EuroTimes Vol. 20 | Issue 2

SPECIAL FOCUS CATARACT & REFRACTIVE CORNEA

TECHNIQUE CAN COMBINE ADVANTAGES OF DMEK AND DSAEK February 2015 | Vol 20 Issue 2

GLAUCOMA

NEW TECHNOLOGIES SET TO IMPROVE ACCESS TO DIAGNOSTICS

Istanbul Welcomes

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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

CONTENTS

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

A EUROPEAN OUTLOOK ON THE WORLD OF OPHTHALMOLOGY

SPECIAL FOCUS CATARACT & REFRACTIVE 4 Many cataract surgeries carried out in Sweden for little reason, study finds

5 Femtosecond laserassisted and standard phaco surgery outcomes compared

6 Japanese surgeons

battle with critical government report

7

8

GLAUCOMA 18 FS cataract combined

procedure effective with glaucoma patients

19 Treatment for visual

loss from idiopathic intracranial hypertension

22 Optical coherence

REGULARS

RETINA

29 Industry News

Diagnostic technologies could help laser refractive surgery outcomes

23 Alternative

Strategy to reduce the risk of posterior capsule rupture

24 Aflibercept outshines

approach to treating retinal ischaemia laser in DME, according to study results

25 Genetics behind diabetic

FEATURES CORNEA 10 Ultra-thin DSAEK –

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tomography – using a smartphone

retinopathy examined

26 ‘No benefit to face down positioning following macular hole surgery’

30 Ophthalmologica update 31 Book Reviews 33 Eye on History 34 Review 36 Resident’s Diary 37 JCRS update 39 Eye on Travel 40 Calendar

Could it provide the best of both worlds?

12 Epi-off CXL the only proven treatment, despite many experiments

15 Careful evaluation and management needed for B-KPro surgery As certified by ABC, the EuroTimes average net circulation for the 10 issues distributed between 01 January 2013 and 31 December 2013 is 40,878.

Included with this issue...

16 Focus on preventing herpes zoster-related disease with vaccination

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Supplements for Rayner and Alcon (a Novartis company) EUROTIMES | FEBRUARY 2015

2

EDITORIAL A WORD FROM FATIH MEHMET MUTLU MD

WELCOME TO ISTANBUL The 19th ESCRS Winter Meeting bridges two continents

T

he ESCRS Winter Meeting is one of the outstanding CULTURAL HISTORY conventions for ophthalmology professionals. Thus it Let me conclude by saying a few words about Istanbul. is a great honour for me to be given the opportunity to The European and Asian continents are bridged across the host this significant event in Istanbul on behalf of my Bosphorus Strait and have embraced a joint cultural history esteemed Turkish colleagues. in Istanbul. This natural geological and geographical situation The annual ESCRS winter meeting provides provides a unique opportunity to experience firsthand the an opportunity to discuss the most current issues and latest merging of centuries of eastern and western cultures - where innovations in cataract and refractive surgery. The full meeting the Orient and the Occident intertwine. agenda is available on the ESCRS website, www.escrs.org.

The narrow Bosphorus Strait has made Istanbul a favoured However, I want to give you a preview of some highlights of the capital city for various cultural empires for 16 centuries, meeting’s agenda. including the Roman, Byzantine and Ottoman Empires. With its * On Friday, February 20th, the first day of the meeting rich history, outstanding architecture, mystic heritage, cultural will present the Annual Cornea Day, organised by ESCRS and harmony and natural beauty, Istanbul offers a warm and friendly EuCornea. There will be case-study presentations and keynote welcome and genuine multicultural hospitality. lectures on the management of corneal complications On behalf of ESCRS and after refractive surgery, as well as incisive tips and pitfalls the Cataract and Refractive The annual ESCRS winter in corneal graft surgery, in ocular surface disease, and in Subdivision of the Turkish corneal inflammation, degeneration and infections. meeting provides an Ophthalmology Society, it is * On Saturday, February 21st, the main symposiums opportunity to discuss the my great personal pleasure and of the Winter Meeting will focus on the following topics: honour to welcome you, the most current issues and Continuing challenges and emerging developments in delegates and our colleagues, from keratoconus management; and Recent updates concerning latest innovations in cataract all around the world to the 19th evolving cataract and refractive surgery and postoperative and refractive surgery ESCRS Winter Meeting. endophthalmitis. Saturday’s highlight event will be live My esteemed Turkish colleagues surgery transmitted from the Ophthalmology Department and I sincerely hope you will enjoy a successful professional of Cerrahpasha Medical Faculty of Istanbul University. It is expected experience and personally memorable times as you join us here in that this live surgery session will attract a great number of attendees Istanbul in February 2015. and that they will find this event highly informative and insightful for enhancing success in their particular practices. * On Sunday, February 22nd, the closing day of the Winter Meeting will present two symposiums. Members of the Cataract and Refractive Surgery Section of the Turkish Ophthalmology Society will present topics based on a spectrum of actual cataract and refractive surgery cases. The Young Ophthalmologists Committee of ESCRS will follow with a presentation focused on cataract surgery in difficult eyes.

Education is at the very centre of ESCRS activities. Thus, various instructional courses, wet labs and five free paper sessions will be * Prof Dr Fatih Mehmet Mutlu is a co-opted member of included in the Winter Meeting, following a similar format used the ESCRS Board in the main annual meetings 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), Bill Aylward (UK), Peter Barry (Ireland), Roberto Bellucci (Italy), Béatrice Cochener (France), Hiroko Bissen-Miyajima (Japan), John Chang (China), Alaa El Danasoury (Saudi Arabia), Oliver Findl (Austria), I Howard Fine (USA), Jack Holladay (USA) , Vikentia Katsanevaki (Greece), Thomas Kohnen (Germany), Anastasios Konstas (Greece), Dennis Lam (Hong Kong), Boris Malyugin (Russia), Marguerite McDonald (USA), Cyres Mehta (India), Thomas Neuhann (Germany), Rudy Nuijts (The Netherlands), Gisbert Richard (Germany), Robert Stegmann (South Africa), Ulf Stenevi (Sweden), Emrullah Tasindi (Turkey), Marie-Jose Tassignon (Belgium), Manfred Tetz (Germany), Carlo Enrico Traverso (Italy), Roberto Zaldivar (Argentina), Oliver Zeitz (Germany)

EUROTIMES | FEBRUARY 2015

SPECIAL FOCUS: CATARACT & REFRACTIVE

SURGERY INDICATIONS

A

Swedish study finds little reason for up to 5.5 per cent of cataract surgeries. Howard Larkin reports

review of the Swedish National Cataract Register shows about four per cent of patients in 2012 and 5.5 per cent in 2013 received 2nd-eye cataract surgery without a discernible clinical indication.

Mats Lundström MD, PhD, Karlskrona, Sweden, told the 2014 AAO annual meeting in Chicago (held in conjunction with SOE 2014) that of these, 19 per cent perceived greater visual disability after surgery than before.

In addition, 10 per cent reported no improvement and nine per cent ended up with worse visual acuity.

A sharp rise in cataract volume prompted Dr Lundström to initiate the study. In 2013 nearly 120,000 cataract procedures were performed for a rate exceeding 11,000 per million inhabitants, up from about 8,600 in 2004.

Courtesy of Mats Lundström MD, PhD

4

OUTCOMES The database study examined prospectively collected data on 7,303 consecutive cataract cases during March 2012 and March 2013. March was selected because it is the month the register collects patient-reported outcomes in addition to other cataract data, Dr Lundström said.

Data collected before surgery included best corrected distance visual acuity, the surgeon’s opinion about indications for surgery, and completed Catquest-9SF, a Rasch-analysed patient questionnaire that asks about activities of daily life.

Surgical data, postoperative visual acuity refraction and a second Catquest9SF taken three months after surgery were also examined.

Altogether 4,325 first-eye and 2,974 second-eye procedures performed at 46 surgical units were examined for a total of 7,303. A stepwise process was used to exclude patients who the researchers thought had reasonable indications for surgery, Dr Lundström said.

Poor vision, defined as best corrected 20/40 or worse, was the first criteria.

Nearly 80 per cent of first-eye surgeries, or 3,388, and 60 per cent of second-eye surgeries, or 1,772, met this test, leaving 2,139 eyes.

Next, Dr Lundström looked at the Catquest-9SF results. Patient dissatisfaction with vision, defined as rather or very dissatisfied plus some functional disability, eliminated 683 firsteye and 646 second-eye surgeries, leaving 810 eyes. Patients satisfied with vision but who perceived vision-related difficulty performing daily life activities eliminated another 595, leaving 215 eyes.

ELIMINATED Finally, the surgeon’s opinion of a reasonable indication such as anisometropia or high intraocular pressure (IOP) eliminated another 26 eyes.

If we go outside health care and talk about these risk numbers for delivering a service or product, they are definitely... unacceptable Mats Lundström MD, PhD EUROTIMES | FEBRUARY 2015

That left 47, or 1.1 per cent, of firsteye surgeries and 142, or 4.8 per cent, of second-eye surgeries without what reviewers considered an adequate clinical indication, Dr Lundström said.

Projecting the numbers on to an entire year, this means about 900 first-eye surgeries and 2,500 second-eye surgeries were done in Sweden in 2013 with a 29 per cent risk of not perceiving better visual function and a nine per cent risk of worse visual outcome after surgery, Dr Lundström said.

UNACCEPTABLE “If we go outside health care and talk about these risk numbers for delivering a service or product, they are definitely definitely definitely unacceptable,” he said.

A possible weakness of the study is the fact that the decision to operate could be based on not reported circumstances.

Prof Lundström intends to follow the trend in the future. He will also start a discussion within the ophthalmic community about indications for cataract surgery. “We want to do that before the payers, which they have done in some European countries.”

Mats Lundstrom: mats.lundstrom@ karlskrona.mail.telia.com

SPECIAL FOCUS: CATARACT & REFRACTIVE

FEMTO OR PHACO? Research finds little difference in FS-cataract and phaco outcomes.

Automated

Howard Larkin reports

L

arge prospective comparative cohort series found little difference in safety or visual outcomes between femtosecond (FS) laser-assisted cataract surgery and standard phaco surgery, Brendan J Vote MD, Tasmanian Eye Institute, Launceston, Tasmania, Australia, told the XXXII Congress of the ESCRS in London.

The study examined 4,080 consecutive cases operated by five surgeons at a single regional day surgery centre from May 2012 through to November 2013, Dr Vote reported.

Patients mostly self-selected into the laser or phaco groups based on cost – about AU$750 additional for laser. However, about five per cent were assigned to phaco because laser was contraindicated due to age below 22 years, extensive corneal scarring, corneal ring inlays or past glaucoma filtration surgery.

Overall, 1,852 cases ended up in the laser group and 2,228 in the phaco group. Mean age, gender, PNS cataract grade and ocular comorbidities were similar between the two groups.

While intraoperative complication rates were low in both groups, statistically significant differences were observed.

The laser group experienced 30 anterior capsular tags, a 1.62 per cent rate, versus one in the phaco group (P=0.0001), though these Brendan J Vote are generally not clinically significant.

However, 34 anterior radial tears occurred in the laser group compared with five in the manual group (P=0.0001). The anterior tear rate did not change significantly from the first to the second half of the series, suggesting minimal effect of a learning curve, Dr Vote said.

There was, however, no significant difference in posterior capsular tear complications, which are those typically considered more clinically relevant. Corneal haze was more frequent in the laser group, with 12 cases versus one in the phaco group (P=0.0009). Docking vacuum appeared to cause haze, Dr Vote noted. Unstable pupils were also more frequent in the laser group at 30 versus 14 (P=0.003).

Dr Vote also noted a trend toward more cystoid macular oedema in laser cases. Visual outcomes were assessed in 933 laser and 895 phaco cases. Baseline best-corrected distance vision was worse in the phaco group, logMAR 0.4 +/- 0.3 compared with 0.34 +/- 0.24 in the laser group (P<0.0001).

The laser group also utilised more toric lenses at 47.7 per cent compared with 34.6 per cent in the phaco group (P<0.0001).

Laser cases achieved slightly better absolute mean distance corrected visual acuity after surgery, at logMAR 0.09 versus 0.13 for the phaco group (P<0.002).

However, the phaco group improved more, gaining a mean 13.5 letters compared with 12.5 for the laser group (P<0.03). The laser group also ended up with a larger mean absolute error.

“The visual benefits of laser cataract surgery have yet to be clearly established. As all of us are aware, cost effectiveness or the lack thereof for laser cataract surgery remains a significant obstacle to the uptake of this technology,” Dr Vote said.

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Brendan J Vote: eye.vote@me.com EUROTIMES | FEBRUARY 2015

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SPECIAL FOCUS: CATARACT & REFRACTIVE

LASIK IN JAPAN Refractive surgeons fight bad publicity.

Sean Henahan reports

J

apan’s sometimes troubled relationship with refractive surgery suffered another complication following the release of a government report critical of LASIK. The report, issued by Japan’s Consumer Protection Agency in late 2013, was based on an internet survey of 1,200 people in Japan, 600 of whom had undergone LASIK and another 600 who were considering having the procedure.

Among those who underwent LASIK, 74 per cent of patients reported they were informed of potential side effects beforehand. The same percentage reported that they did achieve the refractive correction they were hoping for.

