EuroTimes Vol. 20 - Issue 10 by EUROTIMES

SPECIAL FOCUS YOUNG OPHTHALMOLOGISTS CORNEA

NOVEL AGENT APPEARS SAFE FOR TREATMENT OF DRY EYE DISEASE October 2015 | Vol 20 Issue 10

INNOVATION

SMARTPHONE EYE EXAM KITS: EASING THE BURDEN FOR DOCTORS

G N I GO

O L SO

The Essence of Perfection For Retina, Cataract and Glaucoma Surgery • HDC Control for maximum precision, safety and surgery control • Newly developed vacuum and flow tri-pump system • SPEEP® mode for very precise maneuvers • Active and gravity infusion • Up to 10’000 cuts with the Continuous Flow-Cutter • Double light source with color adjustable LED technology • Fully integrated 532 nm green endo laser • Brand new phaco engine for even more efficiency and safety • Wireless, dual linear all-in-one foot switch • Intuitive user interface with Direct Access® • Embedded Controller Technology for utmost system performance

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

CONTENTS

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS YOUNG OPHTHALMOLOGISTS 4 Cover Story: How

trainees can use a vast array of resources to improve their expertise

8 Award-winning

essay charts a long and demanding learning curve

9 How to get the most

out of wetlabs – your essential guide

12 Leading doctors

give advice on the crucial steps of a cataract operation

FEATURES CATARACT & REFRACTIVE

complex interactions between symptoms and pain

21 Benefit of daily oral

supplementation with omega-3 fatty acids

22 Novel agent appears

safe for dry eye treatment, study suggests

CONGRESS REPORTS

RETINA

23 Key news from the 2015

32 Personalised regimen

congresses in Barcelona and Nice

27 ‘Minimally-invasive approach could revolutionise filtration surgery’

15 Adapting to

30 The benefits of

conditions to create the perfect incision

glaucoma – advantages and limitations

fixed-combination treatments

16 ‘FLACS can

simplify removal of subluxated lenses’ surgery: benefits and arguments against

19 SMILE technique

delivering on its promise, showing advantages over LASIK

may lower burden of AMD treatment

33 Case study highlights

GLAUCOMA

28 Cataract surgery for

surgery in eyes with corneal pathologies

P.9

20 Dry eye disease –

14 Performing cataract

18 Same-day bilateral

As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2014 and 31 December 2014 is 42,957.

CORNEA

P.16

importance of eye protection during laser procedures

GLOBAL OPHTHALMOLOGY 37 Dramatic rise in myopia

prevalence provides stimulus for research efforts

REGULARS 39 Eye Contact 40 Innovation 41 Ophthalmologica Update 42 Industry News 44 ESASO Update 45 JCRS Highlights 46 Eye on Technology 48 Calendar Cover illustration courtesy of Eoin Coveney

EUROTIMES | OCTOBER 2015

EDITORIAL A WORD FROM OLIVER FINDL MD

NEVER STOP LEARNING As with other professions, the more you practise the better you will get, and you must always be prepared to make mistakes

s chairman of the Young Ophthalmologists Forum, I Another message that I try to pass on to my trainees is the am delighted that EuroTimes has decided to dedicate importance of treating patients with respect. That does not this issue to doctors in training. As experienced mean simply saying “please” or “thank you”. Every patient has ophthalmologists we sometimes speak a his or her own individual needs lot about the importance of supporting and we should know as much as In the last five years, our younger colleagues, but it is even more we can about our patients before important that our actions support our words and that the ESCRS has dedicated we operate on them. We should we give practical help and support to our trainees. never make promises that we significant resources In the last five years, the ESCRS has dedicated cannot keep and we should always to helping young significant resources to helping young be honest with our patients. ophthalmologists and ophthalmologists and we will continue to do so I would ask all of my trainees: in the future. As is pointed out in this month’s “Why do you want to become we will continue to do EuroTimes cover story, we want our trainees to have an ophthalmologist?” Some will so in the future a good medical knowledge, which they can obtain answer honestly that it can be by watching videos and reading books. In addition, financially rewarding and that it the ESCRS has the iLearn programme which gives them the can earn them good lifestyles. I have no problem with this opportunity to obtain all the medical knowledge they need on answer as long as they can also tell me that they will never put their computers and tablets. the pursuit of financial gain before the care of their patients. Personal interaction with their colleagues and mentors is In conclusion, I must also stress that the best mentors also very important, and I would urge them to attend the or trainers are those who listen to their trainees. With annual ESCRS Congress and the cataract and refractive surgery that in mind, I look forward to seeing you all at the 20th didactic courses at the ESCRS Winter Meeting. Wetlabs are ESCRS Winter Meeting in Athens, Greece, from 26–28 also very important as Sorcha Ni Dhughaill notes in her article February next year, and I urge you to join us at the Young in this month’s issue. Ophthalmologists sessions.

BRILLIANT SURGEONS Dr Sidath Liyanage, winner of this year’s John Henahan Prize writing competition, makes this argument a lot more eloquently than I could have done. The years in training can be very exciting but at times they can also be depressing and lonely. Even the most brilliant surgeons experience self-doubt, regardless of how many years they have been in practice. As with other professions, the more you practise the better you will get, and you must always be prepared to make mistakes. We all learn from our mistakes and these mistakes help to make us better doctors.

Oliver Findl is chairman of the Young Ophthalmologists Forum and secretary of ESCRS

MEDICAL EDITORS

Emanuel Rosen Chief Medical Editor

José Güell

Ioannis Pallikaris

Clive Peckar

Paul Rosen

INTERNATIONAL EDITORIAL BOARD Noel Alpins (Australia), Bekir Aslan (Turkey), 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), Soosan Jacob (India), 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), Leigh Spielberg (The Netherlands), Sathish Srinivasin (UK), 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 | OCTOBER 2015

Icare HOME self-tonometer for easy 24h IOP monitoring by Ophthalmologist recommendation www.icaretonometer.com

COVER STORY: YOUNG OPHTHALMOLOGISTS

Courtesy of Eoin Coveney

PASSING THE TORCH Trainees need great dedication to learn from their mentors and reach the highest levels of skill and expertise. Roibeard O’hEineachain reports

ore than a generation has passed since phacoemulsification and intraocular lens (IOL) implantation became the standard treatment for EUROTIMES | OCTOBER 2015

cataracts in the developed world. The current generation of trainee cataract surgeons therefore have a great advantage over the previous generation, who had to develop their techniques almost from scratch with a lot of trial and error. Moreover, the advent of the Internet, and YouTube and the proliferation of courses and wetlabs at meetings have

increased the availability of relevant knowledge for trainees. “When I started my cataract surgery as a resident there were no videos, no VHS, no videotaping. The only way you could learn was to stand beside the surgeon and learn the technique from the operating microscope. Now the spread of knowledge is much quicker,” Roberto

COVER STORY: YOUNG OPHTHALMOLOGISTS Bellucci MD, University Hospital Verona, Italy, told EuroTimes. “Teaching surgery has also become a little bit less surgical and a little bit more technical. Now it is mandatory to teach how phacoemulsification machines work and how to get the best out of them. Now you need to be a little bit like plumbers to understand fluidics, tubing and the general mechanics of phacoemulsification,” he added. The wide adoption of sutureless surgery has had a dramatic effect on the way cataract surgery is taught, somewhat to the detriment of ophthalmic surgery as a whole, Dr Bellucci said. “Before the advent of sutureless surgery, cataract surgery was more similar to the other types of surgery because it involved incisions that had to be sutured. Now there is no need to learn how to close the eye. So the transition to other types of ophthalmic surgery, like corneal transplants, either deep anterior lamellar or penetrating keratoplasty is now much more difficult for young ophthalmologists than it was before.” He added that the ESCRS is trying to remedy that by introducing specific courses dedicated to teaching young surgeons procedures involving the suturing of large incisions. “The ESCRS has undertaken a major role in ophthalmic education, with the purpose to fill the gap between university teaching and everyday life,” he added.

STARTING WITH A GOOD FOUNDATION As with any new undertaking, learning how to perform cataract surgery involves first finding out as much as possible about the nature of the task and the skills involved, said Oliver Findl MD, Hanusch Hospital, Vienna, Austria. “First of all, I want my trainees to have a good medical knowledge, which they can obtain by watching videos and reading books. We have a syllabus for students. In addition, the ESCRS has the iLearn programme. That gives them the opportunity to obtain all the medical knowledge they need on their computers and tablets. If possible they will go to one or two courses at the international meetings, for example the ESCRS Congress and the cataract didactic courses at the ESCRS Winter Meeting, and I have them go to wetlabs,” he said. Surgical simulators like the EyeSi system can also be very helpful, Dr Findl noted. There have been a couple of studies published in peer-reviewed journals, showing that they do improve skills and knowledge, he said. “One of the advantages of simulators is that they allow you to practise for a long time and simulators also give you direct feedback on your microsurgical technique. I don’t have one myself in my unit because they’re pretty expensive. They are not a must, but I think simulators are nice to have,” he added.

ESCRS e-learning co-ordinator Brendan Strong (right) discusses the iLearn programme with a delegate at the congress in Barcelona

BECOMING ACQUAINTED WITH THE EQUIPMENT Before trainees actually takes part in a surgical procedure, they should become well-accustomed to using the equipment involved, such as the surgical microscope, the knives and forceps and the phacoemulsification machine they are going to use, Dr Findl said. “After the operating list is finished, I tell my trainee to go to the operating theatre in the afternoon or evening and place a tennis ball on the operating table and practise using the pedals of the microscope. After a while they become very comfortable doing this and they don't have to think about the pedals of the microscope anymore. “Then I ask them to practise on the tennis ball using the surgical instruments, including the phaco handpieces, with a gloved hand. I also have a representative from the company who manufactures the phaco machine come in and explain how it works from A to Z. Usually these reps have a lot of technical knowledge and will show all the features of the machine to the trainee.

LEARNING FROM END TO BEGINNING Dr Findl noted that that the older, beginning-to-end, step-by-step approach to teaching cataract surgery was correct about teaching each part of the procedure in individual steps, but simply put things in the wrong order. “When I learned, back in the old days, I would start the surgery at the beginning and see how far I could go before the surgeon took over. That is not a good way of doing it for several reasons. First, the earliest parts of the procedure are also the most difficult and most dangerous. Second, complications occurring during incision creation or capsulorhexis are much more difficult to remedy than are the final steps of the procedure. “That is why I do it from the last step to the beginning - so reverse. First, I have them take the viscoelastic out of the eye, then when they have done that five or 10 times and are confident in their performance, the next step is to learn how to place the lens in the eye, and then later how to perform irrigation and aspiration, remove nuclear fragments, how to perform nuclear fragmentation, hydrodissection, capsulorhexis until

... I want my trainees to have a good medical knowledge, which they can obtain by watching videos and reading books Oliver Findl MD EUROTIMES | OCTOBER 2015

COVER STORY: YOUNG OPHTHALMOLOGISTS the last step of performing the initial incisions,” Dr Findl said.

OPERATING TABLE-SIDE MANNER One thing trainee surgeons should keep in mind from the beginning is the patient attached to the eye on which they are operating, Dr Findl noted. “I think it is very important to talk with the patient during surgery. Most of the procedures are done under local anaesthesia and patients do feel some discomfort during surgery once in a while. Usually the junior surgeon is too stressed to talk to the patient during the procedure. I'm looking through the microscope as well and I comment as I would if I were doing the surgery.”

Courtesy of Soosan Jacob FRCS

THE VIDEO REVOLUTION Soosan Jacob FRCS noted that surgical videos help fill in the gaps of knowledge that can remain even after intensive study and observing surgery first-hand. “Watching a senior or mentor performing is a great technique, because they will explain the many nuances that are difficult to explain without a visual demonstration. But sometimes what happens is that there is a pressure of time on the surgeon or the trainee may be hesitant to ask questions,” said Dr Jacob, Dr Agarwal's Group of Eye Hospitals, Chennai, India, in an interview. “Watching a surgical video where every point is being explained is a very different situation. Now the surgeon can explain each and every step much better. Furthermore, if there’s something of particular interest that occurs during the procedure like a complication, the trainee can actually stop, rewind, go back and watch it again until they are sure they understand,” she added. Dr Jacob said that combining written explanations with video illustration provides the best of both worlds. She therefore makes videos for her YouTube channel that provide a visual demonstration for many of the techniques she describes in her columns in EuroTimes. She noted that making a good instructional video involves time and effort - making sure the lighting is optimum, the microscope is focused and aligned well and that all the steps are shown clearly in a manner understandable to the viewer. This is followed by editing the presentation in such a way that the key points are clearly illustrated and

Soosan Jacob’s popular YouTube surgical teaching channel, which receives many views and comments from trainee and experienced ophthalmologists. Videos are also linked to her teaching columns in EuroTimes

explained. “Making a good video tends to be time-consuming, but the beauty is that when you do this you are also becoming a better and better surgeon and a better communicator,” Dr Jacob said.

