entry/high viscosity OVD blocking egress of fluid, mature cataracts, small rhexis, rapid hydrodissection and using large volumes of fluid are some of the factors that can lead to fluid build-up behind the nucleus in the capsular bag and within the anterior chamber (AC) causing a very high IOP which can ultimately lead to a capsular block syndrome (CBS) and a blow-out of the posterior capsule. This may also occur more commonly in mature cataracts, posterior polar cataracts and myopic eyes. Thus, it is vital to always allow fluid to simultaneously exit from the eye during hydrodissection. CBS can be avoided by using small bursts of fluid as well as by depressing the posterior lip of the main port to allow fluid egress. The fluid wave causes the nucleus to float up against the anterior capsular rim, creating a seal and causing accumulation of fluid within the capsular bag. It is important to tap the nucleus gently down to break this seal and allow fluid trapped behind the nucleus to flow out. This is also important in microincision coaxial phaco and bimanual EUROTIMES | SEPTEMBER 2014

Propagating fluid wave from hydrodissection seen (arrows)

phaco where the incisions are smaller and the nucleus should be tapped down gently and the fluid burped out.

CORTICAL CLEAVING Cortical cleaving hydrodissection is a technique first used by Howard Fine (Figures A and B). The tip of the cannula tents up the anterior capsular rim before injecting BSS. This causes a wave of fluid to flow under the capsule, cleaving the cortex all around from the capsule. It helps in easy cortex removal as the corticocapsular adhesions are lysed. Cortical cleaving hydrodissection allows separation and aspiration of cortex in large sheets. Multi-quadrant and focal cortical cleaving hydrodissection described by Vasavada et al are also important to lyse various types

Cortical cleaving hydrodissection enables easy cortex removal in sheets despite the presence of CTR in subluxated cataract

of corticocapsular adhesions (anterior, posterior and equatorial) and make nuclear rotation easier. This becomes especially important in complex situations such as small pupil cataract surgery, subluxated cataracts etc, and it facilitates both ease and rapidity of surgery (Figure C).

HYDRODELINEATION Hydrodelineation refers to separation of the epinucleus from the endonucleus. Multiple fluid waves can be used to generate multiple epinuclear shells. These shells are seen as one or more golden rings (Figure D). Hydrodelineation is done by inserting the cannula into the substance of the lens and injecting BSS into the substance of the nucleus. This generally requires more forceful irrigation as compared to

Golden ring from hydrodelineation

REVIEW hydrodissection. Creation of an epinuclear shell allows safe phacoemulsification of the endonucleus within this protective shell. The size of the lens fragment that is brought out into the AC and emulsified is decreased. The shell also holds the bag open and prevents aspiration of the capsular bag into the phaco probe. In very soft nuclei, the degree to which the cannula is introduced into the epinucleus may be limited in order to avoid a very small endonucleus and very thick epinucleus.

HYDROPROLAPSE Hydroprolapse of the nucleus can be achieved during hydrodissection by performing the tilt and tumble technique described by Dr Richard Lindstrom. Hydromanoeuvres are used to prolapse the pole of the nucleus opposite the incision out of the capsular bag. Fluid is injected continuously but gently until the fluid wave is seen to proceed along the posterior capsule and lift up the edge of the nucleus from within the capsular bag following which it is emulsified. Excessively vigorous manoeuvres should be avoided in order to avoid increased pressure build-up posterior to the nucleus leading to a capsular blow out.

HYDRODISSECTION Hydrodissection is completely contraindicated in posterior polar

cataracts as the fluid wave can cause a rupture of the weak posterior capsule. A hydrodelineation is done in these cases to mobilise the nucleus. Viscodissection may also be done. OVD is gently injected under the anterior capsule to prevent an accidental fluid wave from entering the sub-capsular plane. Viscodissection/ viscoeexpression may also be used after removal of the nucleus and mobilisation of the posterior plaque from the capsule to bring out the epinuclear shell from the bag into the AC. A good cortical cleaving hydrodissection is especially important in subluxated cataracts where a capsular tension ring (CTR) implantation is planned. This facilitates easy aspiration of cortex trapped beneath the CTR. Hydromanoeuvres should be done very carefully in mature cataracts as the nucleus almost completely fills the bag and the chances of a CBS are greater. Vigorous cortical cleaving hydrodissection is not required as the cortex is minimal in such cataracts. Multifocal gentle hydrodissection is more appropriate in such cases.

occurs with creation of bubbles. Intralenticular gas is thus produced during laser fragmentation and this together with laser-induced cortical changes can increase the intra-capsular volume. Vigorous hydrodissection without decompressing these bubbles from behind the lens can cause a posterior capsular blow-out. Recommendations include decompression of the AC and the capsular bag by removing high-viscosity OVD and by tapping the nucleus; gradual, gentle and multi-quadrant hydrodissection and pre-chopping of hemispheres before hydrodissecting to allow bubbles as well as fluid to escape. * 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