However, the report cited nearly 80 cases of patient complaints. These included glare sensitivity (16 per cent), dry eye (14 per cent), over-correction (five per cent) and pain lasting more than one month (two per cent).

The report contains a dramatic warning that “not only may you not get the results you were looking for, you also run the risk of serious injury”. This was widely reported in the Japanese media.

The report concludes that the risks are not adequately explained to patients when they are considering LASIK. It reports that 40 per cent of patients who chose to undergo LASIK did so based on information they found on the internet (from official medical sources or from medical advertisements), information which has not been verified to adhere to the relevant consumer protection laws. Some of these promotional internet sources were

reportedly misleading or downright false.

“Rather than choosing LASIK lightly based on information from the internet, we advise consumers to hear the full explanation of the surgery’s risks from a licensed medical professional. Consumers should think carefully about whether they will really benefit from LASIK, and understand the risks of the surgery well before undergoing LASIK,” the report advises.

FINDINGS QUESTIONED While refractive surgeons in Japan agree completely that consumers should consult with licensed medical professionals and should learn the potential risks of the procedure, they question the findings of the report.

“We do not think the governmental report was fair since it was not based on scientific research,” Hiroko Bissen-Miyajima MD, president of the Japanese Society of Cataract and Refractive Surgery (JSCRS) told EuroTimes.

“After the report on TV and newspapers, some patients even cancelled their surgeries. For most c l i n i c s , the number of patients who came for LASIK dramatically decreased. Some places experienced more than a 50 per cent decrease in patients and have only

We do not think the governmental report was fair since it was not based on scientific research Hiroko Bissen-Miyajima MD

slightly recovered up until now,” said Dr Bissen-Miyajima.

“This is a tough time for refractive surgery in Japan. We do not know how long it will last. We are at the bottom of the situation and are trying to educate both ophthalmologists and patients to understand the safety and effectiveness of LASIK. “We, as a society (JSCRS), collected the data from laser centres, universities and clinics, and received the results from over 70,000 cases in 2013. We reported this at the JSCRS annual meeting in July 2014 and plan to publish soon.

This data is very positive and different from what the government report showed,” Dr Bissen-Miyajima told EuroTimes.

Minoru Tomita MD, director of the highvolume Shinagawa LASIK clinic in Tokyo, told EuroTimes that before the report appeared he had 100 surgeons on staff.

Following the resultant drop in demand, he had to reduce this number by one third.

Other high volume clinics were equally affected, including one that closed its doors.

“Once Japanese patients believe that LASIK will cause lots of problems after surgery, it is very difficult for us to change their thoughts. The JSCRS is planning to make the best LASIK website for Japanese patients. This will include the explanation of the procedure, indication, postoperative outcomes and Q&A,” Dr Bissen-Miyajima told EuroTimes.

Hiroko Bissen-Miyajima: bissen@tdc.ac.jp Minoru Tomita: minorumd@aol.com

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EUROTIMES | FEBRUARY 2015

RUSSIAN LANGUAGE EDITION NOW ONLINE

SPECIAL FOCUS: CATARACT & REFRACTIVE

PREDICTABLE STRUGGLE Newer diagnostic technologies may improve laser refractive surgery outcomes. Roibeard O’hEineachain reports

U

npredictability will remain a feature of highly individualised photoablative laser refractive treatments until more reliable means become available to evaluate patients’ preoperative vision, their cornea’s biomechanical properties and the likely effects of corneal epithelium healing on the refractive outcome, said Michael Mrochen PhD, Zurich, Switzerland.

“I think we have good tools to address certain patients. With normal myopic eyes, moderate amounts of astigmatism, we get excellent outcomes. But if we go to more complex cases, I think we have a big gap in terms of predictability and giving good visual outcomes,” he told the XXXII Congress of the ESCRS in London.

Examples of the types of patients who may require complex treatments include those with good Snellen visual acuity but poor quality of vision following LASIK because of higher-order aberrations, older patients who want spectacle independence by mono-vision, and those with residual astigmatism after cataract surgery.

Also requiring such individualised treatments are those undergoing presbyopic corrections and those undergoing topography-guided treatment for therapeutic reasons.

“The factors that need improvement in such cases include the predictability of refractive outcomes, the ability to measure and correct aberrations quality of vision or enhance the depth of field. And finally we have some biological limitations, epithelium healing responses and biomechanical factors,” added Dr Mrochen.

IRREGULAR CORNEAS Planning treatment in complex cases is difficult because the preoperative refraction measurements are less dependable in such eyes.

As an illustration, he cited a study showing that the mean repeatability of subjective refraction was similar to the predictability of LASIK in normal eyes, with around 90-95 per cent of measurements being repeatable within half a dioptre, compared to only 44 per cent in eyes with keratoconus.

“Corneal irregularity can definitely influence the predictability of the refraction. But how can we improve our outcome if the gold standard that we use is subjective refraction?

“Our gold standard is actually hiding the possible improvements.

So the reproducibility of the subjective refraction is relevant if we want to improve our outcomes in the future,” Dr Mrochen noted.

In addition, the Michael Mrochen PhD precision of treatment is

Corneal irregularity can definitely influence the predictability of the refraction.

But how can we improve our outcome if the gold standard that we use is subjective refraction?

not always matched by the same precision in outcome, owing to the unpredictable effects of corneal healing.

The optically perfect corneal shape is in some cases not the biologically optimum shape in structural terms. As a result the corneal epithelium will fill in the slight structural irregularities in the stromal surface that can be present after a finely-tuned wavefront-guided or wavefront-guided treatment.

That explains why, although such treatments are effective in reducing large amounts of aberration, they are less effective for smaller aberrations. It also shows why inducing small amounts of spherical aberration with sub-micron precision, as in the case of presbyopic LASIK, is inherently unpredictable using current approaches.

COMPROMISE He noted that inducing a certain amount of aberration can increase depth of focus by 1.0D to 2.0D, although with some compromise in visual quality.

The treatments most of the companies are using for presbyopic correction nowadays try to leave the eye with 0.3 microns to 0.6 microns of spherical aberration over a 6.0mm pupil.

He suggested that preoperative optical coherence tomography (OCT) imaging of the epithelium might make the epithelial effects on postoperative corneal surface curvature more predictable in such cases.

“Epithelial smoothing is masking existing stromal irregularities and might smooth an attempted correction. It can have a lot of relevance in presbyopia correction or for therapeutic applications if we were to do a topography guided treatment,” Dr Mrochen said.

Finally, the cornea's biomechanics also lend an amount of uncertainty to the finer adjustments needed for wavefront-based correction of spherical aberration.

A range of technologies for measuring the cornea’s viscoelastic properties such as Brillouin scattering, dynamic OCT or dynamic Scheimpflug techniques are coming to the market, which may make it possible to take the biomechanical effects of laser refractive surgery into consideration when planning laser ablations.

In addition, collagen cross-linking might be used as a way of actually controlling the biomechanical effects of surgery in order to reduce variability in refractive outcomes.

Validation of preoperative measurements and treatment plans based on postoperative outcomes is essential to achieving any improvements in the efficacy of the procedures.

The advent of electronic recording and analysis of treatment outcome data could facilitate the creation of nomograms individualised to each surgeon, to further improve the outcomes.

“To improve our outcomes, I think we need to reconsider the gold standard for evaluation and improve the diagnostics with high resolution OCT for the epithelium and biomechanical measurements by technologies such as Brillouin scattering.

“I think we have to make individualised assumptions on the corneal response based on those measurements. Last but not least, as clinicians running a refractive surgery centre, you also have to keep in mind that you have competitors and you want to find a way to differentiate yourself from your competitors based on the technology you’re using and based on the outcomes you’re achieving,” said Dr Mrochen.

Michael Mrochen: michael.mrochen@irocscience.com EUROTIMES | FEBRUARY 2015

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SPECIAL FOCUS: CATARACT & REFRACTIVE

CAPSULE RUPTURE Preoperative risk stratification could reduce incidence.

Dermot McGrath reports

W

hile posterior capsule rupture remains one of the most common significant intraoperative complications during cataract surgery, the risk can be reduced if a proper strategy is put in place, especially in ophthalmology training settings, according to Oliver Findl MD. “Posterior capsule rupture is associated with the need for additional surgical procedures, a greater number of follow-up visits, and especially increased frequency of postoperative complications. It is widely regarded as the benchmark complication to judge the quality of cataract surgery,” Dr Findl told delegates attending a joint ESCRS-EURETINA symposium during the XXXII Congress of the ESCRS in London.

The reported rates of posterior capsule rupture are usually around 1.9 per cent in the larger clinical trials, with several studies showing greatly increased rates for ophthalmology residents, noted Dr Findl.

“We know that the risk factors for posterior capsule rupture include older age, presence of pseudoexfoliation, smaller pupil, brunescent cataract and surgical experience. With this in mind, a risk stratification strategy is useful in daily routine and particularly useful in training settings where patients at risk can be treated by more experienced surgeons,” he said.

While the primary function of the vitreous is to act as a support function for the retina and maintain the form and shape of the eye, it also serves as a diffusion barrier between anterior and posterior segment, and also has a metabolic buffer function, said Dr Findl.

With ageing, the vitreous undergoes molecular changes, with the formation of new covalent crosslinks between peptide chains allied to the cumulative effect of light exposure and nonenzymatic glycosylation.

“This then causes structural changes with Oliver Findl MD

Posterior capsule rupture... is widely regarded as the benchmark complication to judge the quality of cataract surgery

INDIA

www.eurotimesindia.org EUROTIMES | FEBRUARY 2015

collagen fibres that aggregate and are no longer separated by hyaluronic acid. These fibres then thicken and associate with pockets of liquid called lacunae.

“As the vitreous liquefaction increases, the resultant lacunae coalesce to form larger cavities followed by shrinkage of the vitreous body from the retina and eventually leading to posterior vitreous detachment (PVD),” he said.

The consequences of a broken vitreolenticular barrier during cataract surgery are multiple, said Dr Findl.

“On the one hand we experience a volume shift which may induce a PVD exposing vitreoretinal adhesions, as well as chemical transfer of solubles from the anterior to the posterior segment, and in particular inflammatory substances that may lead to an increased risk of cystoid macular oedema (CME),” he said.

VISUAL ACUITY Other serious complications are also associated with posterior capsule rupture and vitreous loss, said Dr Findl. “At the end of the day if you have capsular rupture and associated vitreous loss, there is a 15-fold increased risk of retinal detachment, a 10-fold increased risk of CME, and similar increased rates for endophthalmitis. Visual acuity outcomes three to five years after surgery are also worse after posterior capsule rupture,” he said.

The signs of capsular rupture to watch for during cataract surgery include a slight, sudden deepening of the anterior chamber, momentary pupillary constriction, and the nucleus falling back onto the vitreous face and not coming towards the phaco tip, said Dr Findl. A reduction of aspiration may also be apparent due to vitreous obstruction of the tip, he added.

The data for surgical technique associated with posterior capsule rupture risk is also interesting, said Dr Findl.

“One study showed that third-year residents in the United States had a 3.1 per cent to 14.7 per cent incidence of capsule rupture, while it was 4.4 per cent for registrars in the United Kingdom. The incidence decreases with an increasing number of cases performed.

The incidence is also higher in developing countries where there is a higher frequency of white cataracts,” he said.

Dr Findl said one approach might be to develop a scoring system for preoperative risk stratification, with points added for different risk factors. A study by Tsinopoulos et al in 2013 showed that complication rates decreased significantly when high-risk patients were treated by an experienced surgeon, concluded Dr Findl.

Oliver Findl: oliver@findl.at

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CORNEA

ENDOTHELIAL KERATOPLASTY

I

Ultra-thin DSAEK technique combines advantages of DMEK and DSAEK. Cheryl Guttman Krader reports

In the ongoing debate over which endothelial keratoplasty procedure corneal surgeons should perform, Massimo Busin MD is taking the middle ground.

At the 5th EuCornea Congress in London, UK, Dr Busin advocated ultra-thin DSAEK (UT-DSAEK) for its ability to provide the best of DSAEK (descemet stripping automated endothelial keratoplasty) and DMEK (descemet membrane endothelial keratoplasty).

“In medio stat virtus – in the middle stands virtue,” said Dr Busin, quoting Aristotle and Horace. “UT-DSAEK shares DMEK's advantages over conventional DSAEK of faster visual recovery, better visual outcomes, and reduced immunologic rejection risk. At the same time, UT-DSAEK is simpler surgery than DMEK and minimises all types of postoperative complications.”

According to Dr Busin, consistently better quality graft tissue is the reason why UT-DSAEK provides better vision outcomes than conventional DSAEK. He explained that central thickness is not

the only parameter that matters.

“The simple value of central thickness is not sufficient to evaluate the ‘quality’ of a DSAEK graft, which is why a DSAEK lenticule with a 'good' stromal component is perfectly compatible with 20/20 vision, probably regardless of its central thickness.

Surface regularity and planar shape must also be taken into account,” said Dr Busin, professor of ophthalmology, Villa Igea Hospital, Forli, Italy.

“Therefore, corneal surgeons advocating DMEK for its better vision outcomes should not be comparing DMEK against DSAEK in general, but against ‘good DSAEK’, which is DSAEK using a graft with a good quality stromal component.”

Dr Busin undertook the comparison between DMEK and ‘good DSAEK’ using data from his own UT-DSAEK series.