SURGICAL MENTORS EuroTimes columnist Leigh Spielberg MD, FEBO was recently granted permission to perform his first series of independent, unsupervised cataract procedures, which he has described in his column in the September issue. He noted in an interview that very focused observation of his surgical mentors early in his training was among the most essential parts of his learning experience. “Before you’re actually doing surgery, a good understanding of the anatomy of the anterior segment is crucial. Paying very close attention to the procedures performed by the mentor, not just passively watching but really paying attention to each step as it is performed, is an excellent way to learn it,” said Dr Spielberg, Rotterdam Eye Hospital, the Netherlands. Dr Spielberg added that he found preoperative preparation to be very useful, including screening each patient’s medical file and taking note of any surgical risk factors, such as use of tamsulosin, prior retinal tears or pseudoexfoliation. This also shows your surgical mentor that you have done your homework and are

Before you’re actually doing surgery, a good understanding of the anatomy of the anterior segment is crucial Leigh Spielberg MD, FEBO EUROTIMES | OCTOBER 2015

interested in learning, he said. He noted that assisting surgery before participating in the actual surgery itself further enhanced his training. “In my hospital, residents serve as first assistants during most cataract surgeries. This involves handing each instrument to the surgeon throughout the procedure, which requires you to always anticipate the next move and keeps very alert,” Dr Spielberg said. Once you’re performing procedures, there are several important milestones on the road to achieving the confidence necessary to perform cataract surgery without supervision, he noted. “The first intraocular steps are intense, because you’re initially a bit unsure of what you're doing, but each successfully completed step generates a giant boost in terms of confidence. The first time you’re alone at the operating table, with your mentor in the OR but not scrubbed in, that's a big deal. And if your mentor happens to leave during a cataract operation, that's a push towards independence, and it made a big impression on me that someone was willing to entrust their patient to my hands,” he said. Yet regardless of a surgeon’s experience, that confidence must be tempered with modesty and respect for the eye, he stressed. “Even the best ophthalmologist is never completely confident in his or her skills. Everyone has to maintain a sense of humility and a degree of caution during every procedure, because even those who have done tens of thousands of procedures can still encounter a complication.” Roberto Bellucci: robbell@tin.it Oliver Findl: oliver@findl.at Soosan Jacob: Dr_soosanj@hotmail.com Leigh Spielberg: leigh.spielberg@gmail.com

10â&#x20AC;&#x201C;14 September

2016

XXXIV Congress of the ESCRS Bella Center, Denmark

Instructional Course Abstract Submission Deadline 31 October 2015 www.escrs.org

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

A FICKLE BEAST Sidath Liyanage won the 2015 John Henahan Prize for young ophthalmologists

for this essay charting his long, demanding journey from trainee to surgeon

am not a gifted surgeon. A decade has passed since I faced this stark reality during my first phacoemulsification surgery. Having attended a microsurgery course and observed my consultant for a few lists, I thought myself prepared. It was unnerving when all I could do was muddle through the corneal incision before my consultant had to take over. I may have been overly optimistic, but wasn’t I better than that debacle? My illusion of being a gifted surgeon collapsed. From then on, the moments before my twice weekly surgical lists fluctuated between the heady anticipation of operating and the paralysing dread of potential complications. Without access to simulators or wetlabs, I tried to avoid this slide into perceived mediocrity by reading everything I could about phacoemulsification, from sculpting to peristaltic pumps.

EVERYONE LOSES VITREOUS Although this theoretical knowledge gave me confidence, my surgical inexperience meant that I still made mistakes. Due to the unforgiving nature of phacoemulsification, these occasionally spiralled out of control. Soon, I dropped a nucleus. My confidence was savaged. Would I ever be a good surgeon? My consultants were reassuring, evoking the time-honoured mantra that ‘everyone loses vitreous’. These well-meaning words did not ease my misgivings. Was it even ethical for me to essentially practice on patients? My learning curve (or lack thereof!) was compromising the outcome of someone's parent. Self-doubt caused me to regress. My trainers and I decided to change our approach: each list I would only perform one or more steps in every case, perfecting them. Working backwards step-wise from stromal hydration ensured that I would always be operating in an optimal setting.

GETTING BETTER Quickly, things got better. Cases became more predictable. I moved from the realm of unconscious incompetence to that of conscious competence. Learning now stemmed from debriefing. Before each operation, like racing car drivers mentally completing the course, we would anticipate difficulties and how to avoid them. I recorded and religiously reviewed every case. With the straightforward ones, I focused on improving my surgical efficiency. When things didn't go as planned, my consultants and I pored over every pixel of video to identify any details which contributed to the complication, then discussing their prevention or management. Although disheartening, this process of reflection was an effective coping mechanism; by actively addressing these issues, I became both proficient and confident with cataract surgery. I felt ready for vitreoretinal surgery.

INTENSE DELIBERATE PRACTICE To me, that first pars plana vitrectromy represented an exponential increase in surgical complexity: new variables, rules, pathologies and approaches. However, my previous experiences with overcoming difficulties meant that I was less fazed by this challenge. By now, I was familiar with Ericsson’s concept of needing 10,000 hours of intense deliberate practice in order to become an expert. Resolving to amass these hours as quickly as possible, I used a simulator to practice the basics of vitreoretinal surgery and repeat the necessary manoeuvres until they became entrenched in my muscle memory. I completed every module, increasing the complexity as I progressed. I learned what I could get away with, deliberately causing complications, liberated by the knowledge that no patients were harmed. When I became comfortable, asking a consultant to observe me helped to increase the pressure. I became a thief, stealing time from my family to watch instructional DVDs and online videos

... by actively addressing these issues, I became both proficient and confident with cataract surgery Sidath Liyanage EUROTIMES | OCTOBER 2015

of new approaches to operations such as suturing intraocular lenses. Countless hours were spent viewing different methods, with each version claiming to be easily reproducible with minimal complications. While undoubtedly informative, the absence of any formal peer-review on some websites often led me to question the promotional aspects of certain material. Viewing videos at conferences somewhat alleviated these concerns, but I still found myself wanting to quiz the authors about the number of complications and amount of editing required to produce those five perfect minutes. The techniques taught to me by my consultants had been tried and tested by them; I valued the opportunity to question and benefit from their experiences.

STRUCTURED FEEDBACK The more adept I become, the more I realise that I need this personal interaction in order to learn. Surgery is far more than being able to perform complex motor skills dexterously. Structured feedback by my consultants, to the point of coaching, has emphasised other facets of surgery. These include the mental fortitude required to be pragmatic and avoid unnecessary risk, and also the skills needed to communicate effectively and manage patient expectations. All of this is consolidated by watching others. Now, I use every opportunity to ghost between operating theatres, observing and learning from those surgeons who I aspire to be like. Training my junior colleagues is also invaluable, as it forces me to deconstruct and understand the required surgical skills, as well as apply all the learning strategies that I benefited from. My previous difficulties mean I can empathise with trainees experiencing similar problems. Surgery is a fickle beast. Although I am not a gifted surgeon, I have learned enough to tame it in the majority of cases, and to cope when it bites. My surgical skills have been hardfought for and I take immense pride in their acquisition. However, surgery is constantly evolving. The technological advances which have transformed cataract surgery serve as an apt reminder that the challenge of mastering new skills is always on the horizon. Will I ever be a good surgeon? Too early to say, as indeed, my learning has only just begun.

SPECIAL FOCUS: 1YOUNG OPHTHALMOLOGISTS 01/10/15 07:40

protectalon_october.pdf

HANDS-ON TRAINING The do’s and don’ts of making the most of wetlab courses. Sorcha Ni Dhubhghaill reports

etlabs provide hands-on surgical training in a pressure-free environment. They are ideal for making inroads into new techniques, discovering new products, or learning to deal with complications. Unsurprisingly, wetlab courses remain immensely popular, and many of them sell out months in advance. To make sure you get the most out of your wetlab course, here are some do's and don'ts for wetlab participants.

DO:

CMY

• Locate the site of the wetlab well in advance. • Ask questions. All the labs are staffed by knowledgeable surgeons who are ready to answer any queries you might have. • Bring a notebook. The labs concentrate a lot of information into a short time. Jotting down notes as you go is a way to hold on to the crucial details. • Be brave. Wetlabs are great for practising new techniques and managing complications, so don’t be timid. • Ask for another eye, if necessary. • Use your new skills. Do your best to use the skills you have learned as soon as you can when you return home, while they are still fresh in your mind. K

DON’T: • Miss the start of the lab. Many labs begin with a short introduction to cover the fundamental points. Miss this, and you may be one step behind for the rest of the session. • Eat or drink during the lab. Leave the coffee until afterwards. • Get frustrated. Most of these techniques will take a while to learn and even longer to master. • Stay longer than your allotted time. Most labs have another lab straight after so if you stay longer it may deprive the next trainee of their time. • Finally, don’t be disappointed if the wetlab you wanted to attend at the ESCRS Congress in Barcelona was booked out. The ESCRS is providing wetlabs during the 20th Winter Meeting in Athens, Greece, in February 2016, so book your next wetlab early! Sorcha Ni Dhubhghaill is an anterior segment surgeon and guest lecturer at Antwerp University Hospital, Belgium EUROTIMES | OCTOBER 2015

Date of Prep: August 2015 L.GB.MKT.08.2015.12301 Copyright ÂŠ 2015 Bayer HealthCare Pharmaceuticals Inc. | www.bayerhealthcare.com | April 2015

SPECIAL FOCUS: YOUNG OPHTHALMOLOGISTS

STOP COMPLICATIONS Leading doctors advise young ophthalmologists on the steps of a cataract operation, highlighting potentially dangerous moments. Leigh Spielberg reports

“

poorly designed incision can make your life very difficult throughout the whole procedure,” according to Mercé Morral MD, PhD, Barcelona, Spain. Dr Morral spoke to delegates attending the Young Ophthalmologists Session entitled “How to Prevent Complications: What Not to Do During Phaco”, at the XXXIII Congress of the ESCRS in Barcelona. The auditorium was full for this session, suggesting that the subject of cataract surgery complications, how to avoid them and what to do if they occur, is on the minds of many young surgeons. “Smaller incisions are generally better, as they are usually more watertight, leading to better intraoperative fluidics. However, make sure to match the incision size with your instruments. If it is too tight, incision burns can occur, which delay wound healing,” she advised. Regarding tunnel shape, the longer the tunnel is, the more selfsealing it is. Nevertheless, if the incision is too long, distortion of the cornea will occur, as well as restricted movement and potential overheating of the phaco tip, she cautioned. Dr Morral next addressed the capsulorhexis, which is considered by many young ophthalmologists to be the most challenging step of the procedure. “To achieve a good red reflex and to maintain sufficient positive pressure is essential in preventing a rhexis run to the periphery. And if the rhexis does run outwards, re-grasp the flap and pull straight towards the centre, the so-called Little’s manoeuvre,” she said. The session featured six speakers, who progressed chronologically through the steps of a cataract operation, highlighting potentially dangerous moments in the procedure. Khiun Tjia MD, Isala Klinieken, the Netherlands, said many young surgeons seem tempted to move on to fragmentation despite an incomplete hydrodissection, but he added that this increases the risk of problems such as zonulolysis and posterior capsular rupture.

ANTERIOR WAVE “Everyone knows to obtain a posterior fluid wave, but what is often overlooked is the importance of an anterior wave, which is necessary to separate lens adhesions from the anterior capsule,” he said. Dr Tjia showed a video that demonstrated the use of pressure on opposite sides to the anterior mid-periphery of the lens, in order to generate this anterior wave circumferentially. “In the following step, fragmentation, failing to generate fully mobile lens fragments can lead to the same complications as with a poor hydrodissection. Turning large nucleus fragments can overstretch the posterior capsule and zonules. A very simple but often overlooked trick is to turn the nucleus a little sideways in order to gain easy entrance for the second instrument to the bottom of the groove. This will lead to much more effective and easier cracking,” said Dr Tjia. Capsular rupture happens more frequently during irrigation/ aspiration than during the phaco step, said Oliver Findl MD, of the Vienna Institute for Research in Ocular Surgery, Austria. “If this occurs, maintain the pressure in the anterior chamber, make sure to thoroughly tamponade with your ophthalmic viscosurgical device, and attempt to convert the hole into a posterior continuous curvilinear capsulorhexis,” said Dr Findl. Once the eye is ready for implantation of the intraocular lens (IOL), complications can still occur. “When young surgeons get the IOL stuck in the incision, most will try to pull it back out, which can be very difficult and EUROTIMES | OCTOBER 2015

Courtesy of Khiun Tjia MD

Depressing the nucleus at opposite sides to loosen anterior capsule from the lens

traumatic for the eye. Instead, I always suggest slightly enlarging the incision to mobilise the IOL,” said Dr Findl. Richard Packard MD, Windsor, England, then discussed complications involving the iris, the pupil and the intraocular pressure. “For beginning surgeons, iris prolapse is a dreaded complication. Many beginners will try to immediately push the iris back into the eye, but what works better is to first decompress the globe by letting some anterior chamber fluid out of a different incision. The iris is then more likely to re-enter the eye rather than continue to prolapse,” explained Dr Packard. Dr Packard also offered tricks to enlarge the pupil size early in the procedure, including a high-viscosity viscoelastic, nonpreserved lidocaine one per cent, followed by non-preserved phenylephrine 2.5 per cent.