DIFFERENT APPROACH With the advent of femtosecond laserassisted cataract surgery, it is important to know the differences in approach for hydrodissection. Femtosecond disruption

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EUROTIMES | SEPTEMBER 2014

ESASO

ESASO FELLOWSHIPS Take the next step on an international career ladder

n ESASO Fellowship enables talented graduates to develop the expertise and professional network necessary to forge the next career steps in their lives. Under the tutelage of world-renowned practitioners in the field at highly-specialised teaching hospitals and university departments, fellows gain the knowledge and practical skills necessary to practise a subspecialty at the highest level. Some 18 young ophthalmologists submitted their applications by the end of May which were reviewed and fully rated by the Fellowship Committee. On 27 June eight applicants were interviewed by the members of the Fellowship Committee, chaired by Prof Stanley Chang, in Lugano. Two young ophthalmologists were selected to become new ESASO Fellows and thus become part of an international network of experts and leaders. The two young ophthalmologists have the opportunity to choose from 11 world-renowned international institutions where they can attend a complete training programme of a full year. Depending on their Stanley Chang specialisation, the fellows will have the invaluable opportunity to learn from global leaders in ophthalmology in subspecialties such as cataract surgery, cornea and refractive surgery, glaucoma and medical and surgical retina. Currently the two selected fellows are preparing their journey at their fellowship institutions abroad. ESASO congratulates both and wishes them all the best for the coming year.

MEMBERS OF THE FELLOWSHIP COMMITTEE Stanley Chang, chair, USA Ottavio Bernasconi, Switzerland Rupert Bourne, UK Borja Corcóstegui, Spain Nick Evans, UK Giuseppe Guarnaccia, Italy Rafael Navarro, Spain Christoph Scholda, Austria Leonidas Zografos, Switzerland Maurizio Battaglia Parodi, secretary, Italy

“The ESASO fellowship partner institutions are hand selected by the ESASO Fellowship Committee,” said Prof Chang.“They are committed to common training standards to guarantee the highest outcomes in both expertise and reputation,” he said. To date, eight ESASO Fellows have completed their training. They can be contacted through ESASO for anyone who wishes to learn about this invaluable opportunity. Maurizio Battaglia Parodi: maurizio.battagliaparodi@esaso.org EUROTIMES | SEPTEMBER 2014

CHICAGO 2014

Save the Date! Friday, October 17 â&#x20AC;&#x201C; Monday, October 20, 2014 Make the most of your time while in Chicago this fall and attend our EyeWorld programs for additional CME and an opportunity to network with your colleagues.

Registration opens September 2014 www.EyeWorld.org

RESEARCH

STARTING IN RESEARCH

Dr Oliver Findl explains how young ophthalmologists have much to gain by getting involved in research

esearch drives progress in ophthalmology. There are countless examples where a standard technique or procedure is first accepted, then questioned, challenged, rejected only to be replaced by a new approach. For example, intraocular lens implantation and refractive laser surgery both encountered incredible resistance from the medical establishment before gaining widespread acceptance. In contrast, refractive keratotomy might still be used today were it not for long-term research confirming its limitations. Research requires researchers, ophthalmologists who are full of curiosity and who enjoy solving problems. I recommend that any young doctor interested in research should start early in training. Ideally you will be in a training centre that already has a research group and the people and infrastructure to support research. You will find people who have ideas, the facilities and contacts with industry that allow you access to new designs of products and new tools for measuring â&#x20AC;&#x201C; all essential for conducting research. However, all is not lost if you are training at a site that doesn't have a lot of active research going on. This may be a bit more challenging, but not impossible. One thing you can do if you have a good idea is to try to win over the support of a senior surgeon, letting them know that you have an idea and that you will do the work. You might also find a mentor off site, even in a different country, with a bit of help from email. If you don't have a good idea, you will need to get one. Read journals and EUROTIMES | SEPTEMBER 2014

trade publications, attend conferences, listen to podcasts, keeping an eye out for unresolved questions. Very often during the discussion period at the end of a conference presentation you will hear people say there is something that hasn't been looked at. You can start small, working with an established researcher. Some people start with a case report, or series. But it is really best to get involved with a randomised clinical trial as soon as possible. Naturally the first step is to do a literature search. Then, as you launch your project, it is essential to do it properly. You need a good question, the right method and the right equipment. You don't want to get in a situation where something is missing. For example, a common problem is not having enough patients in your study to really answer your question. Then you will have difficulty submitting your study to a conference or journal, and people won't take you seriously. This underscores the importance of consulting a statistician. You might find it difficult to explain to a statistician what you are trying to determine. But once you do, they will really help you define parameters such as how many patients you will need, and what should be your main outcome measures.