The first issue he considered was best spectacle-corrected visual acuity (BSCVA) at one year among eyes with 6/6 potential.

He reported that in his UT-DSAEK cohort, 39 per cent of eyes achieved BSCVA ≥6/6, 71 per cent saw ≥6/7.5, and 95 per cent achieved ≥6/9.

Figure 1: Clinical picture of a 62-year-old patient six months after UT-DSAEK. Uncorrected visual acuity was 20/25, bestcorrected visual acuity was 20/12.5 with +0,25 sphere and -0.50 cylinder @ 135˚

Proportions of eyes achieving those BSCVA thresholds after DMEK were 41 per cent, 80 per cent and 98 per cent, respectively. Endothelial cell loss rates in the UT-DSAEK and DMEK groups were similar as well (34 per cent and 36 per cent, respectively).

Presenting data on speed of visual recovery, Dr Busin showed that

Courtesy of Massimo Busin MD

10

Figure 2: Anterior segment OCT of the same patient as Figure 1. The DSAEK graft has a regular shape with uniform thickness, measuring 58µm centrally

EUROTIMES | FEBRUARY 2015

CORNEA UT-DSAEK had a clear advantage over DSAEK. Although mean BSCVA levels at three and six months were slightly better after DMEK than UT-DSAEK, Dr Busin pointed out that mean preoperative logMAR BSCVA was also better in the DMEK versus UT-DSAEK group, 0.51 versus 0.76.

Compared to the same DMEK group, a better-matched UT-DSAEK cohort (phakic eyes with an average preoperative BSCVA of 0.55 in logMAR units) achieved better levels of vision in a shorter time.

“I am convinced that it is the preoperative condition of the patient and not a thin layer of stroma that makes a difference in vision outcomes,” Dr Busin said.

The outcome of Dr Busin’s UT-DSAEK series also reduces concern about increased risk of immunologic rejection with DSAEK versus DMEK, although he emphasised the importance of an appropriate corticosteroid treatment regimen postoperatively.

UT-DSAEK is simpler surgery than DMEK and minimises all types of postoperative complications

more case of rejection per 100 patients per year. And, if we consider other possible complications, including the need for air re-injection, primary failure and tissue loss, then UT-DSAEK compares quite well against DMEK,” said Dr Busin.

In his UT-DSAEK series with Fuchs or pseudophakic bullous keratopathy, three per cent of eyes needed air re-injection, while both primary failure and tissue loss occurred at a rate of just one per cent. Data from DMEK series show air re-injection rates between 17 per cent and 77 per cent, a nine per cent primary failure rate and a tissue loss rate of up to 13 per cent.

Dr Busin explained that different techniques could be used to harvest the UT-DSAEK graft. Initially, he used a double pass technique with a pivoting microkeratome.

“Accurate thickness could not be achieved after a single pass technique because of the instrument’s tendency to cut deeper at the beginning of the dissection.

To compensate for that effect, a second pass was performed in the opposite direction of the first,” he explained.

Now, with the introduction of new linear microkeratomes that cut at a uniform depth throughout the dissection, Dr Busin prepares UT-DSAEK grafts with a single pass technique.

Massimo Busin MD

Massimo Busin: mbusin@yahoo.com

Figure 3: Creation of an UT-DSAEK graft by means of the singlepass technique utilising a 450µm microkeratome head

He reported that the Kaplan-Meier cumulative probability of immunologic rejection was 2.5 per cent after UT-DSAEK at one and two years, one per cent for DMEK at both follow-up intervals, and six per cent and 10 per cent at one and two years, respectively, post-DSAEK of the conventional type.

“Numerically, the rejection rate for UT-DSAEK is twofold higher than DMEK, but the difference represents just one

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11

CORNEA

EVIDENCE-BASED CXL Epi-on, higher UV power, shorter treatment tantalise, but only epi-off is proven. Howard Larkin reports

D

espite many experiments with corneal crosslinking (CXL) technologies designed to preserve the epithelium and shorten the procedure, the traditional method involving epithelium removal and 30 minutes of 3mW/cm2 ultraviolet radiation remains the only proven CXL treatment for keratoconus, Frederik Raiskup MD, PhD, FEBO told the XXXII Congress of the ESCRS in London.

Dr Raiskup noted some promising tests of various epi-on, high-power radiation and iontophoresis CXL approaches. But some early studies are inconsistent, and long-term clinical studies demonstrating safety and efficacy are lacking.

“We still are not finished (investigating these technologies) and these results are not evidence-based,” he said.

PROMISING BUT UNPROVEN Removing the corneal epithelium is painful and exposes the cornea to possible infection and melting, risking persistent epithelial defects and permanent stromal scars, Dr Raiskup noted.

Preserving the epithelium might reduce these risks, but an intact epithelium prevents diffusion of riboflavin in the cornea, which is essential for crosslinking to occur.

Dr Raiskup and colleagues experimented with epi-on using various pharmacological agents in a rabbit model, and found that adding BAC and hypoosmolar sodium chloride provided adequate riboflavin concentration in the cornea compared with epi-off (Curr Eyes Res. 2012 Mar;37(3):234-8). However, clinical trials uncovered safety problems including postoperative epithelial defects.

“What was working in an experimental study was not working in vivo in human corneas.”

Other studies of pharmacologically assisted transepithelial CXL results are mixed, Dr Raiskup said. One cohort study found the process “appeared to halt keratoconus progression with a statistically significant improvement in visual acuity

Cornea without epithelium soaked with riboflavin during CXL procedure

and topographic parameters” (Filippello et al. J Cataract Refract Surg Feb 2012; 38(2):283-291).

More typically conclusions are more modest, along the lines of “a limited but favourable effect” (Leccisotti A et al. J Refract Surg Dec 2010; 26(12):942-948).

Microscopic examinations also find uneven evidence of corneal structural changes. Still, many epi-on adjuncts remain to be studied, as do the effects of some known substances, he added.

A study using femtosecond-cut pockets was also successful (Kanellopoulos AJ et al. J Refract Surg 2009; 25:1034-1037).

However, whether this is safer than epi-off is unclear, Dr Raiskup noted. Accelerating CXL by increasing radiation fluence is also promising but unproven in the longterm, Dr Raiskup noted. One randomised prospective trial found 30mW/cm2 for four minutes 20 seconds gave results similar to conventional epi-off CXL (Sherif AM. Clin Opthamol 2014; 8:1435-1440).

Other studies suggest a limit of about 40mW/cm2 and at least two minutes UV before crosslinking ceases to be effective (Wernli J et al. IOVS 2013; 54:1176-1180), while others suggest a lack of oxygen causes the stiffening effect to drop off sharply as fluence rises and times drop (Hammer A et al. IOVS 2014; 55:2881-

What was working in an experimental study was not working in vivo in human corneas Frederik Raiskup MD, PhD, FEBO EUROTIMES | FEBRUARY 2015

2884). Total UV exposures up to 40 per cent higher than standard in some accelerated protocols have not been evaluated for safety, he added.

Iontophoresis is also promising, with several studies showing intact epithelium with evidence of corneal stiffening and reduced K values in patients despite lower concentration of riboflavin in stromal tissue compared with epi-off CXL, Dr Raiskup said. Long-term clinical results have yet to be assessed.

EVIDENCE FOR EPI-OFF Epi-off CXL has a long track record including randomised trials showing halting of keratoconus progression at 36 months (Wittig-Silva C et al.

Ophthalmology 2014; 121:812-821), and improved K values and corrected distance visual acuity at nine to 12 years follow-up from early patients treated at Dresden, Dr Raiskup said (Journal of Cataract and Refract Surg 2014: In Print).

“We can say without any pangs of conscience that epi-off is still now the way to treat our patients with progressive keratoconus,” he said.

Still, a review of more than 2,000 published epi-off papers found just 49 methodologically sufficient for analysis, including eight reporting on four randomised clinical trials, 29 prospective studies and 12 retrospective studies. The majority of the evidence was graded low, and “uncertainty remains about duration of benefit” (Craig JA et al. The Ocular Surface 2014; 12(3): 202-214).

Frederik Raiskup: frederik.raiskup@uniklinikum-dresden.de

Courtesy of Frederik Raiskup MD, PhD, FEBO

12

ADVERTORIAL

HAVE YOU EVER SEEN THIS PATIENT?

W

ith more than 20,000 AcuFocus™ KAMRA™ inlays implanted worldwide, the chances of seeing one during a routine cataract, glaucoma, or retinal exam are increasing daily.

The KAMRA corneal inlay is an opaque, annular device made of polyvinylidene difluoride and nano-particles of carbon.

The inlay has a total diameter of 3.8 mm, a central aperture of 1.6 mm, is 5 microns thin and contains 8,400 laser-etched mircoperforations. It is placed monocularly, approximately 200 microns deep in the cornea of the non-dominant eye to treat presbyopia.

The good news is that routine ocular assessments and surgical procedures are possible with the inlay in situ. However, there are some situations where clinicians should take care to avoid damaging the inlay. Here is a quick guide to common diagnostic tests and procedures in eyes with a KAMRA inlay.

CORNEAL & REFRACTIVE ASSESSMENT & PROCEDURES Clinicians should be aware that a mid-point refraction is more reliable than standard or autorefraction in a post-inlay eye. Corneal diagnostics such as confocal imaging and topography can be performed. Femtosecond laser flap creation is not advisable in an eye with a KAMRA inlay, as damage to the inlay has been reported.¹ For patients requiring a refractive enhancement after inlay implantation, surface ablation, such as PRK, is possible.²

CATARACT ASSESSMENT & PROCEDURES The crystalline lens can be easily viewed and lens opacity graded with a dilated pupil. Accurate biometry and lens power calculation for inlay-implanted eyes using the Lenstar (Haag-Streit) or the SRK/T formula have been reported.¹ Clear corneal incisions, Figure 1 arcuate incisions and capsulotomy can be performed manually³, ⁴ or with a femtosecond laser for cataract surgery⁵ in an inlay-implanted eye. Lens fragmentation and extraction should be performed using phacoemImage courtesy of Kevin Waltz, OD, MD ulsification. (Figure 1) “Both cataract removal and IOL insertion are easily performed with the inlay in place” said Kevin L. Waltz, OD, MD, who has now performed cataract surgery on several postKAMRA patients. “When left in place, the inlay continues to provide enhanced visual outcomes after cataract surgery.”

Alternatively, the inlay may be removed and a presbyopia correction IOL implanted.

In the event of posterior capsular opacification, Nd:YAG capsulotmy may be performed with the inlay in place¹, provided one is careful to avoid contact between the laser beam and inlay.

REFERENCES 1.Data on file at AcuFocus.

2.Waltz KL et al. PRK over an Opaque, Intracorneal Inlay. 2014 ASCRS presentation.

3.Tan TE, Mehta JS. Cataract surgery following KAMRA presbyopic implant. Clin 1.Ophthalmol 2013;7:1899-903.

4.Jabbur N, et al. Sequential retinal detachment and cataract surgery in a patient im- 1.

1.planted with a small-aperture corneal inlay. Submitted abstract, ESCRS 2014.

5.Rivera R et al. Effect of a femtosecond laser used during a cataract procedure on a 1.

1.corneal inlay. ARVO poster 2014.

RETINAL ASSESSMENT & PROCEDURES “After using a wide range of diagnostic tools in post-inlay eyes, we conclude that, with an experienced technician, the KAMRA inlay does not interfere with imaging or examination of ocular structures,” says Günther Grabner, MD, who has some of the longest follow-up of inlay patients in the world. He and his colleagues have found, for example, that all retinal quadrants can be examined with a digital, wide-field lens or with Goldmann contact glass fundoscopy. Fundus camera images are of good quality. (Figure 2) High-resolution retinal imaging, such as optical coherence tomography (OCT) and scanning laser polarimetry, is easily achieved, with minimal effect on quality.⁶ Successful completion of a Figure 2 pars plana vitrectomy, transscleral cryotherapy, and air-fluid exchange in a KAMRA eye have been reported.⁴ Anti-VEGF injections, pneumatic retinopexy and use of a scleral buckle should all be possible with the inlay in place. HoweImage courtesy of Günther Grabner, MD ver, retinal lasers may cause thermal damage to the inlay and surrounding tissue.⁷ Therefore, if laser retinopexy, focal or panretinal laser photocoagulation are indicated, the inlay should be removed prior to treatment.

GLAUCOMA ASSESSMENT & PROCEDURES Intraocular pressure measurements using a Goldmann tonometer, non-contact tonometer or dynamic contour tonometer are no different in inlay-implanted eyes than at baseline. Gonioscopy imaging can be used to view the angle in patients with glaucoma.

(Figure 3) Optic nerve and retinal nerve fiber layer evaluation is also easily achieved with the inlay in place.

Data from the US IDE clinical trial show a slight overall decrease in visual field sensitivity after inlay implantation (~1.0 dB change from baseline), however, measurements remain within normal limits, with no Figure 3 scotomas.¹ , ⁸ Further analysis Inlay shows no change in extent and total visual field area between implanted and non-implanted eyes.⁹ While no issues have been reported, removal of the inlay prior to any laserChamber Angle based glaucoma therapy is recommended.