RISK FACTORS Subsequent videos of disastrous complications such as expulsive haemorrhage and lens-iris diaphragm retropulsion syndrome were met with obvious discomfort in the audience, as each delegate hoped to avoid similar iatrogenic dramas. Roberto Bellucci MD, University Hospital of Verona, Italy, addressed the cornea during phaco. “Phacoemulsification is safe for the cornea, although definite risk factors for endothelial cell loss are a low initial endothelial cell count, particularly hard cataract, an inexperienced surgeon, and an intraoperative complication,” said Dr Bellucci. “The most important point is maintaining a safe distance between phaco tip and endothelium. It has not yet been proven that ‘bevel-up’ is worse for the endothelium than ‘bevel-down’ surgery,” added Dr Bellucci. The final speaker was Luis Cordovés MD, a retinal surgeon at the Hospital Universitario de Canarias, Tenerife, Spain. He reminded delegates that one of the most important things they should remember regarding vitreoretinal complications after cataract surgery was to be sure that there is no vitreous left in the corneal wounds at the conclusion of the surgery. He also told the audience about how the use of intracameral cefuroxime has become standard in care for endophthalmitis prophylaxis in cataract surgery, and the lack of sound scientific evidence for the use of perioperative topical antibiotics. Merce Morral: merce.morral@gmail.com Oliver Findl: oliver@findl.at Richard Packard: mail@eyequack.vossnet.co.uk Khiun Tjia: kftjia@gmail.com Roberto Bellucci: robbell@tin.it Luis Cordovés: luis.cordoves@hotmail.es

Athens 2016

Athens 26â&#x20AC;&#x201C;28 February

Athens 20TH

ESCRS

Winter Meeting In conjunction with the 30 International Congress of HSIOIRS TH

MEGARON CONGRESS CENTRE, GREECE t Abstrac n io Submiss e Deadlin ber 31 Octo 2015

www.escrs.org

CATARACT & REFRACTIVE

CORNEAL DISEASE Simple guidelines enhance cataract surgery outcomes in eyes with corneal co-morbidities. Roibeard O’hEineachain reports

erforming cataract surgery in eyes with corneal pathologies like keratoconus or Fuchs syndrome poses many special problems, but there are a few simple rules that can help optimise outcomes, Rudy MMA Nuijts MD, PhD told a Young Ophthalmologists Symposium at the 19th ESCRS Winter Meeting in Istanbul, Turkey. For example, in eyes with minimum and moderate keratoconus, measured keratometric values have sufficient accuracy for use in intraocular lens (IOL) power calculations. However, in eyes with advanced keratoconus, it is better to use a standard K value of 43.5D to avoid hyperopic outcomes due to an overestimation of the actual K values, said Dr Nuijts, University Eye Clinic, Maastricht, The Netherlands. “If you implant a low-power IOL in the eye and then you have to do a keratoplasty later on you will end up with a very low-power lens and a very significant hyperopic shift that will be difficult to correct,” he added. Although keratoconus is generally a contraindication for toric IOLs, studies have shown that the lenses actually tend to be effective in eyes with stable stage 1 to stage 2 of keratoconus (Figures 1 and 2). (Visser N et al, Cataract surgery with toric intraocular lens implantation in keratoconus: a case report. Cornea. 2011 Jun;30(6):720-3) In such cases, it is important to assess the effect of the cataract versus that of the keratoconus on the amount of vision loss. That may be achieved through reviewing the patients’ charts for their visual acuity and their K values over time. It is also important to remember that if the patient should require rigid contact lenses or a keratoplasty procedure later on they may require exchange of the toric IOLs for spherical IOLs.

Figure 1

FUCHS SYNDROME In eyes with Fuchs syndrome, cataract surgery should only be performed without endothelial keratoplasty if the corneal thickness is 620µm to 630µm (Figure 3). (Doors M et al, Phacopower modulation and the risk for postoperative corneal decompensation: a randomized clinical trial. JAMA Ophthalmol. 2013 Nov;13 (11):1443-50) A soft-shell ophthalmic viscosurgical device (OVD) technique should be used in such cases. In addition, the refractive target should be low myopia because of the hyperopic shift that may be induced by an endothelial graft later on. In eyes where the Fuchs syndrome is at a more advanced stage, the surgeon has to choose between doing two separate procedures, the cataract procedure followed by the endothelial keratoplasty, or both together in a triple procedure. “The advantage of a two-stage procedure is that there is a more stable anterior segment which makes the surgery a little bit easier later on,” Dr Nuijts said. When performing Rudy MMA Nuijts MD, PhD a triple procedure, the

If you implant a low-power IOL in the eye and then you have to do a keratoplasty later on you will end up with a very low-power lens...

EUROTIMES | OCTOBER 2015

Figure 2

Courtesy of Rudy MMA Nuijts MD, PhD

Figure 3

best results are generally obtained performing phacoemulsification followed by endothelial keratoplasty, he added. Rudy Nuijts: rudy.nuijts@mumc.nl Nienke Visser: nienke.visser@mumc.nl

CATARACT & REFRACTIVE

THE PERFECT INCISION A variety of approaches needed to suit each patient. Roibeard O’hEineachain reports

he creation of the perfect incision in cataract surgery is an exercise in adaptation to the patient, the surgeon and the available instruments, with the goal of avoiding induced astigmatism and creating a watertight wound with as little trauma to the eye as possible, said Mike Adams MA, MB BChir, FRCOphth, Oxford University Hospital, Oxford, UK. “To achieve a perfect incision you’re going to need four things: the perfect patient, the perfect eye, the perfect instruments and the perfect surgeon. We all know the first two are impossible, but we have to hope that the last two are possible,” Mr Adams told a Young Ophthalmologists Symposium at the 19th ESCRS Winter Meeting in Istanbul, Turkey. The first requirement for a good cataract incision is that it provides good access to the eye for surgery. Temporal incisions are better than superior incisions in that regard and are necessary when a patient has a large brow. In addition, in studies conducted using 3.0mm blades, temporal incisions induced less astigmatism than superior incisions, due to the ellipsoidal shape of the cornea. But superior incisions also have their advantages. For example, they are protected by the eyelid from postoperative trauma. In addition, the brow supports the surgeon’s hands, which can be very helpful for trainee surgeons. Furthermore, in research conducted at the Bascom Palmer Institute, inferotemporal incisions appeared to be associated with a high risk of infection. That may be a result of the wound’s location in the tear lake, where it is more exposed to bacteria. Meanwhile, there have been reports that smaller, 2.2mm blades may reduce the disadvantage of superior incisions regarding astigmatism. Smaller temporal wounds may also be less vulnerable to infection than the 3.0mm temporal incisions used in the past. Incisions for cataract surgery must also provide good access to the anterior chamber. In most countries corneal incisions are by far the most commonly used. They are quicker to perform and easier to learn. An important rule to remember is that the further from the optical zone the incision is, the less astigmatism it will induce. Scleral wounds by contrast involve a peritomy, diathermy dissection of the tunnel with a crescent knife and then finally entering the eye with the keratome. However, scleral wounds are very useful when it is necessary to implant a rigid PMMA lens, since the large incisions needed produce a negligible astigmatic effect compared to corneal incisions. Scleral wounds also have far less risk of leaking than corneal wounds and also tend to have a more consistent shape postoperatively. Mr Adams noted that there remains some controversy over which corneal wound architecture provides the best postoperative

coaptation with the epithelium. In a study carried out by Howard Fine MD in Oregon, USA, in 2007, optical coherence tomography (OCT) examination showed that, unexpectedly, the three-plane incisions actually had poorer coaptation than the stab incisions. Moreover, the stab incision did not result in a vertical wound straight into the cornea, but instead the internal stromal faces of the wound realigned into a curve, forming a very good seal and a smooth surface. However, in another study carried out that same year by Dan Calladine FRCOphth and Richard Packard FRCS in the UK, stab incisions resulted in loss of coaptation compared to multi-plane incisions, with gaps in the stromal layers. That may be because they injected viscoelastic into the eye through a paracentesis prior to making the incisions. “When you press the knife in, the cornea flattens a little ahead of your blade and when you take the blade out and the cornea springs back to its natural shape, you find you’ve created a curve with the stab incision. However, if the eye is hard because you've filled it up with Healon there is less flattening of the cornea with a stab wound when you put a blade in,” said Mr Adams. A cataract incision also needs to be a good fit for the phaco instrument, Mr Adams said. It should be tight enough to ensure a stable anterior chamber, but loose enough to avoid pinching the phaco probe’s irrigation sleeve, or stretching the wound and impairing its closure at the end of the procedure. Moreover, with a too-tight wound, movement of the phaco probe will cause the eye to move as well. Mr Adams noted that different blades perform differently when making a surgical incision in the cornea. For example, a steel trapezoidal blade with a pronounced shoulder may surge into the anterior chamber once the shoulder has passed through the cornea and inadvertently catch the capsule as a result. Similarly, diamond knives are so sharp that in the hands of an inexperienced surgeon they may pass much further through the cornea than intended.

To achieve a perfect incision you’re going to need four things: the perfect patient, the perfect eye, the perfect instruments and the perfect surgeon Mike Adams MA, MB BChir, FRCOphth

Mike Adams: mwjadams@gmail.com

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CATARACT & REFRACTIVE

Figure 1: Marfan’s syndrome patient (left) Figure 2: Traumatic subluxated lens (below)

Courtesy of Armando Crema MD

FS FOR SUBLUXATED LENS Laser technology may ease removal of displaced lenses, improving outcomes. Howard Larkin reports

emtosecond laser-assisted cataract surgery (FLACS) can simplify removal of subluxated lenses in mild to moderate cases, Armando Crema MD, Rio de Janeiro, Brazil, told the 2015 American Society of Cataract and Refractive Surgery Symposium in San Diego, USA. While laser technology is often viewed as a way to improve refractive outcomes with premium lenses, it offers so much of an advantage in fragile eyes that complex cases make up 26 per cent of laser-assisted cataract cases Dr Crema performs. Precutting the anterior capsule and prefragmenting the lens reduces the amount of intraocular manipulation required to remove the cataract, putting less stress on already weakened zonules and supporting tissues, he noted. “Subluxated lenses are a good indication for use of this new technology,” he said. As long as the lens is not displaced too far from the pupil centre, the laser can do the anterior capsulotomy and pre-fragment the lens, Dr Crema said. He showed a case of a patient with Marfan’s syndrome in which the capsulotomy and lens fragmentation were perfectly done by the femtosecond laser, greatly reducing the force needed to remove the lens in a very fragile eye. (Figure 1) Because the lens was off centre in one eye with a severe subluxation, the area of lens fragmentation was reduced, but this EUROTIMES | OCTOBER 2015

still resulted in less mechanical and phaco energy to remove the lens. Dr Crema noted, however, that a free anterior capsulotomy is essential, so the cut should be checked for microtags before beginning the case. Corneal opacities and poor dilation may be contraindications for using laser-assisted cataract technology as they may prevent adequate lens treatment. Dr Crema typically uses a pre-chopper to separate pre-fragmented lenses, and when possible hydrodissects them to the anterior chamber before aspirating. This generally leaves the capsular bag intact and limits any damage to weakened zonules. In traumatic subluxation cases, he has successfully removed lenses even with some zonules torn without further damage to intact zonules. (Figure 2) An endocapsular tension ring may then be inserted in the bag and the bag centred and anchored to the sclera with a stitch. This allows the replacement lens to be implanted in the bag. Dr Crema noted that the anterior capsulotomy easily done by LACS technology also contributes to a good outcome in these cases because it enables implantation of an endocapsular tension ring and centration of the capsular bag and lens implant. Dr Crema reported several cases of well-centred lenses and post-surgery best corrected vision of 20/20 in patients 20/80 to 20/100 before surgery due to a located crystalline lens. However, in severe

cases, where the lens is too far away from centre, the laser cannot cut an adequate capsulotomy, that will be decentred and very peripherally, leaving small anterior capsule margins (Figure 3). The pros and cons of using a femtosecond laser should be evaluated in each case, he said. Armando Crema: acrema@openlink.com.br

Figure 3: Marfan’s syndrome patient with severe subluxation

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CATARACT & REFRACTIVE

BILATERAL SURGERY

Clear benefit for the patient in same-day bilateral surgery, but economic arguments against. Dermot McGrath reports

hile there may be no scientific rationale to rule out same-day or immediately sequential bilateral cataract surgery (ISBCS) for routine cases, the strongest argument against its adoption in France may turn out to be economic, according to Guillaume Leroux les Jardins MD. “In terms of evidence-based medicine, for selected patients there is a clear advantage and no objective scientific argument in terms of safety for not practising same-day bilateral cataract surgery. However, the fact that there is no payment corresponding to two separate ambulatory hospitalizations means an obvious financial loss for the surgeons and care establishments that might otherwise consider it, even if the practice was permitted by the health authorities,” Dr Leroux les Jardins told delegates attending the annual meeting of the French Implant and Refractive Surgery Association (SAFIR) in Paris.