People might hesitate to attempt a randomised trial, thinking the hassles of going through the ethics committee, enrolling patients, informed consent and so on would be insurmountable. It is worth the trouble. I believe it is far better to conduct one proper randomised trial, controlled, with sufficient number of patients, which could take a year or even two, rather than to do two or three series. That is where you need advice from a mentor. Nearly every training site has somebody on board with research experience that will be able to help you. Aside from satisfying scientific curiosity, there is a career-building aspect to research. In big universities and big teaching hospitals, many of the senior surgeons will have done research. That is the way in and the way up. Whether or not you continue on the research track, the experience is extremely valuable. Through research, you will have to read a lot, and you will have extra knowledge and experience you wouldn't have had otherwise. This ultimately will put you in a better position to provide your patients with the best possible care. Oliver Findl: oliver@findl.at

I recommend that any young doctor interested in research should start early in training Oliver Findl MD, MBA

SIDE SIDE AT THE INTERSECTION OF IDEAS AND IMPLEMENTATION Formerly known as Winter Update, this new meeting for anterior segment eye surgeons and ophthalmic practice administrators is focused on integrating good ideas into profitable clinical practice. Top faculty will provide step-by-step instruction on how to take the latest technology and clinical advancements and put them to work for your patients and your practice.

FEBRUARY 12–15, 2015 TURNBERRY ISLE MIAMI AVENTURA, FLORIDA MAXIMUM SAVINGS END— SEPTEMBER 21, 2014 REGISTER TODAY sideXside.ascrs.org

BOOK REVIEWS

A SINKING FEELING It causes a familiar, sinking feeling well known to every ophthalmologist: the diagnosis of a retinal vein occlusion (RVO). The consequences for the patient and his eyes, as well as the implications for the patient’s general health, lifestyle and quality of life are unpredictable and potentially grave. PUBLICATION Considering the many MANAGEMENT OF RETINAL VEIN recent developments in OCCLUSION: CURRENT CONCEPTS the management of retinal EDITOR venous occlusions, a concise, SEENU M HARIPRASAD updated reference is welcome. PUBLISHED BY SLACK INCORPORATED Management of Retinal Vein Occlusion: Current Concepts, (Slack Incorporated), a 150page manual edited by Seenu M Hariprasad, provides the ophthalmologist with a useful update. Chapter 1 introduces the reader to the background information of RVOs: epidemiology, pathophysiology, risk factors, classification of the occlusions, recommended laboratory assessments, systemic workup and prognosis. Chapter 2, titled “Clinical Trials: Historical Perspective and Current Relevance,” covers pivotal early studies such as the Branch (BVOS) and Central Vein Occlusion Studies (CVOS) and outlines the role of retinal laser photocoagulation. Chapter 3 discusses the role of anti-VEGF agents and provides useful information on trials. Chapter 4 moves on to corticosteroid therapies. Chapter 5 covers that most frustrating of RVO complications: macular oedema. It focuses on the role of imaging in managing this complication. Chapter 6 provides the most useful information to those practitioners versed in RVO management but who might be looking for expert advice on combination-therapy and the management of recalcitrant cases. This book is primarily useful for general ophthalmologists looking for an in-depth review of RVO treatments, and retina fellows who are learning to apply these modalities for the first time.

BOOK

REVIEWS

SAN DIEGO APRIL 17–21

ADDITIONAL PROGRAMMING ASCRS GLAUCOMA DAY ASOA WORKSHOPS TECHNICIANS & NURSES PROGRAM

SUBMISSIONS OPEN AUGUST 13–SEPTEMBER 23 BOOK HOUSING RESERVE EARLY TO STAY AT YOUR PREFERRED HOTEL.

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

A joint meeting with

BOTTOM-UP SCIENCE PRIMER On a different note, Basic Sciences in Ophthalmology: Physics and Chemistry (Springer), by ophthalmologists Josef Flammer and Maneli Mozaffarieh and theoretical physicist Hans Bebie, “aims to link clinical ophthalmology to its basic science roots.” This is a very scientific book, with a stronger resemblance to a high-school physics book than to a medical text. The first several chapters delve into the details of light: what is it, how does it react with matter and how can we use it to examine and treat the eye? Later chapters cover chemistry from oxygen, CO2, chemical reactions and biological macro-molecules like DNA and proteins. This book is intended for residents preparing for their basic science examination and other eye care professionals and researchers who require a detailed look at the eye from the bottom up. LEIGH SPIELBERG Books Editor