Image courtesy of Günther Grabner, MD QUESTIONS OR CONCERNS?AcuFocus can provide assistance and resources to help any physician treating a post-inlay patient. Please contact MyKAMRAPatient@AcuFocus.com 6.Grabner G. Effect of an opaque annular corneal inlay on the ability to use retinal 1. and glaucoma diagnostic devices. American Society of Cataract and Refractive 1.SurgeryAnnual Symposium, 2011.

7.Mita M, Kanamori T, Tomita M. Corneal heat scar caused by photodynamic therapy performed through an implanted corneal inlay. J Cataract Refract Surg 2013;39:1768–73.

8.Brooker E et al. Effect of small aperture intra-corneal inlay on visual fields. Invest 1.Ophthalmol Vis Sci 2012; 53:abstract 1391.

9.Brooker E et al. Effect of small aperture intra-corneal inlay on peripheral kinetic 1.

1.visual field. Invest Ophthalmol Vis Sci 2013;54: E-Abstract 3717.

MK-1223 Rev B

13

6th EuCornea Congress

BARCELONA 4â&#x20AC;&#x201C;5 September 2015 Fira Gran Via, Spain

Abstract Submission Deadline 15 March 2015 www.eucornea.org

/EuCornea

@EuCornea

CORNEA

15

GLAUCOMA AND KPRO Prevalence, severity and impact on vision underscore need for frequent evaluation and aggressive management. Cheryl Guttman Krader reports

LOW THRESHOLD Dr Arrondo observed there is a low threshold for performing glaucoma surgery in patients with a B-KPro due to the severity of glaucoma in this population, the challenge of obtaining reliable IOP measurements, and considering that response to topical medications tends to be poor.

“IOP control can be achieved in most patients with our current surgical options.

Optic nerve imaging in a patient with B-KPro

Courtesy of Elena Arrondo MD

B

ecause glaucoma is the most significant vision-threatening complication following Boston Keratoprosthesis Type 1 (B-KPro) surgery, it requires careful preoperative evaluation and postoperative follow-up, said Elena Arrondo MD at the 5th EuCornea Congress in London, UK. Data from various series show glaucoma is present in as many as 75 per cent of patients who present for B-KPro implantation, and glaucoma can also develop or worsen after the keratoprosthesis surgery through a variety of mechanisms.

All patients should be evaluated for ocular hypertension or glaucoma prior to B-KPro surgery, and only those with an open angle and normal intraocular pressure (IOP) off medication should proceed to B-KPro placement alone, advised Dr Arrondo, glaucoma specialist, Institute of Ocular Microsurgery, Barcelona, Spain.

“Otherwise, glaucoma surgical intervention with a glaucoma drainage device (GDD) or cyclophotocoagulation is indicated and should be performed before or simultaneously with the B-KPro procedure,” she advised.

Ahmed valve with pars plana tube insertion in a patient with B-KPro

Although there is no consensus about what type of procedure is better, a GDD is usually the first choice for most surgeons,” she said.

In GDD procedures, pars plana tube insertion into the posterior chamber is preferred over anterior chamber placement, as it decreases risks of tube exposure, tube kinking and vitreous incarceration. In combination procedures, vitrectomy must be complete so that no vitreous can enter and occlude the tube.

Fascia lata, donant sclera or cornea are used to cover the tube since reabsorption of pericardium occurs over time and can result in tube exposure.

“Tube exposure has also been reported with use of Hoffman elbows or pars plana clips. We never use those techniques and have never had exposure of a posterior chamber inserted tube,” Dr Arrondo said.

She noted that tube placement in the anterior chamber has been done in some eyes, but then the tube is inserted through a sclera tunnel at least 3.5mm from the limbus to avoid mechanical trauma from a bandage contact lens that can lead to tube exposure.

Dr Arrondo reported that in a series of 15 valve procedures performed at her institution in patients with B-KPro, they encountered endophthalmitis with secondary plate exposure in two patients who subsequently underwent valve removal. Complications reported by other groups include hypotony and choroidal detachment.

“Glaucoma progression has also been reported despite normal IOP, and so the

target IOP should be very low in patients with B-KPro,” Dr Arrondo said.

CPC (endocyclophotocoagulation or diode laser transscleral CPC) may particularly be chosen instead of a GDD in patients with very low vision, and it also provides very good IOP control after GDD failure.

“CPC avoids concerns about endophthalmitis and tube exposure, but it is difficult to calculate the number of impacts and determine the location of the ciliary processes,” Dr Arrondo said.

Monitoring for glaucoma development and progression in patients with a B-KPro is done using digital pressure to estimate IOP, visual field testing, and optic nerve evaluation.

Visual field testing is done with Goldmann or static perimetry and using a stimulus size based on the patient's visual acuity.

Dr Arrondo noted that optic nerve visualisation in patients with the KPro is similar to visualisation in patients with non-dilated pupils, and that nonmydriatic cameras are a better option for fundus photography.

She added that evaluation of the retinal nerve fibre layer using optical coherence tomography or retinal tomography can also be performed in eyes with a B-KPro, and she presented a case in which clinical assessment of the optic nerve and structural imaging revealed glaucoma progression much earlier than visual field testing.

Elena Arrondo: arrondo@imo.es EUROTIMES | FEBRUARY 2015

16

CORNEA

HERPES ZOSTER Looming increase in incidence puts emphasis on prevention through vaccination. Cheryl Guttman Krader reports

T

he possibility that the incidence of herpes zoster-related disease may be increasing is focusing attention on the value of prevention using the herpes zoster vaccine (Zostavax), according to Marc Labetoulle MD. Dr Labetoulle, professor of ophthalmology, Hôpital Bicêtre, University of Paris-Sud, Paris, France, provided an update on the epidemiology, prevention and treatment of herpes zoster ophthalmicus (HZO) at the 5th EuCornea Congress in London.

HZO accounts for 10 to 20 per cent of all herpes zoster infections. However, studies of various adult populations investigating the prevalence of circulating antibodies against the varicella zoster virus (VZV), and of DNA evidence of VZV in neurological tissue, indicate that almost all adults over the age of 50 are at risk for virus reactivation and of developing zoster, said Dr Labetoulle.

He explained that varicella-specific cell-mediated immunity is an important mechanism in preventing reactivation of latent virus. Contact with a person having active varicella zoster disease (chickenpox) will boost the immune system in a person with latent virus.

However, as a result of widespread use of the chickenpox vaccine, opportunities for such restimulation are now decreased.

Consequently, experts are expecting that the classical epidemiology of herpes zoster may change, forecasting that the incidence of zoster will begin to rise about 15 years after the beginning of systematic use of the chickenpox vaccine.

“We should soon see this in the United States if this prediction comes true.

However, we need to consider that herpes zoster is a debilitating disease with a huge negative effect on quality of life.

"Therefore, it seems that the more efficient is vaccination against chickenpox, the more we will need the herpes zoster vaccine,” said Dr Labetoulle, adding that results from the Shingles

Prevention study showed the vaccine reduced both the incidence of zoster and of post-herpetic neuralgia.

In Europe and the US, the herpes zoster vaccine is licensed for use in adults aged 50 years and older. However, recommendations about who should receive the vaccine vary.

The US Centers for Disease Control recommends vaccination in people 60 years and older, based on the Shingles Prevention study. In France, the recommendation is for persons 65-74 years old. During the first year following its inclusion in the vaccination calendar, people from 75-79 years of age may be vaccinated in the context of a catch-up. In the UK, the vaccine is recommended for persons of 70-79 years old.

Although the vaccine is contraindicated in persons who are immunocompromised, Dr Labetoulle noted some new information indicates that exclusion should be reconsidered.

Recommended antiviral regimens for treatment of zoster ophthalmicus (with or without keratitis) vary depending on the patient’s immune status and age, according to Dr Labetoulle.

...we need to consider that herpes zoster is a debilitating disease with a huge negative effect on quality of life Marc Labetoulle MD EUROTIMES | FEBRUARY 2015

Immune competent patients may be treated with oral acyclovir 800mg five times daily, valacyclovir 1.0g three times daily, famciclovir 750mg once daily, 500mg twice daily, or 250mg three times daily.

“Valacyclovir and famciclovir offer the convenience of less frequent dosing compared to acyclovir, and there is also some evidence that they are more effective for relieving pain and inflammatory complications of HZO,” Dr Labetoulle said.

Treatment should be started within three days of disease onset. The available evidence suggests that for immune competent adults, there is no benefit for treating longer than seven days.

“However, there is evidence that VZV DNA persists for up to 24 days after development of the rash.

Therefore, longer treatment might be considered in certain fragile populations, including the very old, patients who are immunosuppressed, and in children who tend to have more severe complications from HZO and inflammatory recurrence once antiviral treatment is tapered,” Dr Labetoulle said.

Intravenous acyclovir is recommended for treatment of HZ/HZO in patients who are immunocompromised. Oral brivudin (bromovinyl-deoxyuridine) is approved for the treatment of herpes zoster in Italy and Germany, and there is some evidence that it is effective in immunocompromised patients, he added.

Marc Labetoulle: marc.labetoulle@bct.ap-hop-paris.fr

XXXIII Congress of the ESCRS 5–9 September 2015 Fira Gran Via, Barcelona, Spain

Abstract Submission Deadline 15 March 2015

www.escrs.org /ESCRS @ESCRSOfficial

ESCRS

18

GLAUCOMA

FS COMBINED PROCEDURE No IOP increase or added post-op complications seen in glaucoma patients. Howard Larkin reports

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emtosecond laser-assisted cataract surgery is safe and effective for use in combination with non-penetrating deep sclerectomy in glaucoma patients, Prof Svetlana Anisimova, Moscow, Russia, told the XXXII Congress of the ESCRS in London.

In a case comparison study, vacuum docking during the femtosecond laser step did not raise intraocular pressure (IOP) excessively, and complication rates and visual outcomes were similar to patients undergoing conventional phacoemulsification.

Prof Anisimova compared results of 53 glaucoma patients receiving combined sclerectomy and femtosecond laser-assisted cataract surgery with 21 receiving combined sclerectomy and conventional phaco. Also compared were 150 non-glaucoma patients receiving conventional phaco and 145 receiving femtosecond laser-assisted phaco.

All femtosecond laser procedures used the Bausch + Lomb VICTUS platform for capsulorhexis, lens fragmentation and lens incisions, and all phaco in all procedures was done with the Stellaris device. Xenoplast collagen drainage devices were implanted in the sclerectomy procedures to help maintain aqueous outflow and reduce bleb fibrosis.

IOP AND VISUAL OUTCOMES

After applying the laser vacuum docking ring, IOP in the femtosecond laser combined procedure group ranged from 14 to 38mmHg, depending on the severity of glaucoma, Prof Anisimova reported. Docking added a load of 10N, and patients did not lose light perception during the procedure.

After surgery, IOP declines were similar for the femtosecond laser and conventional phaco combined procedure groups, respectively declining from pre-op means of 26.4mmHg and 30.1mmHg, to 24.8 and 29.1mmHg one day after surgery; 16.4 and 19.4mmHg at seven days; and 16.9 and 18.1mmHg at six to 12 months. Patients receiving femtosecond laserphaco or phaco without sclerectomy saw slight increases in IOP one day after surgery, returning to close to preoperative levels at six to 12 months.

Mean best corrected visual acuity improved similarly in all groups, from about 0.2 or 20/100 pre-op to about 0.7 or 20/30 one month post-op. Outcomes were similar between patients with and without glaucoma. Overall, complications were low in all groups, though a few complications specific to the femtosecond laser stage were observed, Prof Anisimova said.

Early on, pupil constriction occurred in 30 per cent of cases, though this was reduced to 12 per cent by using mydriatics and non-steroidal anti-inflammatory drops one day before surgery.

Vacuum was lost in one case leading to laser tracing on the patientâ&#x20AC;&#x2122;s iris, though this did not affect visual outcome, she added. The data suggest that femtosecond laser cataract surgery is safe for use in glaucoma patients receiving combined procedures, Dr Anisimova concluded.

Svetlana Anisimova: xen3744@yandex.ru

EUROTIMES | FEBRUARY 2015

Svetlana Anisimova

GLAUCOMA

19

HYPERTENSION NEI-sponsored study provides evidence base for treatment with acetazolamide. Cheryl Guttman Krader reports

VARIABLE Mean change in PMD from baseline to six months in the most affected eye was analysed as the primary outcome variable, and improvement occurred in both the acetazolamide (1.43dB) and control groups (0.71dB). However, the treatment effect (difference between groups) was statistically significant and stronger among eyes with higher (grade 3-5) versus lower (grade 1-2) papilledema grades (2.27dB vs −0.67dB).

Compared to placebo, acetazolamide was also associated with a statistically significant benefit for greater reduction in optic disc swelling (mean papilledema grade change, −1.31 vs. −0.61) and greater improvement in vision-related and other quality of life measures.

There were also significant differences favouring acetazolamide over placebo in analyses of visual field change and papilledema grade for the fellow eye along with trends for a lower treatment failure rate (1.2 per cent vs 7.6 per cent) and greater CSF pressure lowering (−117.3 vs −72.2mmHg) in the acetazolamide group.

A case of papilledema from an IIH patient

Courtesy of Michael Wall MD

R

ecently reported results from a multicentre, randomised, double-masked, placebo-controlled study provide the first solid evidence to support oral acetazolamide as treatment for visual loss associated with idiopathic intracranial hypertension (IIH) (JAMA. 2014;311(16):1641-51).