... the idea might seem completely incongruous at first glance Guillaume Leroux les Jardins MD

The question of same-day bilateral cataract surgery has been the focus of some intense debate at international conferences and in the scientific journals in recent times, noted Dr Leroux les Jardins. “It is a hot topic at the moment even though the idea might seem completely incongruous at first glance,” he said, noting that countries such as Canada, Finland and Spain have been leading the way in same-day bilateral cataract surgery. In 2008, the International Society of Bilateral Cataract Surgeons (iSBCS.org) was set up to promote education, mutual cooperation and progress in simultaneous bilateral cataract surgery. The Society has very strict criteria on good practice for bilateral same-day surgery, said Dr Leroux les Jardins. “Patient selection is obviously critical. Standard cataract patients only are allowed without ANY associated comorbidities. Cases with a potential to create unwanted surprises are also systematically excluded such as diabetics, immunosuppressed patients, pseudoexfoliation, Fuchs endothelial dystrophy, dense cataracts, epiretinal membrane, diabetic retinopathy, high ametropias, and previous refractive surgery,” he said. Moreover, immediate sequential surgery should never be carried out if any unresolved complication occurred with the first eye, said Dr Leroux les Jardins. For the surgery itself, it is essential to respect complete aseptic separation of right and left eyes, with all equipment and instruments changed for each procedure and mandatory use of intracameral antibiotic. There is a clear benefit for the patient in same-day bilateral surgery, said Dr Leroux les Jardins, including faster visual rehabilitation, less hospital visits and less demand on their entourage. The arguments against same-day surgery are the perceived risks of bilateral endophthalmitis, bilateral toxic anterior segment syndrome (TASS) and incorrect intraocular lens (IOL) power calculation for both eyes.

ECONOMIC FACTORS Economic factors must also be borne in mind, said Dr Leroux les Jardins. “There is the factor of less payment for the second eye for the surgeon and surgical centre and implications for reimbursement for the patient,” he said. For bilateral endophthalmitis, Dr Leroux les Jardins said that only four cases in total have been reported in the scientific literature during the three past decades, but that the basic rules for complete separation of each surgery were not respected in each instance. In 95,606 same-day bilateral cataract cases reported by Steve Arshinoff MD, there were no cases of bilateral endophthalmitis and just one case of unilateral endophthalmitis (0.007 per cent). In this context, the theoretical risk of bilateral endophthalmitis is of the order of one case in 11.9million procedures as a low estimate, or one case in four million bilateral procedures as a high estimate, said Dr Leroux les Jardins. In comparison, during a general anaesthesia the risk of death seems great with one case for 100,000 procedures. Using modern biometry methods should greatly reduce any risk of power calculation errors for IOL implantation, he concluded.

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Guillaume Leroux les Jardins: glerouxlesjardins@gmail.com See also: Eye Contact, where Oliver Findl MD discusses issues related to immediately sequential bilateral cataract surgery in an interview with Steve Arshinoff MD (www.eurotimes.org/eyecontact)

CATARACT & REFRACTIVE

SMILE TECHNIQUE Delivering on its promise of reduced dry eye and inflammation, and good biomechanics. Roibeard O’hEineachain reports

he small incision lenticule extraction (SMILE) technique is becoming a serious contender for top corneal refractive surgery procedure as studies confirm both its efficacy and its theoretical advantages over LASIK, said José L Güell MD, Barcelona, Spain. “What we have observed is that the refractive and visual results of SMILE are similar to the best ones achieved with excimer procedures and that it induces less inflammatory response and dryness. Furthermore, since the majority of biomechanical weakening with LASIK comes from the side-cut, it has obvious conceptual biomechanical advantages,” Dr Güell told the 19th ESCRS Winter Meeting in Istanbul, Turkey. Over the years many corneal refractive techniques have come and gone despite showing great promise in theory, Dr Guell noted. The abandoned techniques include radial keratotomy, because of refractive instability, intracorneal ring segments and intracorneal lenses for ametropia, because of imprecision, although the latter two techniques have been adopted in more recent years for the treatment of ectasia and presbyopia, respectively. It wasn’t until the introduction of excisional laser techniques like LASIK and photorefractive keratectomy (PRK) that refractive surgeons were able to provide patients with real precision and stability through corneal procedures. As a stromal treatment LASIK has additional advantages including the low tissue reaction. However it also has its shortcomings, Dr Güell said. “The excimer laser is a fantastic tool, but has some limitations. We depend on environmental conditions in the operating room, we use gas, we need eye trackers and we have long ablation times, especially for the higher corrections. And of course with LASIK we are using an open flap and therefore have the risk of flap complications,” he added.

MEETING EXPECTATIONS The SMILE femtosecond laser technique overcomes many of those disadvantages, since it uses a contact interface with good centration and is almost completely intrastromal and therefore does not involve an open flap. Moreover, it leaves the more strongly supportive and more heavily innervated anterior stromal layers almost completely intact, in theory providing better biomechanical stability and inducing less dry eye. Data gathered over the last couple of years appear to have confirmed the safety and efficacy of the SMILE procedure as well as some of its proposed advantages, Dr Güell noted. The provisional data show that SMILE achieves refractive results equal to the best results achieved in matching eyes with LASIK, with 80 per cent to 90 per cent achieving an uncorrected visual acuity of 20/25 or better. “We observe the slow but complete visual recovery which takes a few more days than it does with LASIK, possibly related to micro distortions that are produced by dissection of Bowman's membrane, which obviously is reversible after a few days or weeks after surgery,” Dr Güell said. José L Güell MD

The excimer laser is a fantastic tool, but has some limitations

From an optical point of view, there are now also numerous studies showing that the scatter index after SMILE (OQAS-HD Analyzer data) is likewise close to that achieved in the best LASIK cases. There is also evidence that the standard SMILE technique induces the same amount of secondary spherical aberration as does optimised LASIK with femtosecond laser-created flaps. Regarding dry eye, in a study by Dan Reinstein MD, PhD and his associates in London (published in 2012), Cochet-Bonnet aesthesiometry showed considerably greater and longer-lasting reductions in corneal sensitivity after LASIK than after SMILE and this has been supported by other investigators. In addition, the findings of rabbit eye studies indicate that there are fewer reflective particles and fibronectin and CD11b in the cornea after SMILE than after LASIK, showing that there is a lower inflammatory response after SMILE than there is to LASIK. The surgical aspect of the SMILE technique consists of four basic steps, an anterior cut, a posterior cut, a small side cut, and extraction of the lenticule with a forceps, for some surgeons, and the cleaning of the interface. “We still have some challenges such as re-operation, hyperopia correction and wavefront-guided corrections. But I think that the intrastromal laser approach is obviously the best and is a less aggressive approach to attack the cornea,” Dr Güell added. José L Güell: guell@imo.es

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CORNEA

DRY EYE DISEASE

Corn

C o r n

European Society of Cornea and Ocular Surface Disease Specialists

Complex interaction between symptoms and pain for patients. Howard Larkin reports

7 EuCornea Congress th

OPENHAGEN2016

9–10 September

Bella Center, Denmark

www.eucornea.org

atients with concomitant chronic pain syndromes such as fibromyalgia tend to have more severe symptoms of dry eye disease, reported Jelle Vehof PhD at the World Cornea Congress VII in San Diego, USA. Dr Vehof and colleagues at the University Medical Centre Groningen, the Netherlands, compared dry eye signs and symptoms in two groups of patients in the Netherlands and the UK. All patients completed the Ocular Surface Disease Index (OSDI) questionnaire. Patients with chronic pain syndromes such as fibromyalgia, irritable bowel syndrome and pelvic pain had higher symptoms scores in every one of the 12 items on the index, with six reaching statistical significance in the UK group and three in the Dutch group. These include light sensitivity, blurred vision and discomfort in windy conditions. However, a comprehensive evaluation of clinical signs in patients with and without chronic pains syndromes found no significant difference in factors such as tear osmolarity, tear break-up time, or Schirmer’s tests. Jelle Vehof “These findings suggest a role for central sensitivity for neuropathic pain in at least part of the dry eye population. This could help explain the poor correlation between symptoms and signs at the ocular surface. This could also help us with management of patients with dry eye disease,” said Dr Vehof.

PAIN SENSITIVITY In a previous related study (JAMA Ophthalmol. 2013;131(10):13041308), Dr Vehof and colleagues looked at the relationship between dry eye disease and pain sensitivity. That study was based on the TwinsUK study, a population-based cross-sectional study of 1,635 female twin volunteers, aged 20 to 83 years. In that study, 27 per cent of patients met the criteria for dry eye disease. A subset of women completed the OSDI questionnaire. The researchers used quantitative sensory testing using heat stimulus on the patients’ forearms to assess pain sensitivity, expressed in terms of heat pain threshold and pain tolerance . The testing showed that patients with dry eye disease had a significantly lower heat pain threshold and pain tolerance. This indicates that the patients with dry eye disease had greater sensitivity to pain than those without dry eye symptoms. These findings add another piece to the puzzle that is dry eye disease. Previous reports show associations of dry eye disease with the severity of tear insufficiency, cell damage, and psychological factors. “Given the generally poor relationship between symptoms and signs in DED, it would be useful to examine whether any particular clinical findings in DED populations (such as corneal staining, reduced tear break-up time, or reduced Schirmer values) relate to pain sensitivity and pain symptoms,” the researchers note. Jelle Vehof: j.vehof@umcg.nl EUROTIMES | OCTOBER 2015

CORNEA

OMEGA FATTY ACIDS Oral supplementation improves dry eye symptoms in moderate disease. Sean Henahan reports

aily oral supplementation with omega-3 fatty acids appears to provide significant symptomatic benefit in the treatment of moderate dry eye disease, suggest the findings of a randomised, placebo-controlled clinical study presented at the 2015 American Society of Cataract and Refractive Surgery Symposium in San Diego, USA. The trial enrolled 60 patients with untreated moderate dry eye disease. The Meibomian Gland Disease Workshop standard for moderate disease was used, i.e an oil quality greater than eight but less than 13, expressibility score of two, with moderate lid changes, plugging, and vascularity. Participants were randomised to 1.2gm per day of omega fatty acid supplement or 400mg of vitamin E per day over a period of three months. The fish oil capsules combined eicosapentaenoic acid and docosahexaenoic acid. All patients were asked to use warm compresses and were given artificial tears. At the end of the 12-week study, statistically significant improvement in all measures, except Schirmer scores, were seen in both groups. The subjective and objective improvements were statistically significantly greater in patients receiving omega fatty acid capsules, reports Arun K Jain MD, Professor, Cornea, Cataract and Refractive Surgery, Advanced Eye Centre, Post-Graduate Institute of Medical Education and Research, Chandigarh, India.

OBJECTIVE IMPROVEMENT At the 12-week mark, tear break-up time had increased 105 per cent in the omega-3 group, compared with a 51 per cent improvement in the placebo group. Ocular Surface Disease Index scores improved 67 per cent among omega-3 recipients, compared with 27 per cent among those receiving vitamin E. Meibum quality increased 50 per cent among those receiving the fish oil supplements, versus 12 per cent for those receiving placebo. All of these differences were highly statistically significant. “The study showed that daily oral intake of omega fatty acid supplements produced subjective improvement in ocular surface disease indices, and objective improvement in tear break-up time, and Meibomian gland expressibility and meibum quality,” he said. The study results subsequently appeared in the journal Cornea (Malhotra et al, 2015 Jun;34(6):637-43). In addition to the findings reported by Dr Jain, that publication added additional information about the effect of omega-3 supplementation on contrast sensitivity. The researchers conducted contrast sensitivity testing at three, six, 12 and 18 cycles per degree (cpd) at baseline and at 12 weeks. They report that at the end of 12 weeks, significant improvements in contrast sensitivity were measured in omega-3 recipients in seven of eight testing conditions, both photopic and mesopic. However, among patients receiving placebo, significant improvements were noted in only three of the eight testing conditions.

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Arun K Jain: aronkjain@yahoo.com EUROTIMES | OCTOBER 2015

CORNEA

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DRY EYE TREATMENT Novel agent appears safe in longterm trial. Sean Henahan reports

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EUROTIMES | OCTOBER 2015

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ong-term treatment of dry eye disease with the novel investigative agent lifitegrast (Shire) appears safe, although it does appear to produce a relatively high rate of adverse events, suggest the results of a oneyear prospective, randomised, placebocontrolled study conducted in the USA. Eric Donnenfeld MD, New York University, presented the results of the SONATA study during the World Cornea Congress VII in San Diego, USA. The SONATA trial enrolled 331 patients, all with Schirmer’s test ranging from 1.0 to 10mm without anaesthesia, and corneal staining scores above two. The patients were randomised two-to-one to receive either lifitegrast 5.0 per cent ophthalmic solution b.i.d. or placebo for one year. Some 53 per cent of patients on active treatment had treatment-emergent adverse events at some point during the study, versus 34 per cent in the placebo group. The most common complaints were irritation at the instillation site (burning etc), seen in 15 per cent, and transient blurred vision, seen in 13 per cent. “Drilling down, looking at the more significant trend of treatment-emergent adverse events leading to discontinuation, 18 patients (8.2 per cent) discontinued lifitegrast. The most common reasons were instillation site reaction or transient blurred vision, with increased lacrimation and reduced visual acuity. But only two patients, 0.9 per cent, discontinued treatment because of burning, actually less than in the control group,” reported Dr Donnenfeld. As for non-ocular adverse events leading to discontinuation, 1.8 per cent stopped treatment because of dysgeusia, a distortion of the sense of taste. There was no indication of systemic toxicity, due to local or systemic immunosuppression. The SONATA trial, a US FDA registration study, also had secondary exploratory objectives. Among these, the study found no significant changes in visual acuity, slit lamp microscopy, dilated fundoscopy, or intraocular pressure (IOP) associated with active treatment. There was also no worsening of corneal fluorescein staining related to the eye drop, and no evidence of accumulation of lifitigrast in plasma, over time. “The percentage of treatment-associated adverse events was higher in the lifitigrast treatment group than in the placebo group, but most notably, there were no serious adverse ocular events. Discontinuation due to adverse events was infrequent. Lifitegrast ophthalmic solution 5.0 per cent b.i.d. appears to be safe and well tolerated with no unexpected adverse events. These results support the safety profile seen in the earlier OPUS 1 and OPUS 2 trials,” Dr Donnenfeld told the session. Lifitegrast is a first-in-class small-molecule integrin inhibitor. It binds to the integrin LFA-1 (lymphocyte function-associated antigen-1), a cell surface protein found on leukocytes, and blocks the interaction of LFA-1 with its cognate ligand ICAM-1 (intercellular adhesion molecule-1). Blocking ICAM-1 is believed to inhibit T-cell activation at the ocular surface. Eric Donnenfeld: ericdonnenfeld@gmail.com

8/31/15 11:33 AM

CONGRESS REPORTS

XXXIII Congress of the ESCRS 5–9 September 2015

Roberto Bellucci, president of the ESCRS (left), with Richard Packard, who delivered the Binkhorst Medal Lecture

Sidath Liyanage, winner of the John Henahan Prize

ESCRS PROVIDING HIGH-QUALITY, EXPERT-LED EDUCATION FOR OPHTHALMOLOGISTS

ducation and clinical research will continue to be at the heart of the ESCRS, president Roberto Bellucci told delegates at the Opening Ceremony of the XXXIII Congress of the ESCRS in Barcelona, Spain. The Congress was attended by more than 8,500 delegates. “Education and clinical research are the two pillars of the ESCRS. As a dynamic, forward-thinking and well-resourced society, I believe that in these times of information overload the ESCRS stands out as a leader in the provision of high-quality, expert-led education for ophthalmologists of all levels of experience,” he said. “The ESCRS is proud to offer a scientific arena to all of its members, delegates, supporters and the industry. Together we form a community in the interests of science and to the advantage of our patients,” he added. Dr Bellucci noted that the ESCRS already offers many educational opportunities to its members in the form of the annual congresses, the ESCRS On Demand online presentation library, and online courses through the iLearn e-learning platform.