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

EUROTIMES | SEPTEMBER 2014

19 ESCRS WINTER MEETING ISTANBUL TH

In conjunction with

Turkish Ophthalmology Society Cataract & Refractive Surgery Section

20 â&#x20AC;&#x201C; 22 February 2015

www.escrs.org

OPHTHALMOLOGICA

See

’1 R SF09

E SBCooth #

OPHTHALMOLOGICA VOL: 232 ISSUE: 2

GOOD LONG-TERM EFFECT Eyes with non-infectious uveitis can achieve long-term visual gains following intravitreal injection of a dexamethasone implant (Ozurdex®, Allergan) according to the results of a retrospective study involving eight eyes of seven patients. Macular oedema resolved in all eyes by a mean follow-up of 3.9 weeks (range 1–6.9) post-injection. The mean central point thickness improved from 612μm to 250μm (p < 0.05). In five eyes, CME had still not recurred after a mean follow-up of 14.5 months. In three eyes, CME relapsed after a mean 4.7 months but resolved again following further injections. Z Habot-Wilner et al “Long-Term Outcome of an Intravitreal Dexamethasone Implant for the Treatment of Noninfectious Uveitic Macular Edema”, Ophthalmologica 2014; DOI:10.1159/000362178.

IMPLANT’S EFFICACY VARIES AMONG DIFFERENT CME TYPES

LENSTAR LS 900

Lunchtime Symposium.

Rick Potvin, MASc, OD Akron, USA

www.haag-streit.com

EUROTIMES | SEPTEMBER 2014

Graham Barrett, MD Perth, Australia

Sunday September 14, 2014 from 13:00 – 14:00 in the capital suite 14 Master your Toric Planning for Improved Refractive Outcomes with the LENSTAR LS 900 Three experts in the planning of Toric IOL and treatment of cataract are going to present you new ways to improve your refractive outcomes with astigmatic patients. Warren E. Hill, MD, FACS Mesa, USA

The Ozurdex dexamethasone implant resolves cystoid macular oedema (CME) faster and for longer in cases of uveitis than it does in cases of diabetic macular oedema (DME) or vein occlusion, according to a comparative study involving 37 eyes of 33 patients. The patients underwent a total of 53 injections and had a mean follow-up of 22 weeks. CME resolved in a mean of two weeks in seven uveitis patients, compared to a mean of eight weeks among 14 eyes with DME and eight weeks among 15 eyes with vein occlusion. In addition, there were no signs of CME recurrence for a mean of 20 weeks in the uveitis group, compared to a mean of only 13 weeks in the DME group and 11 weeks in the vein occlusion group. N Sorkin et al, “Intravitreal Dexamethasone Implant in Patients with Persistent Macular Edema of Variable Etiologies”, Ophthalmologica 2014; (DOI:10.1159/000360304)

FUNCTION MATCHES STRUCTURE IN STARGARDT'S Multifocal electroretinograms (mfERGs) correlate well with the ophthalmic appearance of the fundus in patients with Stargardt’s disease/fundus flavimaculatus (SFF), a new study shows. Among 49 eyes with SFF, those with type 1 disease had severely reduced mfERGs in the macular area and reduced and delayed responses in the mid-periphery and those with type 2 SFF patients had reduced but recordable mfERGs from the centre of the macula with more depressed responses in the paramacular area. Furthermore, the type 3 SFF patients had reduced and delayed mfERGs both in the macula and periphery and those with type 4 SFF had normal mfERGs in the macular area and delayed responses in all outer zones. Kuniyoshi K et al, “Multifocal Electroretinograms in Disease/ Fundus Flavimaculatus”, Ophthalmologica 2014;DOI:10.1159/000361056.

JOSÉ CUNHA-VAZ Editor of Ophthalmologica The peer-reviewed journal of EURETINA

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CUSTOMERS IN OVER 150 COUNTRIES WITH YOUR AD Advertise with the highest audited circulation for any ophthalmic news magazine in Europe

59 per cent of our readers surveyed in an independent research survey have decision-making power when it comes to the purchase of surgical/medical equipment or supplies. A further 20 per cent are usually consulted before a final decision is made**

* Average net circulation for the 10 issues circulated between 1 January 2013 and 31 December 2013. See www.abc.org.uk ** Results from the EuroTimes

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CALENDAR

JANUARY

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EVER 2014 Congress

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24 January Oxford, UK www.euretina.org

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18–21 October Chicago, Illinois, USA www.aao.org

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5–8 February New Delhi, India www.aios.org

Femto Congress 2014

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

94th SOI National Congress

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21–24 November Rome, Italy www.congressisoi.com

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12 September London, UK www.escrs.org

21 November Dublin, Ireland Email: hmurphy@materprivate.ie

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DECEMBER

12 September London, UK www.wspos.org

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

5th EuCornea Congress 12–13 September London, UK www.eucornea.org

JANUARY 2015

9 January Paris, France www.maculaofparis.org

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