Funded by the National Eye Institute of the National Institutes of Health, the IIH Treatment Trial included 165 adults enrolled at 38 North American study sites. Eligible patients met modified Dandy criteria for IIH, were untreated for IIH, and had mild visual loss [perimetric mean deviation (PMD) between -2dB and -7dB], bilateral papilledema and elevated cerebrospinal fluid (CSF) opening pressure.

All patients were offered a weight loss programme incorporating lifestyle/behavioural modification and a lowsodium weight-reduction diet plan. They were randomised 1:1 to treatment with a maximally tolerated dosage of acetazolamide or matching placebo. Acetazolamide was initiated at 500mg BID and titrated up to a maximum of 4 g/day based on disease signs and symptoms and adverse events.

A normal optic disc

Patients in both groups experienced significant weight loss from baseline, although acetazolamide-treated patients lost significantly more weight than the controls (−7.50 vs −3.45kg), perhaps due to acetazolamide-related side effects. However, a separate analysis established that the treatment effect of acetazolamide on PMD was not mediated by its association with greater weight loss, and the medication was well-tolerated. While adverse events and adverse event-related withdrawals were more common with acetazolamide, there were no unexpected or known permanent untoward side effects associated with its use.

Michael Wall MD, IIHTT director and professor, Departments of Neurology and Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, told EuroTimes, “For the first time, data from a properly controlled clinical trial is available to guide therapy for patients with IIH. Although the effect size of 0.71dB may not be a clinically significant amount of visual improvement, the fact that visual quality of life measures were also significantly better in the acetazolamide group suggests the effect is clinically meaningful.”

Dr Wall said that based on the study outcomes, the investigators strongly suggest that patients with mild visual loss and moderate to marked papilledema associated with IIH be treated with acetazolamide at the maximally tolerated dosage coupled with a low sodium weight loss programme. Since the combined medical regimen was also found to significantly lower CSF pressure, improve general and visual quality of life scores and reduce papilledema, it is also suggested for all patients with IIH-related visual loss, he said.

“Patients with papilledema grades 1 or 2 and no visual field loss can be managed with diet alone, but should be followed closely and started on acetazolamide if they worsen,” Dr Wall added.

He suggested the combined medical regimen or surgery could be considered for IIH patients with worse visual loss (PMD >-7dB).

“Another clinical trial will be needed to establish an evidence base to make recommendations for management of patients with IIH having more severe visual loss. However, starting with the medical intervention and transitioning to surgery if there is worsening would seem to be a reasonable compromise,” Dr Wall said.

Michael Wall: michael-wall@uiowa.edu EUROTIMES | FEBRUARY 2015

20

ADVERTORIAL

ADVERTORIAL

21

GLAUCOMA

iPHONE OCT?

A

New technologies can improve access to modern glaucoma diagnostic techniques. Roibeard O’hEineachain reports

convergence of mobile and cloud-computing technology with new diagnostic techniques for glaucoma has the potential to greatly improved access to expert clinical opinion for glaucoma patients in remote parts of the world, and their capabilities will only expand as the technology improves, according to presentations at the 11th Congress of the European Society of Glaucoma in Nice.

Already there are mobile phone attachments available which can provide a sharp fundus image that can then in turn be uploaded to a database from where it can be assessed by specialists anywhere in the world. Moreover, there is nothing currently standing in the way of creating an optical coherence tomography (OCT) attachment for smartphones that can be used in a similar way, said Prof Rainer A Leitgeb MD, PhD, University of Vienna, Austria.

“Basically all the necessary technology is available today to create a mobile phone based OCT. They only need to be optimised and put together,” he said.

He noted, for example, that the miniaturised integrated interferometer optics necessary for a smartphone-based OCT system are already available. The same is true of the small scanners suitable for such devices, which are available with Micro-Electro-Mechanical Systems (MEMS) technology. Small and efficient light sources have also been developed that would be suitable for use as part of a smartphone-based OCT device.

And finally the data reduction techniques necessary with a smartphone-based system are available in the form of sparse imaging. In a manner similar to JPEG image compression, sparse imaging compressive sampling and then reconstruction of the image provides a good preservation of image quality, he added.

Courtesy of W Blair Donaldson MD

22

Patient in front of TV screen with Wacom pen and pad in right hand. Assistant with laptop on right

The electronic digital interconnectedness of modern society also raises the prospect of perimetry being performed in the practice or even at a patient’s home W Blair Donaldson MD

VISUAL FIELDS THROUGH THE CLOUD The electronic digital interconnectedness of modern society also raises the prospect of perimetry being performed in the practice or even at a patient’s home, said W Blair Donaldson MD, managing director of IbisVision, Aberdeen, Scotland, UK. He noted that he and his associates have developed a perimetry system called RingOfSight™ that only requires some special software, a laptop computer connected to a standard television set and a Wacom tablet and pen, and a camera to measure the direction of gaze.

The test normally takes just over two minutes, making it much faster than standard 24/2 perimetry but provides similar results, he said.

Other advantages include significant advantages in cost because it only requires very conventional hardware.

In addition, the software for conducting the test and assessing and comparing the results is not installed on the laptop connected to the wide-screen TV. Instead it is installed on Rainer A Leitgeb MD, PhD a remote server.

Basically all the necessary technology is available today to create a mobile phone based OCT

EUROTIMES | FEBRUARY 2015

There are two tests available with the new system, a full threshold test and a supra threshold test. The full threshold test involves the patient viewing the screen and moving a ring-shaped cursor over darkening spots that appear at various points in a random manner. The spots are first a very light grey and then gradually darken.

When the patient moves the ring over the target spot a new target spot appears on the screen and the patient moves the ring to the new spot as soon as they become aware of it . The sooner the patient covers the spot , the higher the sensitivity score. The patient repeats the exercise 52 times to build up a visual field.

The supra threshold test comes into play if the patient does not initially see the target. In those cases the spot moves closer to the last ring’s target until the patient registers its position by moving the ring over it.

“This gives an accurate distance of the scotoma from fixation, which is obviously useful in assessing the progress of the disease,” Dr Donaldson said.

Dr Donaldson and his associates have conducted a feasibility study with the RingOfSight system as part of the Northern Finland Birth Cohort Study. The study involved 131 patients, all of whom were tested with both the RingOfSight and the Humphrey perimeter, and 95 per cent of patients said that they preferred the RingOfSight, he noted. rainer.leitgeb@meduniwien.ac.at wbmdonaldson@doctors.org.uk

RETINA

RETINAL ISCHAEMIA Hitting the target with navigated retinal photocoagulation.

Dermot McGrath reports

T

argeted retinal photocoagulation (TRP) seems to offer a safe and potentially less traumatic approach to the treatment of retinal ischaemia in diabetic retinopathy and venous occlusive eye diseases, according to a study presented at the 14th EURETINA Congress in London.

“TRP is an alternative approach to standard destructive pan-retinal photocoagulation in the treatment of ischaemic retinal conditions. Using integrated imaging technology with retinal eye-tracking we can deliver targeted laser treatment to the affected areas while sparing surrounding tissue,” said Igor Kozak MD, PhD, MAS. Retinal laser photocoagulation of the posterior pole has undergone some revolutionary changes in recent years, noted Dr Kozak, with innovations such as semi-automated delivery, micropulse and selective application and the use of imaging technologies helping to improve the safety and accuracy of laser photocoagulation procedures.

Dr Kozak, a retina specialist and vitreoretinal surgeon at the King Khaled Eye Specialist Hospital, Saudi Arabia, said that TRP offers several advantages over pan-retinal laser photocoagulation (PRP), which remains the treatment of choice in numerous retinal ischaemic conditions.

“Complications of PRP even when it is well performed include laser scar expansion, worsening of macular oedema, retinal breaks and subretinal bleeding. The introduction of short-pulse pattern or sub-threshold micropulse lasers has helped somewhat to overcome these problems, but the treatments are still not as targeted as they could be when the latest imaging technology is incorporated into the procedure,” he said.

The rationale behind TRP is to direct laser photocoagulation to pathologic areas of the retina only, said Dr Kozak.

For TRP, Dr Kozak said he uses the Navilas navigated laser photocoagulator (OD-OS, Inc., Irvine, US), which integrates retinal imaging, fluorescein angiography and retinal laser in one device. Photocoagulation is executed based on previously acquired images from the same system, or imported images from another device, and the subsequent treatment plan to target the pathologic areas.

The physician prepares the treatment plan based on either angiography or fundus photos, and then overlays the plan on live retina so laser photocoagulation can follow ocular movements during treatment without contact lenses.

To test the safety and efficacy of the approach, Dr Kozak carried out a pilot case series on eight eyes of six patients with diabetic retinopathy. All pre-planned ischaemic areas were targeted by laser. Four months after treatment, just one eye needed additional photocoagulation for persistent neovascularisation while the other eyes showed no signs of proliferative disease or adverse effects from the treatment.

Dr Kozak said that navigated TRP seems to offer a viable approach to standard destructive PRP in the treatment of ischaemic retinal conditions. “The advantages include precise documentation of treatment areas with decrease in false positive and false negative laser applications,” he concluded.

Igor Kozak: ikozak@kkesh.med.sa EUROTIMES | FEBRUARY 2015

23

RETINA

SUBGROUP ANALYSIS

OCULUS Pentacam HR ®

Aflibercept outshines laser in diabetic macular oedema.

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egardless of the baseline visual acuity, patients with diabetic macular oedema (DME) appear to have better functional and anatomic outcomes with intravitreal aflibercept (EYLEA®, Regeneron Pharmaceuticals) than they do with laser photocoagulation, and those with the worst baseline vision seem to have the greatest functional and anatomical improvements with the antiVEGF agent, according the results of the VIVID and VISTA Phase III studies, said Edoardo Midena MD, PhD, University of Padua, Italy.

In a paper he presented at the 14th EURETINA Congress in London, Dr Midena described the findings of a subgroup analysis he and his associates conducted of the two similarly-designed studies that compared the safety and efficacy of intravitreal aflibercept and macular laser photocoagulation in the treatment of DME with central involvement.

The purpose of the subgroup analysis was to evaluate the impact of baseline visual acuity on visual outcomes and changes in central retinal thickness in DME patients receiving aflibercept.

The two studies involved a total of 865 patients, 404 in the VIVID study, conducted in the US, and 461 in the VISTA study, conducted in Europe and Japan.

In both studies patients were randomised to receive intravitreal aflibercept 2.0mg every four weeks (2q4) plus sham laser, intravitreal aflibercept 2.0mg every eight weeks (2q8) after five initial monthly doses plus sham laser, or laser photocoagulation plus sham intravitreal treatment.

The subanalysis showed that among patients receiving aflibercept there was a trend towards an inverse correlation between baseline best corrected visual acuity (BCVA) and the amount of improvement in BCVA during treatment.

In contrast, the changes in BCVA with laser treatment appeared to bear no relation to baseline BCVA and the results with laser were inferior to those achieved with aflibercept in all baseline BCVA subgroups. In the VIVID trial, the mean changes in BCVA from baseline to week 52 for the 2q4, and 2q8 intravitreal aflibercept regimen groups were gains of 15.3 and 20.6 letters respectively, among those with baseline BCVA of less than 40 letters, gains of 12.0 and 10.2 letters respectively among those with baseline visual acuity between 40 and 55 letters, and gains of 11.6 and 11.5 letters respectively among those with baseline visual acuity between 55 and 65 letters.

The reductions in central retinal thickness followed a similar pattern, Dr Midena noted. That is, central retinal thickness in the 2q4 and 2q8 intravitreal aflibercept regimen groups was reduced by 423.3 microns and –355.3 microns respectively, among those with baseline visual acuity of less than 40 letters, but by only 135.7 microns and 132.6 microns among those with a baseline BCVA greater than 65 letters.

The visual and anatomic results of the VIVID and VISTA studies were virtually identical for all baseline visual acuity subgroups, Dr Midena noted. Laser compared poorly with intravitreal aflibercept in both studies, achieving mean gains of BCVA no greater than 2.8 letters and mean reductions in central retinal thickness no greater than 145.9 microns.

Edoardo Midena: edoardo.midena@unipd.it

EUROTIMES | FEBRUARY 2015

RETINA

25

PHENOTYPE FINDINGS Study probes genetic underpinning of diabetic retinopathy.

Dermot McGrath reports

COMPLICATIONS “As we try to look at why these patients develop complications, risk algorithms based on the diabetic disease are not necessarily completely foolproof. Because every one of us who has dealt in the clinic with patients with diabetes knows that some patients with excellent metabolic control who follow their physicians’ instructions may still develop CSME and potentially proliferative retinopathy, whereas other patients who are less careful never go on to develop macular oedema. It follows then that there is a need to identify causes from natural history studies,” said Prof Cunha-Vaz. Prof Cunha-Vaz’s prospective study of 348 patients with NPDR and two years follow-up set out to examine the association of different candidate genes with different phenotypes of NPDR and risk for development of CSME. Patients were classified in groups of three different phenotypes of retinopathy

Courtesy of José Cunha-Vaz MD

D

ifferent genetic polymorphisms appear to be associated with different phenotypes of non-proliferative diabetic retinopathy (NPDR), according to a study presented by José Cunha-Vaz MD at the 14th EURETINA Congress in London.