New initiatives such as Video of the Month and the Eye Contact studio interviews also underscore the society’s desire to continue to provide the best in educational opportunities to its members. He also cited special measures for trainee ophthalmologists such as free membership of the society, bursaries to attend the annual congress, and an observership programme, which enables young ophthalmologists to gain valuable experience. The ESCRS would also continue its support for important research activities, said Dr Bellucci. “The ongoing funding of clinical research is a primary activity of the society and we hope to continue this commitment with the funding of further projects by the end of this year,” he said.

MEDAL AND AWARDS This year’s Binkhorst Medal Lecture on the topic of “The Evolution of the Capsulotomy: From Crude Forceps to Precision Laser” was delivered by Dr Richard Packard from the UK. The overall winner of this year’s video competition was Jiri Cendelin, Czech Republic, for “Fetal eye vascular development as an explanation of

different surgical findings in eyes with persistent fetal vasculature (PFV)”. First place in the refractive category of the Poster Prizes went to Yu Chi Liu, Singapore, for “Corneal wound healing and inflammatory responses after small incision lenticule extraction: comparison of the effects of different refractive corrections and surgical experiences”. Francisco Alba-Bueno, Spain, won first place in the cataract category for “Halos after diffractive bifocal and trifocal intraocular lens implantation: objective and subjective evaluation”. The winner of the John Henahan Prize for Young Ophthalmologists writing competition was Sidath Liyanage, who is currently nearing the end of his registrar training at Moorfields Eye Hospital, London, UK. His winning entry was on the topic “How Do I Learn Surgery?”

Videos and presentations from the Congress are available on: www.escrs.conference2web.com EUROTIMES | OCTOBER 2015

CONGRESS REPORTS

6th EuCornea Congress

BARCELONA 4–5 September 2015

A MAJOR POINT OF REFERENCE FOR CORNEA SPECIALISTS

orneal experts and researchers from Europe and further afield met in Barcelona, Spain, for the 6th EuCornea Congress. The congress was attended by 784 delegates. At the Opening Ceremony, François Malecaze MD, president of EuCornea, welcomed delegates to Barcelona for the congress. He said Barcelona held special memories for EuCornea, as it was there that the organisation was launched in 2009 during the XXVII Congress of the ESCRS. Dr Malecaze was one of the founding members of the society along with Harminder Singh Dua, José Güell and Vincenzo Sarnicola. “Six years ago, we started from a blank canvas with a shared commitment and enthusiasm. Due to the hard work of all our members the society has gone from strength to strength and it is now firmly established as a major point of reference for cornea specialists,” he said.

World Congress of Paediatric Ophthalmology and Strabismus 4–6 September 2015

MORE THAN 1,200 DELEGATES ATTEND PAEDIATRIC CONGRESS

Helen Mintz-Hittner, who delivered the Kanski Medal Lecture, with Ken Nischal (left) and David Granet of WSPOS

EUROTIMES | OCTOBER 2015

John Dart (left) receiving his medal from EuCornea president François Malecaze after the EuCornea Medal Lecture

The EuCornea Medal Lecture was presented by Prof John Dart, UK. Cicatrising conjunctivitis remains one of the most challenging causes of ocular surface disease today, and early diagnosis and treatment are necessary to prevent vision loss or blindness, said Prof Dart. In a broad overview of the incidence, clinical features and treatment options for the disease, Prof Dart said that cicatrising conjunctivitis remains a major therapeutic challenge. Although early diagnosis and treatment are important, most individual clinicians see few cases and therefore may fail to recognise the clinical features in the early stages of disease which may result in delayed or suboptimal treatment. EuCornea also took another major step forward in its development with the news that a new online journal dedicated to the field of corneal research is set to be launched. “I am excited to be able to announce that we have received approval for the launch of our own journal very soon, which will be called JCornea and will serve a real need in the ophthalmological community,” said Prof Dua. Prof Dua added that an editorial board has now been constituted and that the journal will be fully peerreviewed and will be open-access.

he increasingly global nature of ophthalmic expertise and the need for enhanced interaction and knowledgesharing were highlighted at the 3rd World Congress of Paediatric Ophthalmology and Strabismus (WCPOS) in Barcelona, Spain. Welcoming more than 1,200 delegates to Barcelona on behalf of the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) Executive Bureau, Richard Hertle MD, FAAO, FACS, FAAP, USA, said that this year’s gathering of paediatric specialists at the event would help to advance the cause of paediatric eye care in all parts of the world. “This congress and its venue is like no other in that it allows those of us who care for children and their families to equally share our international and cultural perspectives, from clinical care and research to cuisine and entertainment,” he said. Dr Hertle said that the WSPOS scientific programme offered delegates a wide spectrum of topics and educational opportunities to enhance their daily clinical practice. “This programme is filled with timely and provocative information in the form of keynote lectures, skills transfer, instructional courses, wetlabs, electronic posters, video presentations and novel audience-directed sessions,” he added. Dr Hertle said WSPOS believes that expertise is a global phenomenon, and the society would continue to promote the concept of international collaboration as a cornerstone of its future development. Among the highlights of this year’s WCPOS was the Kanski Medal Lecture, for those whose work has improved the lives of children with ocular disease. Helen Mintz-Hittner MD, USA, became the first Kanski medallist because of her work with antiVEGF agents in the prevention of retinopathy of prematurity. WCPOS also featured the Oscars for its video competition and a non-accidental injury Mock Trial, where two paediatric ophthalmologists took opposing sides in the case and discussed it as if they were actually in a court of law.

CONGRESS REPORTS

Nice 15th EURETINA Congress

17–20 September 2015

Francesco Bandello, president of EURETINA, speaking at the Opening Ceremony

NEW ELEMENTS GIVE EURETINA CUTTING EDGE

rancesco Bandello MD, president of EURETINA, said the society was delighted and proud to have almost 5,000 delegates present at its 15th Congress in Nice, France. “Such a volume of attendance is indeed a most reassuring sign that the EURETINA congress is going from strength to strength both in Europe and internationally,” he said. “The programme this year is more extensive than ever and, while we have maintained many of the popular traditional features of the programme, we have also introduced new elements to keep it fresh and cutting-edge,” he told delegates at the Opening Ceremony. The EURETINA Lecture 2015 was delivered by Dr Alain Gaudric, Professor and Chairman of the Department of Ophthalmology, at the Lariboisiere Hospital, University of Paris 7 Denis Diderot, France. Dr Gaudric said optical coherence tomography (OCT) has definitively changed the diagnosis paradigm of cystoid macular oedema (CME). Bill Aylward FRCS, FRCOphth delivered the Kreissig Lecture on “A logical approach to retinal detachment”. Dr Aylward, UK, discussed topics as diverse as mathematics, statistical theory, medicine and psychology to explain why it is so difficult to resolve some of the more intractable questions surrounding retinal detachment. A new approach to intraocular illumination for vitreoretinal surgery using light-emitting diode (LED) technology won the EURETINA Science & Medicine Innovation Award 2015. “Using LEDs as a light source in vitreoretinal surgery offers a lot of potential advantages,” said Dr Christian Lingenfelder of Alamedics GmbH & Co KG, Dornstadt, Germany, the team leader of the project. First prize in the EURETINA Video Competition Awards was awarded to Ahmed Elshewy of Egypt for “Surgical management of a case of a 360-degree giant retinal break”. Second prize was awarded to Tushar K Sinha of India, and third prize to Maria Isabel Relimpio Lopez of Spain.

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EUROTIMES | OCTOBER 2015

CONGRESS REPORTS

PICTURE GALLERY

EUROTIMES | OCTOBER 2015

GLAUCOMA

NARROWER STENTS Minimally-invasive approach could revolutionise filtration surgery. Howard Larkin reports

Tired of seeing those unhappy patients?

ew narrower stents may make filtration surgery using subconjunctival blebs less invasive, and less prone to hypotony and other complications, while matching the unparalleled effectiveness of trabeculectomy in lowering intraocular pressure (IOP), Thomas W Samuelson MD, Minneapolis, told the ASCRS Glaucoma Day 2015 in San Diego, USA. With a 210-micron outer diameter and a 45-micron lumen, three Xen (AqueSys) gel implants can fit inside the lumen of a Baerveldt tube, Dr Samuelson noted. The Xen is designed for ab interno delivery through an injector inserted through the cornea into the angle and on into the subconjunctival space, eliminating conjunctival dissection and its risks. An antifibrotic is injected to prevent scarring. The Xenâ&#x20AC;&#x2122;s 45-micron lumen and 6.0mm length were calculated to provide enough flow to substantially lower IOP and enough resistance to minimise hypotony risk, Dr Samuelson said. Twelvemonth follow-up data from 69 patients presented at ESCRS 2014 and American Glaucoma Society 2015 showed a mean IOP reduction of 44 per cent to 12.8mmHg from pre-op best medicated values. Six patients, or 8.6 per cent, experienced hypotony, or 6.0mmHg or less Thomas W Samuelson on day one, with one requiring anterior chamber re-inflation and none persisting past one month. With a 350-micron outer diameter, 70-micron lumen and 8.5mm length, the InnFocus MicroShunt is about one-third the inner diameter of conventional tubes, but is implanted similarly, requiring conjunctival dissection. The ab externo approach means more tissue disruption, but is more familiar to surgeons, Dr Samuelson said.

OUTFLOW MECHANISM Early data from 22 patients followed for three years show mean IOP of 10.9mmHg, with a mean 0.5 medications and 73 per cent on no medication, down from 24.0mmHg on 2.8 medications before surgery with none on no medication. Ten per cent experienced hypotony after day one with all resolving spontaneously. Both the Xen and MicroShunt bypass the entire physiological outflow mechanism, making them suitable for many types of glaucoma, Dr Samuelson said. Both also deliver aqueous well posterior to the limbus, promoting better bleb morphology and function. These and other devices are making transscleral filtration surgery more standardised and less invasive, eliminating the need for sutures to control IOP, Dr Samuelson said. He reported that the early non-published results are very promising. But widespread adoption will likely depend on their long-term safety and effectiveness mitigating hypotony, and the success of competing canal-based glaucoma procedure. Thomas W Samuelson: twsamuelson@mneye.com EUROTIMES | OCTOBER 2015

GLAUCOMA

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CATARACT SURGERY Useful for closed-angle, but benefits limited for open-angle glaucoma cases. Howard Larkin reports

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rowing evidence suggests that cataract surgery alone is sufficient to control closed-angle glaucoma in many patients. However, for open-angle cases, cataract surgery often does not lower intraocular pressure (IOP) enough to make it a viable standalone surgical treatment, Norman A Zabriskie MD of the Moran Eye Centre, University of Utah, told the ASCRS Glaucoma Day 2015 in San Diego, USA. The strongest evidence for cataract surgery alone as a primary surgical treatment for closed-angle glaucoma comes from three randomised controlled studies conducted by Clement CY Tham FRCS and colleagues in Hong Kong, said Dr Zabriskie. They compared phacoemulsification alone with laser peripheral iridotomy for medically aborted acute primary angle-closure glaucoma; and compared phaco alone with phaco plus trabeculectomy in patients with medicallycontrolled and uncontrolled chronic closed-angle disease. Acute angle-closure patients receiving early phaco had less late IOP rise, lower mean IOP, higher Shaffer angle grading, and required fewer medications to control IOP than those receiving iridotomy (Ophthalmology. 2008 Jul;115(7):1134-40). For medically-controlled and uncontrolled chronic closed-angle glaucoma, phaco alone produced similar or slightly higher IOP and required about one more medication to control IOP, but had fewer complications and no difference in disease progression than phacotrabeculectomy Norman A Zabriskie (Ophthalmology. 2008 Dec;115(12):2167-2173; Ophthalmology. 2009 Apr;116(4):725-31). “There is compelling evidence from randomised clinical trials to support cataract surgery alone as an important treatment modality in patients with acute and chronic angleclosure glaucoma,” Dr Zabriskie said. Phaco alone is especially useful in cases with early to moderate disease, he added.

OPEN ANGLE, OPEN QUESTION The evidence for phaco alone in managing open-angle glaucoma is less clear, Dr Zabriskie said. One early retrospective study showed phaco’s IOP-lowering effect increased with higher preoperative pressures, reaching 35 per cent IOP reduction in patients with 23 to 29mmHg pre-op IOP, but the studies’ failure to confirm angle status pre-op raises doubts (Poley et al. J Cataract Refract Surg. 2009 Nov;35(11):1946-55). Other studies, including patients who had cataract surgery in the control arm of the Ocular Hypertension Treatment Study, show IOP decreases in the 2.0 to 4.0mmHg range. So cataract surgery alone is not a solution in cases of openangle glaucoma needing IOP-lowering of 20 per cent or more, Dr Zabriskie said. In these cases he usually considers adding a pressure-lowering procedure. However, phaco alone may be useful for open-angle glaucoma patients with well-controlled IOP requesting cataract surgery, and in patients in whom a modest reduction in IOP is desirable. Norman A Zabriskie: norm.zabriskie@hsc.utah.edu

EUROTIMES | OCTOBER 2015

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GLAUCOMA

FIXED COMBINATIONS The benefits of fixed-combination treatments in glaucoma. Dermot McGrath reports

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ixed-combination drugs provide an enhanced quality of life for glaucoma patients by offering simplified daily administration and better adherence, according to Gábor Holló MD, PhD, DSc. “Fixed-combination intraocular pressure (IOP)-lowering drops, combining two or more hypotensive agents in a single bottle, provide several advantages over unfixed combinations in clinical practice,” Prof Holló told delegates attending the 2015 Congress of the European Society of Ophthalmology (SOE) in Vienna, Austria. “The benefits are much greater than the limitations in terms of convenience, adherence and tolerability, although personalised decision-making is essential when introduction of a fixed combination into the treatment regimen is made,” he said. Prof Holló, Professor and Head of the Glaucoma and Perimetry Unit in the Department of Ophthalmology at Semmelweis University in Budapest, Hungary, noted that the European Glaucoma Society (EGS) guidelines on the treatment of primary open-angle glaucoma recommend an Gábor Holló individualised approach to management, setting a target IOP on the basis of risk factors such as family history, IOP at presentation, visual field defects or the presence of pseudoexfoliation, with the goal of preventing significant visual disability in the patient’s lifetime.

EGS GUIDELINES For patients with advanced glaucoma, a high risk of progression and a reasonable life expectancy, early and aggressive initial IOP-lowering may offer the best chance of preventing visual impairment, said Prof Holló. Although the EGS guidelines recommend that initial therapy for glaucoma is usually with a single agent, many patients may require additional agents to reach their target IOP and this is where a fixed-combination medication needs to be considered by the treating clinician, added Prof Holló. By definition, fixed-combination therapies generally offer equivalent efficacy to concomitant use of the individual components, with equivalent or superior tolerability, he said. A broad spectrum of anti-glaucoma drugs is currently available for the treatment of open-angle glaucoma. Typical fixed combinations usually consist of a beta blocker combined with either a prostaglandin analogue, an alpha-adrenergic agonist or a carbonic anhydrase inhibitor. One of the main advantages of a fixed-combination regimen is that it avoids the poor adherence associated with complex therapeutic regimens, said Prof Holló. Using one drop daily from a single bottle also means fewer instillations and reduced opportunity for patient error. “Studies have shown that 75 per cent of patients do not respect the minimum separation time in unfixed combination treatments. Using fixed combinations avoids this problem and is much more convenient for the patient,” he said. Gábor Holló: hollo.gabor@med.semmelweis-univ.hu

EUROTIMES | OCTOBER 2015

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RETINA

AMD DOSING Personalised regimen may reduce the burden of AMD treatment. Dermot McGrath reports

n individually planned treatment regimen for neovascular agerelated macular degeneration (nAMD) may offer the potential to significantly reduce the clinical burden of AMD treatment while obtaining good functional results, according to Irmela Mantel MD at the University Eye Hospital Jules Gonin, Lausanne, Switzerland. “The observe-and-plan regimen significantly improved visual acuity with fewer clinical visits compared to other widely used regimens such as PRN and treat-andextend,” Dr Mantel told EuroTimes. “This approach using a planned treatment regimen in an individualised fashion, based on the measurement of an individual’s first

disease recurrence interval, reduces the number of clinic visits and injections while still maintaining visual acuity improvements throughout the follow-up period,” she said. Dr Mantel said that the idea for the observe-and-plan regimen was inspired by first-hand experience of treating nAMD patients. “It became obvious that this pathology with high incidence needed efficient chronic care management because most patients required ongoing treatment with anti-VEGF injections and new patients were continuously added,” she said. The only regimens available at that time were fixed monthly injections for every patient or PRN retreatment based on monthly visits, said Dr Mantel. While PRN allowed for reducing the number of injections, the burden for caring institutions, with mandatory monthly visits, remained high. Fixed monthly re-injections, while offering the possibility of skipping visits, was unacceptable due to overtreatment of most patients and high medical cost, she added. Dr Mantel and co-workers speculated that it might be possible to combine the advantages of PRN (minimum of injections) with the advantages of a fixed regimen (skipping time-consuming visits) if they could determine the optimal individual treatment interval and if this interval was relatively stable over time. An initial study of 39 patients confirmed the existence of a regular, predictable individual pattern in the need for retreatment with relatively small fluctuations over the follow-up period. Based on these results, the observe-and-plan regimen was developed in

order to take advantage of the predictability of individual need for treatment. After three loading doses of ranibizumab, the disease recurrence interval was determined in monthly observation visits. Retreatment was applied in a series of three injections with individually fixed intervals (two weeks shorter than the recurrence interval), combined with periodic adjustment of the intervals. The allowed injection intervals in treatment plans ranged from one to three months. If there was no recurrence at three months, the patient could change to monitoring alone. The benefit became rapidly obvious to clinicians and patients, said Dr Mantel, with a mean of less than four monitoring visits (compared to 12 with a PRN regimen or approximately eight with treat-and-extend) and a mean number of injections just below eight during the first year. “It became easy to cope with a large number of patients, most importantly without compromising the visual results. Forward planning was facilitated, and resources needed were reduced. Those patients, who were included for their second eye after having experienced the PRN regimen with their first eye, were most satisfied with the reduced number of visits. Some of them needed an injection only every three months and a visit every six months. The reduced number of appointments makes a huge difference for our aged patients,” she said. Dr Mantel and colleagues reported their findings in BJO (2014;98:1192–1196), and Eye (2015;29:450-451). Irmela Mantel: irmela.mantel@fa2.ch

Courtesy of Irmela Mantel MD

Figure 1: Treatment algorithm of this observe-and-plan regimen with ranibizumab for neovascular age-related macular degeneration (nAMD). Every patient received the initial loading dose of three ranibizumab injections at one month intervals (abbreviated as 3 x 1). Subsequently, findings on optical coherence tomography (OCT) defined the pathway in the algorithm

EUROTIMES | OCTOBER 2015

Figure 2: Comparison of injection and visit numbers for different retreatment regimens

RETINA

CRUCIAL EYE PROTECTION Woman blinded in one eye during laser epilation procedure. Roibeard O’hEineachain reports

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recently published case study involving a woman blinded in one eye by a misdirected laser beam while undergoing laser epilation, highlights the need for eye protection at all times for both client and practitioner. “Our experience shows that laser epilation carries the risk of severe damage to the eye if any precaution is neglected. A rushed and reckless procedure performed by a practitioner who has not received proper training may easily cause a vision-threatening accident. Therefore, ensuring adequate safety training for all practitioners is a prerequisite, and laws requiring this will help,” Georgios A Kontadakis MD, MSc, Ophthalmiatreion Eye Hospital of Athens, Greece, a co-author of the study, told EuroTimes. The study, published online in the January 2015 issue of JAMA Ophthalmology, involved a patient in her early 30s in good health with no history of ocular morbidity. At the time of the incident, she was undergoing laser epilation of the hair on her forearms with an alexandrite (755nm) laser and was without eye protection. During the procedure, the laser beam went through the pupil of her right eye and she immediately felt severe ocular pain and had a severe loss of visual acuity. She presented at the Ophthalmiatreion Eye Hospital in Athens four days after receiving the laser injury, at which time her Georgios A Kontadakis uncorrected visual acuity was 20/200 in her right eye and 20/20 in her left eye. Fundus examination of the right eye revealed severe retinal pigment abnormalities in her fovea. Five days later, the uncorrected visual acuity in her right eye had decreased further to counting fingers. Moreover, macular optical coherence tomography (OCT) revealed signs of choroidal neovascularisation (CNV) and the presence of intraretinal fluid, which was confirmed by fluorescein angiography. Treatment with intravitreous injection of an anti-vascular endothelial growth factor (anti-VEGF) brought about a complete regression of intraretinal fluid within one month and there was no relapse of the fluid during the following five months. However, the patient’s uncorrected visual acuity did not improve due to macular scar formation. The study’s authors noted in their discussion of the case that the wavelengths used for laser hair removal, between 700nm and 1,000nm are absorbed by the hair follicle melanin and destroy the follicle by thermal injury. The high melanin concentration in the retinal pigment epithelium (RPE) make it vulnerable to damage by laser beams with those wavelengths. In this case, the alexandrite laser used had a wavelength of 755nm and a fluence usually up to 40 J/cm2. Therefore, before she was even able to blink, the damage was done. The authors noted that the thermal injury caused by melanin absorption of the laser energy can result in the rupture of the Bruch’s membrane, development of CNV and severe vision deterioration. “Close follow-up of the patient is essential the first weeks after the accident,” Dr Kontadakis said.

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Georgios A Kontadakis: g.kontadakis@med.uoc.gr EUROTIMES | OCTOBER 2015

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GLOBAL OPHTHALMOLOGY

GROWING BURDEN Dramatic rise in myopia prevalence provides stimulus for epidemiologic and clinical research. Cheryl Guttman Krader reports

dramatic rise in myopia prevalence in countries throughout the world is driving a need to better understand the public health consequences of this trend and research on methods for controlling myopia. Kathryn Rose PhD and Brien A Holden PhD, DSc discussed these topics at the 2015 annual meeting of the Association for Research in Vision and Ophthalmology in Denver, USA. According to the findings of a recently completed analysis of temporal trends, Dr Holden and colleagues project that by 2050, half of the world’s population will be myopic. “More importantly, however, there will be an increased prevalence of high myopia (5.0D and above). We predict that in 2050, 10 per cent of the world’s population, or about one billion people, will be high myopes,” said Dr Holden, Chief Executive Officer of the Brien Holden Vision Institute, Sydney, Australia. The significance of the latter estimate has to do in large part with the association between high myopia and increased risk of blinding eye disease. Although there is a need for better information to quantify how much visual impairment and blindness is attributable to high myopia, available data indicate that myopic macular degeneration is the leading cause of blindness in Japan and the fifth most common cause in the USA, said Dr Holden. It was also found to be the most important cause of impaired vision among persons aged less than 75 years in the Rotterdam Eye Study. Dr Rose, Head of Discipline (Orthoptics), University of Technology Sydney, Australia, pointed out, however, that even lower levels of myopia (i.e less than 3D) are associated with an increased likelihood of glaucoma, cataract and, most worrisome, retinal detachment. In addition, she cited a study that reported retinal changes were already present among children and teens with -8 to -10D of myopia. (Analysis of High Myopic Maculopathy Based on Fundus Photos: Zhongshan Ophthalmic Center-Brien Holden Vision Institute High Myopia Registry; Ou X, Xinxing G, Mingguang H) Dr Rose also noted that there is a need for better information on the costs associated with undercorrection and uncorrection of myopia. Results of a recent study by Congdon and colleagues showing that providing free glasses improved academic performance of primary school age children in rural China indicate that such cost analyses may need to factor in the impact on educational outcomes, she said.