“It is known that diabetes causes neurodegenerative changes, and in the retina the microvascular response to the degenerative changes is different in different patients and is apparently genetically determined. Our study showed that different phenotypes of progression of NPDR have different risks for progression to clinically significant macular oedema (CSME),” he said.

Prof Cunha-Vaz, Emeritus Professor of Ophthalmology of the University of Coimbra, Portugal, noted that there are different risks for vision loss in different patients with similar metabolic control and duration of disease.

Examples from individual patients belonging to the three different phenotypes.

Phenotype A: MA Turnover ≤ 6 and area with retinal thickness values in the normal range (< 5% increase over normal range) Phenotype B: MA Turnover ≤ 6 and area with > 5% increased retinal thickness over normal range Phenotype C: MA Turnover > 6 and variable retinal thickness. MA T – microaneurysm turnover, calculated over a six-month interval

progression based on non-invasive methods: colour fundus photography to assess microaneurysm turnover using the RetmarkerDR (Critical Health SA, Coimbra, Portugal), and optical coherence tomography (OCT) to measure retinal thickness. The development of CSME was also addressed.

Eleven genes were selected from a list of candidate genes and their single nucleotide polymorphisms (SNPs) were filtered through bioinformatics tools.

Prof Cunha-Vaz said that three different phenotypes of NPDR with different risks for CSME were identified using Ward’s cluster analysis over the follow-up period.

Phenotype A was characterised by microaneurysm turnover of less than six and with normal retinal thickness; phenotype B was also characterised by a

As we try to look at why these patients develop complications, risk algorithms based on the diabetic disease are not necessarily completely foolproof José Cunha-Vaz MD

low microaneurysm turnover less than six, but with increased retinal thickness (greater than 220 microns); while phenotype C had a turnover greater than six and variable thickness (153 to 297 microns).

Phenotype A can be characterised by slow progression with absence or low levels of leakage and microaneurysm turnover; phenotype B as “leaky” with increased retinal thickness on OCT scans; and phenotype C as “ischaemic”, a more rapid progressive type with increased microaneurysm turnover and active remodelling of the retinal circulation, explained Prof Cunha-Vaz. “We found that after two years of follow-up, phenotypes B and C present a much higher risk for CSME development when compared to subjects in phenotype A. In the latter group, only one patient in 133 developed CSME, compared to eight out of 94 for phenotype B, and 17 in 121 for phenotype C,” said Prof Cunha-Vaz. Summing up, Prof Cunha-Vaz said that there are different phenotypes of progression of NPDR which have different risks for CSME, and there is growing evidence of the association of specific SNPs for each specific phenotype.

José Cunha-Vaz: cunhavaz@aibili.pt EUROTIMES | FEBRUARY 2015

26

RETINA

MACULAR HOLE SURGERY Study: Prone positioning provides no benefit.

Sean Henahan reports

F

ace down positioning provides no benefit following macular hole surgery, the latest findings from an Australian multicentre prospective study suggest.

Alex Hunyor MD, a principal investigator of the Australian Macular Hole Study, discussed the latest results of the ongoing study during a session of the American Society of Retina Specialists in San Diego, California.

“The main aim of the study was to have a useful audit tool for surgeons, where we could have a large dataset for benchmarking of results of macular hole surgery, and assess the factors affecting hole closure and visual results,” said Dr Hunyor, Vitreoretinal Surgeon at Sydney Eye Hospital.

The Australian Macular Hole Prospective Survey is a national audit of macular hole surgical outcomes that began recruitment in November 2008. The study tracks all macular hole cases performed by participating surgeons. Initially this was done with a paper entry form system, but the system now involves online data entry.

“This has made it lot faster and more simple. The aim is to have it quick and unambiguous, in order to get good quality data.

Respondents enter baseline information including hole stage and size, vitreous attachment and surgical information. They then follow up later with hole closure data, visual results, lens status and any complications. This can mostly be done by staff. I tested

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it myself recently and it takes less than five minutes. It is a real credit to my colleague Dr Rohan Essex, who devised the system and pioneered the study.”

The utility of prone positioning of patients after macular hole surgery still stirs heated debate. Earlier studies of this question had shortcomings in design and produced ambiguous results. A small number of studies showed some apparent benefit of face down positioning in some patients, but other research casts doubts on this approach, he noted.

While the initial rate of prone positioning reported in 2008 was 90 per cent, this has declined steadily, and in 2014 is at 60 per cent. Surgeons report ordering anywhere from 0-15 days of postoperative prone positioning. During that same period ILM (internal limiting membrane) peeling has become a standard part of the surgical procedure.

“ILM peeling is now pretty universal. It is worth noting that we have not used ICG dye in Australia for 10 years. Rather we are using various blue dyes. ILM peeling has significantly improved success rates with no apparent downside,” he said.

There was no difference in success between the shorter acting SF6 gas and the longer acting C3F8 gas. Those using the longer acting gas may have chosen it based on the idea that those cases were less likely to succeed, Dr Hunyor noted.

With 90 per cent follow-up of more than 2,000 cases, primary hole closure was achieved in 95 per cent of cases. Larger holes of longer duration were less likely to be successfully treated. Patients starting with better baseline vision had a lower chance of improving by three lines. Older age was associated with less improvement. Patients who had undergone combined phacovitrectomy were perhaps not surprisingly more likely to have good early visual outcomes.

Overall complication rates were low, with very few cases of retinal detachment (1.5 per cent) and no cases of endophthalmitis.

As far as the big question was concerned, “the study suggests that face down positioning confers no benefit. In the land down under, there is much less face down under. We would like to see a randomised controlled clinical trial to evaluate this further. I do think there may be a small role for prone positioning in patients who are slightly underfilled with gas on the first postoperative day,” said Dr Hunyor.

“We have not used face down positioning since 1995,” noted Paul Tornambe MD, director of the San Diego Retina Research Foundation and past president of the American Society of Retina Specialists, who published the first paper on no face down positioning in 1997.

“It requires a leap of faith for most retinal surgeons to believe that face down positioning is not necessary. If you advocate face down positioning you believe that the buoyancy of the bubble has some positive effect that helps hole closure. I can’t agree with that.”

The main aim of the study was to have a useful audit tool for surgeons, where we could have a large dataset for benchmarking of results...

Alex Hunyor MD

EUROTIMES | FEBRUARY 2015

Alex P Hunyor: aphunyor@gmail.com Paul Tornambe: TornambePE@aol.com

World Society of Paediatric Ophthalmology and Strabismus

3

rd

World Congress of Paediatric Ophthalmology and Strabismus Fira Gran Via, Barcelona, Spain 4â&#x20AC;&#x201C;6 September 2015

www.wspos.org

/WSPOS @WSPOS

Expertise Does Not Reside in Only One Part of the World

SAN DIEGO APRIL 17–21

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

REGISTER TODAY—TIER II SAVINGS END ON APRIL 3 ·Crossover access to 1,300 ASCRS and ASOA presentations and post-meeting resources ·Roundtables, a comprehensive coding track, and special guest speakers ·Innovative panels, discussions, and lectures on the latest techniques and technologies ·Unique networking events with ophthalmology’s physician and industry leaders ·3-day entry to the ASCRS•ASOA Exhibit Hall featuring over 300 leading vendors FOLLOW @ASCRSTWEETS AND @ASOATWEETS ON TWITTER. #ASCRSASOA2015

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

A joint meeting with

INDUSTRY NEWS

Friday 4 September

ESCRS

Glaucoma Day 2015 Immediately preceding the XXXIII Congress of the ESCRS 5–9 September

INDUSTRY

NEWS

USER FRIENDLY OCT

Scientific Programme organised by

NIDEK has launched the Retina Scan Duo Optical Coherence Tomography (OCT) with a high definition OCT and fundus camera in one compact system.

“The Retina Scan Duo is a user friendly, versatile unit that provides high definition images,” said a company spokesman.

“The NIDEK 3-D auto tracking, auto shot and user friendly interface allow rapid and easy image capturing. Once alignment is completed, OCT and colour fundus images can be captured in a single shot,” he said. www.nidek.co.jp

TRANSZONULAR INJECTION CANNULA Sterimedix has announced the introduction of a new cannula for transzonular injections.

“Designed in conjunction Dr Jeffrey T Liegner MD, the cannula is designed for the intraoperative injection of steroid-antibiotic combinations at the end of a standard cataract procedure which may

replace the traditional patient-administered prophylaxis of antibiotic eyedrops,” said a company spokesman.

Available in 27g, the new cannula is angled with a 2mm distal segment to facilitate safe and easy injection of the drug with minimal risk to the zonules. www.sterimedix.com

www.escrs.org

EUROTIMES | FEBRUARY 2015

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30

OPHTHALMOLOGICA

OPHTHALMOLOGICA VOL: 232 ISSUE: 4 MONTH: DECEMBER 2014

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GOOD PROGNOSIS FOR MACULAR HOLE FELLOW EYES The results of a retrospective study indicate that the healthy fellow eye of patients with macular eye surgery is not at high risk of developing macular holes in the years that follow. The study included 153 patients with a mean age of 65.5 years and a mean follow-up of 33.5 months. OCT detected the vitreomacular attachments in 52 per cent (80 eyes) at initial examination, and 23 per cent at three years. Of the remaining 40 eyes in which vitreomacular separation occurred during follow-up, 11 (28 per cent) developed macular holes at mean interval of 45 months after the surgery. None of the eyes with vitreomacular separation at presentation developed a macular hole. F Otsuji et al, “LongTerm Observation of the Vitreomacular Relationship in Normal Fellow Eyes of Patients with Unilateral Idiopathic Macular Holes”, Ophthalmologica 2014; Volume 232, No 4 (DOI:10.1159/000362460).

FACTORS PREDICTIVE OF SUCCESS WITH DEXAMETHASONE IMPLANT There appears to be several factors that are predictive of visual outcomes in eyes which undergo implantation with Ozurdex dexamethasone intravitreal implants, according to the findings of a retrospective study. The study’s authors analysed the medical records of 43 consecutive treatment-naïve eyes that underwent repeated Ozurdex injections on a PRN basis for macular oedema secondary to recent onset retinal vein occlusion. Both mean BCVA and central macular thickness improved significantly by the end of the 12 to 22 weeks of follow-up (p = 0.0001), and more than 30 per cent of the eyes gained three or more lines within three months of repeated injections. Presence of foveal serous retinal detachment and macular ischaemia were predictive of poor visual outcomes.

Improvements were significantly associated with baseline BCVA and the integrity of the ellipsoid zone. E Maggio et al, “Intravitreal Dexamethasone Implant for Macular Edema Secondary to Retinal Vein Occlusion: 12-month Follow-Up and Prognostic Factors”, Ophthalmologica 2014; Volume 232, No 4 (DOI:10.1159/000364956).

IMPLANT PROVIDES A QUICK FIX The Ozurdex dexamethasone implant is effective in controlling posterior segment inflammation and reduces central retinal thickness quickly and effectively, say the findings of a new study.

Among 84 patients who received a dexamethasone intravitreal implant for intraocular inflammation of various aetiologies, 61 per cent achieved clearance of vitreous haze after four weeks (p < 0.001) which persisted until week 24 (p < 0.001). There was a concurrent reduction of central retinal thickness and improvements in BCVA. U Pleyer et al, “Fast and Successful Management of Intraocular Inflammation with a Single Intravitreal Dexamethasone Implant”, Ophthalmologica 2014; Volume 232, No 4 (DOI: 10.1159/000368987).

SEBASTIAN WOLF Editor of Ophthalmologica The peer-reviewed journal of EURETINA

protectalon_eurotimes3.pdf

1

BOOK REVIEWS 10:42

12/01/15

SYSTEMIC DISEASES As ophthalmologists, we often have the feeling that we can ignore the rest of the patient’s body and concentrate exclusively on the eyes. Nothing could be further from the truth.

Systemic symptoms or abnormalities can often furnish the clinician with important information useful PUBLICATION in the diagnosis of ophthalmic OCULAR SYNDROMES disease. On the one hand, & SYSTEMIC DISEASES these situations are admittedly AUTHOR rare. On the other hand, the FREDERICK HAMPTON ROY diagnoses involved are often serious, and missing them can PUBLISHED BY JAYPEE BROTHERS have devastating consequences.

MEDICAL PUBLISHERS The fifth edition of Ocular Syndromes & Systemic Diseases, by Frederick Hampton Roy (Jaypee Brothers Medical Publishers), is a reference guide for these cases. This giant book covers 1,620 syndromes, arranged alphabetically, and includes everything from common wellknown conditions such as diabetes mellitus to rare and unusual entities like heredopathia ophthalmo-oto-encephalica.

Information is stripped down to the absolutely most basic necessary facts under the headers of: “General”, “Ocular”, “Clinical”, “Laboratory”, “Treatment” and “Bibliography”.

The book is designed to orient the reader and to confirm his or her diagnosis quickly and efficiently. It is a companion text to Ocular Differential Diagnosis by the same author, which rather than being arranged alphabetically by disease, is organised as lists of causes of symptoms, such as ptosis and strabismus.

The manual is useful for all ophthalmologists, including residents who are studying for board exams.

BOOK

REVIEWS

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M

Y

CM

MY

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CMY

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CORNEAL REFRACTIVE SURGERY

Surface Ablation: Techniques for Optimum Results, by Ellen E Anderson Penno (Slack Incorporated), narrows the focus down to a very specific topic, namely non-flap-based corneal refractive surgery. The book covers PRK, LASEK and epiLASIK, starting with an introduction to the reasons for the resurgence of these techniques after a long period of dominance by flap-based procedures. PTK is also covered, despite not being a strictly refractive procedure.