Discussing methods for controlling myopia, Dr Holden emphasised the need for both halting the use of techniques that seem to worsen myopia progression and implementing effective interventions. Modalities to avoid include undercorrection and the use of conventional single-vision spectacles or contact lenses. Methods that can reduce the incidence of high myopia include increasing outdoor activity, treatment with atropine or 7-methylxanthine, orthokeratology, and novel myopia control spectacles and contact lenses that shift the peripheral image in front of the retina or that shift parts of the retinal image forward. Dr Holden postulated, however, that the pharmacological methods in contrast to the optical-based methods are likely to be associated with a rebound effect. Dr Rose observed that school-based programmes appear to have the greatest potential for success in getting children to spend more time outdoors. Now, however, the obstacle remains to gain support from policymakers to implement that strategy. Ideally, the future will bring ways to identify at a young age those children who are fast-growing myopes and at greatest risk for developing high myopia. Still, it remains to be seen if it is possible to control the progression of a child destined for high myopia and its pathological consequences, Dr Holden said. Kathryn Rose: kathryn.rose@uts.edu.au EuroTimes wishes to extend our sincere condolences to the family, friends and colleagues of Dr Brien A Holden, who has sadly passed away since speaking at this year’s ARVO annual meeting. For tributes to Dr Holden’s life and work, visit: www.brienholdenvision.org

ic iatr s d e u f Pa rabism o t y dS iet Soc ogy an d l l r Wo thalmo h

EARLY INTERVENTION Since younger age of onset of myopia is associated with greater annual progression and an increased risk of developing high myopia, there is great interest in interventions that delay the development of myopia and/ or slow its progression. “If we can start controlling myopia progression in any child who is a -1.0D myope and reduce its rate of increase by 50 per cent, we could eliminate 89 per cent of cases of high myopia,” said Dr Holden.

...there is a need for better information on the costs associated with undercorrection and uncorrection of myopia

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Kathryn Rose PhD EUROTIMES | OCTOBER 2015

tried_october.pdf

01/10/15

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EYE CONTACT

NEW SERIES OF INTERVIEWS As techniques and treatments change, they are debated and discussed as a consensus is created

ye Contact, the video news programme on issues and controversies in ophthalmology sponsored by EuroTimes, was launched last year at the XXXII Congress of the ESCRS in London, UK. Prior to the launch of Eye Contact, EuroTimes had hosted a series of topical and informative podcasts called Eye Chat for ophthalmologists, presented by Dr Oliver Findl. Eye Contact was seen as a natural successor for these podcasts and it was decided that the scope of the interviews would be enhanced by videoing the interviews in a live studio setting at major European ophthalmological meetings.

David Granet of WSPOS (left) is interviewed by EuroTimes editor Sean Henahan in the Eye Contact studio

To date more than 10 interviews have been broadcast and posted on the EuroTimes website, www.eurotimes.org. The first set of interviews featured discussions with leading researchers in all fields of ophthalmology including Dr Findl of Vienna, Austria, Dr Peter Barry of Dublin, Ireland, Dr Paul Rosen from Oxford, UK, and Dr David Granet from San Diego, USA. Due to the popularity of the new series, a second set of interviews has just been completed with leading opinionmakers who recently attended the XXXIII Congress of the ESCRS, the 6th EuCornea Congress and the 3rd World Congress of Paediatric Ophthalmology and Strabismus, all held in Barcelona, Spain. MY

CMY

HIGH-LEVEL DISCUSSIONS As techniques and treatments change, they are debated and discussed as a consensus is created on what is best for patients. However, it can take many months before new findings appear in the Journal of Cataract & Refractive Surgery and other ophthalmology journals. The high-level discussions that take place in an Eye Contact interview let all ophthalmologists, from trainee to department head, gain an early understanding of what changes are under way in clinical ophthalmology and what it means for daily practice. The programme does not limit itself only to clinical matters. There are also episodes on topics relating to practice management and education, and on the training of young ophthalmologists. The interviews are designed to fit into the busy clinicianâ&#x20AC;&#x2122;s schedule, with a typical running time of five to eight minutes. The Eye Contact videos can be accessed through any platform â&#x20AC;&#x201C; on PCs or laptops via the EuroTimes website at www.eurotimes.org/eyecontact, on YouTube, or on mobile phones via the EuroTimes app EUROTIMES | OCTOBER 2015

INNOVATION

Vision testing with the Peek system (left) Peek and research vision chart (below) © Peek

SMARTPHONE TESTING Clever eye exam kits may lighten load of ophthalmologists in remote areas. Roibeard O’hEineachain reports

he smartphonebased Portable Eye Examination Kit (Peek) can provide visual acuity measurements as accurate and repeatable as those obtained with Snellen or ETDRS logMAR charts, according to a new study published in JAMA Ophthalmology. “Vision testing is a crucial part of an ophthalmic examination and we demonstrated that it was possible to create a test that was independent of language and could be performed by non-eye care workers,” the study’s lead author Andrew Bastawrous BSc, MRCOphth, of the International Centre for Eye Health, London School of Hygiene and Tropical Medicine, UK, told EuroTimes in an interview.

FOLLOW-UP This study involved 300 adults aged 55 years and older who were part of the six-year follow-up of the Nakuru Eye Disease Cohort in Kenya. All patients underwent visual acuity testing in their homes – performed by healthcare workers with basic eye care training – using both the smartphone-based Portable Eye Examination Kit (Peek) acuity test and a reduced “tumbling E” Snellen chart (Sussex Vision). They also underwent the same testing at a local medical centre performed by the same healthcare worker, in addition to testing using retroilluminated ETDRS charts, performed EUROTIMES | OCTOBER 2015

by an ophthalmic clinical officer, which served as a reference standard. The study was published online in JAMA Ophthalmology, 2015 (DOI:10.1001/ jamaophthalmol.2015.1468). The investigators found that visual acuity measured with the smartphonebased acuity test differed by a mean of 0.07 logMAR from measurements with the ETDRS chart, and by a mean of 0.08 logMAR from measurements with the reduced Snellen chart, less than one line of difference. The Peek kit consists of an Android smartphone, a special lens attachment and a suite of diagnostic software. It is the result of a collaboration between the London School of Hygiene and Tropical Medicine, the University of Strathclyde and the NHS Glasgow Centre for Ophthalmic Research, UK. “Overall the package of diagnostics being developed by Peek will allow taskshifting, moving away from requiring scarce specialist doctors and nurses to leave the hospital and find cases in the community, and moving towards having minimally skilled non-ophthalmic workers providing reliable exams closer to the patient, without the need for the eye worker or patient to travel,” Dr Bastawrous said. He noted that he and his team are close to finalising for publication a study comparing image quality and interpretation of optic nerve photographs obtained with the Peek system to those obtained with a desktop camera, independently graded at Moorfields

Men using Peek

Eye Hospital. They have also recently completed a randomised controlled trial where teachers in Kenya tested the vision of 20,000 children using the Peek kit. Andrew Bastawrous: andrew.bastawrous@lshtm.ac.uk For further information visit: www.peekvision.org

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 234 ISSUE: 2

CROSS-HAIR SCAN OCT GIVES ACCURATE DETECTION Cross-hair scan spectral domain-optical coherence tomography (SD-OCT) appears to provide an accurate measurement of changes in retinal fluid volume in eyes of patients receiving intravitreal ranibizumab for exudative age-related macular degeneration (AMD), according to the results of a retrospective study. The study’s authors assessed visual acuity (VA) and the presence of retinal fluid using volume and cross-hair scan protocols in 31 treatmentnaive patients receiving three intravitreal ranibizumab injections at monthly intervals. VA improved and central retinal thickness decreased significantly during the loading phase. Retinal fluid persisted in two thirds of the patients, but visual improvement was independent of the presence of the residual fluid. The cross-hair scan detected fluid with an accuracy of 93 per cent and may be sufficient for daily practice, the authors concluded. A Ebneter et al, “The Presence of Intra- or Subretinal Fluid during the Loading Phase in the Treatment of Exudative Age-Related Macular Degeneration with Intravitreal Ranibizumab Assessed by Optical Coherence Tomography”, Ophthalmologica 2015; Volume 234 , Issue 2.

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IDEBENONE PROTECTS RPE CELLS Pre-treatment with the neuroprotective agent idebenone appears to improve the survival rate of cultured retinal pigment epithelium (RPE) cells when later challenged with exposure to hydrogen peroxide, according to a new study. The pre-treated cells in the study also had reduced levels of the proapoptotic factor BAX and increased levels of the antiapoptotic factor Bcl-2. Furthermore, the pre-treated cells had a significantly attenuated induction of senescence-associated β-galactosidase (SA-βGal) and intracellular reactive oxygen species. N Arend et al, “Idebenone Prevents Oxidative Stress, Cell Death and Senescence of Retinal Pigment Epithelium Cells by Stabilizing BAX/Bcl-2 Ratio”, Ophthalmologica 2015; Volume 234 , Issue 2.

25-GAUGE VITRECTOMY EFFECTIVE IN SELECT CASES In patients with retained lens fragments following cataract surgery, 25-gauge pars plana vitrectomy (PPV) appears to provide its best results in cases with a smaller amount of fragments and in those treated during the first postoperative week, the findings of a retrospective study indicate. The study involved 40 eyes of 40 patients with a mean age of 78 years and a mean preoperative best corrected visual acuity (BCVA) of 20/80. By the sixth postoperative month, their mean logMAR BCVA had improved to 20/32. Retinal detachment occurred in four patients (10 per cent), all in patients with more than half of the nucleus in the vitreous (p<0.002). A Scupola et al, “25-Gauge Pars Plana Vitrectomy for Retained Lens Fragments in Complicated Cataract Surgery”, Ophthalmologica 2015; Volume 234, Issue 2.

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INDUSTRY NEWS

GET TO THE SOURCE Become an ASCRS member to receive the latest clinical advances, research, and information on issues affecting your practice. INDUSTRY

NEWS

YEAR-ROUND EDUCATION Annual meetings, clinical reports, and the ASCRS MediaCenter (surgical videos, symposia, and paper sessions)

HIGH-TECH BUILDING Heidelberg Engineering is celebrating its 25th anniversary with a move to new a high-tech building, the SkyLabs tower. The brand new office and laboratory building is situated in the Bahnstadt area right next to Heidelberg’s railway station. The Bahnstadt is a new development built on the grounds of a former freight depot that combines living and cultural spaces with commercial buildings to the highest sustainability standards. “The proximity to scientific and research activities is vital for our company and Heidelberg is an ideal place in that sense,” said Christoph Schoess, Managing Director of Heidelberg Engineering. www.heidelbergengineering.com

COMMUNITY Daily online discussions in eyeCONNECTIONS

TOOLS Post-refractive IOL and Barrett Toric Calculators, Toric Results Analyzer, and more online tools

PUBLICATIONS Journal of Cataract & Refractive Surgery, Ophthalmology Business magazine, and EyeWorld News magazine OB Cover_July 2015-DL.qxp_Layout 1 7/15/15 10:00 AM Page 1

Tribute to Robert Sinskey, MD — P. 16 The latest on mydriatic agents — P. 26 Pearls for MIGS success — P. 42

KEY FUNCTIONALITIES IN AN OPHTHALMOLOGY EHR P. 8

A GUIDE TO INVISIBLE LEADERSHIP P. 14

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Femto cataract clinical update Evolution of laser cataract surgery — P. 44 Femtosecond cataract laser upgrades — P. 46 Experiences around the world — P. 48 Forgoing the femto laser — P. 50 Embracing the technology — P. 52

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APPLANATION PRISM Keeler has introduced a new disposable applanation prism, Tonomate, to facilitate safe and fast Goldmann applanation tonometry. “Tonomate prisms are manufactured to the high quality associated with the Keeler brand and designed to fit most applanation tonometer prism holders,” said a Keeler spokeswoman. “Each prism is individually packed in sterile packaging and can be fitted easily without requiring direct contact. The prism is discarded after use to streamline eye examinations and prevent the cross-infection of diseases between patients that can be transmitted via the tear film,” said the spokeswoman. www.keeler.co.uk

INDUSTRY NEWS

NEWS IN BRIEF IOP REDUCTION Glaukos has announced that Health Canada has approved its iStent inject® Trabecular Micro-Bypass Stent for the reduction of intraocular pressure (IOP) in patients diagnosed with primary open-angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma. “The Health Canada approval of the iStent inject is another important advancement in the MIGS category,” said Ike K Ahmed MD, FRCSC, Trillium Health Partners and University of Toronto, Canada. “MIGS devices, used early in the glaucoma treatment algorithm, can provide an effective alternative to additional topical medications that can create adherence challenges, side-effects and quality-of-life issues. The availability of iStent inject, with expanded indications for use as a stand-alone procedure or in conjunction with cataract surgery, means more patients can now benefit from this exciting new class of glaucoma interventions, ” he added. www.glaukos.com

MERGER PLAN Sun Pharmaceutical Industries Ltd has announced that one of its subsidiaries has entered into an agreement and plan of merger with InSite Vision, under which a Sun Pharma subsidiary has offered to acquire InSite Vision. InSite Vision focuses on developing new specialty ophthalmic products, including three late-stage programmes. “Sun Pharma is in the process of establishing a branded ophthalmic business in the USA,” said a company spokeswoman. “This proposed acquisition of InSite Vision, coupled with the recent in-licencing of Xelpros™ (Latanoprost BAK-free eye drops) in June 2015, are steps in this direction. These deals give Sun Pharma access to four late-stage branded ophthalmic products in the USA,” she said. www.sunpharma.com

FDA APPROVES ZEISS OCT ANGIOGRAPHY Carl Zeiss Meditec’s new AngioPlex application is the first optical coherence tomography (OCT) angiography system to win 510(k) clearance from the US FDA, Zeiss CEO Dr Ludwin Monz has announced. It is one of seven new products introduced by the company at the XXXIII Congress of the ESCRS. AngioPlex enables 3D imaging of blood flow in real-time, revealing details of vasculature and lesions in the retina and choroid underlying leakage images that appear with fluorescein angiography (FA). This previously unavailable information will undoubtedly generate new insights into retinal disease, potentially leading to new and better treatments, Dr Monz said. OCT is also non-invasive and requires no contrast agent, eliminating the side-effect risk, expense, difficulty and discomfort of dye injections required for FA, Dr Monz pointed out. www.zeiss.com

EUROTIMES | OCTOBER 2015

ESASO

SEE YOU IN BARCELONA! 15th ESASO Retina Academy to address current challenges

www.esaso.org

EUROTIMES | OCTOBER 2015

he ESASO Retina Academy is a premier CME-accredited, educational meeting that addresses current challenges and the latest innovations in the management of retinal disorders. This year the congress is being held in Barcelona, the beautiful Catalan capital in Spain. The compelling scientific programme includes an examination of whether the results obtained in clinical trials are reproducible in everyday clinical practice, particular challenges when performing cataract surgery in patients with macular diseases, in addition to novel imaging techniques and the application of gene and stem cell therapies in ocular conditions. An expert faculty comprised of internationally renowned retinal specialists from across the globe will present a series of plenary lectures and challenging clinical cases from their own clinical practice, to inform best practice in maximising outcomes for patients; while the optional Master Class programme provides the opportunity for delegates to have a more detailed discussion with the expert panel in a more informal environment, on a topic of particular personal interest. Highlights of this year’s meeting include the opportunity to observe live surgeries, streamed in real-time, with commentary from the surgeons and an expert panel, as well as a chance to influence the agenda by voting on a number of controversial topics to be debated during one of two ESASO-Style Roundtable discussions. For next year, the Scientific Committee has decided to switch the date of the congress to spring. For the first time, the 16th ESASO Retina Academy will be held from 23-25 June 2016. The venue, the Estoril Congress Centre, is conveniently located and easily accessible from Lisbon, Portugal. The scientific programme will be built on the most current evidence from global experts, focussing on topics from all areas of retina. Leaders will present diseases with existing therapies such as wet AMD, PM, DME, RVO, as well as diseases with ongoing extensive research such as GA, dry AMD. Prof Francesco Bandello, President of the ESASO Retina Academy and Chair of the Department of Ophthalmology, University Vita-Salute, San Raffaele Scientific Institute in Milan, Italy, summarises: “There will be a variety of programme styles based on critical evidence interpretation and debates, with the intention to apply directly into clinical practice." As in previous years, ESASO invites young colleagues to challenge each other and submit their abstracts. The best-inclass will be invited by the Scientific Committee to participate in the upcoming congress in 2017. Abstract submission opens by 23 November 2015 and closes by 29 February 2016. ESASO Case Studies are another interactive style format where all delegates can present and share their experience. “These interactive sessions challenge us to present and discuss broad topics in the plenum and share our knowledge. Overall, the conference is an excellent refresher in the areas of diagnosis, clinical management and clinical research,” Prof Bandello points out. ESASO hopes you are able to join in for what promise to be highly stimulating and educational conferences, and looks forward to welcoming you as part of the ever-growing ESASO family: eager to improve through OUR VISION OF COLLABORATION.

JCRS

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 7 MONTH: JULY 2015

BIOMETRY UPGRADE FOR DENSE CATARACTS Optical low-coherence reflectometry (OLCR) allows simultaneous measurement of corneal thickness, true anterior chamber depth, lens thickness, and axial length. However, OLCR does not do well measuring axial length of eyes with dense cataracts and posterior subcapsular cataracts. A new software package could go a long way to improve the situation, report investigators. German and US researchers collected data from two sites where the new Dense Cataract Measurement mode for the OLCR optical biometer (Lenstar LS 900) had been implemented. An analysis of 4,791 eyes found that axial length measurement was possible using the standard algorithm in 94.4 per cent of cases. The use of the new mode allowed for measurement of an additional 4.0 per cent of cases, a statistically significant increase. The researchers believe that further and continuous improvements in the software will improve measurement of difficult eyes with dense cataract and other media opacities. H Shammas et al, JCRS, “New mode for measuring axial length with an optical low-coherence reflectometer in eyes with dense cataract”, Volume 41, Issue 7, 1365–1369.

FLACS VS PHACO Femtosecond laser-assisted cataract surgery (FLACS) yielded faster visual recovery, less deviation from the target refraction, and earlier stabilisation of refraction compared with conventional phacoemulsification cataract surgery in a recent prospective randomised intra-individual cohort study. One hundred eyes of 100 patients had FLACS while the fellow eyes had conventional phacoemulsification. Six months postoperatively, 92 per cent of eyes in the femtosecond laser-assisted group and 71 per cent of eyes in the conventional group were within ±0.50D of the target refractive outcome, and 100 per cent in both groups were within ±1.00D. I Conrad-Hengerer et al, JCRS, “Comparison of visual recovery and refractive stability between femtosecond laser–assisted cataract surgery and standard phacoemulsification: Six-month follow-up”, Volume 41, Issue 7, 1356–1364.

FIBRIN GLUE VS EPITHELIAL INGROWTH Epithelial ingrowth continues to be a complication of LASIK. US researchers reviewed 39 cases with a history of LASIK which had epithelial ingrowth removal with mechanical debridement and fibrin glue application. Following that treatment, 31 eyes (79.5 per cent) had no recurrence of ingrowth at the final follow-up and five eyes (12.8 per cent) had mild epithelial ingrowth not requiring removal. Three eyes required subsequent removal and fibrin application. At the three-month follow-up visit, 76.9 per cent of eyes achieved 20/25 or better corrected distance visual acuity. DR Hardten et al, JCRS, “Fibrin adhesive in conjunction with epithelial ingrowth removal after laser in situ keratomileusis: Long-term results”, Volume 41, Issue 7, 1400–1405.

THOMAS KOHNEN European editor of JCRS

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EYE ON TECHNOLOGY

CROSSLINKING-PLUS CXL-plus is a promising approach to improve visual acuity and regularise corneal geometry. Dr Soosan Jacob reports

pi-off corneal crosslinking (CXL) is a proven treatment for corneal ectatic disease. It halts the ectatic process by strengthening the cornea by means of creating covalent bonds between collagen fibrils. In the last three years many efforts have been made by researchers and ophthalmic companies to improve the quality and the time of treatment through development of new riboflavin solutions and new irradiance protocols. However, even though the main target of halting corneal ectasia is reached in most cases, few patients affected by moderate to severe keratoconus have a consistent visual acuity (VA) improvement. When performed on its own, the CXL procedure is not intended to improve vision, but rather to stabilise disease, and therefore the patient still remains to be rehabilitated visually, thereby affecting their quality of life. Many face the need to wear customised contact lenses and the inability to improve spectacle corrected visual acuity (SCVA) is often frustrating for both patients and surgeons, especially considering the well-known problems of contact lens abuse such as corneal inflammation, erosions, infection, chronic intolerance and so on. Corneal surgeons are therefore searching for techniques that, other than halting keratoconus, also improve corrected VA. Corneal shape regularisation is a key factor EUROTIMES | OCTOBER 2015

for improving the quality of vision and reducing aberrations, especially coma. For this reason, in 2011 the term ‘CXL-plus’ was introduced to describe several combined procedures that aimed at enhancing VA after CXL. Various combinations have been tried towards this goal.

CXL WITH INTACS CXL can be combined with the implantation of intrastromal rings. These have been proposed as simultaneous and sequential protocols. However, the result is not always predictable. Dr Miguel Rechichi from the Eye Centre Clinic, Catanzaro, Italy, who has extensive experience with CXL, says: “CXL-plus is a promising approach to improve VA and regularise corneal geometry. I think that an ectatic cornea can be treated in many ways but the challenge is in finding the best solution that improves corneal geometry without affecting corneal biomechanics. In my opinion it’s crucial to perform the two steps at the same time starting with the 'plus' procedure (intrastromal rings, laser ablation or both) for corneal regularisation followed by accelerated crosslinking to stiffen and ‘fix’ the reshaped cornea. Though I have, in general, good results using intrastromal rings, this is not my first choice because the refractive effect is not always completely predictable even with femtosecond-assisted implantation. I therefore started to look with greater

interest at the excimer laser approach for corneal reshaping and have got very encouraging results.”

CXL WITH EXCIMER LASER ABLATION More recently CXL has been combined with the use of the excimer laser, which may be used for removal of epithelium (transepithelial phototherapeutic keratectomy, or t-PTK) or Cretan protocol, and the topography-guided photorefractive keratectomy (PRK) or Athens protocol.

COMBINED T-PTK AND CXL (CRETAN PROTOCOL) Described by Kymionis et al, t-PTK is used to remove epithelium as well as to smoothen the anterior irregular stroma and decrease irregular astigmatism. Dr Rechichi says: “I had better results removing just epithelium with PTK (Cretan protocol) in corneas thinner than 400 micron. We know that epithelium is thinner over the cone so just removing 50 microns using epithelium as a masking agent by PTK, as suggested by Kymionis et al, improves corneal geometry, removing a limited volume of stromal tissue in the cone area.”

TOPOGRAPHY-GUIDED PRK (ATHENS PROTOCOL) First described by Kanellopoulos et al, topography-guided partial PRK is used to regularise anterior corneal shape and

EYE ON TECHNOLOGY using customised trans-PRK for corneal regularisation followed by accelerated pulsed CXL, and set up a fixed algorithm that we call STARE-XL (Selective Transepithelial Ablation for Regularisation of Corneal Ectasia Crosslinking) in patients with SCVA < 20/30 and age > 20 years. The basic steps of this algorithm are to use the central corneal thickness (CCT) and the thinnest corneal point for customisation of PTK-assisted removal of real epithelial map.”

PATIENT EXPECTATIONS

Figure 1: Comparative map before and after CXL-plus (trans-PTK-PRK + accelerated CXL). SCVA improved from 20/50 to 20/25

decrease irregular astigmatism and is followed by CXL. It consists of a 6.5mm PTK to remove 50μm of epithelium followed by topography-guided partial PRK, application of mitomycin C (0.02 per cent for 20 seconds), and the CXL procedure. No more than 50μm of stroma is removed and up to 2.00-2.50D of astigmatism with up to 1.00D of myopia is treated. Kanellopoulos et al also postulated that CXL in a PRK-treated eye may be biomechanically stronger as a crosslinked eye with a more regular surface and

would likely remain more stable due to strain redistribution than an eye with localised ongoing strain at the cone’s peak. Simultaneous CXL also avoids removal of crosslinked corneal tissue as compared to sequential (CXL before excimer ablation). Dr Rechichi says: “I used topographyguided partial PRK (Athens protocol) in corneas up to 470 microns keeping 50 microns as maximum depth of ablation and found it effective. Two years ago, when I and Dr Cosimo Mazzotta changed our refractive platform, we started

Dr Rechichi says patients affected by medium to severe forms of keratoconus are focused on VA improvement and always ask the same question of him: ‘Doctor, will I see better after the treatment?’ “When I started with CXL alone more than eight years ago, my answer was: ‘The real target is stabilising the cornea, but we have some chance to improve SCVA in the mid- to long-term period after surgery.’ Now I say that we have a good chance of improving spectacle corrected VA in the medium term. (see Figure 1) “The great aspect of this surgical approach is not only the quantitative improvement of vision but also the subjective improvement seen in the quality of vision as well as a significant decrease in aberrations,” says Dr Rechichi. 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

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CALENDAR

Warsaw

NOVEMBER

AAO 2015

14–17 November Las Vegas, USA www.aao.org

↙

95th SOI National Congress

LAST CALL

OCTOBER 2015

113th DOG Congress

1–4 October Berlin, Germany http://dog2015en.dog-kongress.de

Echography Teaching Services International Annual Course and Workshop on Diagnostic Ultrasound in Ophthalmology 5–9 October Naples, Italy www.echography.com

European Association for Vision and Eye Research (EVER) Congress 7–10 October Nice, France www.ever.be

25–28 November Rome, Italy www.congressisoi.com

JANUARY 2016

NEW Cataract Surgery: Telling It Like It Is

13–17 January Naples, USA www.cstellingitlikeitis.com

10th EGS European Resident Glaucoma Course 15–16 January Geneva, Switzerland www.eugs.org

6th EURETINA Winter Meeting 23 January Rotterdam, The Netherlands www.euretina.org

FEBRUARY

NEW WOC 2016 World Congress of Ophthalmology 5–9 February Guadalajara, Mexico www.woc2016.org

20th ESCRS Winter Meeting 26–28 February Athens, Greece www.escrs.org

7th World Congress on Controversies in Ophthalmology 31 March–3 April Warsaw, Poland www.comtecmed.com/cophy/2016

4–8 May Manama, Bahrain www.meaco.org

9–10 September Copenhagen, Denmark www.eucornea.org

ASCRS 2016

NEW XXXIV Congress of the ESCRS

6–10 May New Orleans, USA www.ascrs.org

JUNE

12th EGS Congress 19–22 June Prague, Czech Republic www.eugs.org

JULY

NEW 42nd Annual EPOS Meeting

23–25 September Zurich, Switzerland www.epos-focus.org

27–30 July Nusa Dua, Bali www.apacrs.org

SEPTEMBER

NEW 16th EURETINA Congress

8–11 September Copenhagen, Denmark www.euretina.org

ROTTERDAM www.euretina.org

10–14 September Copenhagen, Denmark www.escrs.org

NEW 29th APACRS Annual Meeting

6TH EURETINA WINTER MEETING

Saturday 23 January 2016

SEPTEMBER

NEW 7th EuCornea Congress

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MARCH

MAY

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