The various techniques are described, as are their variations and enhancements, such as wavefront-optimised and wavefront-guided treatments. Particularly useful are the chapters that focus on patient selection, postoperative management and the factors affecting patient satisfaction. The author stresses that “every refractive surgeon has observed the variability in patient satisfaction”.

The technical aspects of the procedures are also detailed, including such crucial information as which corneal pathologies can be expected to recur following PTK. According to the author, the book “is intended for both new refractive surgeons who want to learn about surface ablation and experienced surgeons who may be transitioning back to no-flap treatments”.

LEIGH SPIELBERG Books Editor

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

EUROTIMES | FEBRUARY 2015

31

San Diego 2015 Save the Date

Friday, April 17 – Monday, April 20, 2015 Make the most of your time at the ASCRS•ASOA Symposium & Congress and attend our EyeWorld programs for additional CME and an opportunity to network with your colleagues.

Registration now open.

Among the topics to be covered in these AMA PRA Category 1 CreditsTM designated sessions are: • A discussion on recent developments in anti-inflammatory therapeutic treatments • Updates on diagnosing and treating the ocular surface, including dry eye disease and meibomian gland disease • New developments in glaucoma medical and surgical treatment options • New considerations and continuing discussions regarding laser-assisted cataract refractive surgery • Maximizing presbyopia-correcting outcomes • Successfully integrating toric IOLs and improving results and patient satisfaction • Mastering phaco dynamics, fluidics, power, and nuclear disassembly techniques • Advanced surgical technologies and techniques for the young physician

These non-CME, ASCRS-authorized educational programs will provide timely and important information on: • Options and considerations in the use of premium IOLs • Advances in technologies, techniques, and outcomes in laser vision correction surgery • An interactive discussion on the applications of femtosecond and excimer lasers for ophthalmic surgery

EyeWorld Corporate Events are directly developed by industry and hosted by EyeWorld. These non-CME meetings provide valuable information on new products, procedures, and applications of existing products. Included among the topics discussed in these sessions are: • Live surgery • New developments in surgical instrumentation • Surgical options for the treatment of dry eye • Growing the overall size of the premium IOL market • Considerations in the selection of a premium IOL • New developments in laser vision correction • Advanced IOL technology • Discussion of technological advances and breakthroughs in cataract surgery • Update on crosslinking • Advances in diagnostic and imaging equipment

Topics are subject to change.

www.EyeWorld.org

EYE ON HISTORY

33

Courtesy of Prof Joaquín Barraquer

Prof Joaquín Barraquer with his daughter and son, Dra Elena Barraquer and Prof Rafael I Barraquer

José Antonio Barraquer Roviralta (1852-1924)

ALL IN THE FAMILY The Barraquers of Barcelona – the family that influenced 20th Century ophthalmology. Dr Andrzej Grzybowski reports

T

he founder of this family of ophthalmologists was José Antonio Barraquer Roviralta (1852-1924), who graduated from medical studies at the University of Barcelona in 1877 and became a PhD in Madrid.

He then devoted himself to studying histology and collaborated with Santiago Ramón y Cajal. His many histological studies contributed to topographical anatomy and histopathological studies, mostly based on eye injuries.

Some of his museum pieces of ocular anatomy and pathology are preserved and deposited in the Centro de Oftalmología Barraquer in Barcelona. Later he was trained in ophthalmology in Paris, under Ksawery Galezowski (1832-1907) and Louis de Wecker (1832-1906).

After returning to Barcelona, he opened an ophthalmic clinic at the old Hospital de la Santa Cruz, where he worked from 1880 to 1890. At that time, it was decided to introduce ophthalmology teaching to medical schools, and he was proposed as the professor of ophthalmology.

In 1903 he founded the Ophthalmological Society of Barcelona, and edited two Spanish ophthalmic journals. His brother Lluis Barraquer Roviralta (1855-1928) was a pioneer of neurology in Spain, and was the first to describe progressive lipodystrophy, also known as Barraquer’s Syndrome.

The son of Jose Antonio, Ignacio Barraquer (1884-1965), was also born in Barcelona, where he studied medicine and earned degrees in both his BA in 1907 and his PhD in 1908.

While still a student, he completed two important works on Dacryocystitis of the newborn and tuberculosis of the iris. Later

he worked at the Holy Cross Hospital in Barcelona, as an assistant and later an assistant professor in the University Chair of Ophthalmology and after his father retired, as his successor.

In 1947 he founded the Barraquer Institute in Barcelona, which soon became one of the world’s best ophthalmology centres. This private centre has organised postgraduate courses, conducted experimental and clinical research, produced scientific and educational films and published ophthalmologic literature.

Ignacio Barraquer is best remembered for his idea of extracting the cataract by applying a vacuum or suction cup (1917) with much less damage than other techniques used at that time.

He also designed the necessary instruments, built up the sucking cup and the vacuum-producing mechanical device producing adjustable vacuum to facilitate the extraction of the crystalline lens, and proved the effectiveness of the procedure.

AQUARIUM Ignacio confirmed that the idea was the result of observation of his aquarium, while watching how a leech apprehended a pebble from the bottom: “If I could catch the human eye lens in the same way that a leech moving it picks up a pebble and moves it along the aquarium without moving any water, the pneumatic suction produced by the sucking cup would break the fibres of the zonule - ligament by which the lens remains fixed - and this way I could gently draw out the cataract with minimal trauma."

The invention brought him and the Barraquer Institute in Barcelona international recognition and patients from all over the world, ensuring he deserved the epithet “Universal Catalan”.

His most famous patient operated on with this technique was Eugenia de Montijo, Empress of France, wife of Napoleon III. He also influenced numerous original techniques (eg dacryocystorhinostomy, sclerotomy, reconstruction of the orbital cavity, strabismus surgery, sclera-iridectomy etc), and developed many surgical instruments (eg sclerotome, forceps for iridectomy, keratoplasty instruments etc).

With his wife Josefa Moner, they had seven children, of whom two, José Ignacio and Joaquín, entered the world of ophthalmology. The eldest son, Jose Ignacio Barraquer Moner (1916-1998), settled in Bogotá in 1953 after specialisation in ophthalmology, where he founded the Barraquer Institute of America in 1964.

His name is best known for his works on keratoplasty and his idea and development of keratomileusis, keratophakia and introducing the refractive surgery to ophthalmology.

Joaquín Barraquer Moner (1927-), Professor of Eye Surgery at the Universitat Autònoma de Barcelona (UAB) and director of the Institut Universitari Barraquer (affiliated to the UAB), in 1957 discovered the action alpha-chymotrypsin on the human zonule and developed the technique of “enzymatic zonulolysis”, a surgical procedure that significantly facilitated the extraction of the cataract.

He also introduced many other developments to ophthalmology, including a new type of microscope and several types of intraocular lenses. Now, the Barraquer dynasty in Barcelona is continued by Joaquín Barraquer’s daughter Elena and his son Raphael, as well as his son’s wife Marinka Kargachin. * Andrzej Grzybowski MD, PhD, MBA, Professor of Ophthalmology; Chair of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland EUROTIMES | FEBRUARY 2015

34

REVIEW

A

B

Figure 1: Biaxial phaco tip showing flow without (A) and with (B) the air pump fixed to infusion bottle. C: Glass infusion bottle with air pump and infusion tubings connected.

D: Schematic showing gas forced infusion to prevent surge

C D

PHACO FLUIDICS

Everything you ever wanted to know about phaco fluidics.

Dr Soosan Jacob reports

F

luidics play an important part in phacoemulsification and should be understood clearly by the beginner surgeon. Flow and vacuum both attract pieces towards the probe whereas phaco power repels pieces.

This article discusses some important terminologies on the subject.

FLUID INFLOW

Fluid enters the anterior chamber (AC) from the infusion bottle. This flow may be regulated by adjusting the bottle height when it is a purely gravity dependent mechanism (approximately 11mmHg above ambient atmospheric pressure for every 15cm bottle height above the patient's eye), or it may be in the form of pressurised infusion (either as an air pump connected externally to the infusion bottle or as inbuilt gas forced infusion).

EUROTIMES | FEBRUARY 2015

FLUID OUTFLOW Fluid exits the AC through the aspiration tubing as well as via leakage from incisions. This outflow is determined by the aspiration flow rate (AFR), vacuum, incision size and geometry.

ASPIRATION FLOW RATE This refers to the amount of fluid that leaves the eye through the aspiration tubing per unit time. It is measured in cc/ minute. A high AFR results in more rapid events. It can therefore result in more rapid removal of nuclear fragments but also result in less time for the surgeon to react, which may result in complications. Inflow needs to be increased when using high AFR to maintain a stable AC. This is better achieved using pressurised air infusion, the other option being to elevate bottle height.

The AFR can act as a third hand within the AC by producing fluid currents that can

be used to direct nuclear material into the aspiration port.

These fluid currents flow from the irrigation ports in the sleeve towards the aspiration port. Faster AFR produces stronger currents. Some degree of turbulence occurs because of incisional leakage and other variables. The currents are stronger closer to the aspiration port, and therefore followability of material can be increased either by increasing AFR or by taking the aspiration port closer to the fragments.

VACUUM This is generated by the phaco machine pump and is the vacuum effective in the AC. It is measured in mmHg. Vacuum may be created by either peristaltic or Venturi pumps. Vacuum is produced in peristaltic pumps (flow based pump) on occlusion of the port. However, it may also be produced without occlusion at high

REVIEW flow rates and thus can emulate a Venturi pump at higher flow rate settings. Flow and vacuum may be adjusted independently.

Vacuum is created even without phaco tip occlusion in Venturi pump (vacuum based pump), however vacuum and flow rate cannot be adjusted independently. Rapid flow rates and rapid rise times are seen with Venturi pumps. Alcon uses a peristaltic pump; the AMO pump can switch between peristaltic and Venturi mechanisms in the same surgery, whereas B&L has both peristaltic and Venturi but these cannot be switched in the same surgery.

PRE-SET OR MAXIMUM VACUUM This refers to the maximum vacuum level set by the surgeon. Actual vacuum depends on foot pedal position (with linear setting), maximum pre-set level, AFR, port size and degree of occlusion. Vacuum rise time is the speed with which the maximum preset vacuum is attained following complete occlusion. Low rise times make surgery more rapid but give less time to react. This is dependent on AFR, tubing compliance and venting mechanism. Higher the AFR, faster the rise time; lower the compliance of the tubings, faster the rise time. Fluid vented machines also have a faster rise time than air vented machines.

SURGE Surge refers to a sudden shallowing or collapse of the AC in response to an excess

of outflow as compared to inflow. It occurs when occlusion is broken. This can result in an anterior movement of the posterior capsule and a posterior movement of the cornea, both of which can result in complications such as a posterior capsular rent or endothelial loss. Various phaco machines deal with surge by in-built mechanisms. This includes change in pump speed, vacuum rise time or AFR during occlusion; increased inflow on break of occlusion; low compliance tubings, venting etc. Alcon has the INTREPID Fluid Management System, AMO has Fusion Fluidics and B&L has EQ Fluidics.

GAS FORCED INFUSION (AIR PUMP) Surge causes an unstable AC. A simple remedy suggested by Dr Sunita Agarwal was the air pump. A simple fish tank aquarium is connected by a 20G needle and tubing to a non-expandable infusion bottle. This gas forced into the infusion bottle causes a pressure rise that increases the amount of fluid entering the eye thus preventing surge even at higher vacuum levels. A millipore filter is used to prevent infection and to ensure particulate free air. The advantage with in-built gas forced infusion is the ability to actively and digitally control the parameters during surgery according to the conditions or the surgical steps of the individual case. This makes even difficult cases like mature white and hard brown cataracts, small pupils etc easier. It increases

the fluid inflow thus resulting in a well formed, deep and stable AC. This decreases chances of damage to endothelium and capsule. As it allows for higher AFR, it makes surgery more rapid and brings nuclear material towards the probe. The fluid acts as a third hand. The air pump can make bimanual phaco easier and allows use of smaller bore instruments, making even sub-1mm surgery possible.

THERMAL BURNS Overheating of the phaco tip can produce thermal burns at the clear corneal incision.

Coaxial phaco depends on adequate needle cooling by fluid flow around the needle through the infusion sleeve, whereas in biaxial phaco, needle is cooled by incisional leakage, smaller needle diameter and higher flow parameters. Most burns occur during tip occlusion. Tip heating can occur within 1-3sec with inadequate irrigation and aspiration flow. Inadequate irrigation can occur from an unnoticed empty infusion bottle, inadequate bottle height, a crimped infusion sleeve, kinked tubings or a tight incision. AFR can be decreased by tip occlusion, low vacuum, crimped aspiration line or improperly loaded cassette/tubings. * Dr Soosan Jacob MS, FRCS, DNB is a Senior Consultant Ophthalmologist at Dr Agarwalâ&#x20AC;&#x2122;s Eye Hospital, Chennai, India and can be reached at dr_soosanj@hotmail.com

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EUROTIMES | FEBRUARY 2015

35

RESIDENT’S DIARY

JOY AND TERROR

Leigh Spielberg describes how it felt when his attending

surgeon first left him on his own to carry out surgery

“T

his looks like I don’t know whether he left a pear,” I said the operating room because he to Dr van actually had something useful Ruyven, as we to do. Maybe he wanted to both peered test me, to see whether I could through the maintain my composure with operating microscope at the no supervision close at hand. next patient’s eye. He tried not Ceding responsibility to a to smile, but couldn’t resist. young cataract surgeon is a “Pear” or “P-E-A-R” is our step-by-step process. Once the acronym for “Perfect Eye for resident has repeatedly shown A Resident”. We use the term that she or he can complete as a subtle way to indicate a procedure independently whether the attending with a reasonable level of skill, surgeon would allow the attending moves further the resident to perform the away from the possibility of next phaco. immediately assisting should “Every single one looks something go wrong. like a pear to you today,” Dr The first step is to scrub in, van Ruyven said. This was but to observe the procedure true. As I neared the end of via the live-feed TV screen my third cataract rotation, on the wall. The next is to I really pressed to get as not scrub in at all, but to stay much experience as possible close, physically and mentally, during the last weeks of to the operating table. As supervised surgery. the resident progresses, the My goal was to do half of attending sits elsewhere in the the day’s 12 procedures each OR only occasionally focusing time I was in the operating his or her attention on the room – and more, if possible. resident’s procedure.

He adjusted the During the previous days microscope’s pupillary in the OR, Dr van Ruyven distance to 65mm, which is had been very chatty with the my setting. Doing this is his nurses while I operated. This My goal was to do half of the day’s way of indicating that the was, at first, a bit annoying 12 procedures each time I was in the next operation was for me. and distracting, but I later operating room – and more, if possible Each patient who undergoes realised that it was the next a phaco in our department step in my training. during a resident’s third and final phaco rotation is informed This realisation was a pleasant one. It suggested to me that Dr ahead of time that a resident might perform their cataract van Ruyven trusted me enough to handle these cases. An OR operation. They are then specifically asked whether they agree. can be full of distractions – telephones ringing, instrument trays Most have no objection. rattled, personnel entering the room – and being able to maintain The attending surgeon, of course, treats those who do object. your concentration despite these interruptions is crucial.

Although patients know that being operated on by a resident is a But when he left the room this time, for the first time, it was a distinct possibility, it seems that many prefer not to know, or at bit of a shock. ‘Is he going away? Seriously?’ One part of my brain least not be reminded of it during the operation itself. was ecstatic and the other panicked. I recalled the first time I The unknown aspect of the experience makes it pedalled my bicycle without training wheels and without support. quite frightening, and we all know that a frightened patient Joy. Terror. is not ideal.

There was no time to think about that now. Autopilot. Two Allowing a resident to perform cataract surgery is a timehundred solo procedures had prepared my hands for this moment, consuming and, I imagine, stressful ordeal for the supervising but had they prepared my nerves? attending. Everything takes longer and becomes more Fortunately, a phaco isn’t too lengthy a procedure. On the complicated, even in the absence of complications. other hand, it can really get messy in a hurry. And yet, most But Dr van Ruyven isn’t the stressed-out type. He tolerates problems can wait a few minutes for an attending to return. I my continual pushing for experience, allowing me to do as regained my composure and all went well. I quickly got used to the much as possible. Then he seems to get bored and does some independence and responsibility of operating alone. procedures himself.

After the last case, I saw Dr van Ruyven taking care of some But while I was creating the sideports on this case, I hadn’t more paperwork as I passed by his office. “Don’t worry about that expected him to announce, to no one in particular: “I’m going to stuff right now,” I called out. “We have a whole day in the OR my office to take care of some paperwork.” tomorrow. Time enough!”

Courtesy of Eoin Coveney

36

EUROTIMES | FEBRUARY 2015

JCRS

JCRS HIGHLIGHTS

VOL: 41 ISSUE: 1 MONTH: JANUARY 2015

18 YEARS OF PRK Researchers in the UK looked at 46 patients who had undergone PRK 18 years ago. All had undergone myopic correction with a 6.0mm optical zone. The mean preoperative spherical equivalent refractive error was −4.86 dioptres. The mean change between the first year follow-up and the 18-year follow-up was −0.31D, with a significant increase in variance. Patients younger than 40 years had a mean change of −0.54D, compared with a change of −0.05D in those older than 40 years. The efficacy index was 0.58, with a safety index of 0.998. The corrected distance visual acuity improved significantly over the 18 years. Ninety-six per cent of corneas were clear at 18 years, with a significant reduction in haze scores. There was no evidence of ectasia. Z Shalchi et al, JCRS, “Eighteen-year follow-up of excimer laser photorefractive keratectomy”, Volume 41, Issue 1, 23-32.

15 YEARS OF LASIK FOR HIGH MYOPIA Spanish investigators reviewed the long-term outcomes in 40 LASIK patients treated for high myopia with or without astigmatism. At 15 years, the safety index was 1.23 and the efficacy index was 0.95. During the follow-up, a significant increase in the dioptric power of all keratometric variables was detected. The most notable increase occurred between three months and one year. Low preoperative pachymetry and low residual stromal bed were predictors of keratometric regression.

J Alio et al, JCRS, “Laser in situ keratomileusis for −6.00 to −18.00 dioptres of myopia and up to −5.00 dioptres of astigmatism: 15-year follow-up”, Volume 41, Issue 1, 33-40.

10 YEARS OF CROSSLINKING

JCRS SYMPOSIUM CONTROVERSIES IN OPHTHALMIC SURGERY: HEAD TO HEAD

– Femtosecond Lenticule Extraction – Versus LASIK – Astigmatism Correction: – Femtosecond Laser or Blade?

– Prevention of Endophthalmitis: – U.S. Versus Rest of the World

MONDAY, APRIL 20, 2015 1:00–2:30 PM Moderators: Nick Mamalis, MD William J. Dupps Jr, MD, PhD

Corneal collagen crosslinking is effective in treating progressive keratoconus, achieving long-term stabilisation of the condition, a new study concludes. The 10-year follow-up study included 34 eyes treated for progressive keratoconus from 2000 to 2004.

Corneal collagen crosslinking was performed by applying riboflavin and ultraviolet-A. The mean apical keratometry value was 61.5 dioptres preoperatively and 55.3D 10 years postoperatively. The decrease was statistically significant.

The mean values for maximum K and minimum K were also significantly lower. The preoperative and postoperative CDVA were statistically significantly different. The mean CDVA improved by 0.14 logMAR over preoperatively; the change was statistically significant. F Raiskup, JCRS, “Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: Ten-year results”, Volume 41, Issue 1, 41-46.

THOMAS KOHNEN European editor of JCRS

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

During the ASCRS Symposium on Cataract, IOL and Refractive Surgery, San Diego, California, USA EUROTIMES | FEBRUARY 2015

37

NICE 15th EURETINA Congress

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

Abstract Submission Deadline 15 March 2015

www.euretina.org /EURETINA

@EURETINA

EURETINA

TRAVEL

39

Promenade du Paillon

3

Nice

VIEWS OF...

FEELING PHOTOGRAPHIC? A number of postcard views in Nice are worth recording. Almost everyone becomes a photographer in Nice – the picture postcard opportunities are too good to resist.

Castle Hill For great vantage points, try Castle Hill, the highest point in old Nice at 92 metres above sea level. The view stretches to the Promenade des Anglais and Baie des Anges to the west, and Port de Nice to the east. Besides the panoramas, there are vestiges of the castle, a few cafes and a gift stall. If you walk you will pass an artificial waterfall.

Alternatively, go to the top by mini-train, taxi or take a free lift (the “ascenseur”) which is a fiveminute walk from Cours Saleya.

Photo-guided Tour If your photography skills need a bit of a brushing up, a tour of Nice with a professional photographer to guide you – and your camera – might be the answer. Book a two-hour, half-day or full-day photography tour. You will explore the region’s best viewpoints, and benefit from an introductory or advanced lesson in digital photography techniques. A critique of your shots rounds out the day. Active participants are limited to four per tour and individual outings can be arranged. The course is suitable for all levels, beginner to expert. Cost of group tours ranges from €40 to €95 per practising photographer, with non-photographer friends allowed to tag along for free. For further details or to book an outing online visit: www.lolphoto06.com.

Theatre de Photographie et de l’Image For inspiration, or just because good photography appeals to you, visit Nice’s photography museum, Theatre de Photographie et de L’image. The museum’s six rooms – in a fine Art Deco building that was once a theatre – are dedicated to a variety of aspects of photography, from photo-journalism to fine art. Exhibits change every three months with a different photographer featured, but a fascinating display of old cameras is permanent. The museum is at 27 Boulevard Dubouchage. Just a few blocks off Avenue Jean Médecin, the museum building itself seems a world away from busy downtown Nice.

Open daily, except Monday, from 10:00 to 18:00. For more information, in French, visit: www.tpl-nice.org.

A NICE DESTINATION

15th EURETINA Congress host city Nice has a lot to offer. Maryalicia Post looks at four top attractions NATIONAL SPORTS MUSEUM This state-of-the-art museum opened in Nice in 2014, a year after the Allianz stadium to which it is attached. The museum’s original home was in Paris, where it was founded in 1963 as one of the first such institutions in the world. In its new home in Nice it has, for the first time, room for the more than 45,000 objects and 400,000 documents in its collection. The exhibits are organised into four sections: individual sports, team sports, one-on-one challenges such as martial arts and fencing, and extreme sports. The exhibits include sports clothing, technical equipment and historical items; four interactive tests challenge the visitor’s sporting abilities.

Most of the signage is in English as well as in French. Closed Monday. For details, in French only, visit: www.museedusport.fr.

ALLIANZ RIVIERA STADIUM The stadium was completed in 2013, in preparation for hosting Euro 2016. Popular guided tours of the premises include a peek at the VIP and press areas and an opportunity to stand on the turf – briefly – as well as an introduction to the ecoresponsible features of the building. Believe it or not, the Allianz Riviera is one of the rare buildings that generates more energy than it requires. The stadium tour takes about 90 minutes. Tickets are not available on site, they are sold exclusively online at: www.allianz-riviera.fr.

axis” on the riverbed of the Paillon River.

Immensely popular with the locals and their chil-dren, the promenade is dotted with playful fountains that function at random and may drench the unwary.

Playgrounds are provided for the younger set. The National Theatre of Nice and the free Museum of Modern and Contemporary Art are at the high end of the walk, which runs through the heart of Nice – from Place Garibaldi to Place Massena and most of the way down to the Prome-nade des Anglais.

‘NICER’ WAY TO SEE TOWN Let a ‘Nice Greeter’ show you the city for free. The service was set up in 2013 with 22 volunteer greeters and was a success from the start. Book online according to your preferred language and interests and explore Nice with an enthusiastic local.

Go antique-hunting boutique-shopping or follow any one of a number of other themes. Sessions last a minimum of two hours. Book seven days in advance online at: www.greeters-nice.com.

View over Nice Bay

WALK IN THE PARK The linear “Promenade du Paillon”, just over a kilometre in length, opened in Nice in 2013. Follow-ing the demolition of an ugly bus station and a car park in 2011, the way was cleared, literally, for a “green

Credit: A Issock

INTERNATIONAL AIRPORT: Nice-Cote d’Azur CURRENCY: EURO AVERAGE SEPTEMBER TEMP: 22˚C

Credit: A Issock

NICE

EUROTIMES | FEBRUARY 2015

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CALENDAR

MARCH

6th World Congress on Controversies in Ophthalmology (COPHy)

APRIL

LAST CALL

FEBRUARY 2015

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

World Cornea Congress VII (WCCVII) 15–17 April San Diego, US http://corneacongress.org/

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

ASCRS.ASOA Symposium and Congress

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

Inaugural Asia-Australia Congress on Controversies in Ophthalmology (COPHy A2) 5–8 February Ho Chi Minh City, Vietnam www.comtecmed.com/cophy/aa/2015/

19th ESCRS Winter Meeting 20–22 February Istanbul, Turkey www.escrs.org

6th Baltic Congress

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

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

Retina in Progress 2015: Present and Future 11–13 June Florence, Italy www.symposiacongressi.eu

CONTACT

AUGUST

28th APACRS Annual Meeting

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

17–20 September Nice, France www.euretina.org

OCTOBER

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

International Conference on Ocular Infections (ICOI) 3–4 September Barcelona, Spain www.ocularinfections.com

Barcelona

6th EuCornea Congress

3rd World Congress of Paediatric Ophthalmology and Strabismus

6–9 June Vienna, Austria www.soe2015.org

EYE

23–27 June Ljubljana, Slovenia www.iscev2015.org

SEPTEMBER

15th EURETINA Congress

4–5 September Barcelona, Spain www.eucornea.org

JUNE

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

NEW ENTRY 53rd Symposium of International Society for Clinical Electrophysiology of Vision (ISCEV)

SEPTEMBER

MAY

SOE 2015 Congress

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

21–24 June Ljubljana, Slovenia www.eunos2015.org

↙

↙

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

JUNE

NEW ENTRY 13th Meeting of European Society of Neuro-ophthalmology (EUNOS)

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

XXXIII Congress of the ESCRS 5–9 September Barcelona, Spain www.escrs.org

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

Sub Macular Haemorrhage Paul Rosen interviews Francesco Bandello Available at www.eurotimes.org/eyecontact and the EuroTimes App

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